슬라이드 1

Size: px

Start display at page:

Download "슬라이드 1"

희순 호
5 years ago
Views:

1 말초신경계 동의과학대학물리치료과교수이태식 신경손상의종류 Seddon 의분류 1) 신경차단 (Neurapraxia) 압박등에의하여축삭의손상없이신경전도가국소적으로차단됨 2) 축삭절단 (Axonotmesis) 슈반세포의손상없이축삭이단절 손상부위이하왈러변성 전도장애 신경속막에의하여재생이잘일어남 말초신경하루에 1-4mm 재생 3) 신경절단 (Neurotmesis) 신경손상중가장심한상태 손상부위이하왈러변성 감각및근육완전마비 예후불량 1

2 신경손상의종류 : Sunderland 1) First-degree injury 가벼운압박 2) Second-degree injury 신경내막의보존에서축삭의손상 3) Third-degree injury 축삭과내막의손상 4) Fourth-degree injury 신경외막과신경주막만이보존 5) Fifth-degree injury 완전절단 변성 (Degeneration) 의종류 1) Wallerian Degeneration 절단부보다원위부는변성 세포체가까운부분은정상 포유동물에서빨리일어남 2) Retrograde Degeneration ( 역행변성 ) 축삭변성이말초부위로부터세포체로진행 세포사가발생 3) Transynaptic Degeneration ( 연접횡단변성 ) 연접을넘어다른신경원에변성 ( 시각전도로에호발 ) 재생 (Regeneration) 축삭의재생은신경관내에서시작, 재생의속도는 1~2mm 정도 손상신경의재생은보통굵고말이집이두터울수록늦고, 가늘고얇은막의신경이재생이빠름 통각 > 촉각 > 고유수용기 > 운동신경의순으로운동신경이가장느림 2

3 신경손상의검사법 1) 근전도검사 (Electromyography; EMG) 2) 신경전도검사 (Nerve Conduction velocity; NCV) 3) Tinel 징후 (Tinel's Sign) 4) 발한검사 (Sweet Test) 5) 피부저항검사 (Skin Resistance Test) ; 자율신경이상유무검사 6) 주름검사 (Wrinkle Test) 7) 신경자극검사 (Nerve Stimulation Test) 질적검사 : 변성반응검사 (reaction of degeneration) 양적검사 : 시치검사, 강시곡선 8) 기타 3

4 신경손상의치료 1) 치료의기본원리초기치료 (Initial care) 1 To prevent or reduce edema 2 To maintain the circulation in the affected area 3 To prevent contractures 4 To maintain activity and power of unaffected muscles 5 To maintain function 6 To look after areas where there is any sensory disturbance (2) 회복기 (Stage of recovery) 의치료 1 Muscle re-education 2 Sensory re-education 3 Functional activities 팔말초신경손상 4

5 5

6 1. 목신경뿌리병증임상적증상, 치료 특징이완성마비, 개별근의위축, DTR 의감소, 섬유속성연축또는섬유성연축 임상적양상몸운동기능마비근육약화몸감각기능 ( 무감각증, 이상감각, 진통, 통각이상예민증 ) 자율신경장애 ( 발한소실, 건조, 영양성변화 ), 구축 치료원칙마비초기 - 부종예방과감소, 침범부위의혈액순환유지, 구축예방회복기 - 근재교육, 근력강화, 감각재교육, 기능적활동의훈련 6

2. Erb s Paralysis(Erb dychenne paralysis) = 분만마비 : C5, C6 Upper arm type C5 Nerve Root injury 시임상적증상 1 Motor defects - rhomboids, deltoid, supraspinatus, infraspinatus, teres minor, biceps brachii,

7 2. Erb s Paralysis(Erb dychenne paralysis) = 분만마비 : C5, C6 Upper arm type C5 Nerve Root injury 시임상적증상 1 Motor defects - rhomboids, deltoid, supraspinatus, infraspinatus, teres minor, biceps brachii, brachilalis, supinator 2 Sensory - lateral shoulder & supper arm 3 Deep tendon reflex - biceps brachii 4 Pain - medial scapular or shoulder C6 Nerve Root injury 시임상적증상 1 Motor defects - deltoid, biceps, brachioradialis or radial wrist extensors 2 Sensory - radial forearm, radial dorsal hand 3 Deep tendon reflex 4 Pain 팔의자세 : 어깨부의모음, 안쪽돌림아래팔의 pronation - 웨이터팁자세, 결과적으로 - 위팔의 abduction 과 external rotation 의마비 ( 보조기자세 ) Erb's Paralysis 의치료 1 Air-plane splint ( 벌림과가쪽돌림유지 ) months 7

nerve root injury 의임상적증상 1 Motor defects - hand intrinscis 2 Sensory loss- medial upper arm 3 Pain-axilla & medial upper arm 4 Honer's

8 3. Klumpke's Paralysis( 크롬프케마비 ) : Lower arm type : C8~T1 C8 nerve root injury 의임상적증상 (Grasp reflex 의결핍 ) 1 Motor defects - long thumb flexor, hand intrinscics, ulnar wrist flexor & extensor 2 Sensory loss - 4th & 5th finger, ulnar forearm 3 Radiating pain - ulnar hand T1 nerve root injury 의임상적증상 1 Motor defects - hand intrinscis 2 Sensory loss- medial upper arm 3 Pain-axilla & medial upper arm 4 Honer's syndrome C8~T1 nerve root injury 의임상적증상 1 Motor defects - all intrinsics, wrist joint, finger long flexor 2 Sensory loss - C8 & T1 control region 8

9 Horner s Syndrome Klumpke's Paralysis 의치료 - opponens splint - kunckle bender 1 Exercise - thumb opposition exercise - opponens pollicis m. 9

4. 긴가슴신경마비 (Long Thoracic Neve Paralysis) (C5~C6) 앞톱니근을지배하는신경의마비 임상적증상 wringing scapular 어깨뼈의기계적위치변화 Push movement 를하지못함 (Protraction) 치료 - shoulder ROM -

10 4. 긴가슴신경마비 (Long Thoracic Neve Paralysis) (C5~C6) 앞톱니근을지배하는신경의마비 임상적증상 wringing scapular 어깨뼈의기계적위치변화 Push movement 를하지못함 (Protraction) 치료 - shoulder ROM - mobilization : clavicle scapular - exercise : serratus anterior - brace - operation 5. 근육피부신경병증 (C5~C6) 부리위팔근, 위팔두갈래두근, 위팔근근지배 아래팔의굽힘과가쪽돌림의약화 Biceps reflex 의소실 10

$dislocated fracture of the surgical neck of the humerus compression of$

11 Musculocutaneous nerve 6. 겨드랑신경마비 (Axillary Nerve Paralysis) (C5~C6) 삼각근과소원근지배 원인 shoulder joint dislocated fracture of the surgical neck of the humerus compression of axillary crutch 임상적증상 - 외전마비 - deltoid & teres minor paralysis - scapular unbalance - shoulder pain - sensory loss : lateral shoulder - EMG 11

$노신경마비 (Radial Nerve Paralysis) C5, C6, C7, C8, T1 의 Posterior cord 원인 - fractures of the$ $mid-shaft of the humerus - supracondylar fractures of the humerus 임상적증상 - injury of axillary$

12 Axillary nerve 7. 노신경마비 (Radial Nerve Paralysis) C5, C6, C7, C8, T1 의 Posterior cord 원인 - fractures of the mid-shaft of the humerus - supracondylar fractures of the humerus 임상적증상 - injury of axillary region - injury of humeral spiral groove - injury of proximal forearm - injury of superficial sensory branches of radial nerve 폄기능의약화또는가쪽돌림의약화변형 : Wrist drop 치료 - support : cook-up splint 12

13 Radial nerve Wartenberg syndrome 13

$- Colles fracture - Carpal tunnel syndrome (Phalen test) 치료 -$

14 6. 정중신경병변 (Median Nerve Lesions) C6, C7, C8, T1 의 med & lat cord 가합쳐짐 원인 - 위팔뼈의위관절융기골절 - Volkman's ischemic contracture - Lunate 의탈구 - Colles fracture - Carpal tunnel syndrome (Phalen test) 치료 - support : opponens splint(or wrist splint) 변형 : 유인원의손 (Ape hand) Medial nerve 14

$cord 원인 - 위팔뼈의안쪽융기골절 - Guyon's canal 의압박 ( 갈고리뼈와콩알뼈사이 ) - by falling asleep with the arm over the back of a chair - by the pressure of the crutch - lacerated wound - humerus fracture &$ elbow dislocation 임상적증상 - injury of upper arm level (mild claw hand, Froment's sign-positive) - injury of elbow (mild claw hand, Froment's sign-positive) - injury of wrist (severe claw

elbow dislocation 임상적증상 - injury of upper arm level (mild claw hand, Froment's sign-positive) - injury of elbow (mild claw hand, Froment's sign-positive) - injury of wrist (severe claw

15 9. 자신경마비 (Ulnar Nerve Paralysis) C8~T1 med. cord 원인 - 위팔뼈의안쪽융기골절 - Guyon's canal 의압박 ( 갈고리뼈와콩알뼈사이 ) - by falling asleep with the arm over the back of a chair - by the pressure of the crutch - lacerated wound - humerus fracture & elbow dislocation 임상적증상 - injury of upper arm level (mild claw hand, Froment's sign-positive) - injury of elbow (mild claw hand, Froment's sign-positive) - injury of wrist (severe claw hand, Froments sign-positive) Froment's sign : Adductor pollicious muscle 의손상으로긴엄지굽힘근과엄지모음근을이용하여엄지를굴곡 Guyon's canal(ulnar tunnel) 치료 - massage - exercise : finger abduction & adduction exercise, - pinching exercise - MP joint flexion with finger extension - old gentleman exercise 변형자세 : Claw hand ( 뼈사이근, 벌레근의마비 ) 보조기 : Knuckle band 착용 15

16 Ulnar nerve ulnar tunnel syndrome benediction hand Guyon's canal syndrome 은 ulnar nerve 가손목의 Guyon's canal 이라불리는 tunnel 을지날때압박되어발생 16

17 froment's sign 다리말초신경손상 1. 허리엉치신경뿌리병증 (Lumboscaral Radiculopathies) lumbar plexus(l1~l4) & scaralplexus(l5, S1~S4) 임상적증상 - L4 Nerve Root Lesion - L5 Nerve Root Lesion - S1 Nerve Root Lesion 17

18 Lumbar / Sacral plexus 18

$넙다리신경병변 (Femoral Nerve Lesions) L2~L4 의뒤분지엉덩허리근의마비 ; hip 의굽힘장애넙다리네갈래근의마비 : knee 의폄장애 원인 - 관통상, 외상, 골반의심한외상, femur fracture, 당뇨 neuropathies, 골반내수술후합병증.$

19 Femoral nerve 2. 넙다리신경병변 (Femoral Nerve Lesions) L2~L4 의뒤분지엉덩허리근의마비 ; hip 의굽힘장애넙다리네갈래근의마비 : knee 의폄장애 원인 - 관통상, 외상, 골반의심한외상, femur fracture, 당뇨 neuropathies, 골반내수술후합병증. hip hyperextension 임상적증상 - knee hyperextension - sensory loss : femur & lower leg & foot anterior medial aspect - quadriceps atrophy 19

$fracture, 당뇨 neuropathies, 골반내수술후합병증.$

20 3. 폐쇄신경병증 (Obturator neuropathy) Hip adductor muscle( 두덩정강근, 긴모음근, 짧은모음근, 큰모음근 ) Hip external rotation muscle 원인 - 관통상, 외상, 골반의심한외상, femur fracture, 당뇨 neuropathies, 골반내수술후합병증. hip hyperextension - 분만, 탈장등에의한압박 임상적증상 - 보행시벌림보행 - 손상받은다리를반대측다리위에올리는것에어려움호소 - 넙다리안쪽부위국소감각소실 폐쇄신경 (Obturator nerve) 20

21 4. 궁둥신경병증 ((Sciatic Nerve Lesions) L4,5 & S1-S3 Semitendinosus Sememembranosus Biceps femoris 원인엉덩관절치환술, 엉덩관절탈구, 종양성질환, 잘못된주사위치, 등 임상적증상 궁둥구멍증 (piriformis syndrome) 발생 sensory loss : foot 의 lateral & dorsal & plantar foot drop : high steppage gait 무릎관절폄은가능 아킬레스건과뒤정강근의깊은힘줄반사약화또는상실 peroneal nerve 21

$5. 종아리신경병변 (Peroneal Nerve Lesions) L4, 5 & S1, 2 원인 - fixed compression - swelling - fibular head fracture 임상적증상 - foot drop : high steppage gait - muscle weakness : dorsiflexor, ankle everters,$

22 5. 종아리신경병변 (Peroneal Nerve Lesions) L4, 5 & S1, 2 원인 - fixed compression - swelling - fibular head fracture 임상적증상 - foot drop : high steppage gait - muscle weakness : dorsiflexor, ankle everters, foot extensor 깊은종아리신경병변 (deep peroneal nerve lesion) - 발목관절의 dorsiflexion 과 toe 의 extension 장애 tibialis anterior, extensor digitorum longus, peroneus tertius, extensor hallucis longus, extensor, digitorum brevis, extensor hallucis brevis 얕은비골신경병변 (superficial peroneal nerve lesion) - Eversion 장애 peroneus longus, peroneus brevis Tibial nerve 22

$6. 정강신경손상 (Tibial Nerve Injuries) 원인 - tarsal tunnel 손상 ( 발목외상, 염좌등 ) - severe fracture of distal femur & proximal tibia - soft tissue injury of posterior knee - 발목굴증후군 ( 발목굽힘근지지띠부위압박 ) - 기능장애 :$

23 6. 정강신경손상 (Tibial Nerve Injuries) 원인 - tarsal tunnel 손상 ( 발목외상, 염좌등 ) - severe fracture of distal femur & proximal tibia - soft tissue injury of posterior knee - 발목굴증후군 ( 발목굽힘근지지띠부위압박 ) - 기능장애 : 발바닥굽힘굴곡, - 발목관절의안쪽번짐발가락굽힘장애보행시발끝및발가락떼기의약화 발목의 medial malleolus 뒤쪽에강한섬유조직의밴드 (flexor retinaculum) 의아래쪽에있는터널을통해신경, 힘줄, 동맥, 정맥이발목아래로내려가는데이를발목터널이라고한다. 이터널이여러가지원인으로좁아지게되면신경을압박하여발목안쪽의감각이둔해지거나전기가통하는듯한통증이다리쪽으로퍼져가는경우도있다. 23

24 얼굴신경마비 얼굴신경 ( 안면신경, facial n.) 특수내장운동섬유 ( 눈물샘, 코안, 입천장, 인두의윗부분, 턱밑샘및혀밑샘에분포하는부교감신경섬유와일반몸감각섬유 ) ( 맛을담당 ) 를포함한다. 얼굴과머리덭개근육, 일부목및귓속뼈근육. 바깥귀길의피부감각, 혀의앞쪽 2/3 의맛 24

25 원인 : - 중추성 : 뇌출혈등에의한겉질숨뇌로 (corticobulbar tract) 손상 - 말초성얼굴신경핵또는신경핵하부의손상 - 중추성 ( 이마에주름가능 ) 과말초성 ( 이마에주름이없다 ) 구분 - 운동성, 감각성, 부교감성신경섬유 ( 광의로는 3 가지신경원 ) 관련이없는근육 - 위눈꺼풀올림근 (Levator palpebrae superior) 눈돌림신경지배 - 씹기근 (mastication muscle) 삼차신경지배 운동방법거울을통한운동건측과의균형적운동실시 25

CASE STUDY

CASE STUDY Biomechanics GACHON UNVERSITY Dept, of Physical Therapy Choi Won Ho Chapter3. Shoulder complex 학습목표 Q. 근육과관절의상호작용에대하여알아본다. 어깨근육들의작용 어깨가슴관절의근육들 팔을올림시키는근육들 어깨관절을모음시키고폄시키는근육들 어깨관절을안쪽돌림시키는근육들과가쪽돌림시키는근육들 3