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Facilitation 더쉽게되도록 고유감각수용기를적절하게자극함으로써신경-근육의반응을촉진시키는치료적방법 4 고유감각수용성의정의 PNF?

1 Proprioceptive Neuromuscular Facilitation ( 고유감각수용성신경근촉진법 ) Sports Medicine Clinic Sky 임승길 1 PNF? 1. Proprioceptive 움직임과체위에관한정보를제공하는감각수용기 2. Neuromuscular 신경과근육 3. Facilitation 더쉽게되도록 고유감각수용기를적절하게자극함으로써신경-근육의반응을촉진시키는치료적방법 4 고유감각수용성의정의 PNF? 피부, 관절, 근육, 건으로부터수용된자극을중추신경 으로전달하는감각신경으로서, 신체의위치감각을전 달하고정보를해석하는기능을하는신체적능력 환자의기능적요구에근접한상대적형태의촉진법을이용한 1:1 운동치료기법 중추신경계질환, 정형외과적질환, 호흡기내과적, 일반내과적환자를포함한모든환자들에게적용 5 6 1

PNF 의역사 1940년대미국 Hurman Kabat 박사에의해시작 1950년초, Kabat & Knott에의해발전 뇌성마비환자를대상 신경생리학적이론에근거 자연적인형태의움직임이근활동에효과적 1970년대에정형외과적환자의치료에적용 현재, 스포츠의학에서많이적용 왜 PNF 를하는가?

2 PNF 의역사 1940년대미국 Hurman Kabat 박사에의해시작 1950년초, Kabat & Knott에의해발전 뇌성마비환자를대상 신경생리학적이론에근거 자연적인형태의움직임이근활동에효과적 1970년대에정형외과적환자의치료에적용 현재, 스포츠의학에서많이적용 왜 PNF 를하는가? 근력 유연성 협응성 (Coordination) 각각의운동요소의선택적재교육 Neuromuscular control Joint stability Coordinated mobility 7 8 치료적운동에대한다른접근방법 1. Bobath method 2. Brunnstrom method 3. Rood method 4. Knott & Voss method PNF 의신경생리학적기초 Neuromuscular disorders Sherrington 촉진과억제의개념을최초로정의 (facilitation & inhibition) 촉진 운동신경 (Motor neuron) 의흥분성증가 억제 운동신경 (Motor neuron) 의흥분성감소 Weak muscle: facilitation Muscle spasticity: inhibition 9 10 근육내수용체 화학수용기 근육내 ph, 세포외 potassium 농도 O 2 와 CO 2 의압력변화정보를중추신경계에전달 운동하는동안심폐계조절의역할 근방추 상대적인근육길이에관한정보를제공 골지건기관 근육에서발휘된장력에관한정보를 feedback을통해중추신경계에제공

신장반사 14 PNF 이해를위한 2 가지신경생리학적현상 PNF 의기본원리 Autogenic inhibition GTO > Muscle spindle로이완 지나친신장에의해야기되는반사적수축으로부터부상예방 Reciprocal inhibition 주동근과길항근의관계

적절한인체자세와역학 15 16 6. 저항 PNF 의기본원리 7. Rotational movement 8. Normal timing 9. Timing for emphasis 10. Traction & approximation 11.

3 신장반사 14 PNF 이해를위한 2 가지신경생리학적현상 PNF 의기본원리 Autogenic inhibition GTO > Muscle spindle로이완 지나친신장에의해야기되는반사적수축으로부터부상예방 Reciprocal inhibition 주동근과길항근의관계 주동근의수축, 길항근의억제 길항근의빠른신장, 주동근의수축촉진 1. PNF patterns에대한교육 2. 시각적자극 3. 청각적격려 미세요 (Push), 당기세요 (Pull), Hold, 힘빼세요 (Relax) 4. 맨손접촉 5. 적절한인체자세와역학 저항 PNF 의기본원리 7. Rotational movement 8. Normal timing 9. Timing for emphasis 10. Traction & approximation 11. Quick stretch 촉진을위한기본절차 저항 근수축과운동조절, 근력강화 방산 (Irradiation) & 강화 (reinforcement ) 자극에의한반응의확산이용 맨손접촉 손을잡는형태와압력에따른근력증가및운동유도 인체위치와역학 AT의체간, 팔, 손의배열에의한운동조절및유도 구두지시 적절한단어와음량

촉진을위한기본절차 시각 (Vision ) 힘의증가와운동을유도하기위해시각이용 견인 (Traction) & 압박 (approximation) 연장하거나압박하여운동성과안정성촉진 Stretch 근수축촉진,

movements), 기능적운동의구성요소 1. 근수축력의촉진 2. 운동조절력증가 3. 운동인식력도모 4.

Kabat(1961) 운동에대한저항은방산을일으키고, 특정패턴에서근육활동의확산을일으킨다.

맨손접촉 (manual contact) 환자의피부감수기와다른압력감수기를자극 팔, 다리의옆면 : 손의위치 ( 중립위치 ) Lumbrical grip 1. 동작에저항을주고회전에저항 2.

4 촉진을위한기본절차 시각 (Vision ) 힘의증가와운동을유도하기위해시각이용 견인 (Traction) & 압박 (approximation) 연장하거나압박하여운동성과안정성촉진 Stretch 근수축촉진, 근피로를감소시키기위하여근육을연장하거나신장반사를사용 Timing 강조를위한 timing 으로근수축력증가 정상적인타이밍조장 (promote) 패턴 공동근집단운동 (synergistic mass movements), 기능적운동의구성요소 1. 근수축력의촉진 2. 운동조절력증가 3. 운동인식력도모 4. 근력증가 저항 (Resistance) 19 방산와강화 (Irradiation & reinforcement) 적절히사용된저항은방산과강화를일으킨다. Kabat(1961) 운동에대한저항은방산을일으키고, 특정패턴에서근육활동의확산을일으킨다. 방산의반응 운동패턴과협동근에대해억제 ( 이완 ) 와촉진 ( 수축 ) 을증가시키는것 강화 (Reinforce) 더강하게하거나순수한힘의첨가에의해강화시키는것 ( 강한근육에저항을주어약한근육의강화를유도 ) 21 맨손접촉 (manual contact) 환자의피부감수기와다른압력감수기를자극 팔, 다리의옆면 : 손의위치 ( 중립위치 ) Lumbrical grip 1. 동작에저항을주고회전에저항 2. 중수지절관절을굴곡하는힘 3. 손가락끝으로잡는것을피하게되어통증유발없이동작조절이가능 22 Rt. Knee Menisectomy Post OP 인체자세와역학 (Body position & mechanics) Johson & Saliba 에의해발달 인체자세 원하는움직임이일어나는동작선상에있을때움직임이가장효율적 AT의체위는동작선혹은작용선상에있어야한다 인체역학 AT의신체에의해저항이발생 저항체중을이용AT의손과팔이비교적이완피로감없음, 환자의반응감지 AT가위치를옮김에따라저항의방향이변하고, 그저항에대하여환자의동작이변함

구두지시 시선 (Vision) 무엇을언제어떻게하는지를전달 간결, 집약 Timing 지시는신장반사를이용할때중요 구두지시의음량은근수축강도에영향 (Johansson, 1983) 큰소리는강력한수축기대, 부드럽고조용한목소리는이완하게하거나통증감소를원할때 예령 : 움직임을준비 동령 : 움직임을시작 교정명령 : 동작을수정또는교정 체위, 동작을교정하거나조절할때이용

5 구두지시 시선 (Vision) 무엇을언제어떻게하는지를전달 간결, 집약 Timing 지시는신장반사를이용할때중요 구두지시의음량은근수축강도에영향 (Johansson, 1983) 큰소리는강력한수축기대, 부드럽고조용한목소리는이완하게하거나통증감소를원할때 예령 : 움직임을준비 동령 : 움직임을시작 교정명령 : 동작을수정또는교정 체위, 동작을교정하거나조절할때이용 시각적인자극으로부터피드백은더욱더강한근수축을유발 AT와환자사이에시선을맞추는것은또다른하나의대화방법이며, 서로의협응을확실히하는데필요 견인 & 압박 (Traction & approximation) Stretch Traction의작용 1. 동작을촉진, 특히당기는동작과항중력운동은촉진 2. 신장반사를이용할때, 근조직이늘어남을돕는다. 3. 동작의어떤부분에서저항으로작용 Approximation의작용 1. 안정성증가 2. 체중부하촉진, 항중력근수축 3. 동작의어떤부분에서저항으로작용 신장자극 길어진근육, 같은관절을지나는협력근, 다른연관된협력근을촉진 (Loofbourrow & Gellhorn, 1948). 신장반사 긴장된근육으로부터일어난다 동작의연속적인진행 Timing PNF 의접근방법 Normal timing 원위에서근위로일어남 강조 Timing 특정한근육을강조하기위해서, 특히원하는동작을강조하기위한동작의정상적이고연속적인변화를포함 근력이 good 이상일때가장좋다 (manual muscle test grade 4). Holistic Integrating sensory motor Psychological aspects of a rehabilitation program

PNF 사용을위한이론적근거 뇌는하나의근육의움직임을인지하는것이아니라오직전체적 인관절의움직임을인지한다. 근수축력 활성화된운동단위. 근력을증가시키기위해 운동단위의최대수동원.

Repeated contraction 3. Slow reversal 4. Slow-reversal-hold 5. Rhythmic stabilization 31 32 Streching techniques 1. Contract-relax 2.

Slow-reversal-hold-relax 특별한문제해결에효과적인 PNF 기법 Rhythmic initiation Pain free arc에능동적움직임이어려운재활초기단계에유용 Slow reversal 근지구력향상 Slow-reversal-hold

6 PNF 사용을위한이론적근거 뇌는하나의근육의움직임을인지하는것이아니라오직전체적 인관절의움직임을인지한다. 근수축력 활성화된운동단위. 근력을증가시키기위해 운동단위의최대수동원. 방산또는 overflow 효과 PNF 에의한협응 (cooperation) 적절한기능으로돌아가기위한 재활의목표를성취하게한다. Strengthening techniques 1. Rhythmic initiation 2. Repeated contraction 3. Slow reversal 4. Slow-reversal-hold 5. Rhythmic stabilization Streching techniques 1. Contract-relax 2. Hold-relax 3. Slow-reversal-hold-relax 특별한문제해결에효과적인 PNF 기법 Rhythmic initiation Pain free arc에능동적움직임이어려운재활초기단계에유용 Slow reversal 근지구력향상 Slow-reversal-hold 등척성운동을통해가동범위중특별한 point에서 weakness 교정 Rhythmic stabilization 관절의안정성과 neuromuscular control PNF patterns PNF patterns of the upper extremity Gross movement 회전 & 대각선운동패턴 모든근육은나선형 & 대각선방향으로놓여있다. 대부분의스포츠와정상적인하루생활에서요구되는움직임과유사 PNF 패턴을구성하고있는 3가지움직임 1. Flexion-extension 2. Abduction-adduction 3. Internal-external rotation

PNF using a body blade/flexbar D1 upper-extremity movement pattern moving into flexion 37 38 Body part D1 upper-extremity

Scapula Retracted Protracted Downwardly rotated Upwardly rotated Forearm Pronated Supinated Wrist Ulnar extended Radially flexed

kr 40 D1 upper-extremity movement pattern moving into extension 41 Body part D1 upper-extremity movement patterns Starting

7 PNF using a body blade/flexbar D1 upper-extremity movement pattern moving into flexion Body part D1 upper-extremity movement patterns Starting position Shoulder Internal rotated Depressed Moving into flexion Terminal position Externally rotated Scapula Retracted Protracted Downwardly rotated Upwardly rotated Forearm Pronated Supinated Wrist Ulnar extended Radially flexed Finger and thumb Left hand inside of volar surface of hand Hand position for AT Right hand underneath arm in cubital fossa of elbow Verbal command Pull 40 D1 upper-extremity movement pattern moving into extension 41 Body part D1 upper-extremity movement patterns Starting position Shoulder External rotated Elevated Moving into extension Terminal position Internally rotated Depressed Scapula Protracted Retracted Upwardly rotated Downwardly rotated Forearm Supinated Pronated Wrist Radially flexed Ulnar extended Finger and thumb Left hand on back of elbow on humerus Hand position for AT Right hand on dorsum of hand Verbal command Push 7

D1 upper-extremity movement patterns D2 upper-extremity movement pattern moving into

Internal rotated Depressed Moving into flexion Terminal position Externally rotated

Supinated Wrist Ulnar flexed Radially extended Finger and thumb Left hand on back of

upper-extremity movement pattern moving into extension 46 Body part D2

Elevated Moving into extension Terminal position Internally rotated Depressed Scapula

Wrist Radially flexed Ulnar flexed Finger and thumb Left hand on volar surface of

8 D1 upper-extremity movement patterns D2 upper-extremity movement pattern moving into flexion 44 Body part D2 upper-extremity movement patterns Starting position Shoulder Internal rotated Depressed Moving into flexion Terminal position Externally rotated Scapula Retracted Protracted Downwardly rotated Upwardly rotated Forearm Pronated Supinated Wrist Ulnar flexed Radially extended Finger and thumb Left hand on back of humerus Hand position for AT Right hand on dorsum of hand Verbal command Push D2 upper-extremity movement pattern moving into extension 46 Body part D2 upper-extremity movement patterns Starting position Shoulder External rotated Elevated Moving into extension Terminal position Internally rotated Depressed Scapula Protracted Retracted Upwardly rotated Downwardly rotated Forearm Supinated Pronated Wrist Radially flexed Ulnar flexed Finger and thumb Left hand on volar surface of humerus Hand position for AT Right hand on cubital fossa of elbow Verbal command Pull D2 upper-extremity movement patterns 8

Isolytic Concentric contraction by the patient while the AT applies an external force in the opposite direction, overpowering the contraction

9 GXT Muscle energy techniques PNF contract-relax & hold-relax techniques의변형기법 PNF 와신경생리학적인원리가같다. 5가지구성요소 1. 환자의능동적인근수축 2. 특정방향으로근수축 3. 환자에의한근수축강도의조절 4. 관절의위치를 AT가조절 5. AT의적절한저항적용 50 MET 의기료 techniques 1. Isometric 2. Concentric isotonic 3. Eccentric isotonic 4. Isolytic Concentric contraction by the patient while the AT applies an external force in the opposite direction, overpowering the contraction and lengthening that muscle MET 의임상적적용 1. 단축, 구축또는강직된근육의신장 2. 약한근육또는근육군의강화 3. muscle pumping을통한부종의감소 4. 제한된움직임이있는관절의 Mobilization 5. Fascia의스트레칭 감사합니다. 53 9

Microsoft PowerPoint - evaluation(창원대)

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