PNF and Movement, 2019; 17(1): 11-18 https://doi.org/10.21598/jkpnfa.2019.17.1.11 Print ISSN: 2508-6227 Online ISSN: 2508-6472 Case Study Open Access 비절단부에적용한 PNF 상지패턴과견갑골움직임에의한방산이절단부주변근육활성도에미치는영향 - 단일사례연구 - 최수홍 이민형 1 하경진 2 이상열 3 1) 경성대학교대학원물리치료학과, 1 부산대학교병원재활의학팀, 2 동아대학교병원재활치료실, 3 경성대학교물리치료학과 Effects of Irradiation on the Muscle Activity Around an Amputation Site During Proprioceptive Neuromuscular Facilitation Pattern Exercise for Upper Extremity and Scapular Exercise on the Non-Amputated Part -A Case Study- Su-Hong Choi Min-Hyung Rhee 1 Kyung-Jin Ha 2 Sang-Yeol Lee 3 Department of Physical Therapy, Graduated school of Kyungsung University, 1 Department of Rehabilitation Medicine, Pusan National University Hospital, 2 Department of rehabilitation therapy center Dong-a University Hospital, 3 Department of Physical Therapy, Kyungsung University Received: February 13, 2019 / Revised: March 6, 2019 / Accepted: March 13, 2019 c 2019 Journal of Korea Proprioceptive Neuromuscular Facilitation Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose: This study verifies the muscle activity around the amputation site during proprioceptive neuromuscular facilitation (PNF) pattern exercise for the upper extremities on the non-amputated part in upper extremity amputees and provides basic data on effective exercise around an amputation site. Methods: Manual resistance was applied to the PNF upper extremity pattern of the non-amputated part to generate muscle activity around the amputation site. The resistance was adjusted to an intensity that could cause maximal isometric contraction. The muscle activity of the amputation site and the non-amputated part was measured using a surface electromyogram for the upper trapezius, middle trapezius, infraspinatus, serratus anterior, and pectoralis major. Results: During the scapular exercise in the painless range, the amputated side showed significantly lower muscle activity and a lower muscle contraction ratio compared with the non-amputated side. During the PNF pattern exercise in the painless range, the amputated side showed lower muscle activity and a lower muscle contraction ratio compared with the non-amputated side. Corresponding Author : Sang-Yeol Lee (sjslh486@ks.ac.kr)
12 PNF and Movement Vol. 17, No. 1 When the direct scapular exercise of the amputated side was compared with the PNF pattern exercise of the non-amputated side, their muscle contraction ratios were similar. Conclusion: This study confirmed the effectiveness of the PNF pattern exercise of the non-amputated part as a way to indirectly train the injured site with no pain for rehabilitation of patients with serious body injuries, such as amputation. It is necessary to develop effective exercise programs for the rehabilitation of the amputation site based on the results of this study. Key Words: Amputation, Irradiation, PNF pattern Ⅰ. 서론팔의절단은흔하지는않지만외상, 감염, 악성종양등으로인해종종필요한과정이고, 절단부의위치와연부조직의내구도그리고환자의기능적목표에따라치료계획의수립이달라진다 (Fitzgibbons & Medvedev, 2015). 절단부의위치는절단환자의기능적인회복과일상생활회복을가늠하는척도가되며또한잔존부위의근육및뼈대계통을이용한재활의수준을결정하는주요기준이된다 (Freeland & Psonak, 2007). 따라서절단부주변근육의재교육과훈련은재활의필수적인과정이고이후의지 (prosthesis) 를이용하여일상생활로의복귀를준비하는중요한절차이다. 절단환자는절단부의구조적제한으로인해통증과근육뼈대계통의기능제한을갖는다 (Jayakaran et al., 2013; Kesiktas et al., 2015). 특히절단되어상실한부위에서느껴지는이상감각과통증으로정의되는환상통은절단환자의 80% 이상에서관찰되고절단부의치료적운동에제한요소로작용된다 (Casale et al., 2009; Ehde et al., 2000). 또한절단부를포함하고있는근육은구조적결손으로인해기능을잃게되고주변연부조직에도영향을미친다 (Carlsen et al., 2014). 이에따라절단부의재활을위한치료적중재에대한연구가다양하게이루어져오고있다. 하지만절단환자의조기재활에있어수술과정에서발생한상처와통증은적극적인운동중재를시작하는과정에서큰제한요소로작용한다 (Flor, 2008). 특히운동시발생하는통증은상처회복을지연시키 고반흔조직의형성을촉진시켜조직치유를지연시키는요소로작용되므로치료중재과정에서고려되어야한다 (Woo, 2012). 그럼에도불구하고구조적결함과약화된절단부주변의근육을회복시키기위한운동은재활의초기과정부터반드시필요하고, 따라서통증을최소화시킬수있는방법의운동중재들이제공되어야한다. 다양한물리치료중재의방법들중하나인고유수용성신경근촉진법 (proprioceptive neuromuscular facilitation, PNF) 은고유수용기를자극하기위하여다양한치료기법과패턴을이용하여신경근을활성화시키고기능적인활동을촉진시키는치료적방법이다 (Adler et al., 2007). 이방법은대각선과나선방향의움직임을이용하여재활이필요한다양한환자들의근육움직임을촉진시키고신체활동의향상과신경근반응의증가를이끌어내기위해사용된다 (Hindle et al., 2012; Moreira et al., 2017). 특히방산 (irradiation) 은저항에대항하여신체반응이증가되거나다른부위로확산되는것을의미하며, 주로약한분절의근육활성도를증가시키기위해강한분절의근육에저항을적용하여사용할수있다 (Munn et al., 2004). 이는환자의기능회복을위한치료의한방법으로서반대측효과, 교차훈련등의개념으로도사용되고있다 (Carroll et al., 2006; Kofotolis & Kellis, 2007). 따라서본연구는우측팔절단환자의좌측팔에적용한 PNF 패턴저항운동이우측절단부주변근육에방산을유도하여효과적인운동을이끌어낼수있는지를확인하기위해실시되었고근육의기능을
비절단부에적용한 PNF 상지패턴과견갑골움직임에의한방산이절단부주변근육활성도에미치는영향 13 양적으로평가하는지표로사용이가능하며근육의동원을상대적으로비교하는도구로적합한근전도를이용하여근육활성도를측정하였다. Ⅱ. 연구방법 1. 연구대상자본사례연구의대상자는 42세남성으로서 2018년 5월경작업중기계에손이말려들어가며발생한오른쪽위팔뼈골절, 자뼈골절, 흉벽손상 (2nd 11st rib Fx.), 등뼈가시돌기골절 (T7 T10), 등뼈가로돌기골절 (T8 T9) 어깨뼈골절등으로인하여입원한대상자이다. 5월 26일팔의모든신경혈관계통손상, 위팔뼈아래피부및위팔세갈래근을제외한신경혈관및근육의완전절단을확인하였고순환장애, 절단부뼈와피부의괴사진행을막기위해정형외과에서절단수술을시행하였다. 수술시행후 6월 7일경후두신경손상으로추정되는삼킴및호흡장애로기관절제술시행하였고, 6월 8일경절단부내부괴사가확인되어절단부를열어습윤상처치료를실시하였다. 6월 15일중환자실에서매트운동에대한교육을 1회받았고, 이후일반병실전실후병동에서가벼운매트운동치료를실시하였으며 7월 12일재활의학과에위치한물리치료실로처음방문하였다. 잔존절단부의통증과환상통을심하게호소하였고 (VAS 7), 잔존절단부에촉진시압통 (VAS 8), 능동운동과저항운동검사시통증을 (VAS 8) 을호소하였다. 2. 연구도구및측정방법본연구는비절단부의 PNF 패턴운동이절단부주변근육에방산을유도하여효과적인운동을이끌어낼수있는지를확인하기위하여, 표면근전도시스템 BTS FREEEMG (BTS FREEEMG 1000, BTS Bioengineering, Italy) 을이용하였다. 환자의절단부에따른기능적잔존수준을고려하여양쪽팔의위쪽등세모근 (upper trapezius), 중간등세모근 (middle trapezius), 가시아래근 (infraspunatus), 앞톱니근 (serratus anterior) 과큰가슴근 (pectoralis major) 의근육활성도를측정하였다. 측정전피부저항을최소화하기위하여, 전극부착부위의털을제거후알코올솜으로닦아내고전극을부착하였다. 기록전극은일회용 Ag/AgCL전극을사용하였고, 근전도신호수집을위한표본추출률 (sampling rate) 은 1,024Hz, 주파수대역통과필터 (band pass filter) 는 20-500Hz, 노치필터 (notch filter) 는 60Hz로설정하였다. 측정된근전도신호는 Myolab 1.12.129 software (BTS Bioengineering, Italy) 를이용하여분석하였다. 표면근전도전극부착부위는다음과같다 (Criswell, 2002). 위쪽등세모근는 7번목뼈와어깨뼈봉우리 (acromion) 절반거리에능선을따라평행하게활성전극두개를 2cm 간격으로부착하였다. 중간등세모근은어깨뼈안쪽면을찾고, 전극을어깨뼈안쪽가시시작점에서수평하게 2cm 간격으로부착하였다. 가시아래근은어깨뼈가시 (spine of the scapula) 를확인하고, 어깨뼈가시 4cm 아래 2cm 간격으로평행하게전극을부착하였다. 앞톱니근은팔을들어올릴때, 어깨뼈끝, 넓은등근 (latissimus dorsi) 바로앞에서두개의전극을겨드랑이밑, 어깨뼈끝에수평하게부착하였다. 큰가슴근은두개의전극을 2cm 간격으로빗장뼈약 2cm 아래, 겨드랑이접히는부분안쪽으로빗장뼈방향으로부착하였다 (Fig. 1, Fig. 2). 표면전극을부착한연구대상자는바로앉은자세에서다음과같이운동을실시하였다. 먼저 PNF 패턴저항운동전어깨뼈의움직임에따른좌 우측의근수축을확인하기위해양쪽어깨뼈의올림 (elevation), 내밈 (protraction), 뒤당김 (retraction) 을각각통증이없는범위에서최대한힘을주어실시하고근육활성도를측정하였다. 휴식후단일동작이아닌다양한면에서의복합적인동작을유도하기위해건측팔의 PNF 의폄-벌림-안쪽돌림패턴 (Ex. 1), 폄-모음-안쪽돌림패턴 (Ex. 2), 굽힘-벌림-바깥쪽돌림패턴 (Ex. 3) 과굽힘- 모음-바깥쪽돌림패턴 (Ex. 4) 을실시하였으며, 방산효
14 PNF and Movement Vol. 17, No. 1 과를최대화시키기위하여절단측잔존근육과가장멀리떨어진범위에서시행하였다. 연구대상자는운동방향과저항을정확히숙지하도록반복적인연습을실시후측정하였고, 운동은임상경력 10년이상의대한고유수용성신경근촉진법학회정회원이시행하였다. 신호측정은 5초간최대등척성수축을유지하도록하고 3회반복측정하여평균값을본연구에사용하였다. 측정된신호는수축전후 1초를제외한 3초간의신호를분석하였다. 또한해당운동을인한근피로를고려하여운동간휴식시간을 1분으로설정하였다. Ⅲ. 연구결과양쪽어깨뼈의움직임동안나타난좌 우근육 활성도와그에따른좌 우근육활성도비율은다음과같이나타났다 (Table 1, 2). 통증이없는범위에서어깨뼈를움직이는동안건측에비해절단측이현저히낮은근육활성도를나타냈고 (Table 1), 또한낮은근수축비율을나타냈다 (Table 2). PNF 패턴을이용한건측의저항운동동안나타난좌 우근육활성도와그에따른좌 우근육활성도비율은다음과같이나타났다 (Table 3, 4). 통증이없는범위에서 PNF 패턴저항운동을하는동안건측에비해절단측이낮은근육활성도를나타냈고 (Table 3), 또한낮은근수축비율을나타냈다 (Table 4). 절단측어깨뼈를직접움직인경우와건측 PNF 패턴저항운동을한경우를비교하였을때근수축이비슷한수준으로나타났다. Table 1. Muscle activities according to scapular exercise (unit: mv ) Muscle Side Elevation Protraction Retraction Upper trapezius non-as 355.46 118.37 394.50 AS 80.09 33.88 89.92 Middle trapezius non-as 23.03 30.92 107.72 AS 32.27 11.60 51.55 Infraspinatus non-as 64.38 60.07 143.07 AS 9.50 7.00 9.79 Serratus anterior non-as 104.84 237.67 19.33 AS 3.57 2.47 3.69 Pectoralis major non-as 90.27 293.07 106.80 AS 7.37 7.23 8.23 Note. non-as: non-amputation side, AS: amputation side Table 2. Ratio of muscle activities according to scapular exercise (unit: %) Muscle Elevation Protraction Retraction Upper trapezius 22.53 28.62 22.79 Middle trapezius 140.12 37.52 47.86 Infraspinatus 14.75 11.65 6.84 Serratus anterior 3.41 1.04 19.09 Pectoralis major 8.16 2.47 7.71 Note. %=amputation side/non-amputation side *100
비절단부에적용한 PNF 상지패턴과견갑골움직임에의한방산이절단부주변근육활성도에미치는영향 15 Table 3. Muscle activities according to PNF pattern for upper extremity (unit: mv ) Muscle side Ex. 1 Ex. 2 Ex. 3 Ex. 4 Upper trapezius non-as 122.66 337.13 413.88 136.36 AS 29.41 34.18 65.07 20.70 Middle trapezius non-as 115.81 80.70 184.72 38.46 AS 33.14 31.20 31.50 25.16 Infraspinatus non-as 152.58 64.61 152.57 42.13 AS 7.56 7.71 9.38 6.04 Serratus anterior non-as 31.11 178.12 274.62 124.67 AS 2.29 12.86 15.86 7.81 Pectoralis major non-as 31.91 30.62 16.86 14.55 AS 7.30 6.96 5.80 7.25 Note. Ex. 1: extension abduction internal rotation pattern, Ex. 2: extension adduction internal rotation pattern, Ex. 3: flexion abduction external rotation pattern, Ex. 4: flexion adduction external rotation pattern Table 4. Ratio of muscle activities according to PNF pattern for upper extremity (unit: %) Muscle Ex. 1 Ex. 2 Ex. 3 Ex. 4 Upper trapezius 23.98 10.14 15.72 15.18 Middle trapezius 28.62 38.66 17.05 65.41 Infraspinatus 4.95 11.94 6.15 14.34 Serratus anterior 7.37 7.22 5.78 6.26 Pectoralis major 22.88 22.72 34.37 49.86 Note. %=amputation side/non-amputation side *100 Ⅳ. 고찰사지절단환자는절단부의구조적결함과주변조직의결손으로인한통증과기능장애로직접적인움직임을수행하기가어렵다 (Kesiktas et al., 2015). 이러한이유로재활에있어큰어려움을겪지만환자의기능회복, 의지착용등사회로의복귀를위한과정으로서반드시필요하다 (Fitzgibbons & Medvedev, 2015). 본연구는우측위팔뼈의근위부절단수술을시행한대상자가수술후초기운동을시작하는과정에서좌측팔을이용한 PNF 패턴저항운동을통해방산에의한절단부주변근육들의활동을확인하기위하여실시하였고, 이를비교분석하기위해대상자의우측어깨뼈를통증이없이최대움직임을이끌어내는과정에서근육활성도를측정하였다. 그결과 Table 3. 에제시된내용과같이건측의 PNF 패턴저항운동을통해절단부의근육활동을통증없이직접수축에가까운수준으로이끌어낼수있음을확인하였다. 이는건강한성인을대상으로한 PNF 패턴운동에서운동을시행하지않은반대측의근육사용을증명한선행연구의결과들 (Park et al., 2012; Park and Lee, 2016) 과마찬가지로절단수술을통해뼈대, 근육, 신경의손상을입은환자의경우에서도동일하게방산을통한효과가나타날수있음을시사하는부분이다. 이러한결과는본연구의대상자와같이절단술이후주변부상처조직과통증에민감하여직접운동을꺼려하는환자들에게절단부를직접운동하지않고도절단부주변근육수축을이끌어낼수있다는점에서의미가있다. 운동시발생하는통증은재활에있어서기능적인
16 PNF and Movement Vol. 17, No. 1 동작을유도하는데방해가될뿐만아니라상처회복을지연시키는요소로작용되며 (Woo, 2012), 통증과함께야기되는근방호는불필요한근육긴장을유발하여근피로와근육통을다시일으키는이른바통증의악순환을발생시킨다. 따라서통증은치료를계획함에있어서반드시고려해야하는부분이다. 본사례연구에서는건측의 PNF 패턴저항운동을통해유도된방산이통증없이절단부근육활성을이끌어냈고이는방산의효과가단지근육활성도증가에만있는것이아니라통증이있는환자들에게다양하게활용될수있음을추측할수있게한다. 방산에대한근거로서자극효과의합성을통한신경생리학적가중 (summation) 을들수있다. 이러한가중에는역치이하의약한자극이누적되어나타나는시간적가중 (temporal summation) 과다른부위에동시에적용된자극이서로흥분과반응을이끌어내는공간적가중 (spatial summation) 이있고시간적가중과공간적가중은동시에사용가능하였을때더큰반응을이끌어낼수있는것으로알려져있다 (Sherrington, 1907). 이와같이방산은자극의빈도와강도가증가될경우일어날수있고이는운동단위를동원하거나억제시킬수있다 (Adler et al., 2007). 본실험에서사용된 PNF 패턴저항운동은정상인을대상으로편측팔을이용한반대측하지근육활성도를확인한선행연구의방법과같이각동작의끝범위에서저항을적용하였고대상자가통증을느끼지않는범위에서가장강한저항의강도로실시하였다 (Kim et al., 2006). 이를통해대상자는몸통과팔의운동단위동원능력을증가시켰고, 근육동원의증가는몸통과연결된절단부주변의근육활성도를증가시키는방산의효과로나타났다. 다만본연구대상자의경우방산의효과가몸통과어깨뼈를연결하는앞톱니근, 어깨뼈와위팔뼈를연결하는가시아래근과같이단일관절을연결하는국소근육에비해큰가슴근, 위쪽등세모근, 중간등세모근과같은다관절을연결하는대근육이높은근육활성비율을나타냈다. 국소근육과대근육을기능적으로분류하는경우 국소근육은신체분절의안정성을제공하는역할, 대근육은주로움직임을만들어내는기능을하는것으로알려져있다 (Richardson et al., 2004). PNF 패턴운동이기능적움직임을강조한다는측면에서이러한결과는의미있다고사료된다. 실제로 PNF 패턴저항운동을통한방산효과와관련된선행연구를살펴보면넙다리네갈래근 (quadriceps femoris), 넙다리두갈래근 (biceps femoris), 앞정강근 (tibialis anterior), 장딴지근 (gastrocnemius) 과같은대근육위주의연구가주를이룬다 (Kim, 2017; Kwak et al., 2012; Lee & Yun, 2012; Park et al., 2011). 따라서기능적움직임을고려한 PNF 패턴은방산을통해새로운움직임을유도시키는역할을할수있다고판단된다. 다만본연구의대상자가흉벽손상과어깨뼈의골절을동반했다는점에서방산의효과가실제로국소근육에적게미치는것인지, 골절주변부근육이라는위치특성때문에통증또는다른손상이문제가되어적은근육활성을나타낸것인지는추후연구를통해확인해야할것으로사료된다. 본연구는기존방산에대한연구들이주로사지의근육활성도를연구한것과는달리사지절단이라는대상자의특성으로인해몸통부의근육을대상으로실험을진행하였다는점에서의미가있다. 하지만팔절단환자를 1명을대상으로실험한단일사례연구로서실험의결과를전체절단환자에일반화시키기에한계가있다. 따라서향후유사한환자를대상자로하는추가연구들이필요할것으로판단된다. 또한방산의효과가단지연결된근육사슬 (muscle chain) 에포함된대근육에주로나타나는것인지신체분절을조절하는국소근육에도영향을줄수있는지에대한통제된연구가필요할것으로사료된다. Ⅴ. 결론본사례연구는상지절단환자를대상으로하여건측 PNF 패턴의적용과견갑골운동의적용이절단부
비절단부에적용한 PNF 상지패턴과견갑골움직임에의한방산이절단부주변근육활성도에미치는영향 17 의근육에방산을유도하여근육활성도가증가하는지를확인하기위해실시하였다. 본연구의결과를바탕으로통증으로인하여절단부에직접적인접촉을할수없거나저항을가할수있는사지가없는절단환자의경우, 손상된부위를통증없이간접적으로훈련시키기위한방법으로서비절단부의 PNF 패턴운동과견갑골운동의적용이절단부의근육활성을유발할수있는것으로생각되며이를바탕으로비절단부를이용한절단부근육을활성시켜재활의초기에적용할수있는운동프로그램의개발이필요할것으로생각된다. References Adler SS, Beckers D, Buck M. PNF in practice: an illustrated guide. Berlin. Springer. 2007. Carlsen BT, Prigge P, Peterson J. Upper extremity limb loss: functional restoration from prosthesis and targeted reinnervation to transplantation. Journal of Hand Therapy. 2014;27(2):106-113. Carroll TJ, Herbert RD, Munn J, et al. Contralateral effects of unilateral strength training: evidence and possible mechanisms. Journal of Applied Physiology. 2006;101(5):1514-1522. Casale R, Alaa L, Mallick M, et al. Phantom limb related phenomena and their rehabilitation after lower limb amputation. European Journal of Physical and Rehabilitation Medicine. 2009;45(4):559-566. Ehde DM, Czerniecki JM, Smith DG, et al. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Archives of Physical Medicine and Rehabilitation. 2000;81(8):1039-1044. Fitzgibbons P, Medvedev G. Functional and clinical outcomes of upper extremity amputation. Journal of the American Academy of Orthopaedic Surgeons. 2015;23(12):751-760. Flor H. Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies. Expert Review of Neurotherapeutics. 2008;8(5): 809-818. Freeland AE, Psonak R. Traumatic below-elbow amputations. Orthopedics. 2007;30(2):120-126. Hindle KB, Whitcomb TJ, Briggs WO, et al. Proprioceptive neuromuscular facilitation (PNF): its mechanisms and effects on range of motion and muscular function. Journal of Human Kinetics. 2012;31:105-113. Jayakaran P, Johnson GM, Sullivan SJ. Concurrent validity of the sensory organization test measures in unilateral transtibial amputees. Prosthetics and Orthotics International. 2013;37(1):65-69. Kesiktas E, Eser C, Gencel E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns. 2015;41(2):401-407. Kim HG. Comparison of muscle activity in the contralateral lower extremity from the PNF arm pattern and leg pattern. PNF and Movement. 2017;15(2):177-183. Kim KH, Park JW, Bae SS. Effect of proprioceptive neuromuscular facilitation applied to the unilateral upper extremity on the muscle activation of contralateral lower extremity. Journal of the Korean Proprioceptive Neuromuscular Facilitation Association. 2006;4(1):9-18. Kofotolis ND, Kellis E. Cross-training effects of a proprioceptive neuromuscular facilitation exercise programme on knee musculature. Physical Therapy in Sport. 2007;8(3):109-116. Kwak SK, Ki KI, Kim DY, et al. The effects of proprioceptive neuromuscular facilitation applied to the lifting on the EMG activation of contralateral lower extremity. Journal of the Korean Proprioceptive Neuromuscular Facilitation Association. 2012;10(4):25-31. Lee BK, Yun JH. Influence of body weight support and walking
18 PNF and Movement Vol. 17, No. 1 speed in the static posture of stroke patients using indirect PNF treatment: a case report. Journal of the Korean Proprioceptive Neuromuscular Facilitation Association. 2012;10(4):71-76. Moreira R, Lial L, Teles Monteiro MG, et al. Diagonal movement of the upper limb produces greater adaptive plasticity than sagittal plane flexion in the shoulder. Neuroscience Letter. 2017;643(16):8-15. Munn J, Herbert RD, Gandevia SC. Contralateral effects of unilateral resistance training: a meta-analysis. Journal of Applied Physiology. 2004;96(5):1861-1866. Park I, Park S, Park J, et al. The effects of self-induced and therapist-assisted lower-limb pnf pattern training on the activation of contralateral muscles. Journal of Physical Therapy Science. 2012;24(11):1123-1126. Park IS, Lee SY. Effects of proprioceptive neuromuscular facilitation leg patterns on activity of gluteus medius at opposite side. PNF and Movement. 2016;14(3): 195-202. Park TJ, Park HK, Kim JM. The effects of PNF arm patterns on activation of leg muscles according to open and closed kinemetic chains. Journal of Korean Society of Physical Medicine. 2011;6(2):215-223. Richardson CA, Hodges P, Hides J. Therapeutic exercise for lumbopelvic stabilization. London. Churchill Livingstone. 2004. Sherrington C. The integrative action of the nervous system. The Journal of Nervous and Mental Disease. 1907;34(12):801-802. Woo KY. Chronic wound-associated pain, psychological stress, and wound healing. Surgical Technology International. 2012;22:57-65.