Transcript MMST(經筋動穴針法)
Myofascial Meridian Stimulation Therapy
Myofascial Meridian Stimulation Therapy
(MMST)
經筋動穴針法
Korean Integrative Medicine Institute
Dr.
Seonghyung Cho, M.D.
Myofascial Meridian Stimulation Therapy
MMST(
筋經動穴針法
) History
통증 치료에 있어 “HOW
”
가 아니라 “WHY
”
라는 하나의 접근 법으로서 MMST(經筋動穴針法) 를 저의 스승이신 김일환 M.D.선생님의 도움아래 고안하게 되었습니다. MMST(經筋動穴針法) 는 근골격계와 자율신경병에 기인한 만성 통증에 있어 Acupuncture 가 왜 동양의학에서만 받아들여지고 서양의학에서는 쉽게 받아들여지지 않는가에 대한 의문점에서부터 출발하게 되었습니다 . 그 이유는 Acupuncture 의 과학적 기전이 완전히 밝혀지지 않았기 때문 이며 실제 임상에서 Acupuncture 를 사용하는 시술자들에게도 그 효과 자체가 수수께끼로 남아있기 때문입니다. 하지만 서양의학적 시각에서 Acupuncture 자체가 동양 철학과 밀접하게 연결되있다는 것을 분명 간과해서는 안될 것으로 보입니다.
Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
ICMART 2004,
호주 시드니
Main Session
논문 발표 Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
ICMART 2005,
체코 프라하 좌장 및
Full Time Workshop
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Myofascial Meridian Stimulation Therapy
MMST(
經筋動穴針法
) Introduction
Western medicine: Myofascial Oriental medicine: Meridian Integrative approach: Stimulation Therapy
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Myofascial Meridian Stimulation Therapy
Western medicine: Myofascial
Myofascia 라는 개념은 근막통증증후군(MPS)의 발통점(Trigger Point)과 연관된 근막(Myofascia)을 의미하는 것이 아니라 우리 몸 전체에 두루 퍼져있는 을 뜻하는 것입니다.
해부학적 근막선들(Myofascial lines) 의 연결 이러한 근막선들의 네트워크를 tensegrity) 와 통해 인체의 긴장통합체(Bio 분절성 신경 체계(Segmental Nervous System) 를 유 지할 수 있는 것입니다.
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Oriental medicine: Meridian
Meridian 이라는 개념은 인체에 퍼져있는 움직임 이나 자세 경락(Meridian lines) 를 통해서 근육을 따라 의 변화를 통해 유지되는 네트워크 체계 를 의미하는 것입니다.
동양의학에서 사용되는 주관적이거나 비객관적인 진단 방법을 지 양하고 이러한 움직임을 통한 경락의 네트워크 체계를 이용하여 보다 객관적으로 진단하는 것입니다.
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Integrative approach: Stimulation Therapy
Stimulation Therapy 라는 개념은 근막선(Myofascial line)의 해부학 적 구조와 경락의 경로(Meridian pathway)간에 상호 연관성과 분절 성 신경 체계를 통해 선택된 경혈점(Meridian point) 을 다음과 같은 방법으로 자극을 하는 것입니다.
Acupuncture, Dry needling, Injection, Magnetic therapy, Subcutaneous taped acupuncture, Myofascial release.
MMST(經筋動穴針法) 는 이와 같이 임상의의 치료범위나 선호도에 따 라 치료방법을 결정할 수 있습니다.
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T.P(Trigger Point or Treatment Point) on the MMST
Segmental facilitation에 의해 야기된 stress는 muscle imbalance를 통해 인체의 tensegrity를 무너뜨리게 된다. 그리고 이러한 유해성 자극 부위와 연속적으로 연결된 kinetic chain (myofascial line)에 가장 취약한 부위가 발생된다. 이러한 부위에서 referred pain이나 hypertonic muscle 그리고 sympathetic dysfunction 등과 같은 비정상적인 증상이 일어나는데 이를 T.P.(Trigger Point or Treatment Point) 이라 한다.
MMST(筋經動穴針法)에서는 이러한 T.P.를 서양 의학적인 concept을 기초로 하여 선택된 meridian point를 이용하여 치료를 한다.
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MMST(
經筋動穴針法
) Introduction
“
古爲今用” 을 통해 MMST(經筋動穴針法) 는 동양 의학과 서양의학에 있어 장점을 포용하고 단점을 보완하여 진단과 치료를 할 수 있는 동서양 의학 의 통합적 접근법(Integrative approach) 으로 이 루어졌습니다.
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A prospective view of the western medicine
Stephen M. Levin
:
Bio-tensegrity(tension + integrity) model
Thomas W. Myers
:
Anatomy of myofascial connections Autonomic nervous system and its relation to voluntary nervous system
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Tensegrity(Tension +Integrity) model
Compressio n element Continuous tension
Bicycle wheels and similar structures with compression elements floating in a continuous tension network have been termed “tensegrity”structures by Buckminster Fuller .
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Bio-tensegrity (Tensegrity Biomechanics) proposed by Stephen M. Levin
Myofascial tension strut CT LS Compressio n element Continuous tension
He asserted the bio-tensegrity model that the human body structure is maintained by bony frame embedded in myofascial tension strut just as a bicycle wheel structure is maintained by reciprocal tension of strut
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Similarity of Tensegrity model between human and other structures
Tension Icosahedron model All human structures are similar to a tension icosahedron model because of they are formed of triangular truss type.
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The kinetic chain concept of biomechanics
Tissue lesion or dysfunction in tensegrity structure Secondary: The weakest link on remote area Weakest link in The same kinetic chain Strain or Limitation Same kinetic chain or myofascial tension line Primary: tissue lesion Symptoms: local inflammation and pain As a result, Pain or Limitation on movement
Owing to ceaseless connection of the whole myofascia, a disorder in one region may be expressed in the form of pain and limitation on certain movement in other part of body mainly in the same kinetic chain(myofascial tension line)
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Definition of Kinetic Chain
Three system: Myofascial, Articular, Neural system Work as an integrated functional unit to provide structural and functional efficiency during integrated activities.
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Why Kinetic Chain is so important in MMST?
Efficiency of Movement and Posture: tensegrity and alignment of kinetic chain Dysfunction of tensegrity and alignment in any kinetic chain: compensatory reaction for maintaining the balance of kinetic chain -> serial distorsion pattern of kinetic chain Compensatory reaction(excess adaptive potency (flexibility, force, neuromuscular control) on tissue): tissue failure and overload -> cumulative injury cycle -> symptom and sign Korean Integrative Medicine Institute
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Cause of kinetic chain dysfunction
Postural dysfunction Joint dysfunction Muscle imbalance Decreased neuromuscular control Myofascial adhesion and shortness Decreased core strength Korean Integrative Medicine Institute
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Dysfunction mechanism
Altered length-tension relationship (Reciprocal Inhibition) Altered force couple relationship (Synergistic Dominance) Altered arthrokinematic relationship (Joint Dysfunction) Result of these relationship: ->Altered neuromuscular control ->Decreased neuromuscular efficiency ->Tissue fatigue and failure ->Cumulative Injury Cycle ->Pain and other signs and symptoms Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
Importance of optimum posture and alignment on the MMST
Help to prevent serial distorsion pattern Help to provide optimal shock absorption Help to provide weight acceptance and transfer of force during functional movement Help to prevent the initiation of the cumulative injury cycle Korean Integrative Medicine Institute
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Ideal alignment and Optimum movement
Ideal alignment -> facilitate optimum movement Malalignment due to repeated movement and sustained posture > joint or surrounding support system에 micro-trauma 유발 가능 성이 증가 (ex:spinal segment-> degenerative change) 자동차의 wheel movement -> wheel balance and good alignment for optimum rotation ->자동차와 지지면 사이에 있는 타이어가 균일 하게 마모 Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
Good postural alignment
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Hypothetical concepts of Connective tissue injury
Piezo(pressure)-electric charge Interference field Electromagnetic field
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Piezo(Pressure)-Electric charge
All the tissue of the body generate electrical fields when they are compressed or stretched Mechanical force -> structural deformation -> piezo-electric effect Muscles are under a constant strain. And also the strain creates a piezo-electric charge that runs through the fascia within and around the muscle On the body surface, the electrical resistance of strained point(acupuncture point) is lower than in its surrounding area .
Low resistance point: meridian point, strained point, myofascial trigger point Korean Integrative Medicine Institute
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Segmental superficial dry needling’s MTrP(strained point) pain-relieving mechanism
Insertion of needle into tissue immediately overlying active pain-producing MTrP Stimulation of A-delta sensory afferents Direct arousal of activity in dorsal horn-situated enkephalinergic inhibitory interneuron PLUS Indirect stimulation of these as a result of creation of activity in a serotonergic descending inhibitory system AND The creation of activity in the descending nonadrenergic system Blockade of intra-dorsal horn passage of MTrP
’
s nociceptive information Alleviation of MTrP pain Korean Integrative Medicine Institute
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Interference Field on tissue strain
+ +
During an injury or other imbalance, the membrane is broken or disrupted. The electrolytes pass freely into or out of the membrane and walls
+ + + +
Cell,nerves,muscles,
+ + -
vessels,others
Damage + + + + Interference field + + + of nerves, + cells, muscles, vessels & others Normal membrane Bio-electrical Potential
Disruption of membrane reverses
normal Bio-electrical Potential – Dysfunction, Pain and Energy loss result
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Electromagnetic Field
Extra-cellular matrix synthesis and repair are subject to regulation both by chemical agent(cytokines and GF) and physical agents,principally mechanical and electrical stimuli.
In soft tissue, alternating current electrical fields induce redistribution of integral cell membrane proteins which could initiate signal transduction cascades and cause a reorganization of cytoskeletal structures.
All physical and mental functions are controlled by electromagnetic fields produced by movement of electro-chemicals within the body.
When an injury occurs and tissue is damaged, positively charged ion move to affected area, causing pain and swelling.
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Characteristics of Connective tissue
As a result,
Piezo-electric charges , Interference fields
and
Electromagntic fields
in connective tissue resulting from constant strains can occur pain and dysfunction in the body.
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fascial consideration
Surrounding, supporting, separating, wrapping of the body Be surrounded from sole to skull as one soft tissue structure Function: ~innervated by many nerve ending ~elastically contraction & relaxation ~muscle attachment ~support & fix for balance ~all exercise ~blood & lymphatic circulation ~change earlier than chronic degenerative disease ~chronic passive tissue congestion ~tissue congestion(formation of fibrotic tissue) d/t H ion increase in the joint area ~stress band in overloading area ~burning nature pain d/t stress injury ~inflammatory action ~mediator:transport of the body fluid & inflammatory substance ~surround the CNS Korean Integrative Medicine Institute
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Myofascial line :
Recently, a model suggested by Thomas W. Myers in his book Anatomy Trains try to explain this concept of the myofascial tension line anatomically and to integrate
with
meridian concept of TCM Myofascial tension strut Bio-Tensegrity network system in the body that controls structure of posture and movement.
Superficial back line Superficial front line Lateral line Spiral line Deep front arm line Superficial front arm line Deep back arm line Superficial back arm line Functional line Deep front line
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Relation between myofascial connections and the kinetic chain concept on tensegrity
Dysfunction due to total myofascial connections-> limitation of movement Sensitive tender point -> pain on remote area (압통점을 못 움직이도록 고정시키기 때문에 오히려 그 긴장도가 멀리 말초까지 뻗치게 됨) 주된 장해부위로부터 사지를 움직이려 할 때에 조직의 tensegrity 구조물들은 어떤 강도 의 감소 없이 그대로 힘을 전달 받아 우리 신체는 외부의 역학적 영향상태에 놓이게 되 는 것이다. 또한 한쪽이 고정된 상태에서 완전 가동운동을 일으키려 시도하면 인체는 보상작용을 하게 마련이다.
As a result, dysfunction in excess movement -> repeated stress (local inflammation and pain) -> 발통 물질 and biomechanical failure Korean Integrative Medicine Institute
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Dysfunction according to Muscle imbalance on movement
Nociceptive stimuli -> postural muscles (tight:facilitated) & phasic muscles(weak:inhibited) chain reaction -> imbalanced pattern and movement dysfunction hypoxia -> ischemic state -> pain -> continue feed-back cycyle -> hyperactivty on neural stimulation -> imbalance and dysfunction 신체의 한 부위가 반복적이고 만성적인 스트레스를 받을 때, 그 부위에 신경 구조들은 overexcitable되어져 아주 쉽게 활성화되고 hyperirritable해지는 경 향이 있다. ->
“
facilitation
”
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Segmental facilitation by I.Korr
Spinal segment: not independently Principal of reciprocity when the threshold of the segment is reached, all neurons will fire.
The segment in lesion has a lower threshold and is hyper reflexive.
“
lens
”
for afferent input collecting facilitatory or inhibitory afferents from segment above and below.
occur at areas of focus for postural stress(muscle imbalance), trigger point, visceral problem Korean Integrative Medicine Institute
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In sequence of Segmental facilitation in disturbed lesioned segment
Facilitation of the sensory pathways -> easier access to the nervous system including the higher centers Facilitation of motor pathways -> sustained muscular tensions, exaggerated responses, postural asymmetries and limited & painful motion.
Since the muscles have rich sensory as well as motor innervation, under these condition, they and related tendons, ligaments, joint capsules may become the source of relative intense and unbalanced streams of impulses.
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The characteristics of the facilitated segment
Roots are overly sensitive or hair-triggered :hyperactive ventral motor root -> intervertebral foramen -> join the sympathetic nerve chain -> in a state of chronic overactivity, result in damage to target organ Produce a palpable change in tissue texture :local paravertebral muscle & connective tissues develop a shoddy feel :joints in the area are less mobile :the tissues are tender to touch :often painfully irritable Sympathetic system dysfunction :changes in skin texture, sweat gland activity & capillary blood supply to the skin Korean Integrative Medicine Institute
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Pathway of Sensory information :
Transmit information to spinal cord through dorsal horn
via ascending fibers to higher centers via intrasegmental fibers to the anterior horn(somatic nervous system) via intrasegmental fibers to the lateral horn(autonomic nervous system)
Transmission of sensory information through dorsal horn is modulated by descending stimuli of high level and intersegmental reflex.
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Gray matter of Spinal cord
Anterior(Ventral) Horn: cell bodies of somatic efferent nerve fibers Posterior(Dorsal) Horn: cell bodies of interneurons upon which afferent(sensory) terminate neurons Intermediated gray(Lateral Horn in the thoracic segments): cell bodies of autonomic(sympathetic) efferent nerve fibers Gray commissure ---- connection of left and right Korean Integrative Medicine Institute
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Anatomy of Autonomic nervous system
Parasympathetic nervous system is divided into cranial outflow and sacral outflow In sympathetic nervous system, the axon of the sympathetic preganglionic neurons leave the spinal cord with the ventral roots of the eighth cervical to the second lumbar spinal nerves.
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Division of Autonomic lateral horn
Medial column is comprised in cell bodies of preganglionic fibers toward internal organs Middle column is comprised in cell bodies of preganglionic fibers toward trunk Lateral column is comprised in cell bodies of preganglionic fibers toward head and extremities
Three columns are related to secondary segmental modulations through various and numerous interneurons
.
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Secondary segmental relation
The MMST uses lateral column of lateral horn toward head and extremities related to secondary segmental modulation Segmental innervation: lateral horn에 sympathetic nervous system의 anatomy C8/T1/T2 T2/T3/T4 T5/T6 T7/T8/T9 T10/T11 T12/L1/L2 Interconnection to lateral column of lateral horn: lateral horn의 preganglionic cell body가 efferent outflow를 따라 머리와 사지로 가는 effector의 segment C1/C2 C3/C4 C5/C6 C7/C8 L3/L4 L5/S1/S2 Korean Integrative Medicine Institute
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Somato-Visceral Point
Secondary segmental relation
We can explain that SomatoVisceral Points (SVP) for treating abnormal somatovisceral reflex use the anatomy of autonomic nervous system through extremities and head and the secondary segmental relation.
For example, In C5/6 dermatome area pain, T5/T6
–
C5/C6 : secondary segmental relation Korean Integrative Medicine Institute
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SomatoVisceral Points (SVP) consisted of UB meridian points on surrounding C8-L2 dermatome area.according to secondary segmental relation Secondary segmental relation Segmental innervation Interconnection to lateral column of lateral horn SomatoVisceral Points (SVP) consisted of .
C8/T1/T2 C1/C2 T2/T3/T4 T5/T6 T7/T8/T9 T10/T11 T12/L1/L2 C3/C4 C5/C6 C7/C8 L3/L4 L5/S1/S2
Magnetic therapy on UB line (paraspinal dermatome area)
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Somato-Visceral Point
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vasodilation (decrease sympathetic tone ) C5/6 Secondary segmental relation T5 T6
Magnetic therapy on UB line (paraspinal dermatome area) onT5-6
In the selection of points for treating abnormal somatovisceral reflex on common C5 segment area, we used magnetic therapy on UB meridian line of trunk related to anatomy of sympathetic nervous system and secondary segmental relation (C5/6-T5/6) instead of using acupuncture needle. SomatoVisceral Points (SVP) consisted of UB meridian points on surrounding T5-6 dermatome area . In using acupuncture needle on T5-6 segment of UB meridian line, the blood vessel tone was increased on C5-6segment area. But in using magnetic therapy, we found the blood vessel tone was not increased in our clinical
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Magnetic Therapy
The application of magnetic field to injured area helps to restore the normal electromagnetic balance.
The magnetic field relaxes capillary walls, as well as surrounding muscle and connective tissues, allowing for increased blood flow.
More oxygen and nutrients are transferred to the injury site, while pain and inflammatory-related electro-chemicals are more efficiently removed.
The overall process restores the normal electromagnetic balance of the area, relieving pain and inflammation and promoting accelerated healing.
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Segmental innervation
If nociceptive stimuli occur in a certain segment, these stimuli will influence same innervated segment (dermatome, myotome, sclerotome and viscerotome). As a result, referred pains, hypertonic muscles, activated trigger points, trophic changes and autonomic symptoms such as vasomotor symptoms can occur.
Dermatome, myotome and sclerotome derived from the same somite embryologically have the same nervous pathway and a referral common afferent pathway.
Relation with sclerotome and dermatome: Anterior and posterior surface of plevis attached to iliolumbar ligament accord with L2 sclerotome. Also, Area of referred pains in iliolumbar ligament accords with L2 dermatome.
Referred pain pattern by ligament laxity follows the pattern of segmental dysfunction.
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Somato-Somatic Point
Area in accordance with dermatome, myotome and sclerotome
Treatment points in the MMST for abnormal somatosomaic reflex use common segment area in accordance with dermatome, myotome and sclerotome.
For example, In C5/6 dermatome area pain C5/6 segment Korean Integrative Medicine Institute
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Somato-Somatic Point
In the selection of points for treating abnormal somatosomaic reflex on left shoulder pain, we applied SSP to common C5 segment area (dermatome,myotome and sclerotome).
These points consisted of LU2, LI15 and TE14 . Also, we stimulated these points by deep dry needling
Stimulate meridian points (combined area of dermatome,myotome and sclerotome on C5/6) by deep dry needling Combined area of dermatome,myotome and sclerotome on C5/6 LU2 TE14 LI15
Deep dry needling
Stimulate skin, muscle and periosteum in order Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy SomatoSomatic Point (SSP)
LU2,LI15, TE14 Common Shoulder pain LI11,LU5, TE9 Common Back pain GB30,BL60 LR8,KI10 ST36,GB34, BL53
Common Knee pain
Deep dry needling (combined area of dermatome, myotome, sclerotome)
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Common Back pain:Lumbar pain with/without gluteal pain
Primary: TL junction syndrome Secondary: Pain on LS junction by ligament laxity Compensatory reaction 1.Acute problem: occur suddemly 2.Iliac crest의 허리볼기 지 역에 pain: neurotrophic change of cellulalgia 3.Typical facet locking 1.Chronic problem: TL problem 이후에 occur 2.LS junction부위에 pain: -compensatory movement -gluteus muscle에 T.P.
-hypersensitivity of greater trochanter (sometimes) Korean Integrative Medicine Institute
ASIS
Common Knee pain
Myofascial Meridian Stimulation Therapy
Q increase: external torsion of the proximal tibia Q Cellulalgic zone VMO와 Medial retinaculum의 작용에 의해 alignment 유지 Tenoperiosteal hypersensitivity ROM is not limited: Knee pain originated from the spine (L3-4) 1.cellulalgic zone: L3-4 dermatome around the knee 2.T.P.: Quadriceps femoris (Vastus medialis oblique) 3.Tenoperiosteal hypersensitivity: pes anserinus area Korean Integrative Medicine Institute
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Common Shoulder pain Relationship between biomechanical overload and painful joints associated with MPS and muscle imbalance Painful joint
Cervico cranial Gleno humeral Upper ribs TMJ
Trigger point
SCM Upper Trapezius Scalenes Lateral pterygoids
Shortened muscle
Suboccipitalis
Inhibited muscle
DNFs Levator scapulae or subscapularis Pectoralis Lower trapezius Diaphragm Masseter Digastrics
Faulty posture
Head forward Rounded shoulder Slumped posture
Faulty movement pattern
Neck flexion Scapulo humeral rhythm Respiration Chin poke Mouth opening Korean Integrative Medicine Institute
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Injection Site: Facet joint & ligament
UB line TL junction problem transitional zone Posterior primary ramus의 medial branch Knee pain originated from the spine(L3-4) GV line LS junction problem: ligament laxity Korean Integrative Medicine Institute
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Spinal transitional zone
CO junction CT junction TL junction LS junction Junction에 variation이 존재 Korean Integrative Medicine Institute