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1、Structural Osteopathy 结构性整骨 Shoulder Practice肩关节操作TakeCare Osteopathic AcademyMilano-Italy1TheclavicolaDysfunctions锁骨功能失常Clavicola in superiority锁骨向上Clavicola in anteriority锁骨向下Clavicola in posteriority锁骨向后Osteopatichedysfunctionsofthearticulationsterno-cost-claveare胸肋锁关节的整骨功能失常2TheclavicolaDysfunct
2、ion锁骨-功能失常TESTINORDERTOESTIMATEtheDYSFUNCTIONINSUPERIORITY(restrictionoftheabduction):Thepatienceissupinewithupperlimbsleaningagainstthesides.Osteopathstandingatthesideofthebedwithbothindicesedgesup.medialendoftheclavicle.Thepzareaskedtoraiseyourshoulderstowardyourearsonbothsides.Collarboneresultins
3、uperiorreturnswhencomparedwiththecontralateralcaudalduringthismovement.测试是为了评估向上的功能失常（外展受限）：患者仰卧，双上肢顶住床边。整骨师站在床边，双食指置于锁骨内侧末端，朝向上。要求患者双上肢向着耳朵方向提肩。在这个运动结束时，若有一侧锁骨的末端高于另一侧，则此侧为功能失常侧3TECHNICALarticulatory(+Trusth):Thepatientissittingwhiletheosteopathisbehindhimwiththethenarofonehandonthetopofthemedialcl
4、avicleandwiththeotherhandgraspstheforearm.Thentheosteopathdoorinabductionthearmtotherestrictivebarrierthenmovestransverselyinthedirectionofthenormalkneewhilewiththethenarpushesthemedialendoftheclavicledown.关节技术（thrust):患者坐位，整骨师位于患者身后，一只手的大鱼际位于锁骨内侧的上缘，另一只手抓住其前臂。整骨师领导患肢外展至障碍点，然后向着相反的，健侧方的膝关节方向做对角运动，同时
5、大鱼际向下推锁骨的内侧头4TECHNICALIMPULSE(Trusth)The patient is sitting or supine,the osteopath standing behind the patient with thehypothenarofahandisplacedonthemedialedgeandtopoftheclavicle,whilehisotherhandgraspsthe patientsarm inabductionandbringingintraction alongthe axisof theclavicle.Thenapplyanimpulseto
6、wardsthelowermedialthirdoftheclavicle.Thrust技术：患者坐位或者仰卧，整骨师站于患者身后，一只手的小鱼际置于锁骨内侧头的上缘，另一只手抓住患者的手臂，领导外展，向着锁骨的长轴方向牵拉。然后施展thrust技术，锁骨内三分之一，朝向下。6TheclavicolaDysfunction锁骨功能失常TESTTOEVALUATETHEDYSFUNCTIONINANTERIORITY(restrictionofflexion):Thepatientissupinewitharmsbent90degrees.Osteopathstandingatthesideof
7、thebedwithbothindicesontheanterioredgeofthemedialclavicles.Thepatientisaskedtoraisetheirarmstotheclaviclesoffitto（ceiling）.Unaresultinpriorartwhenitwillmovetowardstherearthanthecontralateralduringthismovement.测试目的为评估向前的功能失常（屈曲受限）：患者仰卧，肘关节屈曲90度。整骨师站于床的一侧，两个食指置于锁骨内侧头的前方。要求患者提举手臂直到过锁骨水平。结果中若是某一侧的锁骨较另一侧
8、活动更加向后，则此侧为功能失常侧。7TECHNICALarticulatory(+Trusth):Thepatientissittingwhiletheosteopathisbehindhimwiththethenarofonehandonthefrontendofthemedialclavicleandwiththeotherhandgraspstheforearm.Thentheosteopathputs in abduction the arm to the restrictive barrier then moves transversely in a medialdirectionw
9、hilethethenarpushesthemedialendoftheclavicleposteriorly.关节技术（thrust）：患者坐位，整骨师位于患者身后，一只手的大鱼际置于锁骨内侧头末端的前面，另一只手抓住前臂。然后，整骨师外展此臂到障碍点位置，接着朝相反方向（即朝身体正中方向）活动，在此过程中大鱼际向后推锁骨的内侧头末端8TheclavicolaDysfunction锁骨功能失常Osteopathicdysfunctionstheacromio-clavicularjoint肩锁关节的整骨功能失常Dysfunction in abd 外展Dysfunction in add内收
10、Dysfunction in ext.rot.外旋Dysfunction in internal rot.内旋Dysfunction of separation acromion clavicular肩锁关节的分离功能失常10The clavicola Dysfunction锁骨功能失常 TESTTOEVALUATETHEABDUCTIONANDADDUCTION:Thepatientissittingwiththeosteopathbehindhimpalpatinghandwiththetopsurfaceofthearticulationacromionclavicularandcont
11、rolswithhandsidetheproximalforearm.Theosteopathintroducesadductionandexternalrotationofthearmbycontrollingthemovementofdecoaptationinthejoints.TheabsenceofmovementdecoaptationindicatesalesionintherestrictionofADD(rare),thentheosteopathintroducesanabductionmovementofthearmalwayscontrollingmotionatacr
12、omionclaviculargoingtoperceivethattheclavicleslidestowardslowerandmedialthearticulationacromionclavicularduringabduction.测试目的为评估外展及内收：患者坐位，整骨师在身后，一只手触摸肩锁关节顶部的关节面，另一只手控制患者前臂近端的外侧。整骨师通过分离关节的活动来领导前臂内收及外旋。如果患者的关节无法做出分离的运动，则提示有内收受限的功能失常（很少见），然后整骨师再领导前臂外展的动作，同样在肩锁关节处控制并感觉运动，会在外展过程中触到锁骨滑向肩锁关节的内下方11The clav
13、icola Dysfunction锁骨功能失常 TESTTOEVALUATETHEROTATIONORBACKThepatientissittingonthecouchwiththeosteopathstandingbehindhimwithhandpalpatingthemedialuppersurfaceoftheacromion-clavicularjoint,whilehishandsidedoorintheupperlimbabductionkeepingtheelbowflexed.Thentheosteopathintroducesarotationinsideandoneout
14、sideandcurrencymovement.Rememberthat:theclaviclegoesinfrontrotationwhenthehumerusisbroughtintointernalrotation,whilerotationgoesbackwhenthehumerusisbroughtintoexternalrotation.Thetestwillbepositiveiftheexternalrotationofthehumerusduringtheclaviclewillremaininpriorart,andviceversa.测试目的评估旋转及向后的运动患者坐位，
15、整骨师站于身后，一只手触及肩锁关节内侧上关节面，另一只手领导上肢外展，同时肘关节屈曲。接着整骨师领导一次内旋，一次外旋运动。记住：当肱骨内旋时锁骨向前旋转，当肱骨外旋时锁骨向后旋转。如果肱骨外旋时锁骨仍然保持在后方而未向后，则提示测试为阳性13TECHNICALDIRECTIMPULSE(Trusth)FORROTATIONFRONTThepatientissittingosteopathstandsbehindleaningagainsthischest,onehandgraspingthearmofthepatientandwiththehypothenarofthehandisposit
16、ionedbetweenthefrontfaceandtheupperedgeoftheouterthirdoftheclavicle.Then,withonehandpullsthearmslightlyoutwardsassociatingalsoexternalrotationofthearm,whilewiththeotherhandexertsaforcetowardstherearandthebottomleveloftheouterendoftheclavicle,thearmofthepatientisalwaysmaintainedinabduction.向前旋转的直接技术t
17、hrust：患者坐位，向后靠在整骨师胸前。一只手抓住患者手臂，另一只手的小鱼际置于锁骨外三分之一的上边缘骨面。然后，一只手向外轻轻拉患者手臂同时领导外旋的动作，此时另一只手施展向着锁骨外缘末端的后下方的力量，患者的手臂一直处于外展位。15TECHNICALDIRECTIMPULSE(Trusth)FORROTATIONBACKThepatientissittingosteopathstandsbehindleaningagainsthischest,onehandgraspingthearmofthepatientandwiththehypothenarofthehandisplacedont
18、heuppertwo-thirdsofthemedialclavicle.Then,withonehandhepullsthearmslightlyoutwardsassociatingalsoainternalrotationofthearm,whilewiththeotherhandexertsaforcerearanddownwardsattheleveloftheinnerendoftheclavicle,thearmofthepatientisalwaysmaintainedinabduction.向后旋的直接技术thrust：患者坐位，向后靠在整骨师胸前。一只手抓住患者手臂，另一只
19、手的小鱼际置于锁骨内侧三分之二的上部。然后，一只手轻轻向外拉患者手臂，同时领导内旋的动作。另一只手施展锁骨内侧末端水平向后下方的力量，患者的手臂始终处于外展位。16The clavicola Dysfunction 锁骨功能失常TECHNIQUEFORDIRECTCLAVICLEDYSFUNCTIONINSEPARATIONacromioclavicular:Thepatientissitting,theosteopathisplacedbehindthepatient,leaningagainsthischest,onehandgraspingthearmofthepatientwhilet
20、hehypothenarofthehandisplacedontheupperedgeoftheouterthirdoftheclavicle.Then,withonehandpullsthearmslightlyoutwardsassociatinginthetractionphasealsoanelevationofthearm,whilewiththeotherhandexertsadownwardforceattheleveloftheouterendoftheclavicle,thearmofthepatientisalwaysmaintainedinabduction.肩锁关节分离
21、功能失常的针对锁骨的直接技术：患者坐位，倚靠在整骨师胸前。一只手抓住患者手臂，另一只手的小鱼际置于锁骨外三分之一的上边缘。然后，一只手向外轻轻拉患者手臂，同时领导提升手臂的动作。另一只手在锁骨外侧末端水平向下施展力量，手臂一直处于外展位置。18TECHNIQUESMOBILIZATIONscapulaINITSREPORTJOINTWITHCHEST:Thepatientisinlateraldecubitusandtheosteopathispositionedinfrontofthepatient,leaningagainstthechestandthenmobilizestheshoul
22、derinalldirectionsofmovementfavoringtherestrictedmovementwhichwaspreviouslyevaluatedbyacomparativetestwiththecontralateralshoulderblade.利用胸部施展的肩胛骨活动技术：患者侧卧，整骨师站在患者前方，倚靠患者胸前。在所有方向活动肩关节，特别是受限的方向，根据之前双侧肩胛所做的对比评估结果19Osteopathicdiagnosis整骨诊断Testfortherapidassessmentofthecombinedmovementsoftheshoulder肩关节融
23、合运动快速评估active elevation-abd test 主动提升外展测试Test active scratching or test of Apley“抓痒”测试Test passive Mitchell abduction elevation to assess the global movement and the end feel 被动米歇尔测试 被动提升外展来评估整体运动及末端感觉20Osteopathicdiagnosis整骨诊断Test di Jobe TestfortheevaluationofthesupraspinatusmusclePatientseated,sh
24、oulderabducted80,inlinewiththescapularplaneandintraruotataOsteopathbehind,putsresistanceasksthepatientlegelevation(astopushtowardtheceiling)PositivetestifitevokespainN.B.Itcanalsobeanexpressionofneuropathyofthesuprascapularnerve测试冈上肌的功能患者坐位，肩关节外展80度，与肩胛骨同水平整骨师位于患者身后，要求患者提升肩关节（即朝天花板上举），整骨师给予阻力若出现疼痛，则
25、为测试阳性同样可提示肩胛上神经的神经病变21Osteopathicdiagnosis整骨诊断Test di Whipple ForevaluationofalesionofthearticularrotatorcuffPatientstanding,armraisedbefore90,pronationandintermediateadductuptoshoulderlevelcontralateralelbowextendedOsteopathtosideorfronttothepatient,thepatientcallsand“elevatethelimb”againstresistan
26、cePositivetestifitevokespainN.B.ifthepainisrelatedtoliv.acromionclavicularthetestispositiveforthesufferingofthearticulation肩关节囊的功能失常评估患者站立，手臂上举到90度，旋前及内收到肩关节水平的对侧伸展的肘关节整骨师站在患者前方或者侧方，要求患者抵抗阻力上举手臂出现疼痛则提示测试阳性若是肩锁关节附近出现疼痛，则提示该关节功能失常22Osteopathicdiagnosis整骨诊断Palm upTest手心向上测试Testfortheevaluationofthelong
27、headofthebicepsLHB肱二头肌长头的评估Patientstanding,upperlimbsupinationelbowextended,shoulderhighinfront60-80,Osteopathtosideorfronttothepatient,thepatientaskstheelevationofthelimbagainstresistance(pushtowardtheceiling)Positivityofthetestifitevokespaininthebicipitalgroove患者站立，上肢旋后，肘关节伸展，肩关节上举60-80度，整骨师站在患者前方
28、或者侧方，要求患者抵抗阻力上举手臂（朝着天花板上推）若在肱骨结节间沟处出现疼痛，则测试为阳性24Osteopathicdiagnosis整骨诊断Test di JergasonTestfortheevaluationofthelongheadofthebicepsPatientstanding,upperlimballegedthetrunk,elbowbentat90andforearmpronated,Osteopathtosideorfronttothepatient,asksthepatientsupinationoftheforearmtothewristagainstresista
29、ncePositivetestifitevokespaininthebicipitalgrooveLHB肱二头肌长头评估患者站立，上肢离开躯干，肘关节屈曲90度，前臂旋前，整骨师站在患者前方或者侧方，要求患者旋后前臂，腕关节处抵抗阻力若在肱骨结节间沟处出现疼痛，则测试为阳性25Osteopathicdiagnosis整骨诊断Lift off test(Napoleon test Variant)拿破仑测试TestforevaluatingthesubscapularisPatientstanding,upperlimbininternalrotation,elbowflexedtoapprox
30、imately90Osteopathbehindhim,askthepatienttokeepthehandspacedfromthebackofthechestagainstresistancePositivetestresultifthepatientisunabletokeeptheforearmandhandapartfromthechest.orwhenpainduringpushing.肩胛下肌的评估患者站立，上肢内旋，肘关节屈曲大约90度整骨师站于患者身后，要求患者的手从整骨师胸部到自身的背部做抵抗阻力的运动患者无法将手及前臂远离胸部，或者推离过程中有疼痛。26Testforev
31、aluationofamasslesionoftherotatorcuffPatientstandingorsitting,Osteopathtosideorfronttothepatient,heabductsthepatientsarmat90andinviteshimtoloweritslowlyorevensupportitPositivetestresultifthepatientisunabletocurbasharpfallofthearmattheside.测试：肩关节囊的最主要病变患者站立或者坐位，整骨师站于前方或者侧方，外展患者上肢至90度，要求患者慢慢放下或者保持若患者某
32、侧上肢无法控制住而快速下降，则测试为阳性Osteopathicdiagnosis整骨诊断Test della caduta del braccio o drop arm test手臂下落测试28Osteopathicdiagnosis整骨诊断Sulcus testTestforevaluatingalowerscapulahumeralinstabilityPatientstandingorsitting,Osteopathbehindhim,onehandblocksthescapulaofthepatientwhiletheotherpullsthearmdown.Positivetest
33、ifitappearsattheanterolateralshoulderasulcus“测试肩胛骨下部与肱骨连接的稳定性患者坐位或者站立，整骨师站于患者身后，一只手固定住患者肩胛骨，另一只手下拉患者的上肢若在肩关节前侧方出现沟状凹陷，则为测试阳性29Osteopathicdiagnosis整骨诊断Apprehension Test恐惧试验TestfortheevaluationoftheinstabilitiesanteriorshoulderPatientsupineorsitting,shoulderabducted90,Osteopathtothesideorbehindthepati
34、ent,placesonehandunderthescapularhumeral,whiletheotherplacedattheelbowextraruotashouldergentlyPositivetestresultifthepatientshowsfeelingofapprehensionandfear测试肩关节前部的不稳定性患者仰卧或者坐位，肩关节外展90度，整骨师站于患者身后或者侧方，一只手置于肩胛肱骨下方，另一只手置于肘关节处，轻轻向外拉肩关节若患者感觉恐惧则测试阳性31Osteopathic dysfunctions scapulohumeral肩胛肱骨的整骨功能失常Thro
35、ughtheassessmenttestosteopathicyoucandefineanyinefficiencythattheshoulderjointwillbe:通过整骨测试你可能会找到如下功能失常：Dysfunctioninanteriority向前Dysfunctioninposteriority(veryrare)向后（很少）Dysfunctioninsuperiority向上Dysfunctionininferiority向下Theyareeasilyassociateddysfunctions:anterior-superior(oftencombinedwithmalpos
36、itionofLHB)andposterior-inferior.NB:Thedysfunctionsoftheshoulderareoftenofamusclesobeforeyoudoaspecificjobyouhavetoreleaseanytensionthroughtechniquesonsofttissues.这些功能失常通常会并存;前上（通常并存肱二头肌长头的位置异常）和后下通常肩关节的功能失常会因为肌肉引起，所以当你在做调整前，利用放松技术降低肌肉和软组织的张力非常必要32Itisestimatedgloballyshouldermovement,bothactivelyan
37、dpassively,askingthepatienttoperformthemovementsandpossibleactiveandpassiveassistedshoulder:全世界的共识，对于肩关节的评估需要从主动运动和被动运动两方面做，要求患者做主动运动和被动活动肩关节：ANTEPULSION向前RETROPULSION向后ABDUCTION外展ADDUCTION内收EXTERNALROTATION外旋ROTATIONINTERNAL内旋Osteopathicdysfunctionsscapulohumeral肩胛肱骨的整骨功能失常generalevaluation一般评估33Os
38、teopathicdysfunctionsscapulohumeral肩胛肱骨的整骨功能失常Humeralheadinanteriorityorposteriority:Handproximalblocksthescapula:thethumblocksthespineofthescapula,withaveragecouplingthecoracoid.Thecaudalhandimpalmathehumeralheadwiththethumbgoesonthebackofthehumeralhead,andtheotherfourfingersonthefrontsomaintaining
39、goodhumerusitpullstowardsposteriorityandpushingittowardsthepriority.Themovementsareamplefactsandnotwithyourhandbutwiththewholearm,startingfrommyshoulderspecific evaluation特异性测试肱骨头向前或者向后：近端手固定住肩胛骨：拇指固定肩胛冈，接合喙突处。远端手触及肱骨头，拇指位于肱骨头后方，另外四个手指在前方以稳定肱骨头，向前及向后推拉肱骨头注意：推的时候不是用你的手掌而是用整个手臂，发力要从肩关节开始34Humeralheadi
40、nsuperiority:limitationinabduction-flexion-estensione.Incapacitahumeralheadoff.Placinghishandonthecentralareaofthejoint.Itoccursbyplacingaslighttractionthepossibilityoftheheadtomovedownwardsduringtheabductionmovement.Pretension-stress-stressdowninabductionwillperceivethepossibilityofthegapbetweenthe
41、humerusandscapulatoopen.肱骨头向上：外展-屈曲-伸展受限肱骨头无法向下运动。将患者的手臂轻微外展，此时会造成肱骨头的向下运动。在外展过程中增加张力-施压-减压的动作会将肱骨与肩胛骨之间的间距打开35Humeralheadinthepriorart:limitationinflexion-adduction-internalrotation.Inabilityoftheheadofposterioritybutalsoalimitationinliftingthearmforward.Thetestissameasabove,exceptthatthestressisdo
42、wnandposteriority.Placinghishandonthefrontofthejoint.Itoccursbyplacingaslighttractionthepossibilityoftheheadtomovetowardstherearduringmovementofflexion.肱骨头向后：屈曲-内收及内旋受限肱骨头无法向后同时手臂向上前抬起受限测试与之前一样，但是压力施展方向向下后方。将患者的手置于身体前方，会通过屈曲肩关节造成肱骨头向后的运动36Testoverallassessment:Osteopathisasideofthepatientshandholdin
43、gthetailendarmmediumproximalhumerus,thepatientsforearmrestsontheforearmoftheoperator(handlecradle).Thecranialhandrestsontheshoulderofthepatientandcontrolbeforethecollarbone,shoulderbladeandback.Fromthisposition,Itakecontactwithmychestwiththeelbowofthepatient.Thishandlecanthenrun:pushcephalic,caudalt
44、raction,frontpush,rearpush,decoaptation,internalrotation,andexternalrotationtestgloballybachelorhumeralarticulation.整体评估：患者坐位，整骨师站于患者侧方，抓住患者的手，患者前臂置于整骨师前臂以得到支撑（类似摇篮）。另一只手置于患者肩关节，盖住锁骨和肩胛从这个位置，通过胸部接触患者肘关节，通过这个姿势可以进行：向上推，向下推，向前推，向后推内旋及外旋，所有肩关节中肱骨的活动37Osteopathic dysfunctions scapulohumeral肩胛肱骨的整骨功能失常Te
45、chnical standards for the anteriority向前功能失常的标准技术Thepatientissupine,towardstheedgeofthebed,inordertobeabletopushtherearduringthemaneuver.Theosteopathsupportsthearmofthepatientasawholeandtakesintoslightabduction.Searchingforacomponentofinternalrotationtofacilitatethecorrectiontowardsposterioritythenwi
46、ththehandrestsinsidethehypothenaronthefrontofthehumeralhead.ItrunsatractiondecoaptwiththeouterarmthatallowsmetogettothemaximumtensionatthelevelofthescapulahumeralImdealingwith.Thenheputsintensionwiththeouterarm,decoaptthejointandincreasingthecomponentofinternalrotationofthehumerusthenrunathrusthisha
47、ndinsidefrombehindforward.Oftenjustpoweringperformed3-4timestonormalizethedysfunction患者仰卧，靠近治疗床边，以便在手法操作中能够向后调整。整骨师支撑患者上肢，轻微外展。增加内旋动作以帮助向后调整，内侧手的小鱼际置于肱骨头前方。外侧手打开肩胛肱骨关节以达到最佳的调整张力，通过内侧手从前方向后推（垂直于床面）38Patientinthelateraldecubitusposition,theosteopathembraceswithhiselbowelbowofthepatientwithoutcausingpa
48、inandblockingthebackofthehandontheabdomenofthepatient.Withhishandcranialinsteadlocatesthehumeralheadandpositionstheregionmetacarpalphalangealjointofthe1stand2ndfingeronthefront.Soyouputintensionbycreatingaslightdecoaptandyourunathrust,fromfronttobackwithhandcranial(mild).患者侧卧，整骨师在保证无痛情况下环抱住患者肘关节，将患者
49、的手掌贴住其腹部。另一只手的第1和2掌指关节置于肱骨头前方处固定。轻微打开关节以达到最佳张力，用近端的手施展thrust，方向从前向后，力度要轻39Osteopathic dysfunctions scapulohumeral肩胛肱骨的整骨功能失常Technical standards for superiority in dysfunction向上功能失常的标准技术Patientinthelateraldecubitusposition,theosteopathembraceswithhiselbow,theelbowofthepatient,withoutcausingpainandblo
50、ckingthebackofthehandontheabdomenofthepatient.Withhishandcranialinsteadlocatesthehumeralheadandpositionstheregionmetacarpalphalangealjointofthe1stand2ndfingerontop.Withtheelbowofthearmfromthetrunkcaudalhesympathizedperformingtractiondecoapt,untilhearingagoodplacetopasshishandwithacranialcomponenttot