• 대한정형도수물리치료학회지
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• 제28권2호
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• pp.67-75
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• 2022

Background: Scapular winging is a rare disorder that is commonly caused by nerve damage of the dorsal scapular nerve, spinal accessory nerve, or the long thoracic nerve. This affects the scapulohumeral rhythm which may cause abnormal kinetic motion of the shoulder. The purpose of this case report is to describe a self-exercise oriented management incorporating shoulder strengthening to reduce symptoms in a shoulder pain patient with winging scapular. Methods: A 45 year old male patient complained of pain in his both shoulders without any trauma. Shoulders were treated with steroid injections for supraspinatus tendonitis, but although pain improved to some extent, pain and disability continued for 3 months. Both shoulders had pain, decreased active range of motions, muscles weakness, and scapular winging. The patient underwent 9 interventional sessions over 3 months and was managed mainly by self-exercise. The intervention method involved push up plus, sling, muscle strengthening, and stabilization exercises. Loads were increased as symptoms improved. Results: Clinical outcomes were measured at every session. Pain in both shoulders reduced to 0 on a numerical pain rate scale by the 4th session, and the active range of motion was fully recovered. During the 9th session, the strength of the serratus anterior had improved from grade P to G on the right side and grade G to N grade on the left. Conclusion: In this case study, the self-exercise program was effective in reducing pain, increasing active range of motion, and improving muscle strength in subjects with scapular winging.

• 한국전문물리치료학회지
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• 제30권2호
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• pp.160-168
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• 2023

Background: Individuals with scapular winging have a weak serratus anterior (SA) muscle, and to compensate, the pectoralis major (PM) and upper trapezius (UT) muscles excessively activate, which can cause upper extremity dysfunction. This study aimed to compare the effects of isometric horizontal abduction (IHA) on SA, PM, and UT muscle activity, as well as the SA/PM and SA/UT muscle activity ratios during knee push-up plus (KPP) at 90° and 120° of shoulder flexion. Objects: This study aimed to compare the effects of IHA on SA, PM, and UT muscle activity, as well as the SA/PM and SA/UT muscle activity ratios during KPP at 90° and 120° of shoulder flexion. Methods: This study, conducted at a university research laboratory, included 20 individuals with scapular winging. Participants performed KPP with and without IHA at 90° (KPP90) and 120° (KPP120) of shoulder flexion. SA, PM, and UT muscle activity were measured using surface electromyography. Results: PM activity in KPP90 with IHA was significantly lower than KPP90 and in KPP120 was significantly lower than KPP90. UT activity was significantly greater with IHA than without IHA and at 120° than 90° of shoulder flexion. SA/PM muscle activity ratio was significantly higher in KPP90 with IHA than without IHA and in KPP120 than in KPP90. SA/UT muscle activity ratio was significantly lower with IHA than without IHA. Conclusion: KPP90 with IHA and KPP120 are effective exercises to reduce PM activity and increase SA/PM muscle activity ratio. However, applying IHA in KPP90 also reduces SA/UT muscle activity ratio, implying that it would be preferable to apply KPP120 in individuals overusing their UT muscles.

• 한국전문물리치료학회지
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• 제29권2호
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• pp.165-170
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• 2022

Background: The serratus anterior (SA) muscle prevents scapular winging (SW) by stabilizing the medial border of the scapula during arm movement. The upper trapezius (UT) and lower trapezius (LT) muscles may compensate for the weak SA muscle in individuals with SW during shoulder flexion. However, there is no study to examine whether compensation by UT and LT occurs in individuals with SW. Objects: This study compared the muscle activities of UT, LT, and SA as well as the SA/UT activity ratio between individuals with and without SW during shoulder flexion with load. Methods: This study recruited 27 participants with SW (n = 14) and without SW (n = 13). Electromyography data of the SA, UT, and LT muscles and SA/UT activity ratio were recorded and analyzed during shoulder flexion with 25% load of the maximal shoulder flexion force. Independent t-test was used to compare the UT, LT, and SA muscle activities and SA/UT ratio between the groups with and without SW; statistical significance was set at α of 0.05. Results: SA activity was significantly lesser in the group with SW than in the group without SW. However, there were no significant differences in the UT and LT activities and SA/UT activity ratio between the two groups. Conclusion: The SA activity was lesser in the group with SW than in the group without SW with 25% load of the maximal shoulder flexion force, but there was no compensatory muscle activity of the UT and LT observed. Therefore, further studies are warranted to clarify the compensatory strategy of scapular stabilization in individuals with SW during shoulder flexion under other heavy load conditions.

• Archives of Reconstructive Microsurgery
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• 제5권1호
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• pp.24-34
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• 1996

There are many kinds of free flaps for management of extensive soft tissue defect of extremities in orthopaedic field. Free vascularized scapular flap is one of the most useful and relatively easy to application. This flap has been utilize clinically from early eighties by many microsurgical pioneers. Authors performed 102 cases of this flap from 1984 to 1995. We have to consider about the surgical anatomy of the flap, technique of the donor harvesting procedures, vascular varieties and anatomical abnormalities and success rate and the weak points of the procedure. This flap nourished by cutaneous branches from circumflex scapular vessels emerges from the lateral aspect of the subscapular artery 2.5-5cm from its lateral origin passing through the triangular space(bounded by subscapularis, teres minor, teres major, long head of triceps). The terminal cutaneous branch runs posteriorly around the lateral border of the scapular and divided into two major branches, those transeverse horizontally and obliquely to the fascial plane of overlying skin of the scapular body. We can utilize these arteries for scapular and parascapular flap. The vascular pedicle ranged from 5 to 10 cm long depends on the dissection, usually two venae comitantes accompanied circumflex scapular artery and its major branches. The diameter of the circumflex scapular artery is more than 1mm in adult, rare vascular variation. Surgical techniques : The scapular flap can be dissected conveniently with prone or lateral decubitus position, prone position is more easier in my experience. There are two kinds of surgical approaches, most of the surgeon prefer elevation of the flap from its outer border towards its base which known easier and quicker, but I prefer elevation of the flap from its outer border because of the lowering the possibilities of damage to vasculature in the flap itself which runs just underneath the subcutaneous tissue of the flap and provide more quicker elevation of the flap with blunt finger dissection after secure pedicle dissection and confirmed the course from the base of the pedicle. There are minimal donor site morbidity with direct skin closure if the flap size is not so larger than 10cm width. This flap has versatility in the design of the flap shape and size, if we need more longer and larger one, we can use parascapular flap or both. Even more, the flap can be used with latissimus dorsi musculocutaneous flap and serratus anterior flap which have common vascular pedicle from subscapular artery, some instance can combined with osteocutaneous flap if we include the lateral border of the scapular bone or parts of the ribs with serratus anterior. The most important shortcoming of the scapular free flap is non sensating, there are no reasonable sensory nerves to the flap to anastomose with recipient site nerve. Results : Among our 102 cases, overall success rate was 89%, most of the causes of the failure was recipient site vascular problems such as damaged recipient arterial conditions, and there were two cases of vascular anomalies in our series. Patients ages from 3 years old to 62 years old. Six cases of combined flap with latissimus dorsi, 4 cases of osteocutaneous flap for bone reconstruction, 62 parascapular flap was performed - we prefer parascapular flap to scapular. Statistical analysis of the size of the flap has less meaningful because of the flap has great versatility in size. In the length of the pedicle depends on the recipient site condition, we can adjust the pedicle length. The longest vascular pedicle was 14 cm in length from the axillary artery to the enter point cutaneous tissue. In conclusion, scapular free flap is one of the most useful modalities to manage the large intractable soft tissue defect. It has almost constant vascular pedicle with rare anatomical variation, easy to dissect great versatility in size and shape, low donor morbidity, thin and hairless skin.

• 한국전문물리치료학회지
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• 제23권2호
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• pp.57-66
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• 2016

Background: For the treatment of forward head posture (FHP) and forward shoulder posture, methods for strengthening scapular retractors and deep cervical flexors and stretching pectoralis and upper cervical extensors are generally used. No study has yet assessed whether suboccipital release (SR) followed by cranio-cervical flexion exercise (CCFE) (SR-CCFE) will result in a positive change in the shoulders and neck, showing a "downstream" effect. Objects: The purpose of this study was to investigate the immediate effects of SR-CCFE on craniovertebral angle (CVA), shoulder abduction range of motion (ROM), shoulder pain, and muscle activities of upper trapezius (UT), lower trapezius (LT), and serratus anterior (SA) and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction in subjects with FHP. Methods: In total, 19 subjects (7 males, 12 females) with FHP were recruited. The subject performed the fifth phase of CCFE immediately after receiving SR. CVA, shoulder abduction ROM, shoulder pain, muscle activities of UT, LT, and SA, and LT/UT and SA/UT muscle activity ratios during maximal shoulder abduction were measured immediately after SR-CCFE. A paired t-test and Wilcoxon signed-rank test were used to determine the significance of differences in scores between pre- and post-intervention in the same group. Results: The CVA (p<.001) and shoulder abduction ROM (p<.001) were increased significantly post-versus pre-intervention. Shoulder pain was decreased significantly (p<.001), and LT (p<.05) and SA (p<.05) muscle activities were increased significantly post- versus pre-intervention. The LT/UT muscle activity ratio was increased significantly post- versus pre-intervention (p<.05). However, there was no significant change in UT muscle activity and SA/UT muscle activity ratio between pre- and post-intervention (p>.05). Conclusion: SR-CCFE was an effective intervention to improve FHP and induce downstream effect from the neck to the trunk and shoulders in subjects with FHP.

• Archives of Reconstructive Microsurgery
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• 제18권2호
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• pp.55-61
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• 2009

Purpose: To analyze the clinical and radiologic results of the shoulder arthrodesis in brachial plexus injury patients with flail upper extremity. Material and Method: From Aug 1978 to April 2008, 29 shoulders in 29 patients with brachial plexus injury with shoulder fusion, we evaluated 20 shoulders in 20 patients, more than 1 year follow up. The average follow-up period was 6.45years (range: 1year~24years). There were 13 men and 7 women, and the mean age at the time of trauma was 32.0years(2~65 years). The type of injury was a motorcycle accident in 11 patients, in car accident in 5, pedestrian accident in 3, and fall from a height in 1. The lesion of injury was root and trunk in 1 patient, trunk and cord in 1, trunk in 18. Surgery was performed on the whole arm type paralysis in 12 patients, lower arm type paralysis in 8 patients. The preoperative visual analog scale score was 8.7(7~10). When the trapezius and serratus anterior muscle were in function, operation was performed. 18 patients were processed to the additional operation. Gracilis free flap in 6 patients, neurotization in 3, Steindler flexor plasty in 6, and tendon transfer in 3 were performed. Fixation was conducted with cancellous screws in 13 patients, Knoles pins in 5, and cancellous screws and Knoles pins in 2. The position of the arthrodesis at operation was $28.5^{\circ}$($20~45^{\circ}$) in abduction, $30.3^{\circ}$($20~45^{\circ}$) in flexion, and $30.8^{\circ}$($20~40^{\circ}$) in internal rotation. Result: The follow up visual analog scale score was 3.4(0~7). Postoperatively, shoulder spica cast was applied for 15.3weeks(8-20weeks). The median time to bony union was 17.7weeks(9~28weeks). Average range of motion was $32.0^{\circ}$($15~40^{\circ}$) of abduction, $24.0^{\circ}$($10~40^{\circ}$) of flexion, and $18.5^{\circ}$($10~30^{\circ}$)of internal rotation. Conclusion: The shoulder fusion in brachial plexus injury patients is one of the good methods to relieve pain, improve the function and stabilize the flail shoulder joint.

• 한국산학기술학회논문지
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• 제18권4호
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• pp.624-631
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• 2017

본 연구의 목적은 머리 전방 자세 성인에 대하여 8주간 슬링에서의 푸쉬업 플러스 운동이 근활성도와 폐기능에 어떠한 영향을 미치는지 알아보고자 하였다. 총 16명의 머리 전방 자세 성인이 모집 되었고 대조군과 실험군으로 각 8명씩 배정 되었다. 슬링에서의 니푸쉬업 플러스와 안정한 면에서 니푸쉬업 플러스 운동을 2015년 7월 6일부터 8월 28일까지 8주간 나누어 시행하였고 주 3회 실시하였다. 머리 척추각을 측정시 두군에서 (p<0.001)의 증가를 보였고 머리 회전각 측정시 대조군에서 (p<0.05), 실험군에서 (p<0.001)의 감소를 보였다. 두 군에서 근활성도는 위 등세모근(p<0.001)의 감소와 앞톱니근, 아래 등세모근의(p<0.001)의 증가를 나타내었고 폐기능 측정시 대조군에서(p<0.01), 실험군에서(p<0.001)의 증가를 보였다. 결론적으로 푸쉬업 플러스 운동은 머리 전방 자세를 개선시키고 호흡근들의 활성화를 높일뿐더러 폐기능 강화에 효과적이며 슬링에서의 푸쉬업 플러스 운동이 머리 전방 자세의 개선에는 더욱 효과적이지만 폐기능에는 유의한 차이가 없었다. 따라서 슬링에서의 푸쉬업 플러스 운동은 머리 전방자세 성인의 자세 개선과 폐기능에 효과적인 운동으로 추천 된다.

• 한국전문물리치료학회지
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• 제29권2호
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• pp.117-123
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• 2022

Background: Push-up are effective exercises for shoulder stability. Previous studies have documented the effects of support plane and hand position and width on muscle activities during a push-up. Objects: This study aimed to investigate the changes in muscle activities in the upper extremity when performing the standard and the knee-flexed push-up with different hand shapes. Methods: A total of twenty-six healthy males participated in this study. Three different hand shapes (finger abduction, finger adduction, and fists) and two types of push-up posture (standard and knee-flexed push-up) were set as the independent variables. Electrograms were used to measure the muscle activity of the upper trapezius (UT), triceps brachii (TB), pectoralis major (PM), and serratus anterior (SA). Each participant performed the randomly assigned push-up to the sound of the metronome. The mixed-effect linear regression model was used to detect the changes in muscle activities after changing the hand shape and push-up posture. Statistical significance was set at α = 0.05. Results: The UT muscle activity was statistically significantly higher when performing push-up with fists than finger abduction (p = 0.035) or finger adduction (p = 0.044). During the standard push-up, the muscle activity in all muscles was that the push-up with fists showed the highest muscle activity compared to the finger abduction (p < 0.01) and finger adduction (p < 0.01). Regardless of the shape of the hand, UT had the lowest muscle activity compared to other muscles (p < 0.001). In contrast, the SA muscle had the highest muscle activity among four muscles during the standard push-up. Conclusion: Based on the results of this study, we suggest hand shape is related to the difficulty level of push-up either in the standard or the knee-flexed push-up, especially in the push-up with fists. In addition, knee push-up can be recommended as shoulder muscle-strengthening exercises for individuals with low shoulder muscle strength.

• Journal of Chest Surgery
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• 제40권11호
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• pp.765-769
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• 2007

배경: 농흉의 근치적 치료 방법은 흉막박피술이 우선적으로 시도된다. 그러나 근치적 치료가 힘든 고 위험군 환자의 경우는 위험성이 높다. 과거에는 만성 농흉 치료의 최종 단계로서 개방식 배농술을 선택했으나, 일차적인 근치적 치료가 힘든 경우 개방식 배농술과 근육이식술(일시적 혹은 단계적)시행 후, 최종적으로 개방창 폐쇄술을 시도함으로써 비교적 안전하게 농흉의 치료를 꾀할 수 있다. 대상 및 방법: 1995년 1월 1일부터 2004년 12월 31일까지 농흉으로 개방식 배농술을 시행한 21명의 환자를 대상으로 원인 질환과 치료 경과 및 최종 결과를 후향적으로 조사 분석하였다. 결과: 평균연령은 $57.5{\pm}15.5$세($25{\sim}78$세)였으며, 남자 16명(76.2%), 여자 5명(23.8%)이었다. 폐기능 검사결과는 평균 FEV1이 $1.58{\pm}0.49 L$였다. 농흉의 원인으로는 결핵성 농흉이 13예(61.9%), 폐국균증이 3예(14.3%), 폐렴성 농흉이 3예(14.3%), 폐절제 후 농흉이 2예(10%)이었다. 이들 중 14예에서 기관지 흉막루가 있었고, 8예에서 흉막의 석회화가 동반되어 있었다. 기관지 흉막루가 존재한 환자들 중에서 4예는 첫 수술시 전거근으로 기관지 흉막루를 덮었다. 절제된 늑골의 개수는 평균 $4{\pm}1$개였다. 12예에서 개방창 폐쇄가 가능하였으며 개방식 배농술 후 개방창 폐쇄까지 평균적으로 걸린 기간은 $10.22{\pm}3.11$개월이었고, 최종 수술 전 남아 있는 흉막강 결손의 평균은 $330{\pm}110 cc$였다. 12예 중 자연적으로 개방창 폐쇄가 이루어진 경우가 2예, 술 중 접어 두었던 피부만으로 폐쇄 가능했던 경우가 2예, 근육피판치환술 시행이 7예(광배근 4예, 대흉근 3예), 연조직 이용이 1예였다. 합병증으로는 연조직만으로 개방창폐쇄를 꾀했던 1예에서 조직 괴사가 생겨 폐쇄에 실패하였고, 복직근을 사용한 환자에서 복부 탈장이 생긴 경우가 1예 있었으며, 수술 후 30일내 사망한 예가 1예였고 다른 1예는 전이성 암으로 사망하였다. 걸론: 근치적 방법으로 치료가 힘든 경우의 만성 농흉 환자들에게 있어 개방식 배농술과 근육이식술, 근육피판을 이용한 최종적인 개방창 폐쇄술까지의 단계적인 접근 방법이 안전하고 효과적인 대안이 될 수 있을 것으로 생각한다.