INTRODUKSI

MANUALTERAPI

Oleh:
Sugijanto
Disampaikan pada
Kuliah umum manual terapi

Definition of Manual Therapy

A comprehensive system of diagnosing
and treating neuromusculoskeletal
disorders involving specific skills,
including assessment, mobilization,
manipulation and education, in
conjunction with exercise, to restore
optimal motion, function and/or reduce
pain.
MTSC Vision 2001

Sugijanto,

Klien Normal
Specific tissue
impairment

Limitation in
activities

Pathology

Restriction in
participation

Functional
impairment
Keluhan gangguan
NMSVM

HOAC 2

Assessment
Diagnosis

Evidance

Analisis Strategi perencanaan

Prosedur intervensi

Evaluasi dan
penilaian hasil
Sugijanto,

Lingkup kerja: ICF

(International Classification of Functioning, Disability and

Health)

Sugijanto,

PATOLOGI FUNGSIONAL/NMSVM
PATHOLOGY (ICD)

TISSUE SPECIFIC
(Anatomical)
IMPAIRMENT

FUNCTIONAL
IMPAIRMENT

Sugijanto,

MENGANALISIS DARI ICD KE

ICF
Contoh:
Osteoartritis lutut
(ICD)
Jaringan apa yg
terganggu?
Permukaan sendi
mengelupas dan
inflamasi.
Kapsul sendi kontraktur
Otot atrofi dan lemah
Dll
Fungsi (biomekanik)
apa yg terganggu?
Nyeri
Mobilitas sendi
terbatas
Stabilitas sendi

Keterbatasan
aktivitas
Sholat,
bersimpuh
Berdiri dari
duduk
Berjalan dan
Berlari
Hambatan
Dll
berpartisipasi
(sosial)
Bekerja
Olahraga
Rekreasi Sugijanto,

MENGANALISIS DARI ICD KE

ICF
Contoh:
Frozen shoulder
(ICD)
Jaringan apa yg
terganggu?
Vaskularisasi kapiler
jaringan periartrikuler
menurun
Kapsul sendi kontraktur
Otot atrofi dan lemah
Dll
Fungsi (biomekanik)
apa yg terganggu?
Nyeri
Mobilitas sendi
terbatas
Stabilitas aktif

Keterbatasan
aktivitas
Kemampuan
aktivitas
keseharian
menurun
Meraih benda
keatas
Hambatan
Dll
berpartisipasi
(sosial)
Bekerja
Olahraga
Rekreasi Sugijanto,

ANATOMIC DAN FUNCTIONAL

IMPAIRMENT SEBAGAI PUSAT KAJIAN
Contoh:
Nyeri akibat
inflamasi tulang
permukaan
sendi
Hipomobilitas
akibat hambatan
kapsul
kontraktur

Jalan pincang akibat nyeri permukaan sendi

Tidak dapat jongkok akibat kontraktur sendi

Tidak dapat bekerja dalam konstruksi akibat kaku

sendi dan lemah otot

Tidak mampu olahraga akibat nyeri lutut dan

kelemahan otot
Sugijanto,

ANATOMIC IMPAIRMENT
PRIMER
Dalam

mencari faktor utama

patologi dilakukan assessment
untuk menegakkan impairment
pada anatomic (tissue spesifik)
dilanjutkan functional
(fisiologi/biomekanik)
Dilakukan mulai dari anamnesis
khusus hingga tes khusus
Digunakan sebagai tissue target
dan mekanic target dalam
Sugijanto,

PEMAHAMAN ANATOMI TERAPAN

ANATOMI

IN VIVO DAN IN VITRO

Pada keadaan hidup dan kadaver.

Integratif spine dan perifer.
DISCRIPTIVE: penamaan, faktor-faktor yg
berpengaruh.
TOPOGRAFIS
Lokal; regional; segmental; quadrant; total
Posisi jar. thd jaringan lain
Arah jaringan dan serabut

FUNGSIONAL
MEKANISME NMSV

Sugijanto,

HISTOLOGI

- FISIOLOGI JAR.

SPES.
Komponen dasar dan penunjang
Struktur cellular
Spesifikasi komponen
Fisiologi jaringan spesifik

GERAK

DAN FUNGSI

Gerak molecular - cellular - jaringan - organ sistem - individu - lingkungan

Fungsi sbg. Pemelihara sikap dan pembentuk
gerak
Fungsi lokal, segmental dan total

PEMAHAMAN ANATOMI TERAPAN

Analisis

Model sendi

Histologis
Fisiologi/kinesiologis
Aspek sindesmologi
Kesatuan kinesiologis
Neuroanatomi-fisiologi

Sendi

intervertebralis
mrpk three joint compl,
facet sepasang jenis
plan joint.
Sugijanto,

Aspek mekanis sendi

Kajian sendi aspek
Osteokinematic:
Diurai dlm jenis gerak pd bidang
gerak & sumbu gerak
Diukur dlm derajat gerak sendi
atau centi meter.
Analisis Grk spine per regio dlm 3
bidang tsb, gerak dominan sesuai
arah pemukaan sendi.

Sugijanto,

Arthrokinematic Roll-slide
Analisis

gerak dg memandang grk antar

pemukaan sendinya/intra capsular.
Roll-slide diurai dalam gerak:

Traction-Compression: tarikan-tekanan tegak lurus

permukaan sendi (concave) Penerapan pd spine :
Gapping-3 dimensi ekstensi. Th LPAVP
Translation: dorongan sejajar permukaan sendi
Penerapan pd spine: C0-C1 translasi;
Spin: putaran pada sumbu longitudinal.

Sugijanto,

POSISI SENDI
HUKUM

KONKAF-KONVEKS
Lihat teks
POSISI

FUNGSIONAL , LOOSE PACK

POSITION DAN CLOSE PACK POSITION
Lihat teks
CAPSULAR
Lihat

PATTERN

teks
Sugijanto,

Hukum

konkafkonveks

Sugijanto,

Sugijanto,

Loose Pack
Position

Sugijanto,

Closed Pack
Position

CELLS

Tissue spesific
Capsel-ligament
Tendo-muscular
Bone-chondrale
Nerves
Circulatory
DISCRIPTIVE HISTOLOGY - FUNCTION - TOPOGRAPHY
INTERACTION TO OTHER

TAGET TOWARD
TISSUE SPECIFIC

Sugijanto,

STRUKTUR JARINGAN SPESIFIK

OSTEOGEN
collagen, cell tulang
dan matrix dg
komponen pengisi
calcium GAGs

Struktur pasif
lentur thd
tekanan axial
torsi &
tangensial

Kekuatan oleh
calcium,
kelenturan
oleh collagen
& Air

spesifik
Tes kompresi dan
angulasi

Intervensi
stimulasi aksial.
Sugijanto,

Permukaan sendi
Sinovial
Permukaan

sendi arahkan grk Sendi:

Dlm bd sagital: Grk utama fleksi-ekstensi

Dlm bd frintal: Grk utama abduksi-adduksi
Dlm bd sagital: Grk utama fleksi-ekstensi
Arthrokinematika:

Traksi-translasispin sesuai hukum concave-covex

Pd

sistem kapsul tdpt meniscus/discus

Ligament

mrpk penebalan capsel atau

tersendiri

Compression/traction

test
Sugijanto,

CAPSULOLIGAMENTAIR
T.a. srbt collagen
sejajar bersilang,
elastin; cell fibroblast,
dan matrix komponen
utama GAGs, air

Ligament penebalan
tunica capsel /
berdiri sendiri.
Facet ada
meniscoide

Mrpk stabilisator
sendi pasif fs
arahkan gerak
sendi

spesifik

es pasif dan
Interrvensi
JPM
stimulasi rega
Sugijanto,

MUSCULOTENDINOGEN
Otot tonic (red) dan
phasic (white).
Myofibrile terbungkus
oleh jar ikat fascia

Komponen
contractile: myofrile,
komponen
penunjang/static:
jaringan ikat

Sbg. stabilisator
aktif dan penggerak
sendi

spesifik

Muscle mobilization.
sometrik dan palpasi
Sugijanto,

SERABUT NEUROGEN & CELL

Motoric: A, spinal cord &
cortex motoric; Sensoric: A,
A, A dan C; synapstic spinal;
cortex sensoric; Vegetatif:
sympathic dan para sympathic

Serabut perifer sbg

Radix-plexusnerve
trunk & peripher,
melewati jar. lain
Radix: dermatom;
Peripher: nervinal;
Vegetative ber
asosiasi

spesifik

Stimulasi
saraf,
etrik dan area dermatome
Sugijanto,
neural mobilization

PAIN FROM PERIPHERAL

NERVE
Anoxia

Paresthesia
intermittent

Inflamation

Neuropathic
pain

Entrapment
Fibrosis
NERVE

Inflamation

Systemic

Paresthesia
menetap
Neuropathic
pain
Paresthesia
menetap
Sugijanto,

INTERVERTEBRAL FORAMENT
Dibatasi Corpus, Diskus, Arcus, Proc
atrikularis, dan Facet.
Isi lemak, arteria-vena, saraf afferentefferent-vegetative.
Radix terbungkus sarung dura yg sensitif
Gang Segmental: dermatome dan Myotome.
Inflamasi krn iritasi osteofit/disc bulging
/listesis /fraktur

Sugijanto,

SPINAL CANAL
Isi

spinal cord (diatas L1/2),

cauda equina yg dibungkus

duramater yg sensitif, Vascular
dan jaringan penyangga.
Penyempitan

oleh dislocation,

osteophyte, posterior disc

bulging, spondylolisthesis,
fibrous, masa tumor, dll

Sugijanto,

SARAF
-Somatik segmental
Motorik, sensorik, vegetatif
Sinuvertebral nerve kaya
A/C aff mensarafi
duramater; dural slevee
dan lig.longit posterior.
Saraf vegetatif asal Th 9
L1

Sugijanto,

SERABUT NEUROGEN & CELL

Motoric: A synaps spinal
cord & cortex motoric;
Sensoric: A, A, A dan C;
synapstic spinal; cortex
sensoric; Vegetatif:
sympathic dan para
sympathic

Serabut perifer sbg

Radix-plexusnerve
trunk & peripher,
melewati jar. lain
Radix: dermatom;
Peripher: nervinal;
Vegetative ber
asosiasi

spesifik

metrik dan area dermatome

Membebaskan iritan
Sugijanto,
ervina; neurodynamic
testmobilization
neural

DISC

Nucleus pulposus dibungkus annulus

Nutrisi utama dr protein corpus, lapisan terluar annulus dr capilair

Fungsi Nucleus dan annulus:

Memungkinkan gerak luas 6 pasang

Sbg shock absorber
Merubah tekanan aksial ke tangensial
diterima annulus stabilitas sendiri

Beban meningkat bila fleksi, rotasi, terberat: duduk bungkuk, teringan: Psoas
position

Nyeri karena iritasi jaringan sekitarnya.

Sugijanto,

DERMATOGEN/INTEGUMEN
Ta: epidermis, dermis dan
subcutan.
Komponen jar ikat
penyangga, lemak sbg
isolator, saraf sensoris, serta
pembuluh darah/lymphe

Sbg isolator,
protector, penyangga
dan organ sensor

Kelenturan oleh sub

cutan collagen & air

spesifik

orik dan Skin

area mobilization
dermatome & Lymph d
na; Palpasi kelenturan
Sugijanto,

PATHOLOGY
TISSUE PATHOLOGY

Spesific pathology

Inflamation.
Immobilization.

Degenerative.

Complication

Mechanical compression.
Imunoreaction

SPESIFIC TISSUE IMPAIRMENT

Sugijanto,

PATHOLOGY
INFLAMASI

Tissue respons thd injury

Jar ikat, Jar otot, Tulang, Jar

mitochondria

Regenerasi

Collagen wound healing

s:
a
a lit r
d
o
n ua
a
T k t um r
t
a
lo
o
a
d lor
s
r
e
co bo iol
ru ngs
fu

Aktualitas patologi

Tanda2: Tumor, dolor, calor, rubor,

dan fungsiolesa.
Penting dlm penentuan metoda dan
dosis intervensi

Pd spine referred pain luas dan

jauh
Sugijanto,

WOUND HEALING PROCESS

Injury
Algogene.Fibrin
menutup luka
Inflamasi primer.
Inflamasi neurogenik
Gejala radang

Proliferasi
<3-4 hr;Cell
pertahanan &
fibroblast

Tissue damage &

haemorrhage

Inflamation

Produksi
<3 mgg;
produksi
collagen
maksimal

20 - 30
menit

24 - 36 jam

Remodeling
<3 bl; resorbsi
collagen,
penyesuaian
bentuk semula
Sugijanto,

NYERI BERASAL DARI

JARINGAN SPESIFIK
Wound healing process
Inflammation
Nosisensoric sensitization

SPECIFIC
TISSUE

Hypoxia

necrosis

Ischemic
Inflammation

necrosis

Contracture

Fatique
Sugijanto,

Reaksi
INFLAMASI
Iritasi

Kerusakan jar

Pg, Bk, H

nocisensor

zat tachikinine

vasodilatasi

stimulus gln spinale

inflamasi
lokal

P substance

Trans ke p h c.Spinothal tract

thalamus
Lymbics

Kesadaran nyeri

devergensi

transport keperifer

inflamasi
lokal
Sugijanto,

CIDERA - INFLAMASI JAR OTOT-TENDON

Strain, rupture,
avulsion

Myositis, tendinitis, myotendinosis, myofascial

syndrome

Spasm/guarding spasm, taut

band/twisting

Isometrik, palpasi &

CRS

spesifik

Percepat healing proses,

stretching, strengthening
Sugijanto,

NYERI DARI OTOT

Weakness
Strain/
rupture

Inflammation

Immobilsation

Adhesion

?!

Nyeri diam
Muscle
spasm

MUSCLE

Atrophy

Nyeri
kontraksi

Tightness/
Contracture

Nyeri regang

Myofascial
contracture

Nyeri regang

Sugijanto,

CIDERA-INFLAMASI PD
JAR. SARAF
Neuritis: Neropraxia,
axonotmesis, Neurotmesis
neurofibrosis

Triad symptom pd
lesi saraf perifer

Nyeri pd distribusi
saraf, paraesthesia,
hypoaesthesia

Reflex. MMT, Sensoric test,

Neurodynamic test

spesifik

Percepat healing,
mobilisasi saraf
Sugijanto,

CIDERA-INFLAMASI JAR CAPSULE-LIGAMENT

Injury, arthritis, iritasi
osteophyte, RA

Sprain, capsulitis/ arthritis,

-arthrosis

Compression pain,
Pseudoradicular pain

capsular pattern
hypomobility

spesifik

Joint mobilization
JPM test
Sugijanto,

NYERI DARI CAPSEL

Instability
Sprain/
rupture

Inflamation

Nyeri diam
Contracture

Capsel

Immuno
reaction

Immobilzation

Nyeri ssd
aktifitas

Effusion

Acidosis

Adhesion

Inter
collagen
space

Nyeri regang

Nyeri &
hydrops

Nyeri
regang
Sugijanto,

INFLAMASI JAR CAPSULE FACET

Injury,

arthritis, iritasi osteophyte,

RA.
Sprain, capsulitis/arthritis,
spondyloarthrosis
Compression pain,
Pseudoradicular pain.
Diikuti capsular pattern
hypomobility.
Nyeri gerak segmental, joint play
movement positif

Sugijanto,

NYERI DARI PERMUKAAN SENDI

Kompresi prmk
tulang

JOINT
SURFACE

Penglupasn
rawan sendi

Inflamasi tlg
subchondrale

Tumbuh
osteophyte

Lepasan
fragmentasi

Nyeri kompresi
sendi

Penguncian grk
sendi

Nyeri bl gerak

Nyeri bl gerak
ROM tertentu

Sugijanto,

NYERI DARI SARAF PERIFER

Anoxia

Paresthesia
intermittent

Inflamation

Neuropathic
pain

Entrapment
Fibrosis

NERVE

Inflamation

Systemic

Paresthesia
menetap
Neuropathic
pain
Paresthesia
menetap

Sugijanto,

INFLAMASI JAR
INTERNAL / PELVIC
Referred

pain segment
somatovegetative
Gejala dermatom
overlapping
Tes alat gerak negatif
Pemeriksaan data
medik lain

Sugijanto,

Pain from
Ischemia
Pembuntuan
capiler

Penjepitan
capiler
Ischemic

Spasm
Hipoksia
Hipo gizi
Free Radicals

Nyeri
NECROSIS

KEMATIAN SEL

Sugijanto,

TIGHTNESS-CONTRACTURE
Tissue
inflammation

Tissue
immobilization

Fiber cross-links
Tight
Stretch force

Contracted
Compression C aff
Tissue damage

STRECHT PAIN

Sugijanto,

INAKTIFITAS & IMMOBILISASI

Immobilisasi
circulatory statis dan
abnormal cross links

Penurunan air matrix &

elastin kelenturan
menurun dan rapuh

Muscle tightness & Contracture Muscle

weakness & Atrophy otot spasm
/sindroma myofascial

Capsule & Ligament contracture

capsular pattern
Gangguan
Neurogenik

Skin atrophy

Circulatory
disturbance

Bone
osteoporosis
Sugijanto,

INAKTIFITAS & IMMOBILISASI

Capsule

& Ligament contracture

Collagen waving + cross links

Seluruh capsule sendi capsular pattern.
Sebagian capsule sendi non capsular
pattern.
Pd aging jumlah air dlm matrix dan
srbt elastin menurun kelenturan
menurun dan rapuh.
Sinovium meningkat nutrisi kurang
Sugijanto,
Sugijanto,
2012

INAKTIFITAS & IMMOBILISASI

Muscle

tightness & Contracture

Otot spine umumnya jenis tonic, ( guarding spasm &

kontrantur)
Jumlah sarcomer menurun pd posisi memendek.
Dipilah spasm/tightness (myofibrile) dg contracted
(connective tissue)
Muscle

weakness & Atrophy

Otot phasic
Kelemahan & pengecilan.
Kelemahan

juga terjadi pd tonic ms bila kronik

spine: deviasi postural dan stabilitas.
Sugijanto,

INAKTIFITAS & IMMOBILISASI

Bone

osteoporosis

Lebih karena menurunnya circulatory, jml

fibroblast & osteoblast rendah
Aktifitas osteoclast > osteoblast
Karena beban tulang menurun
Pd aging (senile osteoporositc) atau
immobilization porotic.
Pada spine: compression fracture
kyphosis/gibbus.
Ditanggulangi dengan aktifitas pembebanan
tulang pd posisi tubuh normal
Sugijanto,

INAKTIFITAS & IMMOBILISASI

Circulatory

disturbance

Aktifitas turun COP turun, tensi turun, nadi

meningkat.
Stasis dpt timbul deep vein thrombosis/
thrombophlebitis hati2 imboli
Reflex vasoconsrtiction turun orthostatic
hypotension
Hiperaktifitas simphatic: ketegangan abnormal
kulit punggung
Suhu tubuh menurun
Sugijanto,

INAKTIFITAS & IMMOBILISASI

Gangguan

Neurogenik

Penurunan aktifitas neurotransmiter Synaps:

sleeping neuron
Ambang rangsang motoneuron turun reflex
turun, muscle contraction lamban-perlu kalori
besar.
Ambang rangsang A , A, A menurun reflex
turun, keseimbangan turun
Sifat otot lebih tonic

Nocisensoric Micro
circulatory: vegetative reflex.

Vegetative

Sugijanto,

INAKTIFITAS & IMMOBILISASI

Skin

atrophy

Akibat circulasi kulit turun, reflex dilatasi

turun kulit kering, keriput, pucat, dingin.
Gangguan micro circulation: ketegangan sub
cutan connective tissue,
Sensasi turun hati2 decubitus.
Gangguan

respiratory, ginjal,
gastrointestinal, psicologis, dll.

Sugijanto,

FUNCTIONAL IMPAIRMENT
Pain

Pain in rest
Pain in movement
Referred pain etc
Joint

mobility:

Ankylosing
Hypomobility
Joint blockade
Joint

stability:

Hypermobility
Instability
Muscle

performance:

Muscle weakness
Muscle paresis

Balance

Sitting disbalance
Standing disbalance
Walking disbalance,
etc
Gait:

Antalgic gait
Duchene gait
Trendelen burg gait,
etc
Hand

function:

Grip weakness
Prehension disability,
etc
Sugijanto,

JOINT MOTIONS
IMPAIRMENT

Capsular
pattern

Contracture
Non capsular
pattern

Capsular
Ossification

Hypomobility

Inert structure

Blockade

Loose body
Blockade
Tightness

Tendomuscular
Contracted
Sugijanto,

JOINT MOTIONS
Laxity

Joint
hypermobility

LigamenterCapsular
Rupture
Hypermobility &
instability

Bony- structure

Instability

Deformity

Weakness
Active
hypermobility

Tendomuscular
Rupture

Sugijanto,

ANALISIS POSITION AND POSTURE

(sikap)
Gabungan posisi sendi2
posture tubuh
Posisi tubuh lokal total
Dibentuk oleh aktifitas
sensomotorik
Posisi normal aktifitas motorik
minimal

Posisi-sikap-gerak

sensomotorik
Sikap dipengaruhi: intelegensi, spikologis, sosial, budaya,
gender,
Gangguan sikap sangat berpengaruh pd struktur jar spine
Sugijanto,

MOVEMENT
Merupakan

integrasi sensoric - motoric

vegetative menjadi gerak automatic
Gerak mendasar: gerak fungsional
Gerak lokal aktifitas otot simultan
Gerak stabilitas posisi trunk - sendi proksimal
Gerak: Strength, Endurance, Speed, accuracy
Metabolism ergotrophic

Sugijanto,

ANALISIS GERAK
Analisis gerak regional dan total
Gerak segmental terjadi pd movement

segment (segment of Junghann)

Gerak segmental melibatkan three joint
complex: discus dan sepasang facet.
Untuk cervical spine diarahkan uncinate
joint, thoracal spine dibatasi sendi
costovetebral-transversal.
Gerak spine selalu simultan bbrp segment
gerak.
Arthrokinematic spine tidak sama dgn
sendi perifer.
Sugijanto,

Temu 2 Assessment and

intervension

Oleh: Sugijanto

Sugijanto,

Temu 2 Assessment and intervension

PROSES FISIO-MANUALTERAPI
ASESSMENT
DIAGNOSE
PLANNING
INTERVENTION
REEVALUATION
COORDINATION, COMMUNICATION, DOCUMENTATION
STANDAR PRAKTEK FISIOTERAPI
Sugijanto,

METODE H O A C
(Hypothesis Oriented Algorythm for
Clinician
Dalam

melakukan assessment
dibuat hipotesis terlebih dulu
Tiap tahap assessment dilakukan
dengan dua pilihan
Penggunaan evidence base
dalam melakukan tes yang sesuai

Sugijanto,

Sugijanto,

Screening
questionair

Sugijanto,

Red flag for

thoracic
spine

Sugijanto,

Sugijanto,

Red
flag

Sugijanto,

L B P MEDICAL SCREENING QUESTIONAIR

No
1

Have you recently had a major trauma, such as a vehicle accident or a fall from a
height?

Have you ever had a medical practitioner tell you that you have osteoporosis?

Do you have a history of cancer?

Does your pain ease when you rest in a comfortable position?

Have you recently had a fever?

Have you recently lost weight even though you have not been attempting to eat less
or exercise more?

Have you recently taken antibiotics or other medicines for an infection?

Are you currently taking steroids or have you been on prolonged steroid therapy?

Have you been diagnosed with an immunosuppressive disorder?

10

Have you noticed a recent onset of difficulty with retaining your urine?

11

Have you noticed a recent need to urinate more frequently?

12

Have you noticed a recent onset of numbness in the area of your bottom where you
would sit on a bicycle seat?
Sugijanto,
Have you recently noticed your legs becoming weak while walking or climbing

13

PROSES ASSESSMENT
MANUALTERAPI
R/sementara
INSPECTION R/sementara
QUICK TEST R/sementara
PEMERIKSAAN FUNGSI GERAK DASAR
ANAMNESIS

Active R/sementara
Passive R/sementara
Isometric R/sementara

KHUSUS R/sementara
DATA medik/ profesi kesehatan lain
R/sementara
R/ akhir sbg diagnosis manualterapi
PEMERIKSAAN

Sugijanto,

ANAMNESIS
Pain & sensation: jenis,lokasi-distribusi, provokasi-peringanan

Joint mobility: hipo/hiper-mobil, unstable, blockade,

Muscle power: Lemah, penurunan krn nyeri

Hand function: Power grip, prehension,
coordination, dll
Gait: balance, nyeri, coordination dll
Dll
Sugijanto,

INSPEKSI
Dymanic
Static

Total
Quadrant
Segmental
Local

Perhatikan:

Posisi,
Bentuk,
Warna kulit/luka
Konsistensi
Sugijanto,

TES ORIENTASI
TEMPORO

MANDIBULAR JOINT: depression

& elevation
CERVICAL SPINE: Flexion-extension & 3
dimention extension
LUMBAR SPINE: Flexion-extension in
standing
Shoulder complex: Abduksi-elevasi
Elbow joint: Fleksi-supinasi dan ekstensipronasi.
Wris and hand: fleksi dan ekstensi total.
Hip joint: Gait analysis, Squat and
bouncing, rotasi internal.
Knee joint: Gait analysis, Squat and
bouncing, fleksi ekstensi.
Ankle and foot Gait analysis, Squat and
bouncing, hell off - toes off - inversi-eversi
Sugijanto,

GAIT ANALYSIS
Cycles
Rhythm
Bearing
Wide
Stride

Sugijanto,

HAND FUNCTION
Power

grip
Prehension grip

Sugijanto,

ACTIVITY OF DAILY LIVING

Feeding
Dressing
Personal

hygiene

Toileting
Ambulation

Sugijanto,

PEMERIKSAAN FUNGSI GERAK

DASAR
PEM.

GERAK AKTIF
Dalam bidang sagital, frontal
dan transversal
Gerak fungsional

Perhatikan:
Mobilitas, kekuatan,
koordinasi, sirkulasi dan
persiapan gerak
Sugijanto,

PEMERIKSAAN FUNGSI GERAK

DASAR
PEM.

GERAK PASIF
Ditujukan pada Sendi
dan jar. Lunak
Diperhatikan:
Pain
ROM
End feel
Sound

Sugijanto,

PEMERIKSAAN FUNGSI GERAK

DASAR
PEM. GERAK ISOMETRIK
Pd spine: posisi regang
Untuk tendomuscular
problems
Hindari provokasi jaringan
lain
Perhatikan:

Pain & Strength

Sugijanto,

VITAL SIGN
BLOOD

PRESSURE
HEART RATE
RESPIRATORY

Sugijanto,

TES KHUSUS
PALPASI
Menetapkan:

lokasi,
posisi,
bentuk,
tender point,
konsistensi

Sugijanto,

Specific
testManeouvre
Low
Back
I
POSISI TERLENTANG
Hip

flexion knee flex (SIJ) +

adduction & internal rotation

(Hip/ Piriformis)
Hip

flexion external rotation

Patrics test/kontra patrics (Hip

joint)

Knee extension Kernig

(Hamtrings/Ischiadicus)

Sugijanto,

Tes khusus

Low Back Maneouvre II

SLR / Lasegue dan Contra Lasegue (Nerve
root, Ischiadicus)
Bragard (nerve root-n.
ischiadicus)
Neri/Brudzinsky (Dural)
berurutan

Sugijanto,

Specific
test
Low Back
Maneouvre

III
POSISI TENGKURAP
Hip

extension knee extension

fiksasi pada tuber ischiadicum

(Hip Joint)
Hip

extension knee extension

fiksasi pada sacrum (+Sacroiliac

joint)
Hip

extension knee extension

fiksasi pada Lower thoracal

(Lumbar spain)

Sugijanto,

TES KHUSUS
JOINT

PLAY MOVEMENT:

Untuk identifikasi problem

capsuloligamentair
Segmental test, traction-compression,
gapping test,
Pain, limited / over mobility, end feel

Sugijanto,

TES KHUSUS
COMPRESSION

&
TRACTION TEST
Pain, radicular /
pseudoradicular
Kompresi pss fleksi: discuscorpus, esktensi: facet
bilateral, lateral fleksi: facet
unilateral/uncinatus.
Traksi dilakukan sebaliknya.

Sugijanto,

TES KHUSUS
PROVOCATION TEST
Lokasi patologi Segmental, specific
tissue
Nyeri, referred pain, range, end feel

Sugijanto,

TES KHUSUS
MUSCLES

TONE &
LENGTH TEST
Utk tes otot tonic spasm,
tightness/kontracture.
Posisi tertentu
Myofibrile
Connective tissue
Sugijanto,

Neurodynamic test
Normal

srbt saraf
memiliki elatisitas dan
gerak luncur thd jar
sekitar.
Tes terhadap patologi
serabut saraf.
Tension and stretch
test
Upper limb atau lower
Sugijanto,

TES KHUSUS
SENSORIC

TEST

Jenis sensasi
Area dermatome /
nervinal

Sugijanto,

TES KHUSUS
REFLEX

TEST

Saraf terkait
Myotome

Sugijanto,

TES KHUSUS
TES

KHUSUS LAIN:

Joint Stability
Balance
Low back manouvre I dan II
Valsava manouvre
Tes vertebrobasiler insuficiency
Tes TOS
Dll

Sugijanto,

DIAGNOSIS MANUALTERAPI
STRUKTUR

JARINGAN SPESIFIK DAN

FUNGSI:
Discriptive , Topography, dan Hystologi
Fungsi spesifik
PATOLOGI
IDC
PROBLEMA NEURO-MUSCULO-SCELETALVEGETATIVE-MECHANISM
Tissue & Functional impairment (Pain
Sensoric, Posture, mobility, stability, dan
Vegetative reflex)
Activities limitation
Restriction of participation
Sugijanto,

PROGNOSIS & DIF DIAGNOSIS

Prognosis

sesuai diagnosis
meliputi: perkiraan
perjalanan sakit, hasil akhir,
perkiraan waktu.
Diferential Diagnosis:
Kemungkinan
penyimpangan diagnosis
terdekat.
Perlu uji diagnosis: misal
uji intervensi.
Sugijanto,

PLANNING AND PROGRAMMING

Goal & Aims of
intervension
Komunikasi dan persetujuan thd
klien
Program sesuai urutan
prioritas
Pemilihan metoda dan teknik
intervensi
Penetapan instrument pengukuran
evaluasi
Hubungan manualterapis klien: dinamic
interaction. Reevaluasi

Sugijanto,

Exercise & Movement Re-Education for

Patients with Lumbar Spine Impairments
Body Function
Label

Critical
Impairmen

Other
Supportive
Criteria

Interventions

Lumbar Spine
Mobility Deficits
Other terms:
Facet
Syndrome
Mobilization
Exercises

End-range
pain
ROM
limitations

Acute low
back pain
Minimal/no
previous
history of LBP

End-range stretching to
maintain segmental ROM
gained from manipulative
procedures.
Ergonomic instruction, trunk
& pelvic girdle strengthening
& stretching, as indicated, to
prevent future disabili

Lumbar Spine
Stability Deficits
Other terms:
Ligamentous
Instability
Stabilization
Exercises

Symptoms
reproduced
with sustained
end range
positions
Symptoms
eased with
neutral
positions and
midrange
movements

Long history of
progressively
worsening
symptoms
(i.e., less
tolerance to
end range
positions
such as
sitting)

Isometric mobilizations to
normalize pelvic girdle
symmetry.
Ergonomic cuing to maintain
mid-range lumbar and pelvic
girdle positions.
Proprioceptive training and
trunk/pelvic girdle
strengthening to improve
ability to stay in mid-range
positions.
Taping or bracing
as
Sugijanto,
indicated.

Body Function
Label

Critical
Impairmen

Other
Supportive
Criteria

Interventions

Lumbar Spine
and Related
Lower Limb Pain
Other terms:
Disc
Derangement
Extension
Exercise, or
Specific Exercise
Group

Location of
symptoms
move centrally
with repeated
lumbar
extension or
with repeated
lateral trunk
shifts

Difficulty with
sitting and forward
bending
Multiple previous
episodes of LBP
(progression of
Ligamentous
Instability)
Observable
reduced lumbar
lordosis may
have lateral trunk
shift

Manual procedures,
postures, or exercises
that centralize the
symptoms.
Ergonomic cuing to
maintain lumbar
lordosis prevent
peripheralization.
Progress to treatment
of underlying
segmental instability

Lumbar Spine
and Related
Lower Extremity
Radicular Pain
Nerve Root
Adhesion or
Dural
Adhesion
Nerve Mobility
Exercises

Narrow band of
lancinating
pain
Symptoms
reproduced
with SLR
and/or slump
testing

Nerve mobility
deficits with
lower limb
tension testing

Dural and nerve

mobility exercises as
indicated to address
the patients key
impairments
Soft tissue and/or joint
mobilization to areas of
potential spinal and
peripheral nerve
Sugijanto,
entrapments

ANALISIS PROGRAM
Penyebab lain

Penyebab I

Diagnosis & prognosis

Strutur jar 1 dan

patologinya

Patologi
gerakfungsi

Strutur jar 2 dan

patologinya

Patologi
gerakfungsi

Modalitas dan
metode interfensi
lain

Patologi
gerakfungsi

Strutur jar 3 dst dan

patologinya

Patologi
gerakfungsi

Dll

Modalitas dan metode

interfensi lain Sugijanto,

Contoh kasus 1

Capsuloligamentair

Kontraktur immobilisasi

Inflamasi lokal

Aktualitas rendah

ROM terbatas, firm, JPM

nyeri/terbatas/ firm

SWD Sub thermal, lat.

Mobilisasi- stabilisasi
aktif,latih fungsional

Aktualitas tinggi

ROM terbatas,
springy, JPM
nyeri/terbatas/
springy

PRICE, SWD non

thermal, isometric exc,
functional train.

ROM terbatas,
firm, JPM
nyeri/terbatas/
firm

SWD thermal,
joint mobilisat
traksi-translas,
manipulation

ROM
terbatas,
springy, JPM
nyeri/
terbatas/
springy

SWD sub
thermal, joint
mobilisat traksitransl,
Sugijanto,

Contoh kasus 2

Tendomuskular

Inflamasi lokal
Aktualitas rendah

Aktualitas tinggi

Isometrik nyeri, CRS

nyeri

ROM terbatas,
springy, CRS nyeri

SWD Sub thermal, lat.

Mobilisasi- stabilisasi
aktif,latih fungsional

PRICE, SWD non

thermal, isometric exc,

Tegang
CRS
penambahan
panjang besar

SWD subthermal,
relaxing massage
relaxation exc.

Kontraktur
CRS
penambahan
panjang kecil

US, muscle
mobilization, CRS

Sugijanto,

ANALISIS PROGRAM
Penyebab I

Penyebab lain

Diagnosis & prognosis

Strutur jar 1 dan

patologinya

Patologi
NMSVM

Strutur jar 2 dan

patologinya

Patologi
NMSVM

Metode & teknik I

Patologi
NMSVM

Strutur jar 3 dst dan

patologinya

Patologi
NMSVM

Dll

Metode & teknik I dst

Sugijanto,

Analisis uji penanganan

Manualterapi
Dianalisis Mulai dari data klien - tahapan assessment - diagnosis seleksi metoda & teknik - eveluasi
Lihat tabel:

Sugijanto,

INTERVENSI MANUAL
TERAPI

Sugijanto,

INTERVENSION
MUSCLE

MOBILIZATION

Indikasi: spasm, tightness,

contracted, tendo-/myosis,
lymph&/venous edeme, muscle
adhesion, etc
Direct manual stretch
Contract relax & stretching
Massage technique (transverse
friction etc)
Otot spine terutama tonic
Sugijanto,

INTERVENSION
MANUAL

MUSCLE STRETCHING

Muscle mobilization utk melepas

collagen adhesion
Transverse stretching manipulation

MUSCLE

LENGTHENING/STRETCHING

Untuk tonic muscle

Gabungan relaxation-stretching
Lengthening position Agonist
isometric Contract Relaxation
Agonist Stretching
Sugijanto,

INTERVENSION
JOINT

MOBILIZATION

Indikasi capsuloligamentair
contracture peregangan

Traction (gapping)-regional/
segmental mobilization dan
manipulasi.
Mulai pd MLPP (tanpa nyeri)
Gerakan pd pembatasan tiap ROM
dgn intensitas III/IV/IV+.
Teknik gerakan:
Oscillation/Stacato/Static
Diakhiri active stabilization
Sugijanto,

INTERVENSION
JOINT

MOBILIZATION
Meningkatkan mobilitas dan kemampuan
gerak
Intensitas:

Grade I; II; III; IV dan IV force.

I

Restrict
II

III

Normal ROM

IV
mani
p

Sugijanto,

JOINT MANIPULATION
Indikasi

minimal hypomobile dan

joint functional blockade
Grade IV or force grade IV
Strecht Slack
static/staccato/osilasi -- Pulse
Sering digunakan pada spine
(gapping manipulation)
Tdk harus bunyi klik
Sugijanto,

INTERVENSION
TRANSVERSE FRICTION
Friction melintang
serabut jaringan lunak,
jari tegak lurus
Pada ligament dan
otot/tendon
Counter irritation
Improve Blood circulation
To break adhesion
Sugijanto,

INTERVENSION
VENOUS & LYMPH DRAINAGE
Massage:
Effleurage, Strocking etc
ke jantung / lymphatic nodes

Elevation;

Untuk extremity

Bandaging

Elastic material

Pumping

exercise

Exercise under pressure

Sugijanto,

INTERVENSION: NEURAL
MOBILIZATION
Tentukan

faktor penyebab patologi

yang dominan
Tetapkan tempat jaringan scr tepat.
Klasifikasi penyebab dan lokasi:
Central sensitization (hasil dgn
manualterapi kurang baik
cognitive treatment)
Denervation dgn defisit neurologis
(medikamentosa)
Peripheral sensitization
Musculosceletal pain convergence
Sugijanto,

INTERVENSION Joint
stabilization

Passive stabilization

Tapping, Corset, Orthosis

Pseudo active stabilization

Postural corection
Stabilization exc.

Sugijanto,

MECHANICAL TRACTION
UNTUK MOBILISASI DISCUS
Posisi

Cervical lordosis /
Lumbar lordosis.
Sudut tarikan lurus /
ekstensi
Beban tarikan 30% utk
cervical atau 60% utk
lumbale.
Traksi osilasi atau
intermittent.
Sugijanto,

MECHANICAL TRACTION UNTUK

MOBILISASI SENDI FACET
Posisi

Cervical/Lumbar

fleksi.
Sudut tarikan lurus/fleksi
Beban tarikan 30% utk
cervical atau 60% utk
lumbale.
Traksi statik atau durasi
tarikan panjang.

Sugijanto,

PROPER BODY MECHANIC

Posisi

tidur

Gunakan alas tidur tidak keras, tidak terlalu lunak dan

tidak melengkung.
Disc problems tidur pinggang tetap lordosis.
Bangun tidur: Pss telungkup lakukan ekstensi punggung dng
cara push up

Facet problems tidur pinggang tetap datar.

Bangun tidur: pss terlentang, lakukan gerak memeluk lutut.

Memutar

tubuh saat tidur

Upayakan gerak tubuh atas dan bawah bergerak

bersama.
Bangun

dari tidur ke duduk:

Posisi miring sangga tubuh dengan lengan kemudian

duduk

Sugijanto,

PROPER BODY MECHANIC

Posisi

duduk
Pinggang bawah tetap lordosis.
Ganjal pada pinggang dipasang.
Positioning an office chair for back
support
Digunakan tempat duduk dengan
back support. Misal kursi untuk
computer:
Kursi dgn elbow supports untuk
menghindari strain pd leher.
Lutut menekuk dgn sudut siku, dan
gunakan penyangga ujung kaki.
Mata dpt menatap layar dgn posisi leher
lurus.
Sugijanto,

REEVALUATION
Untuk

menilai Output
Dibuat secara serial
Membuat penyesuaian/ perubahan
program
Pertahap seluruh proses
Diukur secara subjective & objective;
Kualitatif & Kuntitatif

Sugijanto,

PENCATATAN
Identitas klien
Seluruh proses assessment dan
diagnosis
Program terstruktur & terukur
Pelaksanaan prosedur intervensi
beserta metoda dan teknik
Reevaluasi bertahap
Reprograming pertahap
Discharge

Sugijanto,

THANKS TO YOUR ATTENTION

Sampai

berjumpa pada
pertemuan lanjut
Sugijanto,