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INTRODUKSI MANUAL

TERAPI
Oleh: Sugijanto
Disampaikan pada Kuliah Manual terapi
Prodi Fisioterapi Universitas Muhammadiyah
Surakarta, 18 Oktober 2019

Sugijanto, 2019
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, 2019
KAJIAN KEILMUAN KLINIS MANUAL
TERAPI
 Merujuk ICD:
 Mampu menjelaskan dan menganalisis ilmu dasar
patologi terhadap kasus terbanyak ditangani
fisioterapi
 Merujuk ICF:
 Menganalisis anatomi terapan dan gangguan
(impairment) terkait patologi
 Menganalisis fisiologi dan biomekanik terapan dan
gangguan terkait patologi
 Menganalisis aktivitas individual dan ketrbatasannya
serta partisipasi sosial dan hambatannya

Sugijanto, 2019
CLINICAL REASONING APPROACH

Merupakan proses berfikir logis dan kritis


utk memaknai temuan klinis (Higgs J
and Jones M, 1995)
Metode: hipotetico-deduktif, algoritma,
pattern recognition dan gejala-tanda
patognomonis.

Sugijanto, 2019
CLINICAL REASONING
 Clinical reasoning adalah proses cognitive atau proses berfikir
yang digunakan dalam evaluasi dan pengelolaan pasien
(Mark A Jone, 1992).
 Clinical reasoning adalah proses berfikir dan membuat
keputusan klinis yang digunakan dalam praktek klinik.
 Menurut Higgs and Jones (1990), Clinical reasoning adalah
proses dalam interaksi antara terapis dan pasien dan yang
lain terkait (mis family atau penyelenggara pelayanan yg
lain), membantu pasien memahami arti, goals, dan health
management strategies based on clinical data, patient
choices, and professional judgment and knowledge

Sugijanto, 2019
CLINICAL REASONING

diperbarui

John, 1995 Sugijanto, 2019


Andersen, Linde &
Broberg, 2014 Sugijanto, 2019
CLINICAL REASONING

 Clinical reasoning
 Clinical prediction rule
 Clinical decision
making
JANGAN BERFIKIR
TERBALIK

IMPAIRMENT/
ALAT/TEKNIK INI PATHOLOGY INI PERLU
INDIKASINYA APA? TEKNIK TES-INTERVENSI
APA?

Salah Benar
Sugijanto, 2019
Spondylo arthrosis cervicalis
Functioning, disability and health Constextual factors

Anatomic impairment Internal External


Facet & factors factors
Disc Capsels Muscle Nerves
Uncinate

Pipih & Chronic Autonom


Erosi Nocisensoric
rapuh inflamation system

Sub chondral Weak- Sympathic


Instability
inflamation atrophy hyperactivity
Inter fiber
adhesion Spasm- Vascular
tightness Functional Activity Participation
contracture impairment limitation restriction
Micro circular
Extension
Capsel constriction
pain
contracture Work
Reading
Muscle
Stretched imbalance Sport
Capsular pain
pattern
Driving Recreation

Postural
Hypomobility Neck pain deformity
Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, Contoh:
Spondyloartritis Cervical (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan aktivitas Hambatan
terganggu? apa yg terganggu? berpartisipasi (sosial)

Permukaan sendi
mengelupas dan
inflamasi.
Kapsul sendi kontraktur
Otot atrofi dan lemah
Osteofit tepi corpus
dan/facet

Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, Contoh:
Spondyloartritis Cervical (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan aktivitas Hambatan
terganggu? apa yg terganggu? berpartisipasi (sosial)

Permukaan sendi Nyeri gerak cervical


mengelupas dan ekstensi
inflamasi.
Kapsul sendi kontraktur Mobilitas sendi
terbatas
Otot atrofi dan lemah Stabilitas sendi
menurun
Osteofit tepi corpus Flat neck/ kyphosis
dan/facet

Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, Contoh:
Spondyloartritis Cervical (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan aktivitas Hambatan
terganggu? apa yg terganggu? berpartisipasi (sosial)

Permukaan sendi Nyeri gerak cervical Duduk waktu lama,


mengelupas dan ekstensi mendongak
inflamasi.
Kapsul sendi kontraktur Mobilitas sendi Nyeri mengemudi,
terbatas parker, menjinjing
barang dll
Otot atrofi dan lemah Stabilitas sendi
menurun
Osteofit tepi corpus Flat neck/ kyphosis Penampilan kaku,
dan/facet

Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, Contoh:
Spondyloartritis Cervical (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan aktivitas Hambatan
terganggu? apa yg terganggu? berpartisipasi (sosial)

Permukaan sendi Nyeri gerak cervical Duduk waktu lama, Bekerja dgn duduk
mengelupas dan ekstensi mendongak atau berdiri
inflamasi.
Kapsul sendi kontraktur Mobilitas sendi Nyeri mengemudi, Rekreasi dgn gerak
terbatas parker, menjinjing cervical
barang dll
Otot atrofi dan lemah Stabilitas sendi Hambatan ketika
menurun Olahraga
Osteofit tepi corpus Flat neck/ kyphosis Penampilan kaku,
dan/facet

Sugijanto, 2019
Lumbar disc herniated

Functioning and disability Constextual factors

Anatomic impairment
Internal External
factors factors
Disc Nerves Muscle Capsels Facet

Annulus Motoric Chronic


rupture Autonom inflamation

Paretic Weak-
Nocisensoric Blockade
atrphy

Nucleus
Sympathic Spasm Inter fiber Activity Participation
hyperactivity adhesion Functional restriction
herniation
impairment limitation
Vascular
Sensitive Capsel contracture
tissue
Micro circular Capsular
Neuropathic constriction pattern
pain Sitting Work
Radicular pain Stretched Lifting
Muscle Sport
pain imbalance
Low back pain Driving
Recreation
Postural
deformity
Pain Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, :
Lumbar disc herniated (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan Hambatan berpartisipasi
terganggu? apa yg terganggu? aktivitas (sosial)

Annulus fibosus robek


diskus menonjol ke
dorso-lateral
Inflamasi lig. Longit.
Duramater dan
Posterior radiks
Muscle tightness and
weakness

Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, :
Lumbar disc herniated (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan Hambatan berpartisipasi
terganggu? apa yg terganggu? aktivitas (sosial)

Annulus fibosus robek Nyeri dan/atau nyeri


diskus menonjol ke menjalar saat fleksi
dorso-lateral trunki
Inflamasi lig. Longit. Nyeri central, nyeri
Duramater dan radikular. SLR
Posterior radiks
Muscle tightness and Instability /muscle
weakness imbalance

Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, :
Lumbar disc herniated (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan Hambatan berpartisipasi
terganggu? apa yg terganggu? aktivitas (sosial)

Annulus fibosus robek Nyeri dan/atau nyeri Duduk lama,


diskus menonjol ke menjalar saat fleksi membungkuk,
dorso-lateral trunki lifting
Inflamasi lig. Longit. Nyeri central, nyeri Duduk, Selonjor,
Duramater dan radikular. SLR membungkuk,
Posterior radiks
Muscle tightness and Instability /muscle Berjalan lama,
weakness imbalance

Sugijanto, 2019
MENGANALISIS DARI ICD KE ICF, :
Lumbar disc herniated (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan Hambatan berpartisipasi
terganggu? apa yg terganggu? aktivitas (sosial)

Annulus fibosus robek Nyeri dan/atau nyeri Duduk lama, Bekerja kantor, BAB,
diskus menonjol ke menjalar saat fleksi membungkuk, mengemudi
dorso-lateral trunki lifting
Inflamasi lig. Longit. Nyeri central, nyeri Duduk, Selonjor, Olah raga,
Duramater dan radikular. SLR membungkuk,
Posterior radiks
Muscle tightness and Instability /muscle Berjalan lama, Rekreasi
weakness imbalance

Sugijanto, 2019
ANATOMIC DAN KINETIC IMPAIRMENT
SEBAGAI PUSAT KAJIAN
Contoh:  Jalan pincang akibat nyeri
permukaan sendi
 Nyeri akibat inflamasi tulang
permukaan sendi  Tidak dapat jongkok akibat
kontraktur sendi
 Hipomobilitas akibat hambatan
kapsul kontraktur  Tidak dapat bekerja dalam
konstruksi akibat kaku sendi dan
lemah otot
 Tidak mampu olahraga akibat
nyeri lutut dan kelemahan otot

Sugijanto, 2019
SPECIFIC BODY STRUCTURE PENYEBAB KELUHAN

Gangguan fungsi Jaringan


tertentu

Penyimpangan fungsi
(mekanis)

Menimbulkan
patologi tertentu

NYERI

Gang Keseimbangan
Sugijanto, 2019
NYERI BERASAL DARI JARINGAN
SPESIFIK
Nyeri: Wound healing process
Inflammation
Nyeri: Nosisensoric sensitization

SPECIFIC Hypoxia Nyeri: necrosis


TISSUE Ischemic
Nyeri: Wound
Inflammation
healing process

Contracture Collagen adhesion Nyeri regang

Fatique Acedosis Nyeri kimiawi


Sugijanto, 2019
CIDERA-INFLAMASI JAR. SARAF
Neuritis: Neropraxia, Nyeri pd distribusi
axonotmesis, Neurotmesis saraf, paraesthesia,
neurofibrosis hypoaesthesia

Triad symptom pd Reflex. MMT, Sensoric


lesi saraf perifer test, Neurodynamic test

spesifik

Sugijanto, 2019
NYERI DARI SARAF PERIFER
Paresthesia intermittent →
Anoxia tinnel test & neural tension test

Inflamation Neuropathic pain → tinnel


test & neural tension test
Entrapment
Paresthesia menetap
Fibrosis →nerve gliding test

NERVE Inflamation
Neuropathic pain →
neural tension test

Systemic Paresthesia menetap →


sensoric, motorik & reflex test

Sugijanto, 2019
Kata kunci
Bila diduga impairment saraf tepi?
 Test sensorik area dermatome (pd radiks) dan area nervina (pd
saraf spinalis)
 Test motoric (myotome)
 Tes reflex
 Neural tension test (tightness) dan nerve gliding test (adhesion)

Sugijanto, 2019
CIDERA JAR. DISC (tanpa inflamasi)
4 tingkat disc lesion: Disc
Beban meningkat bila fleksi, terberat:
bulging; Disc herniated; Disc
duduk bungkuk, ringan: Psoas position
extruded; disc fragmented

Nyeri akibat kompresi Central –


jar. Sensitif sekitarnya peripheral pain

spesifik

Sugijanto, 2019
PAIN FROM DISC IRRITATION
Inflamasi Spurling I Central
Iritasi lig pain
Longitudinal Iritasi Spurling I Bilateral
Stenosis
Duramater hamstrings pain

Lasegue Paresthesia
Anoxia
intermittent

Lasegue Neuropathic
DISC Iritasi radiks Inflamation
/radicular pain

Fibrosis LLTT/nerve gliding


Paresthesia menetap
Iritasi saraf
spinalis Triage Sensoric, motorik,
Inflamation
symptoms reflex
Sugijanto, 2019
Skema umum assessment Disc

? ?
Disc ? ?
? ?

Disc
Nerve ? ?
? ?

Sugijanto, 2019
Skema umum assessment Disc

Spurlings test (compression in ?


flx)
Disc Traction test ?
Valsava maneouvre ?

Disc Tinnel test


?

Nerve Sensoric, motoric and Reflex ?


Upper limb tension test ?

Sugijanto, 2019
Skema umum assessment Disc

Spurlings test (compression in Pain, central – peripheral


flx) sensation
Disc Traction test No pain
Valsava maneouvre Pain and end feel

Disc Tinnel test Pain


Nerve Sensoric, motoric and Reflex Pain, or Paresthesia,
weakness and hypo reflexia
Upper limb tension test Pain and/or paresthesia

Sugijanto, 2019
Kata kunci

Bila diduga impairment discus intervertebralis?

 Springing test / Rosert test (Lokasi impairment)

 Spurling’s test (posisi fleksi)

 Traction test (posisi ekstensi)

 Extension test

Sugijanto, 2019
CAPSULOLIGAMENTAIR
T.a. srbt collagen sejajar Ligament penebalan tunica Mrpk stabilisator sendi
silang, elastin; cell capsel / berdiri sendiri. pasif fs arahkan gerak
fibroblast, dan matrix Terdapat meniscoide sendi

spesifik

Sugijanto, 2019
NYERI DARI CAPSEL
Nyeri pasca aktifitas
Instability → stability test

Sprain/ Nyeri diam →


Inflamation
rupture passive test

Nyeri regang →
Capsule Contracture
passive & JPM test

Immuno Nyeri & hydrops →


Effusion Acidosis
reaction palpasi & ballotement

Intercollagen Nyeri regang →


Immobilzation Adhesion space passive & JPM test

Sugijanto, 2019
Kata kunci
Bila diduga impairment Kapsul sendi:
Lakukan pemeriksaan capsules dgn passive test dilanjutkan joint play
movement test:
 Bila nyeri → rasakan end feel nya:
 Springy oleh tahanan otot yg tegang → mulai intervensi relaksasi atau traksi osilasi
dlm MLPP
 Pengukuran ROM dan end feel penting
 Elastic end feel oleh tahanan capsule yg masih cukup lentur → mobilisasi pd
pembatasan ROM
 Nyeri pd akhir ROM → manipulasi sendi
 Keterbatasan gerak dlm capsular pattern → seluruh capsule contracture →
mobilisasi sendi semua arah
Sugijanto, 2019
Kata kunci

 Bila terasa empty end feel ROM lebih besar dari normal karena
hypermobility → stability program
 Bila joint play movement juga berlebihan dan empty end feel oleh
instability → passive stability program diikuti active stability

Sugijanto, 2019
INFLAMASI JOINT SURFACE
 Injury, arthritis, iritasi osteophyte, RA.
 Sprain, capsulitis/arthritis, spondyloarthrosis
 Compression pain, Pseudoradicular pain.
 Diikuti capsular pattern hypomobility.
 Nyeri gerak segmental

Sugijanto, 2019
PAIN FROM FACET SURFACE
Kompresi Nyeri kompresi sendi
prmk tulang → spurling’s test 2

JOINT Penglupasn Inflamasi tlg


SURFACE rawan sendi subchondrale

Tumbuh Nyeri bl gerak →


osteophyte NAGs test

Lepasan Penguncian Nyeri bl gerak ROM


fragmentasi grk sendi tertentu → NAGs test

Sugijanto, 2019
Skema umum assessment

Permukaan sendi

Facet
Capsule -
ligament

Sugijanto, 2019
Skema umum assessment

Passive test
Permukaan sendi Compression &
traction test
NAGs test
Facet
Capsule - Passive
ligament
Joint play
movement test
Sugijanto, 2019
Skema umum assessment

Passive test Pain/Clicking/crepitation


Permukaan sendi Compression & Pain and No pain
traction test
NAGs test Pain and end feel
Facet
Capsule - Passive Pain, end feel and ROM
ligament
Joint play Pain and end feel
movement test
Sugijanto, 2019
Kata kunci
Bila diduga impairment permukaan sendi:
Lakukan pemeriksaan joint surface dgn passive test dilanjutkan compression and
traction dan pengukuran alignment:
 Bila passive test nyeri → dengarkan (atau dgn palpasi) creptasi sendi
 Bila compresi nyeri → pada posisi tersebut dilakukan traksi
 Bila positif, lakukan pengukuran alignment
 Lanjutnyan pemeriksaan positional fault dan deformitas sendi

Sugijanto, 2019
CIDERA - INFLAMASI JAR OTOT-
TENDON
Strain, rupture, Myositis, tendinitis, myotendinosis,
avulsion myofascial syndrome

Spasm/guarding spasm, taut


band/twisting

Sugijanto, 2019
NYERI DARI OTOT
Atrophy → palpasi
Weakness
& strength test
Strain/
Inflammation Nyeri diam
rupture
Muscle Nyeri kontraksi →
spasm isometric test
MUSCLE
Nyeri regang →
Tightness/
contract relax
Contracture
stretch test

Immobilisation Adhesion
Myofascial Nyeri regang →
contracture palpasi & stretch test

Sugijanto, 2019
Skema umum Muscle
assessment

Myofibrile

Fascia
Muscle
α motoneuron

Sugijanto, 2019
Skema umum Muscle
assessment

Myofibrile Isometric test


Palpasi
Fascia CRS test
Muscle
α motoneuron Isometric
MMT

Sugijanto, 2019
Skema umum Muscle
assessment

Myofibrile Isometric test Pain/Clicking/crepitation


Palpasi Pain and No pain
Fascia CRS test Tightness or shortening
Muscle
α motoneuron Isometric Weakness/paralytic
MMT Pain and end feel

Sugijanto, 2019
Kata kunci
Bila diduga impairment otot:
Lakukan pemeriksaan otot dgn isometric test (/isotonic)
 Bila nyeri lakukan palpasi, temukan tender/trigger point, taut
band/twisting
 Intervensi dgn ischemic compression technique, atau transverse friction,
myofascial release atau manipulasi otot
 Bila lemah lakukan tes lanjut:
 Penyanggaan sendi utk memilahkan lemah karena nyeri
 Pengukuran kekuatan otot bila murni kelemahan otot

 Intervensi blok nyeri atau stabilization/strengthening exc


 Intervensi melepas perlengketan

Sugijanto, 2019
Kata kunci
Bila otot hipertonik (tegang) lakukan contract relax stretched test
 Bila pasca kontraksi otot menjadi lentur → tegang saja
→ intervensi teknik relaksasi
 Bila pasca kontraksi tetap tegang → kontraktur → internensi teknik
peregangan
Bila otot lemah (weakness)
 Strength test / active stability test → strengthening programs / stability programs

Sugijanto, 2019
FUNCTIONAL IMPAIRMENT
 Pain  Balance
 Pain in rest
◦ Sitting disbalance
 Pain in movement
◦ Standing disbalance
 Referred pain etc
◦ Walking disbalance,
 Joint mobility: etc
 Ankylosing  Gait:
 Hypomobility ◦ Antalgic gait
 Joint blockade ◦ Duchene gait
 Joint stability: ◦ Trendelen burg gait,
 Hypermobility etc
 Instability  Hand function:
 Muscle performance: ◦ Grip weakness
 Muscle weakness ◦ Prehension disability,
etc
 Muscle paresis

Sugijanto, 2019
JOINT MOTIONS IMPAIRMENT
Capsular pattern →
ROM in passive test
Contracture
Non capsular pattern →
Capsular ROM in passive test

Ossification Blockade → passive


test & JPM test

Hypo- Inert Loose body Blockade →


mobility structure passive & NAGs test

Tightness → contract
Tendomuscular relax stretch test
Contracted → contract
relax stretch test Sugijanto, 2019
JOINT MOTIONS
Joint hypermobility →
Laxity JPM Test elastic end
Ligament feel
er-
Instability →JPM
Capsular Rupture
Test empty end
feel
Hypermobility Bony- Deformity →
& instability structur Measureme
e nt
Weaknes
Tendomuscul s Active instability
→ Active
ar
Rupture stability test
Sugijanto, 2019
PEMAHAMAN DAN KETRAMPILAN
MENENTUKAN REG FLAG

Mampu melakukan Simple Medical Screening


pada kasus Patologi Serius (Red Flag)
Mampu melakukan System screening

Sugijanto, 2019
ASSESSMENT MANUAL
THERAPY
Temu 2

Sugijanto, 2019
Proses pengelolaan Fisioterapi
1. HISTORY TAKING Profesi
2. INSPEKSI

3. REGIONAL
SCREENING & QUICK
TEST
4. REVIEW OF SYSTEM
& RED FLAG

5. ASSESSMENT EVIDENCE
BASE CLINICAL PRACTICE
6. DIAGNOSIS AND
FUNCTIONAL PROGNOSIS
7. PLANNING
8. INTERVENTION

9. EVALUATION

10. DOCUMENTATION
Sugijanto, 2019
Kata kunci

 Diperlukan pemahaman patologi (juga non patologis) penyebab


gangguan fungsi untuk mebuat clinical reasoning
 Melalui pengambilan data awal keluhan klien dibuat hipotesis
(dugaan kuat) sakit dlm ICD
 dilanjutkan history taking dilakukan uji hipotesis awal apakah positif
atau negative. Dilanjut pembuktian hipotesis awal melaluai inskesi.
 Bila negative, ganti hipotesis lain
 Bila positif lanjutkan pemeriksaan detail sesuai ranah ICF

Sugijanto, 2019
Kata kunci …… lanjutan
 Pemeriksaan fisik diawali dengan regional screening dan tes
cepat utk menegakkan regio asal impairment dan dugaan
impairment nya dengan mengghunakan tes EBCP utk
pembuktian hipotesis yang telah dikoreksi.
 Lakukan tinjauan system tubuh terkait regio tsb dan lanjutkan
identiivikasi dan pemeriksaan red flag
 Bila positif, lakukan konsultasi dengan dokter yang kompeten

Sugijanto, 2019
Kata kunci …… lanjutan
 Bila tidak ada red flag kemudian dilakukan pemeriksaan dengan tes
algoritma baku sesuai EBCP untuk body function and structure
impairment tests
 Dilanjutkan pemeriksaan activity limitation dan participation
restriction
 Serta pemeriksaan contextual factor (prognosis factors) faktor
sebagai penguat maupun penyulit
 Pada kasus tertentu diperlukan pemeriksaan penunjang sesuai
dengan kebutuhan klinisnya.

Sugijanto, 2019
Kata kunci …… lanjutan

 Dari hasil pemeriksaan dibuat analisis kritis sesuai clinical reasoning, dan
clinical prediction rule untuk membangun clinical decision yang tepat.
 Untuk dibuat penegakan diagnosis fungsional dlm ICF yg dikaitkan
patologi dlm ICD
 Lakukan penetapan prognosis fungsi sesuai diagnosis dan problema yg
ditemukan
 Penetapan target gerak dan fungsi akhir dan bertahap
 Buat program sesuai dengan body structure impairment target dan
body function impairment target
 Dilanjutkan disability target dan
 Prognosis faktors

Sugijanto, 2019
Kata kunci …… lanjutan

 Lakukan inform consent dengan memberikan penjelasan


tentang sakit dan rencana intervensi serta minta persetujuan
klien
 Lakukan prosedur intervensi sesuai dengan program, urutan
dan dosisnya
 Lakukan evaluasi
 Lakukan program lanjutan dan atau terminasi

Sugijanto, 2019
Client complain
Body structure
(anatomic) Activities
impairment Non Pathologi/ Limitation
Pathologi
Body Function Participation
(biomechanic) Restriction
Gangguan Gerak-
impairment Fungsi

Critical thinking

HOAC 2 Assessment E B(C)P


Clinical
reasoning Clinical
Diagnosis and prediction
Clinical prognosis rule
decision
making Analisis Strategi
perencanaan
Prosedur intervensi

Evaluasi dan
penilaian hasil Sugijanto, 2019
HYPOTHESIS ORIENTED ALGORYTHM
DALAM ASSESSMENT

Dalam pemeriksaan selalu dibuat hipotesis yg harus


diuji (tes) kebenarannya
Mahasiswa memiliki dasar keilmuan yang kuat
Body structure
Body function
Impairment and Pathology
Individual activity
Sosial participation
Sugijanto, 2019
Physical Therapy Assessment The HOAC is a tool
to structure YOUR
clincal reosanig

Hypothesis-Oriented
Algorithm for Clinicians II
(HOAC II – PART 1)
Rothstein et
al.,2002

Sugijanto, 2019
DIAGNOSIS
❑ Dihasilkan dari pemeriksaan & evaluasi & merupakan hasil dari
alasan-alasan klinis.
❑ Menunjukkan adanya difungsi gerak atau mencakup kategori
gangguan, keterbatasan fungsi, ketidakmampuan atau sindrom.
 Diagnosis: proses keputusan klinis terkait patologi.
 Mengacu ICF dalam menganalisis patologi (ICD)
 Meliputi Body function & structure impairment
 Activity limitation & participation restriction of disability
 Akibat Patologi (ICD) tertentu.
 Memperhitungkan factor hambatan atau fasilitasi dari personal dan
lingkungan,

Sugijanto, 2019
Diagnosis Medis Vs Diagnosis FT

❑ICD Vs ICF

The International Classification of Functioning, Disability and Health by the World Health Organization 2001(p. 18) Sugijanto, 2019
Diagnosis Terkait Treatmen
& Prognosis

❑ Proses evaluasi terkait penyebab


disfungsi gerak & system klasifikasi
berdasarkan clinical decision rules.
❑ Terkait dengan pertimbangan patologi.
❑ Mengarah kepada tissue-specific
diagnosis.
❑ Mampu mengidentifikasi keterkaitan gangguan, dengan keterbatasan
aktifitas & partisipasi.
❑ Pertimbangkan faktor internal & eksternal (konseptual).

Sugijanto, 2019
Diagnostic Reasoning

❑Salah satu komponen alasan klinis.


❑“…formasi diagnosis terkait
disabilitas fisik & gangguan dengan
pertimbangan terkait mekanisme
nyeri, patologi jaringan. . .”.
❑Review system berdasarkan struktur
anatomi & fisiologi.
❑Menentukan ada/tidak red flag.

Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical
therapy. Phys Ther. 2004;84(4):312–330; discussion 331–335
Sugijanto, 2019
Hierarchy of Evidence for
Treatment

Penggunaan Evidence Systematic


Base Reviews & Meta-
analyses of RCTs
Multiple RCTs

Randomized Controlled Trial (RCT)

Systematic Review of the studies below


Observational Cohort or Case Control
Studies, Large Case Series

Case Reports, Small Case Series


Unsystematic Clinical Observations

Sugijanto, 2019
PENGGUNAAN EVIDENCE BASE
CLINICAL PRACTICE DALAM
PEMERIKSAAN FISIOTERAPI

 Merujuk HOAC
 Pemeriksaan cepat, akurat
 Memerlukan dasar pengetahuan yg baik

Sugijanto, 2019
INTERVENTION
Mampu menjelaskan dan mendemontrasikan target intervensi
 Anatomic Impairment target:
 Topografik target
 Tissue specific target
 Specific impairment target
 Kinetic Impairment target:
 Positional vault/Postural deformity
 Hypomobility/hypermobility/unstability
 Weakness/imbalance
 Movement incoordination
 Dll
 Disability target

Sugijanto, 2019
PENGATURAN DOSIS FITT
ditentukan:
 Jenis pendekatan:  Waktu dan Frekwensi:
 Tissue specific impairment  Aktualitas patologi
target
 Kronisitas
 Kinetic impairment target
 Disabilitas
 Intensitas:
 Aktualitas patologi/impairment
 Tujuan intervensi

Sugijanto, 2019
Contoh Fisioterapi pada kasus
ortopaedi/Musculoskeletal

Sugijanto, 2019
Client complain
Body structure
(anatomic) Activities
impairment Limitation
Non Pathologi/
Pathologi
Body Function Participation
(biomechanic) Restriction
impairment Gangguan Gerak-Fungsi

Critical thinking

HOAC 2 Assessment E B(C)P


Clinical
reasoning
Diagnosis and Clinical prediction
prognosis rule
Clinical decision
making

Analisis Strategi perencanaan


Prosedur intervensi

Evaluasi dan
penilaian hasil
Sugijanto, 2019
PT MANAGEMENT
1. HISTORY TAKING

2. INSPECTION
More cost-effective management of patient with
3. REGIONAL SCREENING musculoskeletal disorder in primary care after
& QUICK TEST direct triaging to physiotherapist for initial
4. REVIEW OF SYSTEM assessment compare to initial general practitioner
& RED FLAG assessment. (Lena Bornhoft, 2019)

5. ASSESSMENT EVIDENCE
BASE CLINICAL PRACTICE
6. DIAGNOSIS AND
FUNCTIONAL PROGNOSIS

7. PLANING

8. INTERVENTION

9. EVALUATION
10. EVALUATION Sugijanto,
Sugijanto,2019
2019
TES ORIENTASI UNTUK PEMETAAN
LOKASI REGIO ASAL
KELUHAN/IMPAIRMENT

 Untuk memudahkan hipotesis regio pd keluhan Nyeri leher hingga


lengan

Sugijanto, 2019
Analisis NECK ARM PAIN
patologi

Temporo-mandibular joint Cervical spine Thoracic spine Shoulder Thoracic outlet

tendomuscl
Interartic muscles disc Capsules Glenohumeral Positional
disc fault
Capsule Joint surface neurovege costoverte bursae
/ lig TMJ facet &
uncinate Inflamasi muscle
Irregular
Myofascial Blockage tightness
shap
adhesion osteofit
Micro Contracture Capsulo-lig
Sprain circulation contracture
iritasi radix
Blockage
tightness calcification brachial nerve
Iritasi Jar ischemic hipertone
sensitif entrapment
Joint Contracture
nyeri lokal/
irritation contract referal
tight nerve ischemic

Capsular Radicular Pseudo fibrosis


TMJ-Neck
pattern pain radicular
pain

Nyeri leher dan/atau lengan


Sugijanto, 2019
Case 1: TO TEST THE COMPLAIN FROM
TEMPOROMANDIBULAR JOINT
• Client came to Physiotherapist practice
because of mandibular pain that refer to
the neck, especially during eating.
• Began from special anamnesis to data
review of the TMJ problems:
• Do the pain increase as eating or TMJ
depression?
• Was the TMJ block when mouth large opening?
• Do TMJ depression and elevation while palpate
the joint line of TMJ found crepitation or clicking

Sugijanto, 2019
Case 2: THE IDENTIFICATION OF CERVICAL
SPINE PATHOLOGY/PATHOKINETIC
HISTORY TAKING

Client came to physiotherapist because of neck pain


refer to arm. Pain and tingling especially when he/she
flexed his/her neck.
Start with anamnesis for cervical impairment/
pathology including:
 Are his/her complain provocated by specific neck
position or movement?

Sugijanto, 2019
REGIONAL SCREENING
& QUICK TEST
SCREENING OF THE CERVICAL SPINE
AS THE COUSE OF COMPLAIN
Movement of the cervical spine added the ‘over
pressure’ at:
 Cervical Flexion-extension in upright siting or standing
 3D extension to the right and left
 The test positive when provocate the neck-arm pain
during that test

Sugijanto, 2019
Case 3: THE EXAMINATION TO
IDENTIFY THAT IMPAIRMENT FROM
THORACIC SPINE
 Client complain of upper back pain and
sometimes referred to the chest
 Anamnesis:
Are that provocate by position & movement of
the thoracic spine?
Provocate by deep breathing while thorax
extension?
 Located on segmental of the thoracic spine then
movement test done by cervical motion or arm.
 PACVP and LPAVP test

Sugijanto, 2019
Case 4: THE EXAMINATION OF
SHOULDER COMPLEX PROBLEM
 Client with shoulder-deltoid pain when arm lifting.
 Anamnesis khusus terkait keluhan berasal dari impairment shoulder
complex:
 Apakah keluhan tersebut meningkat bila gerak tangan
dibelakang leher dan tangan dibelakang punggung
 Apakah juga terprovokasi oleh gerak bahu tertentu seperti
lengan kesamping-depan tubuh
 Gerak abduksi-elevasi dalam ritme/lingkup tertentu keluhan nyeri leher-
lengan ter provokasi
 Pada posisi abduksi bahu dimana terprovokasi keluhannya, kemudian
dilakukan ‘over pressure caput humeri kearah superior (impingement),
kearah anterior (instabilisasi) atau kearah rotasi eksterna (frozen)
 Tes positif bila keluhan nyeri leher-lengan ter provokasi oleh gerak

Sugijanto, 2019
Case 5: THE EXAMINATION TO IDENTIFY
THORACIC OUTLET IMPAIRMENT

 Client complain of shoulder pain that referred to


upper arm, especially when she carrying a heavy
things.
 Anamnesis for suspect thoracic outlet origine:
Paresthesia rise when hyper abduction but
decrease when arm down
Or paresthesia rise when arm down but
decrease when hyper abduction
 Adson’s Test
 Hyperabduction test

Sugijanto, 2019
REGIONAL
SCREENING & QUICK
TEST
Case 6: IDENTIFICATION TO LUMBAR
SPINE PROBLEMS

 The other Client complain of low back pain refer to gluteal


area, but sometimes refer to hamstrings area
 Test trunk flexion-extension in standing
 Trunk 3 D extension to the right and left in siting position
 Ad ‘over pressure’ on lumbar spine process

Sugijanto, 2019
REGIONAL
SCREENING & QUICK
TEST
Case 7: IDENTIFICATION OF
LOWER THORACIC SPINE
ORIGINE
 Client complain of lateral lumbar area refer
to iliac crest sometimes to trochanter area.
 Be sure that pain at lateral lumbar area –
iliac’s crest – gluteus medius - trochanter
 Trunk flexion - extension
 PACVP/LPAVP test on spine process and
facet
 Extension while give over pressure on lower
thoracic spine process

Sugijanto, 2019
Case 8: SACROILIAC JOINT
IMPAIRMENT

 Other client complain of pain at gluteal area, and gluteal fold


 Be sure that pain at sacral area to gluteal fold
 Found asymmetry of PSIS when standing position and trunk flexion
 Screening:
 Sacral trust test
 Thigh trust test
 Gaenslen test

Sugijanto, 2019
REGIONAL
SCREENING & QUICK
TEST
Case 9: THE EXAMINATION TO
IDENTIFY HIP JOINT PROBLEM

 Be sure that pain lies on inguinal area (groin) to trochantor


 Gait analysis has seen duchene gait
 Contra Patric’s test
 Patric’s test

Sugijanto, 2019
REGIONAL
SCREENING & QUICK
TEST
Case 10: PIRIFORMIS
SYNDROME
 Pain felt on gluteal region referred
to one side of hamstring region and
provocates by siting on hard chair
 Screening:
◦ Palpate on piriform muscle
◦ Thigh cross test
◦ Contract relax stretch test to piriformis
positive
 Slump test if there was nerve
irritation
Sugijanto, 2019
REGIONAL
SCREENING & QUICK
TEST
Case 11: Assumption of
Lysthesis

 Be sure that pain/tingling on bilateral hamstring


regions and sometimes feel clicking,
 Screening:
 Palpate on spine process to identified step off or step
on (L4)
 Passive stability test:
 Active lumbosacral stability test (Prone position at the
edge of bed) with fixation and without fixation

Sugijanto, 2019
PROCEDURE TESTS AFTER REGIONAL
SCREENING

REVIEW OF SYSTEM & • Review of Systems


RED FLAG
• Serious pathology (Red Flag)

Sugijanto, 2019
KASUS LAIN …Berasal dari regio
manakah impairment nya?
A. Nyeri samping paha dari trocantor mayor ke
atas lutut
B. Pasien lain mengeluh terasa baal (anesthesia}
daerah anus dan kelamin, disertai gangguan
buang air kecil dan kadang gangguan
buang air besar juga.
C. Pasien lainnya lagi datang dengan keluhan
nyeri pedas/panas pada inguinal menyebar
ke paha depan,
D. Seorang pasien lain mengeluh nyeri pada
Sugijanto, 2019
PROCEDURE TESTS AFTER REGIONAL
SCREENING

REVIEW OF SYSTEM & • Review of Systems


RED FLAG
• Serious pathology (Red Flag)

Sugijanto, 2019
RED FLAG

Sugijanto, 2019
Sugijanto, 2019
REVIEW OF SYSTEM (Guide-APTA)

 To support the hypotheses of serious pathology • Checklist general symptomps


(red flag) that support the spectrum of an
 Anatomic dan physiologic assessment of impairment in the specific body
cardiovascular/pulmonary, integumentary,
musculoskeletal, neuromuscular systems parts using interview
• ROS as a part of history taking
• Purpose: to identify potential
problem related to PT
intervention
• Depends on medical records
and location/pain characteristics

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG Test for Red flag: Vertebral
Artery Test (VBI)

 Cervical rotation hold in 30 second


 Dizziness, nausea and nystagmus
 Differentiate to vestibular symptoms

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG Red flag: Upper cervical complex
Instability Sharp –Purser Test

 Index finger on spine proc of C2


 Apply compression to PA
 Posterior slide: + AA instability
 Note:
Aware to sign of instability:
 VBI sign
 Cord sign
 Neck pain and stiffness
 Hypoaesthesia on face, lips and tounge

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG Red flag: Upper cervical
Red flag: Upper
complex Instability
cervical complex Tectorial Membrane (PLL)
Instability Alar lig
laxity  Lateral flexion of • Fix on spine proc
occiput through the of C7
contralateral
transverse process of • Traction to the
the atlas
head in neutral
than flexed
position

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG CLINICAL EXAMINATION FOR
PANCOAST SYNDROME

 Man age >50 years


 Chronic coughing and history of smoking
 Paresthesia at along of ulnar nerve
distribution
 ULTT for ulnar and then deep breathing

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG Red flag:
Myocardial infark

 Damage of myocardial tissue due to coronary arterial block for a short period of
time caused byspasme or thrombus, heart muscle dysfunction/infark.
 Angina
 Palpitation
 Intermitent Claudication
 Risk of coroner heart disease: Cholesterol abobe 180 mg/dl on the age of <30,
or above 200 mg/dl on the age of >30, supposed to have a risk of coronary
arterial disease.

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG RED FLAG: PLEURISY

 Sharp pain in inspiration


 History of lung disease
 Dypsnea, chest expansion very limited

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG APENDICITIS Red flag
examination
 Abdominal rigidity:
 Rebound tenderness
 Mc Burney point +
 Psoas and Obturator sign +

Nyeri
Sugijanto, 2019
ekstensi
REVIEW OF SYSTEM &
RED FLAG
Red Flag: PYELONEPHRITIS

 Kidney Infection
 Pain felt bilateral posterior low back and unilateral
abdomen, position or movement have no effect
 Test with clap on dorsal lower thoracic spine

Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG Red flag: Back cancer/infection
(osteomyelitis)

 Age >50 year, with history of cancer  History of resent infection


 High body weight lost  The used of intravenous
 Fail in conservative treatment medication
 Inconsistent of complain.  Concurrent
 Constant pain unchanged on immunosuppressive
position/activities; getting worst in the night.
disorder
 Deep constant pain,
worst in weight bearing
 Fever, malaise, and
edema
 Spine rigidity
Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG RED FLAG: CAUDA
EQUINA SYNDROME

 Retention uri or incontinence uri / alvi


 Saddle anesthesia
 Weakness of the inferior extremity increase progressive
 Test to sensory deficit (L4, L5, S1)
 Quick test: Ankle dorsiflexion, toe extension, and ankle
plantarflexion weakness

Sugijanto, 2019
PT MANAGEMENT ON
SPINE PROBLEMS
 Comparison of CPG’s for diagnosis, prognosis and
management of non specific neck pain.

Pulak Parikh , et al, 2019

 The effect of manual therapy and


stabilizing exercise on FHRSP
Kiana Fatholahnejad, et al,
2019 Sugijanto, 2019
REVIEW OF SYSTEM &
RED FLAG RED FLAG: CAUDA
EQUINA SYNDROME
 Retensi uri atau inkontinsia uri / alvi
 Saddle anesthesia
 Kelemahan otot ekstremitas inferior progresif
 Defisit sensorik (L4, L5, S1)
 Ankle dorsiflexion, toe extension, and ankle
plantarflexion weakness

Sugijanto, 2019
PROSEDUR PEMERIKSAAN

History taking:
 Pertanyaan utk pembuktian hipótesis
awal (ICD)
 Dugaan HNP cervical: Nyeri ngilu
cervical hingga sisi kepala atau lengan
pd area dermatome, Terpicu posisi
menunduk lama/gerak menunduk
 Dugaan artritis: Nyeri – kaku bangun
tidur; Posisi tengadah & grk rotasi
cervical nyeri/ nyeri meningkat ekstensi

Sugijanto, 2019
PROSEDUR PEMERIKSAAN
Observasi:
 Forward head position; Flat neck atau deviasi

Tes orientasi:
 Dugaan artritis: Gerak ekstensi cervical nyeri, atau +
kompresi posisi ekstensi nyeri;
 Gerak esktensi 3 D cervical limitasi gerak dan nyeri
leher, interscapular dan paresthesia hingga lengan
 Dugaan HNP: Gerak fleksi cervical nyeri, atau +
kompresi nyeri

Sugijanto, 2019
Quick test dugaan disc
problem
Aktif:
Fleksi nyeri-
ekstensi
hilang
Valsava
maneouvre
Nyeri
bungku Compression
in flexion
PENYEBAB DISC
k PROBLEMS
pain
(Spurling)
Traction in
extension no
pain

PACVP pain
Sugijanto, 2019
Quick test dugaan facet

Aktif: Nyeri
Eskensi dan
fleksi negatif

Spurling test:
Bila Nyeri Compression
Menenga test ekstensi PENYEBAB FACETS
nyeri dan PROBLEMS
dah
Distraction test
nyeri hilang
3 D fleksi
terbatas
elastic
Sugijanto, 2019
PROSEDUR SPECIFIC TEST
Spurling test (test 1)
 Tes kompresi saraf dgn bertahap: 3D-extension
 Tahapan:

1. Kompresi posisi fleksi


2. Kompresi posisi ekstensi
3. Kompresi posisi 3D ekstensi
Hasil
 Test + nyeri timbul mulai dr leher dan menyebar ke sisi
kepala atau sisi dorsal bahu, dorsolateral lengan atas,

Sugijanto, 2019
PROSEDUR SPECIFIC TEST
 Traction and distraction test (test 2)
 Pasien terlentang
 Lakukan traction leher

Hasil:
Test + bila nyeri hilang oleh traksi dan timbul saat
dilepaskan

Sugijanto, 2019
Cervicogenic headache (CH). IHS 1999

Flexion-rotation test
(Hall 2004, Ogince 2006)

Flexion-rotation test: Nyeri leher dan


kepala unilateral. Occipital
Flexion rotation test: positive more than
10 degrees in limitation

Sugijanto, 2019
Prosedur pemeriksaan

Tes khusus (Evidence base approach)


 Joint play movement lateral gapping test atau
 3 dimentional flexion terbatas firm end feel.
 Tes dengan PACVP nyeri segmental

Sugijanto, 2019
TEST KHUSUS

 PALPASI POSTERIOR
 Spinous proc. C2,6,7, C3-4-5
 Proc transversus
 Trapezius m.

◼ PALPASI ANTERIOR
◼ Carotis tub -> Stelate gln

◼ Sternocleido mastoid m
◼ Supra clavicular fossa
Sugijanto, 2019
Shoulder Abduction Sign

Kompresi radix C5-6


Penurunan symptoms
berarti positive

Sugijanto, 2019
Upper Limb Tension Testing A

Scapular Depression
Shoulder Abduction and
External Rotation
Elbow Extension
Forearm Supination
Wrist and Finger Extension

Sugijanto, 2019
Upper Limb Tension Testing B

Supine in 30º Abd


Scapular Depression
Shoulder Internal
Rotation
Elbow Extension
Wrist and Finger Flexion
Opposite Cervical SB
and Rot

Sugijanto, 2019
Upper Limb Tension Test (ULTT)

Lateral fleksi-rotasi
kontralateral, diikuti gerakan
bertahap sbb:
➢Depresi dr girdle
➢Abduksi bahu
➢Lateral rotasi bahu
➢Ekstensi siku
➢Supinasi lengan bawah
➢Ekstensi perg tangan
➢Ekstensi jari2

Hasil:
Test + bila muncul nyeri
radiks. Sugijanto, 2019
Ulnar Nerve Testing

 Shoulder Retraction
 Shoulerd Extension and
External Rotation
 Elbow Flexion
 Forearm Supination
 Wrist Extension and Radial
Deviation
 Finger Extension
 Cervical Side Banding and
Rotation away

Sugijanto, 2019
NEURAL TENSION TEST

 LLTT: Slump test; N. tibialis dan N. Peroneus suerficial


 Lower limb tension test
 Tes ketegangan saraf
 Nerve gliding test
 Tes mobilitas saraf

Sugijanto, 2019
T1 Nerve Root Stretch

Abduct to 90º
Flex pronated arms to 90º
Flex elbows and place
behind the neck
Pain in scapular area is T1-
Pain in Ulnar distribution is
Ulnar

Sugijanto, 2019
TEST KHUSUS
Segmental CO-C1
Self test: Active Flexion seluruh
cervical: Gerak Fleksi-ekstensi
kepala
Pasif: Translasi Occyput ke
dorsocranial
Segmental C1-C2
Self test: Active Flexion seluruh
cervical dan ekstensi kepala,
gerak rotasi kepala.
Pasif: Posisi CPP, kepala ekstensi,
Rotasi melalui proc. Transversus C1
Sugijanto, 2019
Test khusus LOWER CERVICAL

Segmental Lat.flexion test: C2-3,


C3-4, C4-5, C5-6, C6-7 dan C7-Th1.
Tekanan proc transversus kontralat
gerak ipsilat
Gapping uncinate joint dan
facet kontralateral

Sugijanto, 2019
SPECIFIC TEST

• P.A.C.V.P TEST C2 sd. C7


– Provokasi segmental
– Hanya untuk tes
• 3D Flexion test
– Tes Capsel sisi kontra lateral
• SEGMENTAL GAPPING TEST
– Segment tertentu
– Rotasi ipsilat, fleksi lat kontralat
dan fleksi
• Perhatikan: pain, (range),
dan end feel.
Sugijanto, 2019
SPECIFIC TEST
 UPPER THORACAL VERT:
 Terkait faktor mekanik dan vegetative
 LPAVP
 Unilateral facet gapping test

 NAG test
 Arah 600 ventrokranisl
 Catat: Nyeri, range dan end feel. Firm
end feel indikasi hypomobility.
 Costo Vertebral-Transversal Joint
 Mobilizarion test costovert dan gapping
test costotransversal
 Nyeri dan firm end feel indikasi adanya
Hypomobility
Sugijanto, 2019
 Stabilization test:
 tes stabilisasi lumbosacrale fiksasi pd lumbale dan
mendorong femur ke posterior.

Sugijanto, 2019
SPECIFIC TEST
MUSCLE LENGTH TEST

Contract relax stretch test


 UPPER TRAPEZIUS M
 Fleksi lateral cervical kontralat, depresi
girdle ipsilat

 LEVATOR SCAPULAR M
 Posisi dan pelaksanaan spt Upper
trapezius m. tangan belakang kepala
SCALENUS M

 Cervical fleksi lateral kontralat, CostaI depresi dan rotasi


kepala

 Perhatikan bila clicking costa I

Sugijanto, 2019
MUSCLE LENGTH TEST
 Contract relax stretch test
 PECTORALIS MAYOR M.
 Posisi glenohumeral Abduction -horizontal
abduction.
 Expiration dan horizontal abd.

 PECTORALIS MINOR M.
 Posisi girdle retraction
 Expiration dan girdle retraction

Sugijanto, 2019
Tendon reflexes,
Neurologisch onderzoek with reflex hammer

- Biceps reflex (C5-6). Compare left and


right
- Triceps reflex (C6-7), compare left and
right

-Outcome/result
-Test + by hyporeflex – areflex of one or
more reflexs

-Babinski reflex, compare left and right

Demonstration in
supine position

Sugijanto, 2019
SPECIFIC TEST

Sugijanto, 2019
DERMATOM DAN TES REFLEX

Sugijanto, 2019
DATA PENUNJANG

X Ray AP, MRI, CT SCAN, ATHROSCOPY.


Data dr Orthopaedi, bedah, bedah
rahang, internist, dll

Sugijanto, 2019
DIAGNOSIS

◼ Gangguan neuro-
musculoskeletal-vegetative
mechanism atau gerak dan fungsi
:
◼ Body structure and body function
impairment:
◼ Disability:
Sugijanto, 2019
INTERVENSI MANUAL
TERAPI
Temu 3

Sugijanto, 2019
Konsep mobilisasi otot
 Mobilisasi myofibrile (serabut otot)
 Teknik relaksasi otot
 Static stretching
 Mobilisasi Myofascial (pembungkus otot)
 Contract relax stretching
 Myofascial release
 Muscle Energy Technique
 Mobilisasi tendon
 Eccentric stretching
 Mobilissi tendoperiosteal

Sugijanto, 2019
INTERVENSION TECHNIQUES

MANUAL MUSCLE STRETCHING


Ischaemic compression technique
Muscle mobilization utk melepas
collagen adhesion
Myofascial release
Transverse stretching
manipulation

Sugijanto, 2019
INTERVENSION TECHNIQUES
 MUSCLE LENGTHENING/STRETCHING

Muscle Energy Technique


Contract relax stretching
Gabungan relaxation-stretching
Lengthening position → Agonist
isometric Contract → Relaxation →
Agonist Stretching

Sugijanto, 2019
Konsep Mobilization

Ditambahkan gerak passive ROM


beberapa derajad The anatomic
barrier ctidak dapat
dilewati tanpa
kerusakan integritas
sendi
Sugijanto, 2019
Konsep Mobilization

Gerak fisiologis dibatasi oleh


physiologic barrier
Tegangan muncul oleh
jaringan sekitarnya
(joint capsule, ligaments and
connective tissue) Sugijanto, 2019
INTERVENSION
JOINT MOBILIZATION
Meningkatkan mobilitas dan kemampuan
gerak
 Intensitas: Grade I; II; III; IV dan IV force.
Restrict
I
II Normal ROM

III
IV
mani
p

Sugijanto, 2019
Konsep Concave-convex

 Traksi (traction): tarikan tegak lurus


permukaan sendi
 Translasi (glide): gerak luncur sejajar
permukaan sendi
 Roll glide: gerak fisiologis terdiri dari gerak
arthrokinematics berpasangan antara
gerak gelinding (roll) dan luncur (glide)
sesuai dengan hokum cekung-cembung.

Sugijanto, 2019
Konsep Mobilization

 Mobilization
 Mobilization vs. manipulation
(thrust)
 Self-mobilization /
automobilization
 Mobilization with movement
(Mulligan’s techniques /
natural apophyseal glides)

Sugijanto, 2019
Konsep mobilisasi serabut saraf

 Dilakukan setelah entrapment di be


 baskan
 Nerve tightness → neural mobilization
 Nerve Adhesion → nerve gliding
 Regional neural mobilization:
 Proximal
 Distal

Sugijanto, 2019
Konsep mobilisasi venosus & lymphatic drainiage

 Venous edeme → Elevation; Elastic bandaging


massage; pumping exc
 Lymphatic edeme → lymph drainage;
compression technique; taping

Sugijanto, 2019
INTERVENSI MT

MOBILISASI SEGMENTAL C0-1


 Posisi head flexion (atlanto occypitalis) → traksi
occyput dan translasi kearah dorsocranial.

MOBILISASI SEGMENTAL C1-2


 Posisi netral: head traction kmd rotation dan
kembali posisi semula
 Mendorong transverse proc atlas ke rotation.

Sugijanto, 2019
INTERVENSI MT

MOBILISASI SEGMENTAL C2-3, C3-4,


C4-5, C5-6, C6-7 dan C7-Th1.
Lateral flexion dg mendorong
transverse proc arah contra lat.
Rotation dg mendorong
transverse proc arah rotasi
bersama head-neck rotation

Sugijanto, 2019
NAGS AND SNAGS

 Auto mobilization

Sugijanto, 2019
INTERVENSI MT
 CERVICAL TRACTION
 INDIKASI:
 Manual
 Seluruh cervical spine
 Segmental
 Dengan alat
 Posisi lordosis sudut traksi lurus : utk disc problem
 Posisi fleksi sudut traksi tertentu : utk facet problem
 Posisi fleksi lateral sudut traksi tertentu utk uncinate
joint.

Sugijanto, 2019
Prosedur Intervensi
1. Cervical oscillated traction in lordotic position.
2. Natural apophyseal glides technique (NAGs:
Mulligan concept)
3. Mobilisasi nucleus grk segmental extension
4. Mc. Kenzie Extension exc
5. Neural mobilization / nerve gliding technique
6. Postural correction & proper neck
mechanic/ergonomic

Sugijanto, 2019
Prosedur Intervensi
• Intermittent lumbar pd Disc problems: traction posisi
lumbar lordosis
• Intermittent lumbar pd Facet problems: traction posisi
lumbar fllexion
• Mobilisasi discus gerak ekstensi: Ekstensi lumbale dengan
PACVP
• Extension program (Mc. Kenzie); Muscle strengthening
untuk stabilisasi

Sugijanto, 2019
Joint mobilization
 Joint mobilization:
 3D flexion (capsular target)
 NAGs and SNAGs
 Extension SNAGs (disc target)
 Flexion SNAGS (facet tasget)
 Gapping manipulation (facet target)

Sugijanto, 2019
INTERVENSI MT

 GAPPING MANIPULATION LOWER CERVICAL


FACET
 Posisi cervical rotation homolat, lateral flexion
contralat dan flexion
 Manipulasi dengan mendorong transverse
proc kearah rotation homolat.

Sugijanto, 2019
Joint mobilization
 Mulligan concept: NAGS, SNAGS,
MWM, SMWAMS, dan Fist Traction
Upper thoracic joint Mobilization
With movement (MWM)
 Rotasi bersamaan gerak cervical rotation
 Thoracic Mobilization
 Extension dengan NAGs dan SNAGs
 NAGS: 600 ventrocranial glide
 SNAGS sambil gerak fleksi, ekstensi,
rotasi dan lateral fleksi
 LPAVP : unilateral segmental
mobilization

Sugijanto, 2019
Joint mobilization

 Costovertebral manipulation
 Lower thoracic traction manipulation

Sugijanto, 2019
MANIPULATION

 Thoracal spine Gapping manipulation


(minimal
hypomobility/blockade)
 2 or 3dimentional manipulation
 NAGs and SNAGs

Sugijanto, 2019
INTERVENSI MT

NELSON TRACTION
 Sand back pd spinous proc upper thoracal.
 Manipulasi dgn menarik bahu pasien dan mendorong
sand bag keventral.
 Utk minimal capsular pattern

Sugijanto, 2019
Intervention

3 Thrust
Manipulations
2 reps of each
Seated Distraction

Sugijanto, 2019
Myofascial pain para vertebral
muscle thoracal spine

 Ischemic compression technique: kompresi


lokal >30”
 Transverse manual stretching
 Longitudinal manual stretching

Sugijanto, 2019
PROSEDUR INTERVENSI

Intervensi Scalenus Syndrome


 Contract relax stretching m.
scalenus
 Mobilisasi costa1
 Neural mobilization nerve trunk
via:
 N. radialis
 N. Medianus
 Postural correction retraksi
cervical (scalenus)
Sugijanto, 2019
SELF THORACIC MOBILIZATION

 Latihan mobilisasi ekstensi thoracal dgn


foam roller
 Crawl exercise
 Unilateral stretching

Sugijanto, 2019
INTERVENSI MT

 TERAPI LATIHAN
 POSTURAL CORRECTION
 Posisi neck retraction

 STABILIZATION
 Pd posisi terkoreksi

 MOBILISATION
 Mobilisasi cervical hati-hati
 Dlm full ROM kecuali extension.

Sugijanto, 2019
INTERVENSI MT

 STABILISASI PASIF
 Neck collar : soft, semi rigid atau rigid.

 STABILISASI AKTIF
 Neck stabilizing exercise

Sugijanto, 2019
Terapi latihan cervical spine

 Latihan
 Postural correction
 Isometric contraction
 Stretching

Sugijanto, 2019
Terapi latihan thoracal spine

 Latihan
 Postural correction
 Stretching
 Mobilization

Sugijanto, 2019
INTERVENSI MT

 PROPER NECK MECHANIC


 Posisi berdiri, duduk dan bekerja
 Penempatan alat kerja yg tepat
 Penyesuaian kacamata

Sugijanto, 2019
INSTRUMENT
NYERI (VAS, VRS, VDS, dll)
ROM (Goniometer, tip
measure), MOBILITY (elasticity) ,
END FEEL (quality)
STABILISATION
MUSCLE PERFORMANCE (MMT,
HHD, Spygmomanometer)
MUSCLE TONE (myotonometer),
LENGTH (tip measure)

Sugijanto, 2019
Nyeri pada bahu Relevance &
CLINICAL Impingement syndrome contextual
REASONING
Contextual
Fungsi dan disabilitas
factors
Internal External
Anatomic factors factors
impairment
Cuff muscle SLAP
Lesion
AC Bursa Functional
Joint subacromial Pectoralis minor, Participatio
levator scapulae Capsule/ impairment
lig laxity n restriction
osteophyte Serratus anterior
Activity
Inflamation- Tightness limitation
Supraspinatus GH
calc formation
Instability
Weakness
Subscapularis, Over head Work
infraspinatus, Internal
impingement
activity
Inflamation Scapular
dyskinesis Carrying Sport
Inflamation
Tight- Lifting Recreation
hypertrophy

External The used of


impingement arm in ADL
Shoulder pain
Sugijanto, 2019
Nyeri bahu dan
lengan impingement
Ha: Shoulder Keluhan nyeri area deltoid, syndrome
terutama angkat lengan, crepitasi. Ganti hipotesis
Impingement syndrome
tdk
Ya
Pada tes abduksi elevasi tampak Ganti hipotesis
paiful arc humeroscapular rhythm, tdk
Ya
•Jobe’s test;
•Neer test Pemeriksaan red flag:
H5-7 Penyebab • Hawkin Kennedy test Pancoast tumor, Cervical
impingement •Isometric resisted external rot. tdk instability/disc lesion, dll

EXTERNAL SHOULDER IMPINGEMENT


Glenohumeral INTERNAL SHOULDER IMPINGEMENT
H1: Superior capsel
instability

H1: Supraspinatus H2: Subacromial


H3: Infraspinatus H4: Subscapularis H8: SLAP lesion
Traksi caudal: no pain bursa
and No sulcus sign Abdominal press
Empty can test, External rot
Neer-Hawkin test, Internal rot
Abduksi isometric isometric,
test, Crepitasi isometric, palpasi
dan Palpasi posisi Palpasi posisi
dan palpasi posisi netral
borgol sphynx
Superior capsule posisi ekstensi
contracture penyebab
impingement Tendinitis Subacromial Tendinitis Tendinitis
supraspinatus akibat bursitis akibat infraspinatus akibat subscapularis
impimgement impimgement impimgement impimgement

Scapulothoracal
dyskinetic

Scapular tiping Scapular shrugging Scapular winging Sugijanto, 2019


Shoulder External Competency base
impingement approach

Penyebab Akibat
impingement impingement

Subacromial GH
space Instability (a) Tendinitis
sempit Scapular Supraspinatus
Bursitis (b) Tendinitis
dyskinesis
subacromial Subscapularis, (c)
1. Traksi statik ke infraspinatus,
1. Anteroposition:
caudal
Strenghtening /MWM in
2. Roll glide Abd +
posterocaudal correction 1. Transverse friction pss
rotasi eksternal/ 1. Transverse friction pss
2. Instability: Glenohumeral ekstensi
internal (a) borgol/ (b) netral/
functional stabilization 2. Traksi statik ke caudal
3. Mobilization under (c) sphynx
exc 3. Mobilization under
caudal traction 2. Contract relax
caudal traction stretching
1. Tipping: pectoralis
minor stretching
2. Shrugging: levator
scapula
stretcjhing 1. Edukasi proper
3. Winging: Serratus hand activity
anterior strength 2. Stretching
3. Stabilization exc

1. Edukasi: Postural correction


2. Joint stabilization exc Sugijanto, 2019
EVALUATION

ALAT UKUR/EVALUASI FISIOTERAPI YG


DIBUTUHKAN
 Pengukuran nyeri: VAS/VDS/dll
 Pengukuran Stability: Endurance test
 Pengukuran ROM: Goniometer
 Analisis scapulohumeral rhytm
 Analisis scapulothoracal rhytm
 Pengukuran movement disfunction
 Pengukuran disabilitas: SPADI, DASH

Sugijanto, 2019
Resume Clinical pathway
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
4 Nyeri dan Pemeriksaan US/SWD Ringan: 3x/ Nyeri
disabilitas Impingement (5): subacromial, traksi – mgg, 1 sesi berukrang
bahu akibat Painful arc translasi static Sedang: : tiap
external Jobe’s test caudal, Mobilisasi 3x/ mgg, 2 kunjungan
impingement Neer test saat caudal sesi Berat: : Fungsi normal
syndrome Hawkin Kennedy test traction, MWM 2x/ mgg, 4 <2-4 mgg
External rotation sesi
isometric test
+subacromial Bursa subacromial mobilization under idem idem
bursitis Neer & Hawkin test caudal traction,
+supraspinatu Palpasi pisisi ekstensi Contract relax
s tendinitis M Supraspinatus stretching
Jobe’s/Empty can
test
Isometric Abd pada
MLPP
Palpation posisi borgol

Sugijanto, 2019
Relevance
Lumbar disc herniated
&
contextual Functioning and disability Constextual factors

Anatomic impairment
Internal External
factors factors
Disc Nerves Muscle Capsels Facet

Annulus Motoric Chronic


rupture Autonom inflamation

Paretic Weak-
Nocisensoric Blockade
atrphy

Sympathic Spasm Inter fiber Functional


Nucleus
herniation
hyperactivity adhesion impairment
Vascular Activity
Sensitive Capsel contracture limitation Participation
tissue restriction
Micro circular Capsular
Neuropathic constriction pattern
pain Sitting
Work
Radicular pain Stretched Muscle Lifting
Low back pain
pain imbalance Sport
Driving
Postural Recreatio
deformity n
Pain Sugijanto, 2019
Klien dengan keluhan nyeri pinggang
menjalar hingga punggung kaki.

ya Buat hipotesis awal HNP

History taking: Nyeri duduk. Membungkuk, Pemeriksaan red flag:


(Ha: HNP) berkuranhg bila jalan Acute herniated, myelitis dll
tdk
ya
ya
Observasi: Lumbar deviation.
Konsul dokter spesialis
ya yang kompeten

Pemeriksaan Tes orientasi Lumbarl: fleksi trunki nyeri &


Algoritme
fungsi gerak: terbatas, tetapi ekstensi tidak nyeri,
pemeriksaan lain
tdk
ya
Springing test positif, Spurling’s test positif, Algoritme pemeriksaan
Tes khusus: disc traction posisi ekstensi nyeri menurun, valsava
maneouvre positif fisioterapi pada
ya
Radicular pain akibat
Sensoric test dermatome positif, Lasegue positif, Lower
hernia Nucleus
Tes khusus: radiks
Limb Tension Test positif. Kenn muscle bisa positif HIPOTESIS Pulposus Lumbale
LAIN
ya tdk

MRI untuk melihat tingkat HNP dan Nyeri tekan


MRI
Pemeriksaan Penunjang dgn algometer/VAS; Kenn muscle dengan MMT
Dan Pengukuran

Nyeri Pinggang menjalar ke kaki akibatHNP lumbale


Diagnosis

Body structure Impairment: Discus and Nerve root


Identifikaasi
Body Function Impairment:
problem dlm ICF
Disabilitas:
Sugijanto, 2019
Competency base
approach

Lumbar disc
herniated

Annulus rupture, Iritasi jaringan Lumbar straight


nucleus migrate Lumbar disability
dorsal discus posture

Sensitive tissue Nerve


inflamation entrapment
1. Core stability exercise Functional activity
2. Proper body and participation
1. Oscillated traction mechanic education education
in lordotic position
2. POLD methode
3. Extension NAGS 1. Neural mobilization
4. Mc Kenzie 2. Nerve gliding
extension technique
exercise

1. Corset
Sugijanto, 2019
EVALUATION
ALAT UKUR/EVALUASI FISIOTERAPI
YG DIBUTUHKAN

 Pengukuran nyeri: VAS, VRS,


 Pengukuran fleksibilitas/ekstensibilitas otot:
 Pengukuran mobilitas
 ROM: Goniometer, Inclinometer, Schober
 Pengukuran disabilitas
 Oswestry

Sugijanto, 2019
Resume Clinical pathway
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
2 Low back pain Pemeriksaan Discus: SWD, oscillated Disc bulging: 3x Nyeri hilang,
and nerve • Springing test traction pss extension, (3x/mgg) dan 4x ROM dan fungsi
irritation/ • Spurling’s test oscillated POLD (2x/mgg) pulih
adhesion • Distraction test method, NAGs
• Extension test extension mobilization, Disc herniated: Nyeri kurang,
Pemeriksaan stability: Cobra exercises, 6x (2x/mgg) ROM & fungsi
• Core stability test pulih

Extruded- Nyeri menurun,


fragmented: ROM meningkat
Preoperative PT Fungsi membaik

Pemeriksaan Idem
Integritas radix: Neural mobilization idem
Dengan iritasi • Dermatome test Nerve gliding
radix • Kenn muscle test
• Lower Limb Tension
Test (LLTT)

Sugijanto, 2019
OA Lutut Relevance
CLINICAL
&
REASONING
Functioning, and disability contextual
Contextual
factor
Anatomic impairment
Internal External
Rawan Capsul factor factor
Otot/ Vascular
Sendi Ligamen Tendon
Micro
Laxity Spasme Circulation
Erosi
Kontraktur
Inflamasi tl Penumpukan Functional Participation
Subchondral zat iritan impairment restriction

Immobilisasi Nyeri Activity


Osteofit Deformitas
pagi limitation
Tightness/
Iritasi
Kontraktur Antalgic
Jaringan gait Work Recreatio
Lemah n
Capsular
Inflamasi Pattern Nyeri naik Sport
Kronis
tangga
Nyeri
kompresi Nyeri Nyeri jongkok
Regang
Hypomobility Sugijanto, 2019
Nyeri inguinal dan kaku sendi
Anamnesis utk panggul akibat osteo atritis,
menegakkan ICD Ha: Contraktur akibat
Ya OA panggul
Nyeri dan kaku panggul bangun
tidur, krepitasi, internal rotasi Ganti hipotesis
sangat terbatas Tdk
Ya
Patologi serius/
Posisi sendi: Red flag?
Inspeksi Tdk
Ya
Duchene gait; Posisi Tengkurap,
rotasi internal terbatas
Tes Cepat:
Ya ALGORITMA
Red flag: PEMERIKSAAN
Test Gerak Pasif FISIOTERAPI PADA
:Nyeri & terbatas (rotasi internal < abduksi
CAPSULAR PATTERN
Muskular?
< Fleksi dengan Elastic - Firm End Feel)? Tdk HYPOMOBILITY SENDI
Ya PANGGUL AKIBAT
Isometric test dan
Joint Play Movement (Nyeri, Elastic - Firm
End Feel), Traksi pembatasan ROM abduksi, palpasi OSTEO ARTRITIS
Tes khusus
rotasi internal dan rotasi eksternal
Penunjang: X-Ray

Diagnosis CAPSULAR PATTERN HYPOMOBILITY OF


THE HIP AKIBAT OSTEOARTRITIS

Problem: Contracture lutut aibat OA


Body structure impairment: Joint surface/capsules
Body function impaitmen: Capsular pattern Hypomobility
Disabilitas: Sugijanto, 2019
Competency base
approach
OA LUTUT
Anatomic
impairment Kinetic
target impairment
Muscle
Joint surface weakness/tightn
inflammation/erosi ess Tibial lateral
Capsular glide posture
Mal Tibial medial
pattern alignment glide position
1. Active stabilization
1. Traksi osilasi inferior 2. Contract relax
2. Pengurangan berat stretching otot
badan MWM dengan
contracture/tegang
3. Olah raga dalam medial glide
3. Muscle
kolam reposition
strengthening &
Functional exc
Penggunaan AFO MWM dengan
1. Traksi osilasi MLPP Penggunaan
2. Mobilisasi pada akhir lateral glide
orthopaedic shoes reposition
pembatanan rom
3. Roll glide
Sugijanto, 2019
EVALUATION
ALAT UKUR/EVALUASI FISIOTERAPI
YG DIBUTUHKAN

 Pengukuran nyeri:
 VRS, VDS, NRS.
 Pengukuran stabilitas sendi:
 One Leg Standing Test,
 Pengukuran mobilitas sendi:
 ROM: Goniometer
 Analisis berjalan
 Gait Analysis
 Pengukuran movement disfunction:
 Agility test
 Pengukuran disabilitas:
 KOOS, Womac,

Sugijanto, 2019
Resume Clinical pathway
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
Knee joint Pemeriksaan alignment: SWD/US, tibiofemoral Kellgren 1: 3x Nyeri hilang,
Capsular pattern • Deformitas/Alignment: joint and (3x/mgg) dan ROM dan fungsi
hypomobility valgus/ varus/ patellofemoral joint 4x (2x/mgg) pulih
akibat knee recurvatum oscillated mob. in
osteoarthritis Pemeriksaan rawan sendi: MLPP, end range Kellgren 2: 6x Nyeri kurang,
• Crepitasi joint mobilization, (2x/mgg) ROM & fungsi
• Compression nyeri MWM and active pulih
• Traction test nyeri - mobilization exc,
Pemeriksaan Capsul: MWM Kellgren 3-4: Capsules-
• Passive test: capsular pre operatif muscle-Nerve
pattern; elastic e f. 3x (seminggu) lentur
• Joint play movement Rehabilitatif 6x Fungsi membaik
nyeri dan elastic/firm end (2x/mgg)
feel
• Stability test: ligament
laxity
Dengan knee + medial glide varus idem idem
valgus mobilization

Dengan knee + medial glide varus


varus mobilization
Sugijanto, 2019
Sugijanto, 2019