INTERVENTION PROGRAM

IN MUSCULOSKELETAL PHYSIOTHERAPY
(EXTREMITY)

HERI PRIATNA
MODULE MUSCULOSKELETAL ORTHOPEDIC ILOMPT
04 SEPTEMBER 2020

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Intervention Program
“Bagian dari proses Fisioterapi”

* Asesmen pasien : pemeriksaan & evaluasi

* Penegakan diagnosa Fisioterapi
* Perencanaan intervensi
* Intervensi
* Evaluasi / Re-evaluasi
* Komunikasi & edukasi
* Dokumentasi
Merupakan hasil pemeriksaan dengan konsep berfikir kritis
• Sesuai dengan kriteria ICF
• Gunakan metoda HOAC
• Bdsk Evidence Based Clinical Practise (EBCP)
• Pasien value / need

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Ruang lingkup
* Prinsip intervensi terapi pada jaringan lunak dan tulang
* Soft tissue lesi
- Beberapa kasus soft tissue lesi
- Kondisi klinis akibat trauma dan patologi
- Tingkat soft tissue injury
- Tahapan inflamasi dan reparasi
- Treatment/intervention guidline
* Fraktur
- Pertimbangan klinis periode immobilisasi
- Pertimbangan intervensi terapi periode immobilisasi
- Pertimbangan klinis periode paska immobilisasi
- Pertimbangan intervensi terapi periode paska immobilisasi

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 Prinsip Terapeutik pada jaringan lunak dan tulang
Tujuan:
1. Identifikasi contoh-contoh Soft tissue lesi
2. Identifikasi karakteristik perbaikan soft tissue selama tahap peradangan,
penyembuhan dan pemulihan fungsi
3. Identifikasi pertimbangan khusus, tujuan dan rencana tindakan terapeutik
soft tissue lesi tahap inflamasi, penyembuhan, perbaikan pemulihan fungsi
4. Identifikasi pertimbangan khusus, tujuan dan rencana tindakan terapeutik
untuk joint disorder pada tahap eksaserbasi dan remisi gejala/simptom
5. Identifikasi pertimbangan khusus, tujuan dan rencana tindakan terapeutik
pada pemulihan kasus patah tulang/fraktur
6. Identifikasi pertimbangan khusus, tujuan dan rencana tindakan terapeutik pada
manajemen pra dan paska operasi

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Soft tissue lesi
1. Strain
2. Sprain
3. Subluxation
4. Dislocation
5. Muscle/tendon rupture – tear
6. Synovitis
7. Tendinous lesions : Tenosynovitis, tendinitis, tenovaginitis, tendonosis
8. Hemarthrosis
9. Ganglion
10. Bursitis
11. Contusion
12. Overuse syndromes : Kumulatif trauma, repetitive strain
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1. Strain : overstretching, overexertion, overuse soft tissue
Trauma ringan dan berulang pada jaringan musculotendinous
Tingkat keparahan – less than sprain
2. Sprain : soft tissue severe stress, stretch, tear
Capsule dan ligamentum. Umumnya pada ligamentum
first grade (mild), second grade (moderate), third grade (sprain)
3. Subluxation : incomplete/partial dislocation sebagai secondary trauma disekitar
jaringan lunak
4. Dislocation : displascement struktur sendi, disertai soft tissue damage, inflamasi,
nyeri dan spasme otot
5. Muscle/tendon rupture-tear :
Partial tear: nyeri pd regio cedera bila otot terulur / resisted
Complete tear: stretching & kontraksi otot tdk timbulkan nyeri
6. Synovitis :
Inflamasi membran sinovial ; kelebihan cairan sinovial dalam sendi atau tendon
sheat akibat trauma or disease
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7. Tendinous lesions :
- Tenosynovitis: inflamasi membran sinovial yang menutupi tendon
- Tendinitis: inflamasi tendon akibat scar tissue atau deposit Calsium
- Tenovaginitis: inflamasi disertai penebalan selubung tendon
- Tendonosis: degenerasi tendon akibat repetitive trauma
8. Hemarthrosis :
perdarahan dalam ruang sendi akibat trauma berat
9. Ganglion :
balon dinding capsul sendi/selubung tendon, timbul paska trauma & akibat RA
10. Bursitis : Inflamasi Bursa
11.Contusion : memar akibat pukulan langsung, sebabkan ruptur kapiler,
perdarahan, edema, dan respons peradangan
12. Overuse syndrome : kumulatif trauma , repetitive strain injury
Gesekan/friksi berulang pada otot atau tendon, sebabkan inflamasi dan nyeri
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Kondisi klinis: akibat trauma & pathologi
 Dysfunction:
hilangnya fungsi normal jaringan ; adaptif shorthening, adhesion, muscle weakness
atau kehilangan mobilitas normal
 Joint dysfunction:
loss fungsi & pain; trauma, immobilisasi, aging, Path condition
 Contractures :
shorthening or tightening; skin, fascia, muscle, capsul sendi
 Adhesions :
penumpukan kolagen saat imobilisasi akibat trauma / komplikasi Ops
 Reflex muscle guarding :
prolonged kontraksi sbg respon stimulus nyeri, berhenti bila nyeri relieved
 Intrinsic muscle spasm :
kontraksi otot sebagai respons thd perubahan sirkulasi & metabolisme lokal
 Muscle weakness
penurunan kekuatan kontraksi otot, oleh lesi sistemik, chemical, lokal CNS/PNS dll

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Tingkatan soft tissue ijury

 Grade 1 ( first-degree):
Nyeri ringan saat cedera atau dalam 24 jam, mild swelling, local
tenderness yang timbul saat jaringan ditekan/stressed
 Grade 2 ( second-degree):
Nyeri sedang sebabkan aktivitas terhenti, nyeri bertambah
saat jaringan teraba / tertekan secara kuat.
 Grade 3 ( third-degree):
Complete-tear atau avulsi jaringan (tendo/ligament) dengan
nyeri berat. Tekanan pada jaringan tdk timbulkan nyeri,
kerobekan jaringan/Ligament sebabkan instabilitas sendi

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Tahapan: inflamasi dan reparasi
Tahap Akut : Reaksi inflamasi
 Karakteristik :
- Respon cellular & imunitas humoral
- Vascular change ... Predominate/menonjol
- Eksudasi cells dan solution/zat terlarut dari vena utk bentuk Clot
- Netralisasi iritasi kimia atau noxious stimuli
- Phagocytosis, fibroplastic activity awal & formasi kapiler baru
- Berlangsung selama 4 – 6 hari
 Clinical signs :
- Swelling, redness, heat, pain
- LGS terbatas
- Muscle guarding sebelum mencapai full LGS
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 Tahapan: inflamasi dan reparasi

Tahap Sub-akut : Repair-healing

 Karakteristik :
- Deposisi dan sintesa kolagen, noxious stimuli hilang & growth capillary
- Fibroplastic activities; formasi kolagen, peningkatan jaringan granulasi
- Pertumbuhan fibroblast : 4 – 21 hari ... Produce new collagen
- Immatur Collagen gantikan eksudat yang awalnya membentuk Clot
- Wound closure ; otot & kulit 5-8 hari, tendo & ligament 3-5 hari
- Berlangsung selama 14 – 21 hari setelah cedera/kadang s.d 6 mg
 Clinical signs :
- Tanda-2 inflamasi berkurang s.d hilang
- Pengukuran ROM ; timbul nyeri pd akhir gerak oleh resistensi jaringan

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Tahapan: inflamasi dan reparasi
Tahap Kronik : Maturasi & remodeling
Tissue repair/rekoveri tanpa tanda-2 peradangan, blm mampu full fungsi
Berlangsung> lama dengan episode disfungsi saat healing process
 Karakteristik :
- Maturasi connective tissue; serat kolagen dari fibril & scar tissue mature
- Remodeling; serat kolegen menjadi lebih tebal, Density connective tissue
 Clinical signs :
- Tidak ada tanda-2 inflamasi
- Pengukuran ROM ; tidak terasa nyeri sampai akhir gerak
- penurunan kekuatan, LGS & kehilangan sebagian fungsi
- Mulai restorasi fungsi

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Tahapan: inflamasi dan reparasi
Tahap Inflamasi Kronik :
 Karakteristik :
- proses inflamasi tetap berlangsung pd intensitas rendah meski “scar tissue
remodeling” mendapat tekanan/iritasi
- proliferasi fibroblas - peningkatan produksi kolagen, degradasi mature
kolagen & dominasi kolagen imatur baru... Lemahkan jaringan
- aktivitas myofibroblastic tetap berlanjut , sebabkan limitasi gerak progresif
- tissue stretch.... Timbulkan iritasi dan limitasi progresif
 Clinical signs :
- Increased pain, swelling, prolonged kontraksi bbrp jam stlh aktivitas
- Stiffness feeling after rest, loss LGS 24 jam stlh aktivitas
- increased progressive stiffness tissue selama iritasi berlangsung

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TREATMENT GUIDELINES
FASE AKUT

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A. Pertimbangan klinis : Protection phase of treatment
 Tahap inflamasi : nyeri & gangguan gerak oleh chemical iritasi, oedema, muscle
guarding & spasme, joint swelling(efusi)
 Rest & proteksi (24 jam-I):
- kurangi nyeri Muskuloskeletal & promote healing process
- Complete immobilisasi; adherence fibrils, weakness connective tissue,
articular cartilage changes
- Goal & methods: reduce efek inflamasi, proteksi injury lanjut, cegah
degradasi efek immobilisasi
 Long term goal Tx :
- Formasi jaringan complete & tanpa hambatan restorasi
- Utk pengaruhi pertumbuhan jaringan ( organized scar) awali Passive mov
( carefully, tolerans & controlled) ....Cegah abnormal adherence
- Active Mov neighboring regio: maintain integrity un-injured tissue
( circulation & lymphatic flow )
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 Dosis & teknik: Jaringan spesifik
- Sendi & Ligamentum :
+ Passive ROM toleransi, Har Grk tanpa tahanan/stress
+ Gentle passive joint traction/glides within limit of pain, tanpa stretch
capsul-ligament, Grade I / II distraksi, glides, oscilation in pain free position
(maintaining mobility capsul & ligament, moving synovial fluids... to enhance
cartilage nutrisi & diffusi waste product, to block nociceptive stimuli
transmision to relieve pain via mekanisme neurologi)
+ Gentle massage: benefit circulation-Lymp flow, decrease oedema & pain
+ Intermitten muscle setting: related muscle & circulation tanpa grk sendi
- Otot :
+ Passive ROM toleransi, Har Grk tanpa Resisted/stress... No stretching
+ Intermitten muscle setting / E.Stimulasi shorthened range (Same benefit)
+ Gentle massage ; circulation&lymp flow (decrease oedema & pain)
+ JPM Grade I/II - related joint (maintain normal mov saat proses healing)
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 Dosis & teknik: Jaringan spesifik
- Tendinous
+ Gentle transverse massage; haluskan permukaan tendo yang kasar
+ Passive ROM within limit of pain; maintain joint range tolerans
+ JPM ( grade I / II; Maintain joint range without stressing injured tissue

- Other connective tissue

+ Passive ROM toleransi, Har Grk tanpa Resisted/stress... No stretching
+ Muscle setting Exc ; assist circulation & muscle function
+ JPM ( grade I / II ); maintain joint integrity
+ Gentle massage ; maintain mobility connective tissue & bantu circulation
dan lymp flow

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 Pertahankan kondisi fisiologis area normal terkait selama tahap Proteksi
- ROM :
+ Active / Passieve ROM, tergantung kondisi area cedera
- Muscle strength :
+ Resistance; pada otot diluar area cedera
+ Persiapan penggunakan assistive devices... Improve functional activities
- Functional activities :
+ Peralatan supportive dan adaptive untuk functional activities
- Vaskularisasi / circulation :
+ Supportive elastic wrap
+ Elevating tissue part
+ Appropriate massage
+ Muscle-setting tecniques
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 B. Pertimbangan Treatment : Protection phase
 Impairment / Rangkuman masalah :
- Inflamasi, pain, oedema, spasme otot
- Impaired movement
- Joint effusion ( bila cedera sendi/ arthritis )
- Penurunan penggunaan area terkait
 General Treatment Goal & Plan :
NO GOALS PLAN
Cold, compression, elevation, massage (48 hour),
1 Control Pain, oedema, spasme immobilisasi (rest, splint, tape, cast), avoid positions of
stress to the part, gentle (grade-I) joint Oscillations

2 Maintain soft tissue , joint integrity & mobility Passive Mov limit pain, intermitten muscle setting,
Elektrikal Stimulasi
3 Reduce joint swelling Protection ( splint, cast), medical; rapid blood

4 Maintain integrity & function associated area Asisted, free, resisted, modified aerobik exc, Adaptive /
assistive devices

5 Educate Patient Inform patient recovery time, how to protect injured

part while maintaining functional activities
Note: too much movement are increased pain & inflammation
Contra indications: Active ROM, stretching activities, resistance exercise 19
TREATMENT GUIDELINES
FASE SUB AKUT

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A. Pertimbangan klinis : Control motion phase
 Saat healing proses: Pain & inflamasi berkurang, jar baru yg msh rapuh(fragile)
- Over Tx sebabkan injuri baru pd fragile tissue
- Low Tx: new fragile tissue adheres... Sumber nyeri & limited mobility
- Active exc: reduce swelling & pain, Har LGS – without pain
 Intensitas Tx dikurangi: bila inflamasi meningkat & ROM menurun progresif
- Multiple-angle, submaximal isometric exc; kontrol kontraksi yg disadari
- AROM Exc in pain-free range; Kontrol perkembangan gerak
- Protected close Chain Exc; stimulate stabilizing co-contraction
 Restricted motion & adherence pd acute stage ; decreased flexibility.
- Joint & Lig ; Passive JPM in limits pain-grade II. (effusion...no capsule stretch)
- Muscle ; gentle contract relax/ES (Length muscle), cross-fiber massage/CFM, JPM grade II/
glides sendi terkait sampai otot terulur penuh
- Tendon ; CFM, JPM grade II ( traksi & glides )
- Other tissue ; CFM/soft tissue massage, JPM grade II/associated joint... Tissue full flexibility
 Correct postural stability, muscle length – strength – inbalance
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 B. Pertimbangan Treatment : Controlled motion phase
 Impairment / Rangkuman masalah :
- Pain of the end-ROM
- Decreasing soft tissue oedema
- Decreasing joint effusion (if joints are involved)
- Developing soft tissue, muscle and joint contracture
- Developing muscle weakness (reduce usage)
- Decreased functional use (part & associated areas)
 General Treatment Goal & Plan :
NO GOALS PLAN
1 Promote healing of injured tissues Protect healing tissues ; Ass devices, splints, tape & wrap

2 Progressively restore; soft tissue, muscle, joint Progres; Passive-Active assisted-Active ROM
Gradual; increase mobility of scar & Jar spesifik terkait
3 Progressively strengthen muscles Multiple-angle Isometric Exc tolerans, Close chain-stab exc,
Open chain isotonik-resistance & JPM
4 Maintain integrity & function associated area Progresive strength exc & Stability exc
5 Educate Patient Instruct Patient ; Home program & monitor effect
Note: Some discomfort ; activities level is progressed
Too much motion/activities; resting pain, fatigue, weakness and spasm 22
 TREATMENT GUIDELINES
FASE KRONIK - REMODELING STAGE

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 A. Pertimbangan klinis : Return to Function phase
 Reduction in size of wound, Quantity collagen stabilize ; balance synthesis & degradation, force
berlebihan ... Re-injury, chronic inflammation & hambat return of function
 Maintained mobility  progression activity & function  with greater intensity & complexity
 Motion beyond LGS  “Nyeri”(first PT’s).... Contractures; stretched / Adherence; be broken
 Progression Tx: ... Attention;
- Free JPM (functional ROM)  avoid Joint trauma / Restricted  use Joint mobilizing tech
- Incresed strength with loos Joint play  Multiple-angle isometric recommended / Joint
play restored  Resisted isotonic exc
 Adhesion Fascia, skin, lig dll  restricted motion  mobilized with soft tissue stretching tech
 Principles of Tx : To be continued  part in “pain” free, normal ROM & Good stength
 Progressive Tx design  prepare Patient meet Functional outcome goals:
- Exc simple to multidirectional mov  requiring Coord muscles / Strength exc (close-open
chain)  spes demand / controlled stabilization trunk & proximal segment  effective
extremity motions / preventing injury associated with fatigue  develop muscle endurance
 To return activities: Plyometric exc, agility training & skill development  stimulate work & sport
24  Proper education : To safe progression on exercise & to avoid damaging stresses
 B. Pertimbangan Treatment : Return to Function phase
 Impairment / Rangkuman masalah :
- Pain is experienced only when stress is applied to structures in dysfunction
- Soft tissue, joint contracture, adhesion limit normal ROM / joint play
- Muscle weakness
- Decreased function of the involved part Note:
Activities too quickly / too great a dosage; joint
- Unable to function normally in a described activity swelling, pain (lasts 4 hr), decrease strength and
 General Treatment Goal & Plan : fatiguing easily
NO GOALS PLAN
1 Decreased pain from stress; contracture & adhesion Stretch limiting structure, develop control & stabilized,
biomechanical counseling

2 Increase soft tissue, muscle and joint mobility
3 Strength supported & related muscles, develop
biomechanical balance between muscle groups
4 Develop muscular endurance ; prime mover & stab
5 Progress functional independence
Soft tissue ; Passive stretch & massage / Joint, capsul, selected lig;
Joint mob/Lig, tendo, adhesion tissue; CFM / muscle; flexibilty tech
Sub max to max resistance, concentric & exenctric, open &
close Chain, single to multi plane, simple to complex
Increased time at slow speed, progress complexity and time,
progress speed and time
Device  ROM functional with good joint play/ progressive
strength exc  advanced training

25 6 Educate the patient Instruct patient in safe progression,Tech prevention

 TREATMENT GUIDELINES
FASE CHRONIC RECURRING PAIN
(CHRONIC INFLAMMATION)

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 A. Pertimbangan Klinis :
1. Chronic inflammation : Acute stage
Masih terdapat inflamasi respon  continued tissue irritation
 Biomechanical counseling : selain modality & rest
 Initially ; only nonstresfull activities
 Exercise dimulai dengan nonstressfull intensities pada area cedera dan sekitarnya
2. Sub-Akut & Chronic stage : Healing the chronic condition
Constant pain has decreased, mampu bertahan thd functional stress
 Contracted scar limit ROM  Friction massage, soft tissue manipulation, stretching tech
- Inflammation from stretching maneuvers  Tx as Acute injury
- Chronic inflammation : proliferasi scar tissue & contraction scar  Warning Stretch Full
- Stabilization & safe adaptive patterns training  protect body part from excessive motion
 Strength & stab exc ; applied in working & recreational adaptation  minimize irritating patterns
 Endurance exc  muscle re-education program
 Progressive exc; develop functional independence  prepare patient to return work, sport etc
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 B. Pertimbangan Treatment : Chronic inflammation

 Impairment / Rangkuman masalah :

- Varying degrees Pain in the involved tissue :
+ Only after doing repetitive activities
+ When doing repetitive activities
+ When attempting to do activities
+ Continued and unremitting
- Soft tissue, muscle, joint contracture or adhesions that limit normal ROM / Joint play
- Muscle weakness, poor muscular endurance  in postural / stabilizing muscle
- Imbalance (length & strength) antagonic muscles  Biomechanical dysfunction
- Decreased functional use of the region
- Faulty position / movement pattern  perpetuating the problem
( pss salah) (timbulkan masalah)

 General Treatment Goal & Plan : Chronic inflammation period

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disebalik .......................
 B. Pertimbangan Treatment : Chronic inflammation
 General Treatment Goal & Plan : Chronic inflammation period
NO GOALS PLAN
1 Promote healing : decreased pain & inflammation Cold, compression, massage ( rest-splint-tape-cast)

2 Eliminate irritating factors: involved Px in program Education & counseling; biomechanics & adaptation environtmen

3 Maintain integrity & mobility of involved tissue Nonstressful Passive Mov, massage, muscle setting in limit pain
4 Develop support in related regions Awareness training, stabilization exercise

 General Treatment Goal & Plan : Return to Function phase

NO GOALS PLAN
1 Develop strong, mobile scar Friction massage, soft tissue mobilization

2 Develop balance in length & strength of the muscles
3 Progress functional independence
4 Correct environmental factors causing problem
Appropriate stretching & Strengthening  Correct faulty
muscles & joint mechanics
Train muscle to function, coordination & timing, develop
endurance & patient education
Job, activities analysis, environmental adaptation, Px education

Note:
• Progressive Loss ROM as the result of stretching  Do not continue stretching
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 Fraktur

A. Pertimbangan klinis periode Imobilisasi:

1. Imobilisasi / Fiksasi:
Connective tissue weakening, degenerasi cartilago, atrofi otot,
sluggish/lamban sirkulasi, scar formasi.
Gerakan toleransi area diluar imobilisasi... Seawal mungkin
2. Bed rest/Immobilisasi dalam Bed, skeletal traksi:
Perubahan fisiologis sistem tubuh secara sistematis.
General exercise bagian tubuh yang tdk terfiksir
3. Fraktur ekstremitas bawah:
Alat bantu berjalan/device sesuai kondisi fraktur

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 B. Pertimbangan Treatment periode Immobilisasi:
1. Impairment:
a. Inflamasi, swelling, atrofi, kontraktur, deg cartilago, sirkulasi
b. Berpotensi “overall body weakening”  lama di Bed
c. Limitasi fungsi  saat imobilisasi sesuai lokasi fraktur

2. General Treatment Goal & Plan:

NO GOALS PLAN

1 Kurangi efek inflamasi masa akut Ice, elevasi, intermittent muscle setting

2 Kurangi efek immobilisasi Intermittent muscle setting, AROM above / below Imobilisasi

3 Pelihara kuat otot dan ROM major Resistive ROM major muscle groups diluar area imobilisasi
muscles group pada in bed pasien persiapan ambulasi

4 Mengajarkan fungsional adaptasi Asisted, free, resisted, modified aerobik exc, Adaptive /
Penggunaan assistive / supportive devices utk ambulasi dan
bed mobility

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C. Pertimbangan Klinis paska Imobilisasi:

1. Terdapat: decreased ROM, atrofi otot, joint pain pada struktur paska
imobilisasi. Aktivitas awal toleransi agar tidak terjadi trauma pada
struktur yang melemah
2. Nyeri awal gerakan sendi akan hilang/berkurang seiring bertambahnya
ROM, kuat otot dan gerakan sendi secara progresif
3. Kerusakan jaringan lunak saat fraktur, sebabkan ROM berkurang dan
nyeri regang. Lakukan Teknik mobilisasi toleransi yang disesuaikan
dengan kondisi jaringan
4. Amati gambaran radiologi untuk menentukan apakah fraktur telah pulih
5. Pemulihan fungsi: ROM, kuat otot dll setelah konsolidasi

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 D. Pertimbangan treatment paska immobilisasi
1. Impairment:
a. Keterbatasan LGS dan joint pain (nyeri regang)
b. Atrofi dan kelemahan otot
c. Gangguan fungsi dan aktivitas ( berjalan utk lower extremity)
2. General Treatment Goal and Plan

NO GOALS PLAN
1 Kurangi nyeri post fiksasi & spasme Relaxation exc,TENS, cold, heat, CPM early stage

4 Cegah joint stiffness & kontraktur CPM / PROM segera paska immobilisasi

5 Cegah atrofi otot sendi terfiksir Muscle setting exc immediately after surgery

6 Pelihara ROM dan kuat otot sendi
above and bellow
7 Pelihara functional mobility pada
protecting site
Continue to maintain functional
integrity of un-fiksasi areas
33 8 Educate patient
Active & resistive exc un-Fiksasi areas
Adaptive equipment and assistive device
Progressive strengthening un-fiksasi areas: using
resistance exc in open or closed kinetic chain
Teach Px to monitor the effects of exc program