Pengelolaan FT Impingement Syndrome. J
Pengelolaan FT Impingement Syndrome. J
SHOULDER IMPINGEMENT
SYNDROME
Oleh: Sugijanto,
Disampaikan pada: Webinar Perfi CAB JAKARTA BARAT
OKTOBER 2021
Sugijanto 2021
SHOULDER IMPINGEMENT SYNDROME
Sugijanto 2021
SHOULDER PAIN AND DISABILITIES
- The incidence in the Dutch primery care is 15 - 25 per 1000
- The primairy cause of nocisensoric of shoulderpain is mostly
localized in the rotatorcuff tendon.
- 75% of the non-traumatic shoulderpain is diagnostic as an
impingement syndrome.
Sevinsky S, 2004
Shoulder
Impingement
syndromes
External Internal
Impingement Impingement
Primer Sekunder
Cools e.a.2008
Sugijanto, 2021
Shoulder
Impingement
syndromes
External Internal
Impingement Impingement
Primer Sekunder
Cools e.a.2008
Sugijanto, 2021
Shoulder
Impingement
syndromes
External Internal
Impingement Impingement
Primer Sekunder
Cervical
Thoracal spine
spine Costa I – XII,
ACJ, SCJ
Sugijanto, 2021
Fisioterapi profesional
Sugijanto, 2021
BAGAIMANA ANDA MENGANALISIS ICD
DALAM ICF?
• APAKAH JARINGAN SPESIFIK DAN MEKANIK
YANG TERGANGGU PADA SHOULDER
1. IMPINGEMENT?
Environment
Person
DISEASE / DISORDER
ICD / ICPC
• APAKAH KETERBATASAN AKTIVITAS DAN
HAMBATAN PARTISIPASI PADA SHOULDER
functions / anatomical
characteristics
(Impairments)
(limitations in)
activities
(restrictions in)
participation
2. IMPINGEMENT?
FUNCTIONING
external factors personal factors
• APAKAH FAKTOR INTERNAL DAN EKSTERNAL
YANG BERPENGARUH TERHADAP
3. PENYEMBUHAN PADA SHOULDER IMPINGEMENT?
• Use of the ICF Model as a Clinical Problem-Solving Tool in Physical Therapy and
Rehabilitation Medicine (Steiner et al, 2002)
Sugijanto, 2021
PERTANYAAN NO 1 TENTANG ANALISIS ICD KE
DALAM ICF
Bagaimana meng analisis patologi penyakit (disease = ICD) ke dalam
gangguan gerak dan fungsi sesuai ICF
• Pada shoulder impingement syndrome?
• Body structure impairment: Muscle? Capsules?
• Body function impairment: Painful arc? Joint stability? Scapular
dyskinesis?
• Activity limitation: ADL? Hand activities?
• Participation restriction: Work? Sport?
• Contextual factors? DM?
Sugijanto, 2021
BODY STRUCTURE (ANATOMICAL)
ASPECT
Tulang & persendian pembentuk shoulder complex:
• Scapula dengan glenoid cavity bersedi dengan humerus dan
acromion bersendi dengan claviculae serta dengan thoracis
• Humerus dengan caput humeri bersendi dengan glenoid cavity
sebagai sendi Glenohumeral joint
• Clavicula bersendi dengan acromion sebagai acromioclavicular
joint
• Sternum bersendi dengan clavicula sebegai sternoclavicular joint
• Costae bersendi dengan scapula sebagai scapulothoracic “joint”
dan bersendi dengan vertebra sebagai costo vertebral-transversal
• Cervicothoracic junction secara tak langsung melalui otot terlibat
gerak shoulder complex
Sugijanto, 2021
GLENOHUMERAL JOINT
• Persendian:
• Glenoid cavity cekung landai dengan tepian
labrum bersendi dengan head of humerus bulat.
• Glenoid cavity posisi menghadap sedikit keatas
depan sehingga humerus sedikit menumpang
• G-H joint capsules
• Anterior: tebal dengan 3 ligament glenohumeral
lig.
• Inferior: membentuk lipatan longgar
• Posterior: lebih tipis
• Mobilitas luas
• Fleksi-ekstensi: S 1800 /00/600
• Abduksi-adduksi: F 1800 /00/450
• Rotasi internal-eksternal: T 950/00/850
Sugijanto, 2021
GLENOHUMERAL JOINT (lanjutan)
Sugijanto, 2021
ACROMIOCLAVICULAR JOINT
• AC Joint mobility:
• Elevasi-depresi, dan
• Protraksi-retraksi,
• Hypomobility menimbulan penyimpangan gerak
scapulohumeral → impingement
• AC Joint stability:
• AC capsule
• Coracoclavicular lig.
• Costoclavicular lig
• Ligament laxity menimbulan penyimpangan gerak
scapulohumeral → impingement
• AC Joint Instability test:
• Palpasi untuk mengetahui dislokasi acromion dan ujung distal
clavicle dan beri tekanan 4 arah
• Penebalan AC joint dan osteophyte menimbulkan
impingement.
Sugijanto, 2021
STERNOCLAVICULAR JOINT
• SC Joint mobility:
• Elevasi-depresi:
• Protraksi-retraksi:
• SC Joint stability:
• SC joint capsule
• Interclavicular lig.
• Claviculocostal lig.
• SC Joint Instability test:
• Lakukan tekanan pada SC joint ke anterior, superiorl dan
inferior
• Determine stability or pain associated with a joint sprain
Sugijanto, 2021
SCAPULOTHORACIC ‘JOINT’
• Scapulothoracic Joint mobility
• Elevasi-depresi
• Abduksi-adduksi
• Rotasi keatas-kebawah
• Scapulothoracic Joint stabibility
• Sepenuhnya oleh otot
• Scapulothoracic Joint movement impairment
(dyskinesis)
1. Scapular winging
2. Capular shrugging
3. Scapular winging,
• Ketiganya menimbulkan penyimpangan gerak →
impingement
Sugijanto, 2021
Mobility shoulder – shouldergirdle – CTO
(Stenvers)
Sugijanto, 2021
NYERI BERASAL DARI JARINGAN
SPESIFIK (ANATOMIS)
Wound healing process
Hypoxia necrosis
Ischemic
SPECIFIC Inflammation necrosis
TISSUE Connective tissue Cross links
Adhesion
Myofibrile Tightness
Sensitization Hiperalgesia
Sugijanto 2021
PERTANYAAN NO 2 TENTANG NYERI
• Apakah patologi/impairment yang dapat menimbulkan sensasi
nyeri kompleks bahu?
• Bagaimana membuktikan nyeri berasal dari inflamasi jaringan
otot? Contoh pada m. supraspinatus tears?
• Bagaimana membuktikan nyeri berasal dari iritasi osteofit sendi
acromioclavicular? Contoh cuff tendinitis oleh osteofit ACJ?
• Bagaimana membuktikan nyeri berasal dari instabilitas
glenohumeral joint? Contoh subacromial impingement akibat
glenohumeral anterior instability?
Sugijanto, 2021
BODY STRUCTURE IMPAIRMENT ASSESSMENT & INTERVENTION
Sugijanto, 2021
PERTANYAAN NO 3 TENTANG KAPSUL SENDI
Sugijanto, 2021
MUSCULAR
Sugijanto, 2021
MUSCULAR
• Deltoid m.
• Trapezius:
• Upper
• Middle
• Lower
• Levator scapulae
• Teres mayor
• Rhomboid mayor & minor
• Latissimus dorsi
• Pectoralis mayor
• Pectoralis minor
Sugijanto, 2021
MUSCULAR: CUFF MUSCLE
1. Supraspinatus
• Memulai abduksi
• Paling sering cidera
2. Infraspinatus
3. Teres Minor
• Keduanya rotasi eksternal humerus
4. Subscapularis
• Rotasi internal humerus
Sugijanto, 2021
BODY STRUCTURE IMPAIRMENT ASSESSMENT & INTERVENTION
Sugijanto, 2021
BODY FUNCTION IMPAIRMENT
• PAIN Balance
• PAIN IN REST
◦ Sitting disbalance
• PAIN IN MOVEMENT
• REFERRED PAIN ETC ◦ Standing disbalance
• JOINT MOBILITY: ◦ Walking disbalance,
• ANKYLOSING etc
• HYPOMOBILITY Gait:
• JOINT BLOCKADE
◦ Antalgic gait
• JOINT STABILITY:
◦ Duchene gait
• HYPERMOBILITY
• INSTABILITY
◦ Trendelen burg gait, etc
• MUSCLE PERFORMANCE: Hand function:
• MUSCLE WEAKNESS ◦ Grip weakness
• MUSCLE PARESIS ◦ Prehension disability, etc
Sugijanto 2021
POSTURE OF THE SHOULDER
• Anterior position of the head of humerus
• Penyimpangan posisi (positional vault) yang
paling banyak ditemui
• Banyak pada shoulder impingement
• Penyi mpangan posisi memulai kesalahan
gerak
• Superior position of the head of humerus
• Sub acromial space yang sempit penyebab
utama shoulder impingement
Sugijanto 2021
Dynamic Shoulder Stabilizers
• Group I
• Origo vertebra dengan insersi humerus
• Latissimus dorsi, pectoralis major
• Group II
• Origo Scapulae
• Deltoid, teres major, coracobrachialis
• Subscapularis, teres minor, supraspinatus, infraspinatus
• Short rotators (rotator cuff) integrated into joint capsule
• Rotator bersama biceps membentuk stabilisasi dinamis, mencega
loslokasi humerus
• Rotator cuff membentuk beberapa gaya yang menjaga tekanan
humerus terhadap glenoid mencegah gerak luncur berlebih
• Dynamic equilibrium
• Imbalances menyebabkan mekanis abnormal → impingement
Sugijanto, 2021
Static Stabilizers
• Glenohumeral ligaments
• Anterior glenohumeral ligament membatasi ekstensi, abduksi dan
rotasi eksternal
• Posterior glenohumeral ligament membatasi ekstensi dan rotasi
eksternal n
• Inferior glenohumeral ligament
• Membatasi abduksi, ekstensi dan rotasi eksternal
• Critical for overhead stabilization
• Joint capsule
• Rotator cuff tendons menghasilkan dynamic capsular tightening
• Tegangan terbesar saat rotasi internal
• Laxity capsul dan ligament menimbulkan instabilitas → impingement
• Labrum
• Increases glenoid depth approximately two times
• Tilted superiorly 5 degrees to assist in inferior glenohumeral stability
Sugijanto, 2021
Stability in Shoulder Joint
Sugijanto, 2021
JOINT MOTIONS
Joint
Laxity hypermobility
Ligamenter-
Capsular Rupture Instability
Sugijanto, 2021
PERAN SINERGI OTOT SHOULDER COMPLEX
Scapulohumeral Rhythm
• Sinergi otot shoulder complex sebagai stabilisator
dan penggerak utama menghasilkan gerak sinkon,
dan kordinatif
Sugijanto, 2021
PENYIMPANGAN SCAPULOHUMERAL RHYTHM
• Bila pada awal gerak abduksi bahu tidak mampu kelemahan m. supraspinatus
• Bila rasio gerak humerus : scapula terbalik dikenel sebagai Reverse Humeroscapular
Rhythm, penyimpangan gerak khas pada frozen shoulder
• Bila terasa nyeri/menyimpang pada abduksi 600 – 1200 dikenal sebagai painful arc,
merupakan gejala khas subacromial impingement
• Bila timbul bunyi clicking (& nyeri) pada abduksi 600 – 1200 dikenal sebagai
pianophenomen akibat subluksasi aromioclavicular joint
• Bila pada abdulsi 1600 – 1800 timbul nyeri dikenal sebagai ACJ/SCJ painful arc,
akibat patologi (OA) sendi tersebut
• Bila hiper abduksi semutan pada tangan dikenal sebagai hyper abduction syndrome
akibat pemendekan m. pectoralis minor
Sugijanto 2021
PERTANYAAN NO 5 TENTANG PENYIMPANGAN
GERAK BAHU
Sugijanto, 2021
Sugijanto 2021
ICD: THE YOUNG, ADULT AND OLDER SHOULDER
PATIENT
Sugijanto 2021
NCCI Research Brief:
Thinking About the Aging Workforce (Restrepo 2005)
Lost-Time Frequency Ranks by Age for the Top 10 Diagnosis Codes Sugijanto, 2021
SHOULDER PAIN AND DISABILITIES
- Merupakan keluhan muskuloskeletal ke 3
- Penyebab utama shoulder pain kebanyakan dari
rotatorcuff tendon.
Sugijanto 2021
SHOULDER EXTERNAL IMPINGEMENT
PATOMEKANIK PENYEBAB IMPINGMENT
• Penyempitan subacromial space:
• Supraspinatus tightness
• Superior capsule contracted
• Long head Biceps tendon
• Anterior position of the head of humerus
• Posterior capsule laxity
• Pectoralis mayor tightness
• Subscapular tightness
• Scapular dyskinesis
• Scapular tiping
• Scapular winging
• Scapular shrugging
• Glenohumeral joint instability
• Anterior instability
• Penebalan/osteophyte AC joint
• Menyebabkan gerusan langsung saan gerak GH joint
Sugijanto 2021
CLINICAL
Nyeri pada bahu
REASONING
Impingement syndrome
FUNGSI DAN DISABILITAS Contextual factors
Internal External
Anatomic impairment factors factors
Inflamation- Tightness
Supraspinatus calc formation
GH
Weakness Instability
Subscapularis, Over head Work
infraspinatus,
activity
Internal
Inflamation Scapular impingement
dyskinesis Carrying Sport
Inflamation
Tight- Lifting Recreation
hypertrophy
Sugijanto 2021
MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of
tight humerus tinggi
m.supraspinatus
Capsular/ligam Glenohumeral
ent laxity instability
Tigthness/weak Scapular
ness pd otot dyskinetic
scapula
Penebalan Hypomobility
capsule AC joint/ ACJ, Painful arc
Osteophyte
Sugijanto 2021
MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of Nyeri aktivitas
tight humerus tinggi angkat lengan
m.supraspinatus
Capsular/ligam Glenohumeral Nyeri aktivitas
ent laxity instability tertentu pd
Tigthness/weak Scapular posisi lengan
ness pd otot dyskinetic tertentu
scapula
Penebalan Hypomobility Terbatas & Nyeri
capsule AC joint/ ACJ, Painful arc full ROM
Osteophyte Nyeri gerak
lengan
Sugijanto 2021
MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of Nyeri aktivitas Bekerja,
tight humerus tinggi angkat lengan olah raga
m.supraspinatus ataupun
Capsular/ligam Glenohumeral Nyeri aktivitas rekreasi
ent laxity instability tertentu pd menggunakan
posisi lengan tangan
Tigthness/weak Scapular
ness pd otot dyskinetic tertentu
scapula
Penebalan Hypomobility Terbatas & Nyeri
capsule AC joint/ ACJ, Painful arc full ROM
Osteophyte Nyeri gerak
lengan
Sugijanto 2021
MENGANALISIS DARI ICD KE ICF, CONTOH: SHOULDER
IMPINGEMENT (ICD)
Jaringan apa yg Fungsi Keterbatasan Hambatan Prognosis factors
terganggu? (mekanik) apa aktivitas berpartisipasi Internal Eksternal
yg terganggu? (sosial)
Hypertrophy- Posisi head of Nyeri aktivitas Bekerja, Motivasi sembuh Apatis
tight humerus tinggi angkat lengan olah raga tinggi Memiliki
m.supraspinatus ataupun Kesehatan fisik komorbid: DM,
baik Sakit jantung, dll
Capsular/ligam Glenohumeral Nyeri aktivitas rekreasi
Peralatan rumah Lingkungan
ent laxity instability tertentu pd menggunakan tangga rumah
posisi lengan tangan ergonomis menghambat
Tigthness/weak Scapular
ness pd otot dyskinetic tertentu
scapula
Penebalan Hypomobility Terbatas & Nyeri
capsule AC joint/ ACJ, Painful arc full ROM
Osteophyte Nyeri gerak
lengan
Sugijanto 2021
NYERI DARI OTOT &TENDON
Weakness Atrophy
Sugijanto 2021
TENDON SUBSCAPULARIS
Sugijanto 2021
TENDON INFRASPINATUS
Sugijanto 2021
SCAPULAR DYSFUNCTION
Tipping ACCORDING TO KIBLER
Winging
Shrugging
Type 3 dyskinesie
Prominentie angulus
superior scapulae
Type 2 dyskinesie mediorotatiestand
Prominentie margo “shrugging”
Type 1 dyskinesie medialis scapulae “winging
Prominentie angulus
inferior “tipping” The Role of Scapulothoracic Dyskinesis, Johnson et al, 2003
Sugijanto 2021
Abduction- Palpation lower angel on
Scapular Tippng
elevation the scapula
Sugijanto 2021
PATTERNS OF SCAPULAR DYSKINESIS
• Type II Scapular winging = abnormal
motion around a vertical axis so that
the scapula has abnormal lateral or
external rotation; the clinical
manifestation is prominence of the
entire medial scapular border.
Sugijanto 2021
PATTERNS OF SCAPULAR DYSKINESIS
Sugijanto 2021
ANALISIS SCAPULAR WINGING DAN
GLENOHUMERAL INTERNAL ROTATION
Sugijanto 2021
LEVATOR SCAPULAR SHORTEN
Sugijanto 2021
SERRATUS ANTERIOR
Sugijanto 2021
SCAPULA TILTED/TIPPED
Sugijanto 2021
PECTORALIS MINOR SHORTHENING
Sugijanto 2021
GLENOHUMERAL INSTABILITY
• Joint instability
• Passive instability
• Active instability
• Capsular stretch test
• Apprehension test
• Relocation test (Load and sift test)
• Isometric stability test
Sugijanto 2021
ANTERIOR AND POSTERIOR
APPREHENSION TESTS
• Anterior Apprehension Test
• Posisi awal glenohumeral abd
900, elbow flex 900, tes gerak
rotasi eksternal dan dorong
humerus ke anterior.
• Posterior Apprehension Test
• Posisi awal ‘arm cross’ dilakukan
dorongan ke posterior
Sugijanto 2021
RELOCATION TEST
Sugijanto 2021
GLENOHUMERAL INTERNAL ROTATION DEFICIT (GIRD)
Sleepers stretch
Sugijanto 2021
SLAP LESION
• Slap test
• Athroscopy
Sugijanto 2021
SLAP LESION
• Slap test
• Athroscopy
O Brien’s test
Sugijanto 2021
Client complain
Body structure
(anatomic) Activities
impairment Non Pathologi/ Limitation
Pathologi
Body Function Participation
(biomechanic) Gangguan Gerak-Fungsi Restriction
impairment
HOAC 2 Assessment E B(C)P
Critical thinking
Clinical
reasoning Clinical
Diagnosis and prediction
Clinical prognosis rule
decision
making
Analisis Strategi perencanaan
Prosedur intervensi
Evaluasi dan
penilaian hasil Sugijanto 2021
PROSES PELAYANAN FISIOTERAPI
1. HISTORY TAKING
2. INSPEKSI
7. PLANING
8. INTERVENTION
9. EVALUATION
10. DOCUMENTATION
Sugijanto 2021
Nyeri bahu dan lengan impingement syndrome
Ha: Shoulder Keluhan nyeri area deltoid,
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
Scapulothoracal
dyskinetic
Sugijanto, 2021
ASSESSMENT NO 2: INSPEKSI
Sugijanto 2021
ASSESSMENT NO 3: REGIONAL
SCREENING & TES ORIENTASI
muscles tendomuscl
disc Capsules Glenohumeral Positional
fault
Joint surface facet neurovege costoverte bursae
& uncinate
Inflamasi muscle
Myofascial Blockade tightness
osteofit adhesion
Micro Contracture Capsulo-lig
circulation contracture
iritasi radix
tightness
calcification brachial nerve
Iritasi Jar ischemic hipertone
sensitif entrapment
nyeri lokal/
tight contract referal nerve ischemic
Sugijanto, 2021
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, 2021
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, 2021
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, 2021
QUICK TEST (ORIENTASI) FOR
SHOULDER EXTERNAL IMPINGEMENT
Sugijanto 2021
PERTANYAAN NO 6 TENTANG REGIONAL SCREENING
Sugijanto, 2021
ASSESSMENT NO 4: REVIEW OF SYSTEM
AND RED FLAG
• Review of Systems
• Serious pathology (Red Flag)
Sugijanto, 2021
Sugijanto 2021
ROS & RED FLAG IN CERVICAL SPINE-SHOULDER
No Regio ROS Red flag Red flag:
Anamnesis Anamnesis - Test
1 Cervical Musculoskeletal Fracture; instability Apakah sakit kepala dan leher disertai kaku otot leher
spine syst: berat?
Nyeri meningkat ketika menunduk=tengadah? atau
Arthritis/ Bamboo miring ke kanan-kiri?
spine Pusher test; Alar lig test; dan
Tectorial lig test
X ray
Cardio vascular VBI/ Apakah menderita sakit kepala kronis disertai episode
muntah? Apakah pusing mual bila menengok ke satu sisi?
Apakah pernah kepala memutas satu arah dalam wahktu
lama terasa pusing, mual-muntah? VBI test
Vertigo Epley maneouvre
Sugijanto, 2021
PERTANYAAN NO 7 TENTANG REVIEW OF
SYSTEM AND RED FLAG
Sugijanto, 2021
PERTANYAAN NO 7 TENTANG REVIEW OF SYSTEM
AND RED FLAG
• Apakah pertanyaan dan test untuk mengetahui keluhan berasal dari gastro
intestinal? Apakah yang harus diperhatikan bila diduga gangguan Colon
cancer?
• Apakah pertanyaan dan test untuk mengetahui keluhan berasal dari deficit
neurologi? Apakah test untuk cauda iquina syndrome?
Sugijanto, 2021
ASSESSMENT NO 5A: BODY STRUCTURE IMPAIRMENT TEST
UNTUK MEMASTIKAN GANGGUAN JARINGAN SPESIFIK PEYEBAB PATOLOGI
SEHUNGGA DAPAT MENETAPKAN BODY STRUCTURE IMPAIRMENT
Sugijanto, 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Berdasar evidence Base Clinical Practice:
• Pemeriksaan terhadap shoulder external
impingement:
• Abduction-elevation: painful arc
• Neer test
• Jobe’s test
• Hawkin & Kennedy test
• Isometric external rotation
Sugijanto 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Sugijanto 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Berdasar evidence Base Clinical Practice:
• Pemeriksaan panjang otot:
• Supraspinatus tigthness
• Pemeriksaan Otot stabilisator:
• Stabilization test
Sugijanto 2021
PROSEDUR PEMERIKSAAN FISIOTERAPI
Berdasar evidence Base Clinical Practice:
• Pemeriksaan Otot stabilisator:
• Stabilization test
Sugijanto 2021
• Pemeriksaan Scapular dyskinesis:
• Glenohumeral Abduction-elevation dan Tolak pinggang identivikasi:
• Scapular tipping
• Scapular shrugging
• Scapular winging
• Pemeriksaan AC joint:
• Mobility test
• Stability test
• Osteophyte
• Pemeriksaan mobilitas regio cervicothoracic junction:
• Melalui gerak bahu dan melalui gerak leher.
• Pemeriksaan lain:
• X ray
Sugijanto 2021
TES EVIDENCE BASE SHOULDER
EXTERNAL IMPINGEMENT SYNDROME
SUB ACROMIAL SPACE TERLALU SEMPIT
• Traksi statis humerus arah inferior dipertahankan 30 detik
• Pembuktian: Nyeri berkurang,
• Tidak tampak sulcus sign
• GHJoint:
• Superior capsule.
• ACJ: Superior glide (elevation), anterior glide (protraction)
• Cervico Thoracic Junction: Rotation, NAGs test
Sugijanto 2021
BILA DUGAAN MUSCLES
PROBLEMS
MUSCLE LENGTH TEST & CONTRACT RELAX STRETCH
TEST
• UPPER TRAPEZIUS M
• Fleksi lateral cervical kontralat, depresi girdle ipsilat
• PECTORALIS MAYOR M.
• Posisi glenohumeral Abduction -horizontal abduction.
• PECTORALIS MINOR M.
• Posisi girdle retraction
• ROTATOR CUFF MS.
• Supraspinatus m: Traksi statis arah inferior
• Subscapular m: Posisi extrernal rot
Sugijanto 2021
PERTANYAAN TENTANG TES DARI HIPOTESIS
BODY STRUCTURE IMPAIRMENT
Sugijanto 2021
ASSESSMENT NO 5B: BODY FUNCTION IMPAIRMENT
Sugijanto, 2021
BODY FUNCTION IMPAIRMENT ASSESSMENT
Sugijanto, 2021
PERTANYAAN TENTANG TES DARI HIPOTESIS
BODY FUNCTION IMPAIRMENT
Sugijanto 2021
ASSESSMENT NO 5C: DISABILITIES
Disabilities Outcome measure Temuan
Hand and arm Shoulder Pain Disability Index Score
function Disability of Arm Shoulder and Hand
INTERVENTION
ADL IADL Unable, full support, partial support,
supervision or able to do at specific task
Work Work in office, work in field, work in Unable, support, super vision, able to do
Sugijanto, 2021
ASSESSMENT NO 6 PEMERIKSAAN PENUNJANG
• Sebagai penegakan hasil temuan dari asesmen fisioterapi
• Memberikan data-data dalam bentuk ukuran tertentu
• Mempertegas Diagnosis yang dibangun
• Menjadi pertimbangan dalam penetapan program
• Menyisihkan differential diagnose
• Data evaluasi program yang objektif
• Beberapa penunjang diagnosis
• Laboratorium; X Ray; MRI; Ultrasonography musculoskeletal; EMG, dll
Sugijanto, 2021
ASSESSMENT NO 7: PROGNOSTIC
(CONTEXTUAL) FACTORS
• Faktor internal yang memperberat atau sebagai penyulit
• Commorbidities atau penyakit lain terkait atau Faktor psikososial yang menghambat
Sugijanto, 2021
KELUARAN ASSESSMENT:
PT DIAGNOSIS DAN FUNCTIONAL PROGNOSIS
• Diagnosis merupakan simpulan pada pemeriksaan dalam lingkup gerak dan fungsi (ICF)
yang berdasar patologi (ICD). Diagnosis menurut APTA (2017)
• Muscle pain and tightness sec. myofascial syndrome
• Pain and instability sec, Lumbar spondylolisthesis
• Neck pain with radiating pain (radicular) sec. HNP
• Dalam lingkup gerak dan fungsi tanpa patologi.
• Neck pain with mobility deficits (in capsular pattern)
• Low back pain sec. Hip joint hypermonbility.
• Neck pain sec forward head posture
• Lumbopelvic pain sec, leg discrepancy
• Dll
Sugijanto, 2021
PERTANYAAN TENTANG PROSES
ASSESSMENT FISIOTERAPI PADA SHOULDER IMPINGEMENT
Sugijanto 2021
PROSES INTERVENSI FISIOTERAPI
1. HISTORY TAKING
2. INSPEKSI
3. REGIONAL SCREENING &
QUICK TEST
5. ASSESSMENT EVIDENCE
BASE CLINICAL PRACTICE
6. DIAGNOSIS AND
FUNCTIONAL PROGNOSIS
7. PLANNING
8. INTERVENTION
9. EVALUATION
10. DOCUMENTATION
Sugijanto, 2021
PLANNING
• Penjelasan tentang patologi, diagnosis, target, tujuan, rencana intervensi dan
hasil yang diharapkan
• Persetujuan pasien terhadap target, tujuan dan tindakan intervensi fisioterapi
• Target harus jelas:
• BODY STRUCTURE (Anatomic) IMPAIRMENT TARGET:
• Capsules
• Muscles
• BODY FUNCTION (Kinetic) IMPAIRMENT TARGET :
• Mobility of Glenohumeral, scapulothoracal, Acromioclavicular-Sternoclavicular and
Cervicothoracic junction
• ACTIVITY LIMITATIN TARGET:
• ADL
• Hand activities
• PARTICIPATION RESTRICTION TARGET:
• Work
• Sport
• Recreation
Sugijanto, 2021
shoulder impingement
Muscle
1. Traksi osilasi pd endurance 1. Static inferior traction-
MLPP posterior glide
2. Traksi inferior end 2. MWM ininferior- posterior
Active stabilization Muscle
range position glide correction
exc Stretching
3. Roll glide
Functional
training Sugijanto 2021
INTERVENSI FISIOTERAPI
SHOULDER IMPINGEMENT
• Pemilihan Modalitas
• Pemilihan metode dan Teknik intervensi
• Latihan
• Edukasi
Sugijanto 2021
INTERVENSI FISIOTERAPI
• MODALITAS DAN METODA
• Body structure Impairment target:
• US / SWD contra planar tepat utk capsule yg tegang
• Scapular mobilization
• Shoulder joint mobilization, traction at end range position and Roll glide
• Stabilizing exercise tepat utk kelemahan otot bahu.
• Body function Impairment target:
• Latihan mobilisasi sendi
• Latihan stabilisasi bahu
• Disability target
• Activity limitation target
• Paticipation target
Sugijanto 2021
PEMILIHAN MODALITAS, METODE DAN TEKNIK
INTERVENSI SPESIFIK
Static stretching
Shoulder MWD/SWD Ischemic compression technique
Muscle contraplanar Longitudinal stretching
Tightness/ US longitudinal Myofascial release technique
contracted application Muscle energy technique
Contract relax stretching
EBPP (I), Electrical Stimulation No recommendation for: Rot cuff, dislocation, SLAP tear, AC jt.,
Frozen Shoulder (Hegmann et al, 2011)
Sugijanto, 2021
• Muscle static stretching, Contract relax stretching,
dan Muscle Energy Technique (MET).
• Supraspinatus m
• Posisi lengan netral disamping tubuh
• Static stretching
• Subscapular m
• Posisi lengan abduksi 900 disamping tubuh
• Contract relax stretching atau MET
• infraspinatus m
• Posisi lengan menyilang depan tubuh
• Contract relax stretching atau MET
• Levator scapular m
• Posisi cervical lateral fleksi kontra lateral,glenohumeral
abduksi dan girdle depresi
Sugijanto 2021
CONTRACT RELAX STRETCHING &
MUSCLE ENERGY TECHNIQUE
• PECTORALIS MINOR M.
• Peregangan static elevasi-retraksi
• Expiration dan girdle retraction in girdle retraction
• PECTORALIS MAYOR M.
• Expiration dan horizontal adduction. In shoulder abducted
Sugijanto 2021
PEMILIHAN MODALITAS, METODE DAN TEKNIK
INTERVENSI SPESIFIK,
Sugijanto, 2021
GLENOHUMERAL JOINT &
SHOULDER GIRDLE TARGET
Glenohumeral Capsular
• Static GH posterior glide
• Traksi osilasi MLPP, Traksi inferior, Roll glide dan
MWM
Sugijanto 2021
INTERVENSI
• ACJ mobilization
• Traction to lateral
• Elevation,
• Retraction
• SCJ mobilization (bila perlu)
Sugijanto 2021
INTERVENSI MT
Sugijanto 2021
MANIPULATION CTJ - NELSON
NELSON TRACTION
◦ Sand back pd spinous proc upper thoracal.
◦ Manipulasi dgn menarik bahu pasien dan
mendorong sand bag keventral dengan teknik
HVLA.
◦ Utk minimal capsular pattern
Sugijanto, 2021
TERAPI LATIHAN
• Latihan
• Postural correction
• Stabilization
• Stretching
• Mobilization
Sugijanto 2021
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row (retraction/ext)
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
• Closed Kinetic Chain
• Closed Chain Scapular
Motion
• Scapular Clocks
• Low Row
• TheraBand Neutral Shoulder
• TheraBand Scapular
Adduction
• TheraBand Scapular
Adduction with Shldr ER
• TheraBand Prone on Elbows
Shldr ER
EXERCISES
Sugijanto 2021
CLINICAL PATHWAY SHOULDER IMPINGEMENT SYNDROME
No Problem Assessment Intervensi Alat ukur/ Kondisi yg Jumlah
fisioterapi evaluasi diharapkan kedatangan
Nyeri dan Pemeriksaan Impingement US/SWD Nyeri diukur Nyeri Ringan: 3x/
disabilitas bahu (positif minimal 3): subacromial, traksi – dgn VAS/ berukrang mgg, 1 sesi
akibat external Painful arc translasi static caudal, NRS tiap kunjungan
impingement Jobe’s test Mobilisasi saat caudal Painful arc: Sedang: : 3x/
syndrome Neer test traction, MWM goniometer Fungsi normal mgg, 2 sesi
Hawkin Kennedy test Disabilitas: <2-4 mgg
External rotation SPADI/ Berat: : 2x/
isometric test DASH/ mgg, 4 sesi
+subacromial Bursa subacromial mobilization under
bursitis Neer & Hawkin test caudal traction,
+supraspinatus Palpasi pisisi ekstensi Contract relax
tendinitis M Supraspinatus stretching
Jobe’s/Empty can test
Isometric Abd pada
MLPP
Palpation posisi borgol
Sugijanto 2021
Sugijanto, 2021
PERTANYAAN TENTANG PROSES PENGELOLAAN FISIOTERAPI
PADA SHOULDER IMPINGEMENT SYNDROME
Sugijanto 2021
SAMPAI JUMPA
Sugijanto 2021