CLINICAL REASONING

ORTHOPADIC MUSCULUSKELETAL
PHYSIOTHERAPY SPINE

Oleh: Sugijanto
Disampaikan pada:
Outcome learning ILOMPT

Sugijanto, 2020
 Kompetensi klinis Fisioterapi (APTIFI)
 Mampu menggunakan prinsip dan metoda Fisioterapi dalam
memecahkan masalah gangguan gerak dan fungsi
 Mampu melakukan pemeriksaan dengan berfikir kritis untuk
menetapkan diagnosis fisioterapi sesuai kriteria ICF (International
Calassification of Functioning, disability and health) dengan
menggunakan metoda pemeriksaan HOAC (Hypothesis Oriented
Algorythm for Clinician) berdasarkan EBCP (Evidence Base Clinical
Practice).
 Mampu merumuskan dan menyusun masalah dan
penanggulangannya serta membuat perencanaan,
 Mampu malaksanakan prosedur intervensi program yg bersifat preventif
dan promotif, kuratif dan rehabilitatif
 Mampu melakukan evaluasi secara cermat dan terukur.
 Mampu mendidik dan meningkatkan peran serta masyarakat untuk
meningkatkan taraf kesehatan.
Sugijanto, 2020
 CRITICAL THINKING

Clinical Clinical
prediction rule: Clinical
reasoning: decision
Identifikasi
Semua proses interaksi making:
tindakan kompleks Pedoman
fisioterapi perkembangan pengambilan
memiliki alasan impairment/ keputusan klinis
klinis patologi
Standard of Clinical Practice
Sugijanto, 2020
Andersen, Linde &
Broberg, 2014
Sugijanto, 2020
 CLINICAL REASONING
 Pertanyaan mendasar ketika fisioterapis mengelola pasien:
Apa diagnosisnya dan apa problem FT? → ICD & ICF
Apa intervensinya? → Problem solving lingkup ICF
Apa metode dan Teknik intervensi yang tepat? → ICF target
oriented.

Fisioterapi JANGAN
BERFIKIR TERBALIK

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

Salah Benar Sugijanto, 2020

1. BAGAIMANA ANDA MENGANALISIS
ICD DALAM ICF?

 Use of the ICF Model as a Clinical Problem-Solving Tool in

Physical Therapy and Rehabilitation Medicine (Steiner et
al, 2002)

Sugijanto, 2020
 NECK ARM PAIN -
Spondyloarthrosis
cervicalis
Penipisan, pengerasan &
erosi rawan sendi
Forward head posture
Mulai instabilitas → iritasi
Nyeri meyebar saat
jar. → psudoradicular pain
ekstensi
Capsule-lig. contracture &
muscle tight /contracted Mobilitas cervical
Facets iritation terbatas semua arah
→ osteofit tepi facets dan
corpus Capsular pattern
Ketegangan otot tonik dan
Muscle tightness-
Kelemahan otot fasik
Penyempitan foramen I.V. contracture
Neural irritation Nyeri saat duduk lama
Iritasi radix→Radicular pain

Proses patologi Anatomic impairment Kinetic impairment Sugijanto, 2020

 MENGANALISIS DARI ICD KE ICF, :
Cervical Spondyloarthrosis (ICD)
Jaringan apa Fungsi Keterbatasan Hambatan Prognosis factor
yg terganggu? (biomekanik) apa aktivitas berpartisipasi
yg terganggu? (sosial)
Fasilitasi Inhibisi

Permukaan Nyeri gerak Duduk waktu lama, Bekerja dgn Motivasi Malas
sendi cervical ekstensi mendongak duduk atau baik, latihan
mengelupas berdiri disiplin
dan inflamasi. latihan
Kapsul sendi Mobilitas sendi Nyeri mengemudi, Rekreasi dgn Sehat, Komorbid
kontraktur terbatas parkir mobil, gerak cervical senang DM,
menjinjing barang d olah raga Hipertensi,
Otot atrofi dan Stabilitas sendi Hambatan ketika Peralatan Peralatan
lemah menurun Olahraga kantor kantor tidak
ergonomis ergonomis
Osteofit tepi Flat neck/ Penampilan kaku,
corpus kyphosis
dan/facet Sugijanto, 2020
 NYERI RADICULAR – LUMBAR
DISC BULGING/HNP

Degeneratif + injury → Nyeri menyebar

annulus fibrosus robek
Pergeseran nucleus →
disc menonjol ke
posterolateral/posterior
Iritasi jar lunak radix →
inflamasi → radicular
pain
Penonjolan menekan saat fleksi
Lig. longit posterior/
Nyeri pinggang
Dural/dural sleeve →
inflammation sampai kaki lateral
Neuropathic pain Batuk/bersin/
mengejan nyari
Rasa baal, nyetrum
sampai lateral kaki

Proses patologi Anatomic impairment Kinetic impairment

Sugijanto, 2020
 MENGANALISIS DARI ICD KE ICF, :
Lumbar disc herniated (ICD)
Jaringan apa Fungsi Keterbatasan Hambatan Prognosis factor
yg terganggu? (biomekanik) aktivitas berpartisipasi
apa yg (sosial) Fasilitasi Inhibisi
terganggu?
Annulus fibosus Nyeri BAB, duduk Bekerja kantor, Motivasi Apatis
robek diskus dan/atau nyeri lama, sembuh tinggi
menonjol ke menjalar saat membungkuk, mengemudi
dorso-lateral fleksi trunki lifting Kesehatan fisik Memiliki
Inflamasi lig. Nyeri central, Duduk, Olah raga, baik komorbid: DM,
Longit. nyeri radikular. Selonjor, Sakit jantung,
Duramater SLR membungkuk, Rekreasi dll
dan Posterior
radiks Peralatan Lingkungan
rumah tangga rumah
Muscle Instability Berjalan lama, mendukung menghambat
tightness and /muscle
weakness imbalance
Sugijanto, 2020
 NYERI PINGGANG DAN KEDUA
HAMSTRINGS - SPONDYLOLISTHESIS
Pasca injury → rusakan Nyeri pinggang hingga
proc. articularis lipat pantat – kedua
Vertebral subluxatio hamstrings
Micro/repetitive injury Iritasi cauda equina
→ rusak proc. artic Postural deficit & Gerak tertentu
active unstable pinggang bunyi klik
Spondylolysis → erosi
(lisis) proc. Articularis → Berdiri lama makin
subluxatio antar corpus nyeri
vertebrae
Kasus berat ada
Iritasi cauda equina
gangguan vegetatif
Active unstable
Proses patologi Anatomic impairment Kinetic impairment
Sugijanto, 2020
 MENGANALISIS DARI ICD KE ICF, :
Lumbar Spondylolisthesis (ICD)
Jaringan apa Fungsi Keterbatasan Hambatan Prognosis factor
yg terganggu? (biomekanik) apa aktivitas berpartisipasi
yg terganggu? (sosial) Fasilitasi Inhibisi

Sendi facet Nyeri gerak Berdiri miring, tidak Bekerja dgn Motivasi Apatis,
luxatio lumbal menjalar mampu lama, Lalan duduk atau baik, disiplin Latihan
kedua hamstrings nyeri berdiri latihan cepat lelah
Kapsul sendi Instabilitas lumbar Nyeri kadang bunyi Rekreasi dgn Sehat, Komorbid
Laxity spine gerak lumbar spine gerak cervical senang olah DM,
raga Hipertensi,
Otot atrofi dan Posisi pinggang Berdidi/ jalan cepat Tidak mampu Peralatan Peralatan
lemah miring capai Olahraga darat kantor kantor tidak
Proc artic lysis Semutan bias ergonomis ergonomis
disertai gangg.
vegetatif

Sugijanto, 2020
2. BAGAIMANA FISIOTERAPIS
MENGELOLA PASIEN DALAM ICF?
 Menganalisis patologi (ICD) kedalam functioning (ICF)
 Assement menggunakan HOAC II dengan
menggunakan EBCP
 Membuat diagnosis dan prognosis dengan critical
thinking
 Intervensi sesuai target anatomic dan kinetic impairment
target serta disabilitas target
 Evaluasi dan reevaluasi menggunakan alat ukur yang
valid dan reliabel
 Smua tercatat dengan pencatatan baku
Sugijanto, 2020
 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
ma Analisis Strategi
perencanaan
Prosedur intervensi

Evaluasi dan
penilaian hasil Sugijanto, 2020
 Proses pengelolaan Fisioterapi
Profesi Berpedoman Clinical
HISTORY TAKING
Resoning
INSPEKSI

REGIONAL SCREENING
& QUICK TEST

REVIEW OF SYSTEM &

RED FLAG

ASSESSMENT EVIDENCE
BASE CLINICAL PRACTICE
DIAGNOSIS AND
FUNCTIONAL PROGNOSIS

PLANING
INTERVENTION
EVALUATION
Sugijanto, 2020
 BODY STRUCTURE IMPAIRMENT
Jaringan tubuh Tes Temuan intervensi
Joint capsules Passive test Terbatas elastic end feel Nyeri. Joint mobilization
Joint play movement test Elastic end feel Joint manipulation
Muscle Isometric test Nyeri Muscle release
Palpasi Nyeri, tonus tinggi, Muscle mobilization
Contract relax stretch test Tegang, contracture
 INTERVENTION Muscle stretching
Strength test Lemah, paresis Strengthening
Joint surface Compression-traction test Nyeri Traction mobilization
Alignment test Valgus/varus Postural correction
Movement in corrected Pain free movement in Mobilization With Movement
position test corrected position
Peripheral nerve Dermatome/nervinal test Paresthesia/hypo-anesthesia Release compression
Myotome test – Reflex test Pain
Tinnel test Neural tension/adhesion Neural mobilization/gliding
ULTT/LLTT
Vena Pitting test, elevated test positif Elevation, massage, pumping
Stemmer test Lymph drainage, under
Lymphatic
Torkinet test/Vacuum test pressure
Arteria Vacuum compression
Intervertebral PA spring, Spurling, Pain central/peripheral Disc nuclear mobilization
Traction-distraction test, No pain-pain Extension exercise
Disc
Valsava maneouvre, Postural correction/proper
extension test No pain mechanic Sugijanto, 2020
 BODY FUNCTION IMPAIRMENT
Fungsi Pemeriksaan
Pain Pain provocation jaringan
tertentu
Mal alignment Postural test
Pengukuran alignment
Hypomobility Structural hypomobility
(Capsules/Muscle/Nerve)
Functional hypomobility
Hypermobility Structural hypomobility
Functional hypomobility
Instability Static instability
Dynamic instability
Movement Positional corrected mobility
test/Painfree
impairment
Movement Muscle imbalance
incoordination
Temuan
Nyeri
Postural disorder
Valgus/varus/round back/Stright
back dll
Tes terhadap jaringan terkait
Tes functional mobility
Tes terhadap jaringan terkait
Tes functional mobility
Non contractile structures test
Contractile structure test
Functional stability test
Positional vault
Movement incoordination
Cocontraction test
Intervensi
Tergantung temuan tissue
impairment
Postural correction
Realignment, Support; exrcise
Intervensi thd body structure
impairment
Fuctional training
Intervensi thd body structure
impairment
Fuctional training
Passive stabilization
Active stability exc
Fuctional stability test
Pain free strengthening in
corrected position
Pain free strengthening in
corrected movement
Functional training
Sugijanto, 2020
 DISABILITIES
Disabilities Outcome measure Temuan Intervensi
Bascic Sequences basic functional Unable, full support, partial Basic functional training
functional measure support, supervision or able at specific sequence
disability to do at specific sequence and above

Ambulation Gait analysis, walking Pathological gait, full

 INTERVENTION Gait training, Training in
analysis with walking edge, support, partial support, the used of walking
wheel chair ability, etc supervision or able in walking edge
edge, etc
ADL IADL Unable, full support, partial ADL training at specific
support, supervision or able level
to do at specific task
Work Work in office, work in field, Unable, support, super vision, Work training at specific
work in able to do task
Sport Individual sport Unable, support, super vision, Specific exercises and
Team sport etc able to do training in sport
Recreation In door recreation Unable, support, super vision, Specific exercises
Out door recreation able to do
Pain & disability NPDI, SPADI, DASH Score disabilitas Specific treatment
Sugijanto, 2020
3. ASSESSMENT MENGGUNAKAN HOAC
(HYPOTHESIS ORIENTED ALGORITHM)
 Dalam pemeriksaan selalu dibuat hipotesis yg
harus diuji (tes) kebenarannya
 Tes dilakukan terhadap:
 Body structure Impairment
 Body function Impairment
 Pathology
 Individual activity limitation
 Sosial participation restriction
 Internal and external contextual factors
 Tes diambil dari Evidence Base Clinical Practice
Sugijanto, 2020
EVIDENCE BASE CLINICAL PRACTICE

Evidence Base
Clinical Practice

Evidence Base Clinical Practice

 Menggunakan Evidence Base
Practice
 Merujuk pendapat Expert
 Memperhitungkan manfaat pada
pasien

Sugijanto, 2020
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, 2020
 Assessment no 1: ANAMNESIS
KHUSUS PERTANYAAN HIPOTESIS
DUGAAN PATOLOGI YA/TDK

Dugaan HNP cervical Apakah nyeri ngilu cervical hingga sisi kepala atau lengan pd area Ya
dermatome,
Apakah terpicu posisi menunduk lama/gerak menunduk Ya

Osteo artritis lumbal Apakah Nyeri dan kaku bangun tidur; Ya

Apakah Posisi tengadah & grk rotasi cervical nyeri/ Ya
Apakah nyeri meningkat tengadah dan berkurang membungkuk
Neuropathic Apakah terasa nyeri panas dan menjalar, Ya
Apakah nyeri tekan diatas serabut saraf & nyeri posisi slump ya

Capsular pattern Apakah nyeri gerak terbatas semua arah: Ya

Apakah nyeri / tak mampu tangan belekang punggung dan
belakang leher? Ya
Apakah leher nyeri dan menengok? Ya
Apakah nyeri dan kaku memutar pinggang Ya
Rheumatoid Arthritis/ Apakah nyeri dan kaku dengan bengkak sendi jari-jari tangan, Ya
bamboo spine Apakah nyeri dan kaku tiap bangun tidur? Ya
Apakah seluruh tubuh nyeri dan kaku ke semua Gerakan?
Spondylolisthesis Apakah nyeri atau semutan lipat pantat / kedua hamstrings? Ya
lumbal Apakah bila dari duduk ke berdiri/ sebaliknya pinggang bunyi? ya
Sugijanto, 2020
Assessment no 2: INSPEKSI
DUGAAN PATOLOGI Inspeksi YA/TDK

Dugaan Cervical flat (straight neck) Ya

Osteoarthritis Forward head posture Ya
cervical
Dugaan HNP Lumbar deviation dengan konveks ke sisi sakit Ya
lumbal Lumbar reverse lordosis antalgic pposture Ya

Neuropathic pain Elevasi Bahu sisi sakit, kecenderungan fleksi siku Ya

brachial pexus ya

Capsular pattern Stright neck posture Ya

Stright lumbar posture Ya

Bamboo spine Neck: forward head posture Ya

Thoracic round back Ya
Lumbar hypolordosis ya
Ya
ya
Sugijanto, 2020
Assessment no 3: REGIONAL
SCREENING & TES ORIENTASI
UNTUK PEMETAAN LOKASI REGIO
ASAL KELUHAN/IMPAIRMENT

 Untuk memudahkan hipotesis regio pd keluhan Nyeri leher hingga

lengan

Sugijanto, 2020
 Analisis
patologi NECK ARM PAIN
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, 2020
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, 2020
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, 2020
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, 2020
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, 2020
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, 2020
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, 2020
 LOW BACK AND LEG PAIN

Lumbar spine Thoracic spine Sacroiliac joint Hip joint Piriformis syn

disc muscles Capsules ligament Capsules

Muscle
Joint surface neurovege costoverte
facet & uncinate Tight Joint surface
inflammation
Myofascial Blockade
osteofit contracture muscle
adhesion Micro tightness
circulation Contracture Loose body
iritasi radix blockade

Iritasi Jar tightness ischemic hipertone calcification Ischiadic

sensitif entrapment
tight contract nyeri lokal/ nerve ischemic
referal
Radicular Pseudo fibrosis
pain radicular

Nyeripinggang dan Sugijanto, 2020

PEMILAHAN BILA KELUHAN
BERASAL DARI LUMBAR SPINE

 Pusat sensasi nyeri pd lumbal-gluteal-tungkai

belakang-samping-kaki
 Gerak aktif kemudian ditambahkan ‘over pressure’
 Fleksi-ekstensi trunki posisi berdiri: nyeri pinggang atau
radiasi ke kaki
 3 dimensi ekstensi kanan-kiri punggung posisi duduk
tegak
 Tes positif bila keluhan nyeri pinggang-tungkai ter
provokasi oleh gerak trunki tersebut

Sugijanto, 2020
PEMILAHAN BILA KELUHAN
BERASAL DARI THORACAL SPINE

 Pusat nyeri pinggang samping – crista iliaca –

trochanter
 Diberikan posisi dimana ada keluhan ringan, Kemudian
diberikan provokasi gerak rotasi vertebra thoracalis
melalui proc spinosus vertebra atas- vertebra bawah
nya.
 PACVP pada puncak kurva

 Tes positif bila keluhan nyeri pinggang ter provokasi oleh

gerak vertebra thoracalis tersebut

Sugijanto, 2020
 PEMILAHAN bila keluhan
berasal dari sacroiliac joint

 Nyeri daerah lipat pantat

 Fleksi ekstensi tubuh posisi berdiri:
ketinggian SIPS asimetri
 Pada posisi tengkurap, dilakukan Sacral
trust test bersamaan ektensi sendi panggul
 Pada posisi berbaring terlentang,
dilakukan Thigh trust test
 Pada posisi berbaring terlentang Gaenslen
test

Sugijanto, 2020
 PEMILAHAN bila keluhan
berasal dari Hip joint

 Gait analysis tampak duchene gait

 Pada posisi tengkurap dilakukan
gerak internal rotasi bersamaan
kanan dan kiri

Sugijanto, 2020
Pemilahan keluhan dr piriformis
syndrome

 Nyeri daerah pantat, kadang

meyebar ke paha belakan
 Provokasi oleh tekanan duduk pada
tempat keras
 Palpasi dan contract relax stretch
test pada piriformis positif
 Slump test positif

Sugijanto, 2020
 Dugaan lysthesis

Pinggang sering bunyi click, palpasi

dijumpai step off atau step on (L4)
 Stabilization test:
Tes stabilisasi pasif lumbosacrale fiksasi pd
lumbale dan mendorong femur ke
posterior.
 Posisi ditepi bed sampai pelvic, angkat
kedua tungkai ekstensi. Di Fiksasi dan
tanpa fiksasi

Sugijanto, 2020
 Assessment no 4: ROS & RED FLAG

REVIEW OF SYSTEM & • Review of Systems (ROS)

RED FLAG
• Serious pathology (Red Flag)

Sugijanto, 2020
YELLOW FLAG
 Yellow flags are psychosocial indicators suggesting increased risk of
progression to long-term distress, disability and pain.
 Yellow flags were designed for use in acute low back pain. In principle they
can be applied more broadly to assess likelihood of development of
persistent problems from any acute pain presentation.
 Yellow flags can relate to the patient’s attitudes and beliefs, emotions,
behaviours, family, and workplace. The behaviour of health professionals
can also have a major influence.
 Key factors in low back pain are:
 The belief that pain is harmful or severely disabling
 Fear-avoidance behaviour (avoiding activity because of fear of pain)
 Low mood and social withdrawal
 Expectation that passive treatment rather than active participation will help.

Sugijanto, 2020
ROS & RED FLAD IN CERVICAL SPINE
No Regio ROS Red flag Red flag:
Anamnesis Anamnesis - Test
1 Cervical Musculoskeletal Fracture; instability Pusher test
spine syst: Alar lig test
Tectorial lig test
Arthritis/ Bamboo X ray
spine
Cardio vascular FBI/ Vertigo FBI test
Epley manouvre
Immune system Cancer Pancoast test

Neuromuscular Tekanan tinggi Neri test

intracranial Nafziger test
Cervical cord lesion Sensoric- Motoric &
reflex test

Sugijanto, 2020
 ROS & RED FLEG IN THORACIC SPINE
No Regio ROS Red flag Red flag:
Anamnesis Anamnesis - Test
2 Toracic spine Musculoskeletal Fracture;
syst: Osteo porosis X ray
TBC
Bamboo spine
Cardio vascular Angina Palpitasi
Intermitent claudication
Cholesterol >200 mg/dl
Immune system Cancer Pancoast test
Respiratory Pleuritis Sharp pain in inspiration
History of lung disease
Dypsnea, chest expansion
very limited
Gastrointestine Gatrointeritis Nyeri perut
Nausea/muntah; hilang
nafsu makan
Diarrhea atau constipasi

Sugijanto, 2020
ROS & RED FLEG IN LUMBAR SPINE
No Regio ROS Red flag Red flag:
Anamnesis Anamnesis - Test
3 Toracic Musculoskeletal Fracture;
spine syst: Spina bifida X ray
Neuromuscular Cauda equina Retensi uri atau inkontinsia uri / alvi
syndrome Saddle anesthesia
Kelemahan otot ekstremitas inferior
Defisit sensorik dan motoric (L4, L5, S1)
Immune system Cancer Pancoast test
Kidney Pyelonephritis Pain felt bilateral posterior low back and
unilateral abdomen, position or movement
have no effect
Test with clap on dorsal lower thoracic spine
Gastrointestine Apendixitis Abdominal rigidity:
Rebound tenderness
Mc Burney point +
Psoas and Obturator sign +

Sugijanto, 2020
 REVIEW OF SYSTEM &
RED FLAG Red flag: Back cancer/infection
(osteomyelitis)

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

cancer  The used of intravenous
 High body weight lost medication
 Fail in conservative treatment  Concurrent immunosuppressive
disorder
 Inconsistent of complain.
 Deep constant pain, worst in
 Constant pain unchanged on weight bearing
position/activities; getting worst in
 Fever, malaise, and edema
the night.
 Spine rigidity

Sugijanto, 2020
Assessment no 5: Specific Assessment in
HOAC and EBCP

Sugijanto, 2020
 CERVICAL ANATOMI IMPAIRMENT TEST
Jaringan tubuh Tes Temuan
Facet Joint Passive test Terbatas elastic end feel Nyeri.
Joint play movement test Elastic end feel
capsules
3D flaxion test
Muscle: I. Isometric test posisi cerv
 INTERVENTION Nyeri
1, Sub occipital m flexion & Palpasi Nyeri, tonus tinggi,
suboccipital region Tegang, contracture
2. Upper trap 2. Isomtric pd posisi depressi Lemah, paresis
& neck contra lat side flex &
3. Scalenus m Contract relax stretch test
3. Idem depressi costa 1
Facet: 1. Alignment test (FHP Nyeri
atlantooccipital jpint Valgus/varus
1. C0-C1
2. Head flexion + rotation Pain free movement in corrected
2. C1-2 3. Compression-traction position
3. C2-3-4-…. test, NADs test
4. T1-2-3-4 4. LPAVP & Nags test
CERVICAL ANATOMIC IMPAIRMENT TEST
Jaringan tubuh Tes Temuan
Facet joint Passive test Terbatas elastic end feel Nyeri.
Joint play movement test Elastic end feel
surface
Intervertebral PA spring, Spurling, Pain central/peripheral
Traction-distraction test, No pain-pain
Disc
Valsava maneouvre,
extension test No pain
Brachiel plexus: Dermatome/nervinal test Paresthesia/hypo-anesthesia
Myotome test – Reflex test Pain
1, Median N
Tinnel test Neural tension/adhesion
2, Radial N ULTT
3. Ulnar N
 CERVICAL ANATOMIC IMPAIRMENT TEST
Jaringan tubuh Tes Temuan
Lumboacral Dermatome/nervinal Paresthesia/hypo-anesthesia
test Pain
plexus:
Myotome test – Reflex Neural tension/adhesion
1, Femoral N test
2, Sciatic N Tinnel test
3. Tibial N 1. Femoral tension test
2. SLR (Lasegue) test
4, Peroneal n
3. Tibial n tension test
4. Peroneal nn tension
test
Duramater 1. Slump test Pain/ paresthesia
2. Neri test
Forament Gapping test Iritasi hilang/menurun
Lumbar Flexion test
intervertebral
BODY FUNCTION IMPAIRMENT
Fungsi Pemeriksaan Temuan

Pain Pain provocation: 1. Nyeri akibat anatomic

1. jaringan tertentu impairment
2. Gerak tertentu 2. Nyeri akibat movement
impairmen
Mal alignment 1. Postural test 1. Postural disorder
2. Pengukuran alignment 2. Kyphosis, roscoliosisund back,
3. Test penggunaak 3. Kebutuhan orthotic di=evice
device tertebtu
Hypomobility 1. Tes terhadap jaringan 1. Temuan jaringan spesifik
penyebab Structural terkait
hypomobility
(Capsules/Muscle/Nerve
) 2, Functional mobility impairment
2. Tes Functional tertentu
hypomobility
Hypermobility 1. Tes thd jaringan 1. Temuan pada jaringan spesifik
tertentu penyebab terkait
Structural hypomobility
2. Functional 2. Functional hypermobility
hypomobility
Sugijanto, 2020
BODY FUNCTION IMPAIRMENT
Fungsi Pemeriksaan Temuan

Instability 1. Static instability test 1. Non contractile structures test

terhadap structure jaringan Contractile structure test
tertentu
2. Dynamic instability dgn 2. Temuan neuromuscular
Functional stability test penyebab instability
Movement 1. Positional corrected 1. Positional vault
mobility test/Painfree
impairment
2. Movement correcten 2. Movement vault
mobility test
Movement 1. Muscle balance test 1. Muscle imbalance
incoordination 2. Movement cocontraction 2. Movement incoordination
test

Sugijanto, 2020
 DISABILITIES
Disabilities Outcome measure Temuan Intervensi
Bascic Sequences basic functional Unable, full support, partial Basic functional training
functional measure support, supervision or able at specific sequence
disability to do at specific sequence and above

Ambulation Gait analysis, walking Pathological gait, full

 INTERVENTION Gait training, Training in
analysis with walking edge, support, partial support, the used of walking
wheel chair ability, etc supervision or able in walking edge
edge, etc
ADL IADL Unable, full support, partial ADL training at specific
support, supervision or able level
to do at specific task
Work Work in office, work in field, Unable, support, super vision, Work training at specific
work in able to do task
Sport Individual sport Unable, support, super vision, Specific exercises and
Team sport etc able to do training in sport
Recreation In door recreation Unable, support, super vision, Specific exercises
Out door recreation able to do
Pain & disability NPDI, SPADI, DASH Score disabilitas Specific treatment
Sugijanto, 2020
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
 Menunjang differential diagnose
 Data evaluasi program yang objektif
 Beberapa penunjang diagnosis
 Laboratorium
 X Ray
 MRI
 Ultrasonography
 EKG
 Ekografi
 EMG
Assessment no 7: PROGNOSTIC
(CONTEXTUAL) FACTORS
 Faktor internal yang memperberat atau sebagai penyulit
 Commorbidities atau penyakit lain terkait atau Faktor psikososial yang menghambat
 Faktor eksternal yang memperberat atau sebagai penyulit
 Faktor lingkungan yang mengganggu sakitnya
 Faktor internal yang memperingan atau sebagai pefasilitasi
 Faktor sosial, intelegensi dan lainnya yang membantu proses penyembuhannya
 Faktor eksternal yang memperingan atau sebagai pefasilitasi
 Faktor lingkungan dan sosial yang membentu proses penyembuhannya

Sugijanto, 2020
Keluaran assessment: PT DIAGNOSIS dan
Functional prognosis
 Diagnosis merupakan simpulan pada pemeriksaan dalam
lingkup gerak dan fungsi (ICF) yang berdasar patologi (ICD).
 Capsular pattern hypomobility sec cervical spondyloarhtrosis
 Muscle pain and tightness sec. myofascial syndrome
 Pain and instability sec, Lumbar spondylolisthesis
 Dll
 Dalam lingkup gerak dan fungsi tanpa patologi.
 Low back pain sec. Hip joint hypermonbility.
 Neck painsec forward head posture
 Lumbopelvic pain sec, leg discrepancy
 Dll
Sugijanto, 2020
PLANNING

 Penjelasan tentang patologi, diagnosis, target, tujuan,

rencana intervensi dan hasil yang diharapkan
 Persetujuan pasien terhadap target, tujuan dan
tindakan intervensi fisioterapi
 Perencananaan intervensi secara bertahap meliputi:
 Body structure impairment target:
 Body function impairment target:
 Activity limitation target:
 Participation restriction target:.
 Contextual target:

Sugijanto, 2020
 INTERVENSI

Body structure Body function

Disabilities
impairment impairment

Modalitas, Modalitas, Modalitas,

Metode Metode Metode
dan Teknik dan Teknik dan Teknik
yg tepat yg tepat yg tepat
Sugijanto, 2020
MUSCLE IMPAIRMENT TARGET

Pirieormis Myofibrile tightness

• Teknik relaksasi otot

• Static stretching

Gluteal Myofascial contracted

•US/ESWT
•Contract relax stretching
•Myofascial release , MRT

ITB Tendon shortening

•Eccentric stretching
•ES Under tension

Sugijanto, 2020
CAPSULE IMPAIRMENT TARGET

Capsule contacted
• Joint mobilization / end range
• Mobilization With Movement
Capsule minimal tightness
• Joint manipulation
• Mobilization exercise

Capsule – ligament laxity

• Passive stabilization
• Active stabilization

Sugijanto, 2020
PERIPHERAL NERVE IMPAIRMENT

Neural inflammation
• Partial immobilization
• Circulatory improvement
• Electrical stimulation

Neural tightness
• Neural mobilization

Neural adhesion
• Nerve gliding technique

Sugijanto, 2020
DISC IMPAIRMENT TARGET
Disc bulging - Herniated

• Disc mobilization
• Extension exercise

Disc extruded - Fragmented

• Send to the docter

• Pre and post oprative

Postural deformity

• Lordotic posture
Sugijanto, 2020
FACET JOINT SURFACE
IMPAIRMENT TARGET
Inflammation/arthrosis
• Partial immobilization
• Alignment/deformity correction

Corpus libera
• Oscillated manipulation

Impingement
• Roll glide / Mobilization under traction
• Mobilization With movement

Sugijanto, 2020
VASCULAR IMPAIRMENT TARGET

Venous edema
• Elevation and pumping exercise
• Massage

Lymph edema
• Lymph drainage
• Electrical stimulation under pressure

Arterial dry edema

• Vacuum and compression

Sugijanto, 2020
POSTURAL DEFORMITY TARGET
Mal alignment
• Postural correction
• Self correction

Functional deformity
• Exercise
• Bracing

Structural deformity
• Exercise & Bracing
• Operative

Sugijanto, 2020
 INSTABILITY TARGET
Muscle imbalance
• Stabilization exercise
• Strengthening exercise

Functional instability
• Functional exercise
• Bracing

Structural instability
• Bracing
• Operative
• Exercises

Sugijanto, 2020
EVALUATION

 INPUT REEVALUALITION
 Reevaluasi data dan hasil assessment
 PROCESS REEVALUATION
 Reevaluasi metoda dan teknik intervensi
 OUTPUT REEVALUATION
 Reevaluasi hasil intervensi dengan instrument pengukuran

Sugijanto, 2020
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, 2020
PROSES FISIOTERAPI PADA
PATOLOGI CERVICAL SPINE

Sugijanto, 2020
 Spondylo arthrosis cervicalis

Functioning, disability and health Constextual factors

Anatomic impairment
Internal External
Disc Facet &
Muscle Nerves factors factors
Capsels
Uncinate

Pipih & Chronic Autonom

Erosi Nocisensoric
rapuh inflamation system

Sub chondral Weak- Sympathic

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

Hypomobility Neck pain Postural

deformity Sugijanto, 2020
 Klien dengan keluhan nyeri leher -
pundak / samping leher dan temporal.

ya
Pemeriksaan red flag:
Pancoast tumor,
History taking: Nyeri kaku leher banngun tidur,
Cervical
(Ha: SAC) duduk lama.
tdk instability/disc lesion,
dll
ya ya

Observasi: Forward head position, Konsul dokter

 Algoritme pemeriksaan
cervical deviation, Flat neck. spesialis yang fisioterapi Capsular pattern
kompeten
ya hypomobility akibat
Tes orientasi Servikal: ekstensi nyeri & spondyloarthrosis cervicalis
Pemeriksaan fleksi tidak nyeri/ tegang, 3D ekstensi nyeri Algoritme
fungsi gerak: pemeriksaan lain
tdk
ya

Tes pasif: Servikal fleksi & rotasi tegang/nyeri &

springy, Ekstensi: nyeri dorsal hard end feel

ya

Tes khusus: Joint Play Movement Test: Nyeri dan elastic end Hipotesis lain
feel pada saat gapping. 3D flexion test nyeri regang
tdk
ya
Pemeriksaan
Penunjang X Ray dan Nyeri tekan dgn algometer/VAS; X Ray
Dan Pengukuran Postur dgn plumb line

Diagnosis Nyeri dan kaku leher disertai capsular pattern

hypomobilityakibat spondyloarthrosis cervicalis
Sugijanto, 2020
 CERVICAL
SPONDYLOARTHROSIS

Anatomic Kinetic
impairment target impairment

Joint surface Muscle

inflammation/erosi weakness/tightness
Capsular Forward Upper thoracic
pattern Head Posture spine kyphosis

1. Traksi static pss fleksi 1. Active stabilization

2. Gapping 2. Contract relax stretching
mobilization otot contracture/tegang
3. Stright neck 3. Stright neck stabilization

1. Mobilisasi pada Postural correction Upper th LPAVP

akhir pembatanan Neck stabilization & /nelson
rom exc traction
2. 3D flexion
mobilization
Sugijanto, 2020
ALAT UKUR/EVALUASI FISIOTERAPI YG
DIBUTUHKAN

Pengukuran nyeri
Pengukuran fleksibilitas/ekstensibilitas
otot
Pengukuran ROM,
Pengukuran movement disfunction
Pengukuran disabilitas

Sugijanto, 2020
 HNP cervicalis
Functioning and disability Constextual factors

Anatomic impairment
Internal External
Nerves factors factors
Disc Muscle Capsels
Autonom
Rupture Weak- system Nocisensoric Motoric
Guarding
annulus spasm atrophy
Vascular Nerve root
Intability Postural
Ischemic Pain
tight Functional
Nucleus
Micro circular impairment Activity
Tightness Muscle constriction
nonjol dorsal imbalance
limitation
Neuropathic
Participation
Iriasi jar. dorsal pain restriction
Hypomobility Long period
Active sitting
Nyeri Work
sentral instability
Driving Sport
Nyeri
lateral
Pain
Nyeri Flat neck Recreation
radicular deformity
Sugijanto, 2020
 Klien dengan keluhan nyeri leher
menjalar hingga tangan.

ya Buat hipotesis awal HNP

Nyeri duduk. Menunduk lama, Pemeriksaan red flag:

History taking: berkurang bila tengadah Acute herniated,
tdk myelitis dll
ya ya  Algoritme
Observasi: Cervical deviation. Konsul dokter spesialis
yang kompeten
pemeriksaan
Tes orientasi Lumbarl:yafleksi-ekstensi fisioterapi pada
cervical nyeri & terbatas, tetapi ekstensi
tidak nyeri, Algoritme Radicular pain
akibat hernia
Pemeriksaan pemeriksaan lain
fungsi gerak: tdk
ya

Springing test positif, Spurling’s test positif, Nucleus

Pulposus
Tes khusus: disc traction posisi ekstensi nyeri menurun, valsava
maneouvre positif

ya Cervicale
Sensoric test dermatome positif, Lasegue positif,
Tes khusus:
Lower Limb Tension Test positif. Kenn muscle bisa
radiks HIPOTESIS
positif
LAIN
ya tdk
Pemeriksaan
Penunjang MRI untuk melihat tingkat HNP dan Nyeri tekan
Dan Pengukuran dgn algometer/VAS; Kenn muscle dengan MMT
MRI

Diagnosis
Nyeri leher menjalar ke tsngsn akibat HNP Cervical
Sugijanto, 2020
 Discogenic
neck pain

Annulus rupture, Iritasi jaringan Cervical Cervical

nucleus migrate dorsal discus straight posture disability

Sensitive tissue Nerve

inflamation entrapment
Functional
1. Core stability exercise
activity and
2. Proper body
participation
1. Oscillated traction mechanic education
education
in lordotic position
2. Extension SNAGS 1. Neural
3. Chin in - Tuck mobilization

Neck Collar 2. Nerve gliding

technique

Sugijanto, 2020
ALAT UKUR/EVALUASI FISIOTERAPI YG
DIBUTUHKAN
 Pengukuran nyeri
 Pengukuran Posture
 Pengukuran ROM,
 Pengukuran movement disfunction
 Pengukuran disabilitas

Sugijanto, 2020
 Thoracal joint blockade/Round back

Functioning and disability Constextual factors

Anatomic impairment
Internal External
Disc Facet Costovert Muscle Nerves factors factors

Capsels Autonom
system Nocisensoric
Migration Guarding
Postural
spasm Vascular
tight
Disc
Facet Ischemic Pain Micro circular Functional
Blockade
Blockade constriction impairment
Activity
Tightness Muscle
Nucleus limitation
nonjol dorsal imbalance Participation
restriction
Iriasi jar. dorsal Non capsular Long period
pattern sitting Work
Nyeri Hypomobility
lateral Driving Sport
Movement
Nyeri
dysfunction
sentral
Recreation
Pain Sugijanto, 2020
 Nyeri punggung-dada meningkat saat inspirasi.

ya Ha: thoracal facet blockade

Pemeriksaan red flag:

History taking: Nyeri saat duduk lama terutama
Pancoast tumor, Cervical
tanpa sandaran punggung tdk instability/disc lesion, dll
ya
ya
Round back/kyphosis/scoliosis
Observasi: Konsul dokter spesialis
yang kompeten
ya
Trunk: ekstensi nyeri & fleksi tidak nyeri/ Algoritme
Tes orientasi: pemeriksaan lain
tegang, 3D ekstensi nyeri
tdk
ya Algoritme
Tes pasif: Thoracal fleksi & rotasi tegang/nyeri & springy, pemeriksaan
Ekstensi: nyeri dorsal hard end feel
fisioterapi pada
ya
Thoracal spine joint
PACVP dan LPAVP: Nyeri dan firm end feel. Gapping Algoritme
Tes khusus:
testpositif. 3D extension test nyeri regang
tdk
pemeriksaan lain blockade
ya

Pemeriksaan Penunjang X Ray dan Nyeri tekan dgn algometer/VAS; Postur

Dan Pengukuran dgn plumb line LPAVP dengan end feel MRI?

Nyeri dan kaku leher disertai capsular pattern

Diagnosis
hypomobilityakibat spondyloarthrosis cervicalis

Identifikaasi Body structure Impairment: Facet dan capsules

problem dlm ICF Body Function Impairment: Nyeri punggung atas dan
hypomobility dalam capsular pattern Sugijanto, 2020
EVALUASI/PENGUKURAN FISIOTERAPI
YG DIBUTUHKAN PD JOINT BLOCKADE
 Pengukuran nyeri
 Pengukuran Posture
 Pengukuran ROM,
 Pengukuran movement dysfunction
 Pengukuran disability

Sugijanto, 2020
 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

Sympathic Spasm Inter fiber Functional

Nucleus
hyperactivity impairment Activity
herniation adhesion
limitation Participation
Vascular restriction
Sensitive Capsel contracture
tissue
Micro circular Capsular
Neuropathic constriction pattern
Sitting Work
pain Lifting Sport
Radicular pain Stretched Muscle Driving
pain imbalance
Recreation
Low back pain
Postural
deformity
Pain Sugijanto, 2020
 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
LAIN
Pulposus Lumbale
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, 2020
 Competency base approach

Lumbar disc
herniated

Iritasi jaringan
Annulus rupture, Lumbar straight Lumbar
dorsal discus
nucleus migrate posture disability

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

Sugijanto, 2020
ALAT UKUR/EVALUASI FISIOTERAPI YG
DIBUTUHKAN
 Pengukuran nyeri
 Pengukuran fleksibilitas/ekstensibilitas otot
 Pengukuran mobilitas
 ROM,
 Pengukuran disabilitas
 Oswestry

Sugijanto, 2020
 Spondylo arthrosis lumbalis
Functioning and disability
Constextual factors

Anatomic impairment
Internal factors External factors
Disc Facet Capsels Muscle Nerves

Erosi Nocisensoric
Chronic
Pipih & Weak-
inflamation
rapuh atrophy
Corpus Inter fiber Autonom
libera adhesion system
Instability Sympathic
Blockade Vascular hyperactivity
Inflamasi
Functional Activity Participation
impairment limitation restriction
Iritasi Capsel Micro circular
Spasm-
jar.sensitif contract constriction
tightness
Standing Work
Stretched
Capsular pain Muscle
pattern Walking Sport
imbalance
Recreation

Pain Postural
deformity Sugijanto, 2020
 Klien dengan keluhan nyeri pinggang
menjalar ke pantat atau paha.

ya

History taking: Nyeri kaku pinggang banngun Pemeriksaan red flag:

(Ha: SAL) tidur, duduk lama. Pancoast tumor, Cervical
tdk instability/disc lesion, dll
ya ya
Observasi Flat back, cervical
deviation, Konsul dokter spesialis
yang kompeten
Algoritme
Tes orientasi fleksi-ekstensiya
trunki: ekstensi nyeri &
Pemeriksaan
fungsi gerak:
fleksi tidak nyeri/ tegang, 3D ekstensi nyeri
Algoritme
pemeriksaan lain
pemeriksaan
tdk fisioterapi pada
ya
Capsular pattern
Tes pasif: lumbale fleksi & rotasi tegang/nyeri &
Tes khusus: springy, Ekstensi: nyeri dorsal hard end feel hypomobility akibat
spondyloarthrosis
ya
Joint Play Movement Test: Nyeri dan elastic end
lumbalis
feel pada saat gapping. 3D flexion test nyeri regang

ya
Pemeriksaan Penunjang
X Ray dan Nyeri tekan dgn algometer/VAS;
Dan Pengukuran X Ray
Postur dgn plumb line

ya

Nyeri dan kaku pinggang disertai capsular pattern

Diagnosis
hypomobility akibat spondyloarthrosis lumbalis

ya

Identifikaasi Body structure Impairment: Facet dan capsules

problem dlm ICF Body Function Impairment: Nyeri leher dan
hypomobility dalam capsular pattern Sugijanto, 2020
 Competency base
Spondyloarthrosis approach
lumbale

Anatomic Kinetic
impairment target impairment

Joint surface Muscle

inflammation/erosi weakness/tightness Joint Movement
Capsular Postural hypomobility impairment
pattern impairment
Joint instability
1. Traksi osilasi inferior 1. Active stabilization
2. Pengurangan 2. Contract relax
Joint mobilization
berat badan stretching otot Mobilization with
Joint manipulation
3. Olah raga dalam contracture/tegang movement
kolam 3. Muscle strengthening Functional exercise
& Functional exc

1. Mobilisasi pada akhir Postural correction

pembatend range Passive stabilization
Proper body mechanic
2. 3D flexin mobilization Active stabilization
3. Gapping mobilization/
manipulation
Sugijanto, 2020
 Spondylolisthesis lumbalis

Function & disability

Constextual
factors
Anatomic impairment
Internal External
Capsels & Conus
Disc Facet Muscle factors factors
Ligament cauda
luxation
Stenosis
Rupture Overstretch
Weak-
atrophy
Proc. artic Laxity
lysis Cauda Bilateral
Spasm- syndrome paresthesia
tightness
Functional Activity Participation
Pain & impairment limitation
Intability Myofascial restriction
paresthesia
adhesion

Work
Muscle
imbalance Siting
Sport

Driving
Recreation

Pain Postural
deformity Sugijanto, 2020
 Klien dengan nyeri pinggang menjalar hingga
gluteal atau kedua belah paha belakang.

ya Hhipotesis awal Lysthesis

History taking: Nyeri bangun tidur, habis duduk Pemeriksaan red flag:
(Ha: lysthesis) dan bunyi ketika memutar Acute herniated, myelitis dll
tdk
ya ya
Observasi:
Lumbar deviation./asymmetry,
Konsul dokter spesialis
ya yang kompeten

Pemeriksaan Tes orientasi Lumbar: fleksi –ekstensi

Algoritme
fungsi gerak: trunki nyeri & bunyi clicking
pemeriksaan lain
tdk
ya

Tes khusus
Palpasi → step off/on Algoritme pemeriksaan
Gapping test early clicki ng, Stability test dgn
lumbar lysthesis
tigh trust nyeri & clicking. Active stability test + fisioterapi pada
ya
Gluteal/hamstrings
Slump test , LLTT
pain akibat hernia
Tes khusus: sayaf HIPOTESIS
perifer
Bladder funtion test LAIN Spondylolyethesis
ya tdk

X Ray untuk mengukur besarnya lysthesis, tekan

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

Nyeri Pinggang menjalar ke hamstrings akibat

Diagnosis sondylolysthesis

Body structure Impairment: Discus and Nerve root

Identifikaasi
Body Function Impairment:
problem dlm ICF
Disabilitas:
Sugijanto, 2020
Sugijanto, 2020