MMT CONCEPT

Dynamic Active Release Technique

For Mechanical Lower Back Pain
Tingkatkan Praktek klinik anda dalam
menangani Mechanical Lower Back Pain
dengan pendekatan yang efektif ( Proven
Method )

Speaker / Instructor :
Mujianto / Director Of MMT Concept
Waktu Pelaksanaan :
Hari Minggu / 27 Maret 2022
Jam 19.00 WIB
Online Via Contact Person :
Rista 0852 3845
3224
 Pose.
Membantu
mobilisasi
tulang

Never Stop Learning

belakang dan
bantalannya (
Untuk HNP
Ringan )
Lower
Back
Pain
LBP menjadi masalah MEDICAL dan
Sosial Ekonomi

Negara Statistic

Inggris 100 Juta jam kerja hilang/tahun

Swedia 28 Juta Jam Kerja hilang/tahun dari sebelumnya 7 Juta

jam kerja

AS 149 Juta jam kerja hilang/tahun, dengan total dot US$

100 - 200 Miliar/Tahun

❏ Tren terus naik dan menjadi

penyebab disabilitas.
❏ Years Lived Disability
 Lower Back Pain

Gangguan Muskuloskeletal yang

menyerang 85% populasi orang
dewasa, 2-3% disertai referral pain
ke daerah sacroiliac Joint.

Menyerang areal costa terakhir – gluteal,

bisa disebabkan karena gangguan struktur
neuromuskuloskeletal.
 Etiologi :

● Mechanical
● Degenerative
● Inflammatory
● Oncologic
● Infectious

Non Back Related Disorders/Visceral

Disease

Patrick N, Emanski E, Knaub MA. Acute and chronic low back pain. Med Clin North Am. 2014
Jul;98(4):777-89, xii.
 LBP

Spesifik

Penyakit
Viscerogenic Psyichogenic Neoplastic Infeksi
Inflamasi

Non Spesific
LBP

Myogenic Neurogenic Spondylogenic

Risk Factor
Individu Vs Ergonomi

Poor Nutrition,
Poor Overall Poor Rest &
fitness and
Health Habits Recovery
hydration
 Risk Factor

Individu
al Ergonomi

High Task Repetition Angkat

Berat
• Menimbulkan Cidera
Akut

Forceful Excertion • Repetitif strain

Paling • Posisi statis yang
Sering tidak netral
Repetitive /Sustained
Awkward Posture • Pengulangan dengan
Pencegah Interval Pendek
an
• Posisi Netral
Hypersensitive —> tanda- Nyeri Ekstensi :
1. Facet —> Lokal.
tanda myofascial pain? 2. HNP tingkat parah —> disertai
sengatan listrik ke tungkai

TEST &
DIAGNOSIS
Nyeri pada fleksi lumbal —> HNP.
—> Pastikan dengan Test
Kompresi pada Foramen I.V

—> Jika tidak ada defisit

neurologist —> struktur
myofascial ?
Cara Membedakan
Tidak menunjukkan gejala
penyakit tertentu

Non Spesifik/Faktor Mekanis

● Muscle Imbalance
● Stress Emosional
● Deconditioning posture

Nyeri menjalar ke pantat ketika

fleksi lumbal

Discogenic

Positif Test SLR

Resource :
Update management of Lower back Pain.
Prof. Wahid Sultan, Professor of Rheumatology & Rehabilitation, Mansoura University,
 Spinal Stenosis : Nyeri
Saat Ekstensi

Posterior

Spondylolysis
Facet : Rotasi &
( IAV):
Ekstensi
Rotasi & Ekstensi
Resource :
Update management of Lower back Pain.
Prof. Wahid Sultan, Professor of Rheumatology & Rehabilitation, Mansoura University,
 Usia : 20 Tahun / >60
tahun. R: >35 Tahun

Lansia Jarang->Spinal
Stenosis

Pria / wanita
sebanding

88 % Disc adalah cairan, Patologis : 60% menurun ( dehidrasi )

 50-60%
Recovery LBP & 1minggu,
Sciatica 96% 3 Bulan,
50% 1bulan

Post Ops 1 th ada

perbedaan, namun
Observasi 3 Bulan, kecuali dgn
dalam 4-10 tahun
deficit neuologis.
tidak ada perbedaan
significant.

Resource :
Update management of Lower back Pain. Prof. Wahid Sultan, Professor of
Rheumatology & Rehabilitation, Mansoura University,
<S> 1999 Scott Bod ell
Physiology Of Pain ? Neuropathic

Nociceptive

Psychogenic

Monheim : “An unpleasant emotional experience usually initiated by

noxious stimulus and transmitted over a specialized neural network to the
CNS where it is interpreted as such.”

Is an unpleasant sensory and emotional experience associated with

actual and potential tissue damage, or described in terms of such damage.
(American Pain Society[APS],2003;Gordon,2002)
Fisiologi Nyeri ❑ Neurofisiologis kompleks akibat adanya
transduksi/stimulus nociceptor perifer.

❑ Transduksi -> Konduksi -> Transmisi ->

Neuropathic

Nociceptive
Persepsi

Monheim: "Pengalaman emosional yang

tidak menyenangkan biasanya dimulai
oleh stimulus berbahaya dan
Psychoge
nic
ditransmisikan melalui jaringan saraf
respiratory khusus ke SSP yang diinterpretasikan
seperti itu."
Pain

Pulse
1 dari 5 Vital Signs

Merupakan pengalaman sensoris dan

Blood Pressure emosional yang tidak menyenangkan yang
Temperature terkait dengan kerusakan jaringan aktual dan
potensial, atau dijelaskan dalam istilah
Pain
kerusakan tersebut. (American Pain Society
[APS], 2003; Gordon, 2002)

Aktivasi
Kognitif Neurohumoral Plastisitas Neural Neuroendokrin
Simpatoadrenal
Pain Matrix
Spinal —>Talamus & Cortex —>
Terkolektif menjadi Pain Matrix

Modulasi Persepsi Nyeri secara

Internal :
Emosi Plasebo Distraksi

Tracey A, Dickenson A. Sel 2012; 148 (6): 1308-e2.

Transduksi Konduksi Transmisi Persepsi

Biopsychosocial Model of Pain ,Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624.

Inflammatory Soup
Prostaglandins
When there is significant & Potassium
damage to tissue, several
chemicals are released into
the area around the Bradykinin ( Blood
nociceptors. Plasma )

Serotonin (
This develops into what is blood
called the "inflammatory platelets )
soup," an acidic mixture
that stimulates and
Substance P
sensitizes the nociceptors oleh
into a state called Nociceptors
hyperalgesia, which is OK Nast Cell
melepas
Greek for "super pain." Histamine.
Some of the chemicals
involved:
 Slow pain: poorly
Chemical localized, dull,
Mechanical throbbing
/thermal
stimuli
Pain ❑ Serotonin
❑ Prostaglandins
❑ Substance P
❑ CGRP

❑ K+
Pain stimuli

❑ ADP
❑ ATP
Fast pain: ❑ Bradykinin
Sharp well ❑ histamine
localized ,
pricking type
 Protective Role : vital early warning
❑ Senses noxious stimuli
❑ Triggers withdrawl reflex and heightens sensitivity after tissue damage
to reduce risk of further damage

Unpleasant Experience
❑ Suffering - physical, emotional and cognitive dimensions
❑ Continuous unrelieved pain can affect physical ( eg : Cardiovascular, renal,
gastrointestinal systems, etc ) and psychological states.

Maladaptive Response
❑ Neuropathic and central sensitization/dysfunctional pain
❑ Not protective
❑ Lessens quality of life

Costigan M et al. Annu Rev Neurosci 2009; 32:1-32; Wells N et al. In: Hughes RG (ed). Patient Safety and Quality: An Evidence-
Based Handbook for Nurses. Agency for Healthcare Research and Quality; Rockville, MD: 2008; Woolf CJ et al. Ann Intern Med
2004; 140(6):441-51.
Time to resolution 1 2 3
Acute pain Chronic pain
Pain that has persisted beyond
Normal, time-limited normal tissue healing time
response to ‘noxious’ (usually more than 3 months)
experience (less than 3
months) ❑ Usually has no protective
❑ Usually obvious tissue function
❑ Degrades health and
damage function
❑ Serves a protective
function
❑ Pain resolves upon
healing
Chong MS, Bajwa ZH. J Pain Symptom Manage 2003; 25(5 Suppl):S4-11; Cruccu G et al. Eur J Neurol 2004; 11(3):153-62; Dray A. Br J Anaesth 2008;
101(1):48-58; International Association for the Study of Pain. IASP Taxonomy. Available at:
http://www.iasppain.org/AM/Template.cfm?Section=Pain_Definitions. Accessed: July 15, 2013; McMahon SB, Koltzenburg M (eds). Wall and
Melzack’s Textbook of Pain. 5th ed. Elsevier; London, UK: 2006; Woolf CJ. Pain 2011;152(3 Suppl):S2-15.
 Chronic pain is
defined as ‘pain that
Acute pain is
pain persists for three
months or more, or
pain due to beyond normal tissue
tissue injury e.g. healing time’
trauma, surgery.
acute chronic
Pain goes away
when the tissue
injury heals. Can be due to cancer
or non-cancer causes
Analgesia should
be stopped
when there is no
more pain

Non-Cancer Pain
Cancer
Pain

Nociceptiv
Widespread
Neuropathic
Nociceptive Pain
Nociceptive e
 BIO-PSYCHO-SOCIAL MODEL OF PAIN

Injury
Believe/Concer
Other illnesses
ns about pain

Psychological
Factors Coping Strategies
Anxiety/anger/depr
ession

Cultural issues Social Factors

Language, e.g. Famili,
expectations work

Pain
What the patient says hurts.
What must be treated.
Pain History Worksheet

P Place

Aggravating
A Factors

I Intensity

Nature /
N Neutralizing Factors
 S O C R A T E S
Onset – Characte Radiatio Associatio Time Exacer Severi
Site –
When did r – What n– ns – Any course – bating/ ty –
Where
the pain is the Does other Does the relievin How
is the
start, and pain the pain signs pain g bad is
pain?
was it like? radiate or sympto follow factors the
Or the
sudden or An ache? anywhe ms associa any – Does pain
maxim
al site gradual? Stabbing re? ted with pattern? anythi
of the Include ? the pain? ng
pain also chang
whether it e the
is pain?
progressive
or
regressive.
 •Specificit •Strong’s The Fourth
•Intensive Pattern Theory of
y Theory Theory
Theory Theory Pain oleh
1874 oleh Erb 1895 Oleh Von 1895 Oleh 1929 Oleh J.P 1940 s Hardy, wolf,
Frey Strong and Goodell
Nale

Central
Summatio •Sensory •Gate Control
Interaction Theory Oleh Biopsychosoci
1943 n Theory al Model Of
Oleh 1959 Theory Oleh
Noordenbos
1965 Melzack &
Wall
1977 Pain Oleh
Livingston George Engel
e

Pain Theory
 Modulasi Nyeri
Segmenta
l
Inhibition
Gate Control Mechanisme
Doley, et al. 2013).

Endogenou
s Opoid
System Release Endorphine dan
ENkhepalin
Boyling, Tunisia, 2015

Descending
Inhibitory
System
Release Noradrenaline
(Bialosky et al., 2009, Savva et al., 2014, Zafereo and Deschenes,
2015
33
Sensory fiber types
Erlanger-
Conduction Associated sensory
Type Gasser Diameter Myelin
velocity receptors
Classification
Responsible
Ia Aα 13–20 μm Yes 80–120 m/s[4]
for proprioception
Ib Aα 13–20 μm Yes 80–120 m/s Golgi tendon organ
Secondary receptors
II Aβ 6–12 μm Yes
33– of muscle spindle
All cutaneous
75 m/s mechanoreceptors

Free nerve endings of

touch and pressure
III Aδ 1–5 μm Thin 3–30 m/s Nociceptors of neospi
nothalamic tract
Cold thermoreceptors

Nociceptors of paleos
0.5–
IV C 0.2–1.5 μm No pinothalamic tract
2.0 m/s Warmth receptors
Pain Inhibition
Mechanisme
 Structure
Impairm
Problem Solving
ent

Opoids
Mechano Chemical
Endogens
Receptor Receptor
Mechani
cal Load
Respons

Neurohormo
Pain Pain
nal Pain
Inhibition Inhibition
Inhibition
Structure Psychophysiolog
Manipulation ical Tanifia, 2015
Bialosky et al., Roy et al.,
2009, Savva 2010,
Viscoelasti et al., 2014, Teodorczyk
CBT,
s Respone Zafereo and -Injeyan et
placebo
& Tissue Deschenes, al., 2006
effect
Repair 2015)
Tanifia, 2015
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities
in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York. Fascilitate
Opoid Endogens
Minasny, B., 2009. Understanding the process of facial unwinding. Response
International journal of therapeutiv massage and bodywork 2 (3), 10-17
Respon Adaptif
Jaringan

Inhibisi sinyal Menekan/menghambat

biosintesis mediator-
nyeri mediator proinflamasi

Viscoelastis Opoid Endogen

Response
Response

Respon saraf Psychophysiologic

otonom al Respon
Manual Therapy
Manual Therapy can be defined as the fascilitation of mechanical,
neural, and psychophysiological adaptive potential interfaced via the
myofascial system.
( Kegerneis SK, 1992 )

Neural, Spesificts
Mechanotransduction goal
psychophysiological
adaptive
Manual Therapy
Manualtherapy can be defined as the
fascilitation of mechanical, neural,
and psychophysiological adaptive
potential interfaced via the myofascial system. (
Kegerneis SK, 1992 )
Manual Therapy creates a temporary change in tissue tone or mechanoreceptor
and nocioceptor sensitivity
Changes TONE of muscle
Appropriate stress could guide collagen formation and therefore tissue make up

Reduces Pain, Increases Range of Movement, Improves how a muscle contracts ,

Increases Patient Satisfaction
ALWAYS used as an adjunct to exercise
Study tentang Manual Therapy

In a recent study, Bron et al. conducted a

controlled trial in the treatment of myofascial
trigger points in patients with shoulder pain.
They decided to only
use manual
techniques associated with home
exercises and ergonomic
recommendations.
After 12 weeks of treatment there was a
statistically significant improvement in the
intervention group compared with the control
group.
Fascilitation of Fibroblast
The intent of deep pressure is to create
inflammation and draw fibroblasts to the
region to facilitate the healing process of
the degenerated collagen fibers.

Fibroblasts produce the glycosaminoglycans,

collagens, elastic fibers, reticular fibres and
glycoproteins that can be seen in the
extracellular matrix. When tissue damage has
occurred, the fibrocytes are stimulated to
undergo mitosis or multiplication by replication
and division.
( Mandal A, 2014 )
Study Biochemistry tentang Cortisol, serotonin,

Touch Research Institutes,

University of Miami School of Medicine, Miami,
Florida 33101, USA.
dan dopamine

Dopami
31 %
ne

Seroton 28%
in

cortisol 31%

Field T, Hernandez-Reif M, Diego M, Schanberg S, Kuhn C., Cortisol decreases and serotonin and dopamine
increase following massage therapy, Int J Neurosci. 2005 Oct;115(10):1397-413
Hasil Study Metode Cyriax

The Cyriax manual therapy approach

consisting of deep friction massage and
manipulation was utilized only by Guler-
Uysal and Kozanoglu.

After one week of treatment, patients in

the Cyriax group demonstrated
significant improvements in passive
range of motion into flexion, external
rotation, and internal rotation
compared to the modality group.

After two weeks, the Cyriax group

continued to demonstrate significantly
improved passive range of motion into
external and internal rotation compared
to the modality group.
Guler-Uysal F, Kozanoglu E. Comparison of the early response to two methods of
rehabilitation in adhesive capsulitis. Swiss Med Wkly. 2004;134:353–358
Helene Langevin, M.D., L.Ac., Research Assistant Professor,
University of Vermont, Department of Neurology,
Burlington,
January 04, 2012 Vermont
kolagen,
glikosaminoglikan
tendons, (GAG), kadar air
ligaments, joint dan arsitektur.
capsules

fasciae, subcutaneous,
Viscoelastis
interstitial, connective Response
tissues.

Mechanical Force

Respons viskoelastik jaringan terhadap kekuatan mekanik ditentukan oleh

komposisi matriks jaringan ikatnya (kolagen, glikosaminoglikan (GAG), kadar
air) dan arsitektur.
 kolagen,
glikosaminoglikan
tendons, (GAG), kadar air dan
ligaments, joint arsitektur.
capsules

fasciae, subcutaneous,
interstitial, connective
Viscoelastis
tissues. Response

Mechanical Force

1. secreting matrix components and thus regulating matrix

composition .
2. actively responding to mechanical forces via mechanotransduction—or mechanisms
that directly link mechanical forces to active changes in cell shape,
intracellular signaling mechanisms and/or expression of specific
mechanosensitive genes (including collagen, GAGs, metalloproteinases and
growth factors).
 Sekresi Matrix
Mechanical forces actively Componen % Regulating
Matrix Composition

participate (via cellular

responses) in remodeling of
connective tissue’s Vasodilatasi
extracellular matrix

Viscoelastis
Response
Mechanical
& Physical
Behaviour

Physiologica
l Effect
 The immediate effect of traditional Malay massage on substance P,
inflammatory mediators, pain scale and functional outcome among patients
with low back pain: study protocol of a randomised controlled trial. 4

• Decreasing Amount Of Pain

Experienced,1,2,3
• Increasing Sleep,2,3

• Decrease Movement While Sleeping,3

• Decreasing Need For Analgesic
Medication,1
• Decreasing Cortisol Levels,2

• Decreasing Substance P Levels, And By 3

• Decreasing Anxiety And Depression. 3

1.Brattberg, Gunilla. “Connective tissue massage in the treatment of fibromyalgia.” European Journal of Pain 3(1999): 235-244.
2.Sunshine, William; et al. “Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation.” Journal of Clinical Rheumatology: Practical Reports on
Rheumatic & Musculoskeletal Diseases1(1996): 18-22.
3.Field, Tiffany; et al. “Fibromyalgia Pain and Substance P Decrease and Sleep Improves After Massage Therapy.” Journal of Clinical Rheumatology: Practical Reports on Rheumatic
& Musculoskeletal Diseases2 (2002): 72-76.
4.https://www.massagemag.com/massage-improves-sleep-decreases-pain-and-substance-p-in-fibromyalgia-patients-3465/
 Stimulasi non nociceptor (
mechanoreceptor ) serabut Aβ —>
Local mempengaruhi impuls pada sel DHC dan
Tissues stimulasi Descending Path ways untuk
melepaskan opoids endogen yang dapat
menghambat transmisi nyeri.

Efek mechanotransduction / viscoelastis

response akan mempengaruhi CNS (
Ascending dan Descending Pathways ) dan
perubahan kimiawi lokal dan perbaikan struktur
komposisi matrix dari Collagen.

Peripheral
 How evidence suggests there is a Peripheral
Mechanism to Manual Therapy:
Local
Tissues • Reduction blood and serum level
inflammatory mediators
• Altering nociception or inflammatory markers locally
(Roy et al., 2010, Teodorczyk-Injeyan et al., 2006)

• Cells respond to mechanical load or force

through mechanotransduction
• Fibroblast activity changes in response to internal and
external forces applied to cells
• Fibroblast activity controls the make up of a tissue
(collagen formation, extracellular matrix)
• Tissue responds and adapts to the force and stress
applied to it
• This process takes a long time and repeated stress is
required

Peripheral (Langevin et al., 2011)

 How evidence suggests
there is a Spinal
Mechanism to Manual
Therapy:

• Decreased activation of
the dorsal horn
• Changes in muscle activity
at spinal level
(Malfait & Shnitzer, • Change in pain pressure
2013) thresholds or even
temperature at the spinal
level
Efek Spinal (Bialosky et al., 2009)
 How evidence suggests there is a
Supraspinal Mechanism to Manual
Therapy:
• Decreased activation of areas of the brain
responsible for central pain
• Various autonomic responses to manual
therapy
• Activation of descending inhibition of the
periadequctal grey matter
• Improvement in psychological outcomes
(Malfait & Shnitzer, • Improvement in somatosensory
2013)
processing within the cortex
• Release of opioids
(Bialosky et al., 2009, Savva et al., 2014, Zafereo and
Deschenes, 2015)
Efek Supraspinal
Konsep Dynamic Active Release

Pemulihan Jaringan
yang ditandai :
Mechanical Potential Adaptive of Nyeri Nerkurang,
Neuromuscular Neurophysiological response Pemulihan ROM,
DYsfunction Fascilitation in anatomical structure Peningkatan
Kemampuan
Fungsional, perbaikan
saraf otonom

Metabolic
Ischaemic
stress
Active Pain Inhibition
Neurohormonal

Dehidrasi PT
Inflammation
Fascia
Viscoelastis Metabolisme
Feedback
Adhesive Scar Fibrous Band
Autonomic
Dynamic Fluid
System
Psikososial
 ROLE OF Manualtherapy & & &
& Dynamic Active Release
Therapy
Fasilitasi terhadap Potensi Adaptasi
Mechanik, Saraf, fisiologis, dan
Psikologis terhadap jaringan tubuh
untuk tujuan tertentu ( efek
fisiologis/therapeutic efek ).

Timi
• Viscoelastis Respon 🡪 Sirkulasi & ROM ng
• Mechano Receptor 🡪 Pain Inhibition.
• Neurohormonal / Opoid Endogen Response 🡪 Kompone Effo
n rt
Pain Inhibition.
• Supress Inflammation Mediator/Nociceptive
Targ
Irritant. et
• Metabolic 🡪 metabolic stress release
• Autonomic System
• Dynamic Fluid
 Activ
e

PT

Feedba
Dynamic Active Relea
ck

o Fascilitasi respon adaptif fisiologis menggunakan

modalitas mekanik secara aktif dan pasif release, yang
mana pasien berpartisipasi secara aktif dengan
menggerakan ekstremitas yang terkena pada batas
kemampuan geraknya, dikombinasikan dengan terapis
melakukan fascilitasi mekanis pada struktur yang
terkena.

o Dilakukan mulai dari keterbatasan hingga tercapai

ROM Optimal, dengan tujuan mengurangi nyeri,
menambah ROM dan mengoptimalkan gerak
fungsional untuk melakukan ADL.
 Tanifia, 2015
Neurohormo Fascilitate Opoid Endogens
nal
Response
NeuroPhysiological Respon

Autonomic Pain
System Inhibition Inhibisi transmisi
Informasi nyeri di
Dorsal Horn Cell
Doley, et al. 2013).
Tanifia, 2015 🡪 GCT
Tanifia, 2015
Enchepalin 🡪 Pain
Inhibition pre
synaps

Dynamic
Viscoelastis Helene Langevin,
Fluid
M.D., L.Ac., 2012

Tanifia, 2015
Increase Dynamic
Fluid Mandal A, 2014
Metabolisme

Langevin H, 2012
 Viscoelastis is
Matter
Helene Langevin, M.D., L.Ac., Research Assistant
University of Vermont, Department of Neurology,
Professor,

Burlington, Vermont
January 04, 2012

Mechanic Viscoelastis Response

• Sekressi Kolagen,
Physiological
Response
glicoaminogilkan ( GAG ),
al kadar air dan arsitektur
• Tissue Repaire
• Functional ability

Fascilitati
on
•Tendons
•Ligaments
•Joint Capsules
•Fasciae
•Subcutaneous
•Interstitial

Respons viskoelastik jaringan terhadap kekuatan mekanik

•Connective Tissues

ditentukan oleh komposisi matriks jaringan ikatnya

(kolagen, glikosaminoglikan (GAG), kadar air) dan
arsitektur.
Fisiologis Response
Aktifasi Fibroblast
The intent of deep pressure is to
create inflammation and draw
fibroblasts to the region to facilitate
the healing process of the degenerated
collagen fibers.

Fibroblasts produce the glycosaminoglycans,

collagens, elastic fibers, reticular fibres and
glycoproteins that can be seen in the
extracellular matrix. When tissue damage has
occurred, the fibrocytes are stimulated to
undergo mitosis or multiplication by replication
and division.
( Mandal A, 2014 )
Changes in blood flow and cellular metabolism at a
myofascial trigger point with trigger point release
(ischemic compression): a proof-of-principle pilot study

The findings from this brief investigation are intriguing for

future research on MTrP’s and MPS. We found that upon
MTrP release, dialysate lactate concentration and blood
flow increased at the MTrP. Although more robust subject
numbers are needed to confirm the current findings, this
study opens the possibility for investigations of cellular
metabolism and blood flow within the myofascial trigger
point before, during, and following interventions
designed to reduce MTrP contracture and pain.

Albert F. Moraska, PhD, Robert C. Hickner, PhD,

Wendy M. Kohrt, PhD, and Alan Brewer, MD

Arch Phys Med Rehabil. 2013 Jan; 94(1):

196–200.
Study tentang Manual Therapy

In a recent study, Bron et al. conducted a

controlled trial in the treatment of myofascial
trigger points in patients with shoulder pain.
They decided to only
use manual
techniques associated with home
exercises and ergonomic
recommendations.
After 12 weeks of treatment there was a
statistically significant improvement in the
intervention group compared with the control
group.
Konsep Dynamic Active
Release
Pemulihan Jaringan
yang ditandai :
Mechanical Potential Adaptive of Nyeri Nerkurang,
Neuromuscular Neurophysiological response Pemulihan ROM,
DYsfunction Fascilitation in anatomical structure Peningkatan
Kemampuan
Fungsional, perbaikan
saraf otonom

Metabolic Activ Pain

Ischaemic
stress e Neurohormo
nal Inhibition

Dehidrasi PT
Inflammation
Fascia
Viscoelastis Metabolisme
Feedba
ck
Adhesive Scar Fibrous Band
Dynamic Autonomic
Fluid System
Psikososial
 ROLE OF Manualtherapy &
Dynamic Active Release
Therapy
Fasilitasi terhadap Potensi Adaptasi
Mechanik, Saraf, fisiologis, dan
Psikologis terhadap jaringan tubuh
untuk tujuan tertentu ( efek
fisiologis/therapeutic efek ).

Timi
• Viscoelastis Respon 🡪 Sirkulasi & ROM ng
• Mechano Receptor 🡪 Pain Inhibition.
• Neurohormonal / Opoid Endogen Response 🡪 Kompone Effo
n rt
Pain Inhibition.
• Supress Inflammation Mediator/Nociceptive
Targ
Irritant. et
• Metabolic 🡪 metabolic stress release
• Autonomic System
• Dynamic Fluid
 Activ
e

PT

Feedba
Dynamic Active Relea
ck

o Fascilitasi respon adaptif fisiologis menggunakan

modalitas mekanik secara aktif dan pasif release, yang
mana pasien berpartisipasi secara aktif dengan
menggerakan ekstremitas yang terkena pada batas
kemampuan geraknya, dikombinasikan dengan terapis
melakukan fascilitasi mekanis pada struktur yang
terkena.

o Dilakukan mulai dari keterbatasan hingga tercapai

ROM Optimal, dengan tujuan mengurangi nyeri,
menambah ROM dan mengoptimalkan gerak
fungsional untuk melakukan ADL.
 Tanifia, 2015
Neurohormo Fascilitate Opoid Endogens
nal
Response
NeuroPhysiological Respon

Autonomic Pain
System Inhibition Inhibisi transmisi
Informasi nyeri di
Dorsal Horn Cell
Doley, et al. 2013).
Tanifia, 2015 🡪 GCT
Tanifia, 2015
Enchepalin 🡪 Pain
Inhibition pre
synaps

Dynamic
Viscoelastis Helene Langevin,
Fluid
M.D., L.Ac., 2012

Tanifia, 2015
Increase Dynamic
Fluid Mandal A, 2014
Metabolisme

Langevin H, 2012
 Viscoelastis is
Matter
Helene Langevin, M.D., L.Ac., Research Assistant
University of Vermont, Department of Neurology,
Professor,

Burlington, Vermont
January 04, 2012

Mechanic Viscoelastis Response

• Sekressi Kolagen,
Physiological
Response
glicoaminogilkan ( GAG ),
al kadar air dan arsitektur
• Tissue Repaire
• Functional ability

Fascilitati
on
•Tendons
•Ligaments
•Joint Capsules
•Fasciae
•Subcutaneous
•Interstitial

Respons viskoelastik jaringan terhadap kekuatan mekanik

•Connective Tissues

ditentukan oleh komposisi matriks jaringan ikatnya

(kolagen, glikosaminoglikan (GAG), kadar air) dan
arsitektur.
Fisiologis Response
Aktifasi Fibroblast
The intent of deep pressure is to
create inflammation and draw
fibroblasts to the region to facilitate
the healing process of the degenerated
collagen fibers.

Fibroblasts produce the glycosaminoglycans,

collagens, elastic fibers, reticular fibres and
glycoproteins that can be seen in the
extracellular matrix. When tissue damage has
occurred, the fibrocytes are stimulated to
undergo mitosis or multiplication by replication
and division.
( Mandal A, 2014 )
Changes in blood flow and cellular metabolism at a
myofascial trigger point with trigger point release
(ischemic compression): a proof-of-principle pilot study

The findings from this brief investigation are intriguing for

future research on MTrP’s and MPS. We found that upon
MTrP release, dialysate lactate concentration and blood
flow increased at the MTrP. Although more robust subject
numbers are needed to confirm the current findings, this
study opens the possibility for investigations of cellular
metabolism and blood flow within the myofascial trigger
point before, during, and following interventions
designed to reduce MTrP contracture and pain.

Albert F. Moraska, PhD, Robert C. Hickner, PhD,

Wendy M. Kohrt, PhD, and Alan Brewer, MD

Arch Phys Med Rehabil. 2013 Jan; 94(1):

196–200.
Study tentang Manual Therapy

In a recent study, Bron et al. conducted a

controlled trial in the treatment of myofascial
trigger points in patients with shoulder pain.
They decided to only
use manual
techniques associated with home
exercises and ergonomic
recommendations.
After 12 weeks of treatment there was a
statistically significant improvement in the
intervention group compared with the control
group.
 Test &
Diagnosis

Assesment Planing

Process

Evaluasi &
Intervensi
Follow Up
Procedure
Problematik Pemeriksaan Treatment
Facet Joint Ekstensi dan
Rotasi Ipsilateral

Ekstensi, Side
Discogenic Fleksi dan Rotasi
Ipsi Lateral
LSR Test

Myofascial Palpasi Trigger

Trigger Point Point
Test Regang
Problematik Pemeriksaan Treatment
Spinal Stenosis Ekstensi

Discogenic Ekstensi, Side

Fleksi dan Rotasi
Ipsi Lateral
Myofascial
Trigger Point Palpasi Trigger
Point
Test Regang
 Healthy : Food, posture, control
stress

Exercise

Active

Advice
Trigger Point Palpasi
Design Home Program
Stretching

Strength
Edukasi
ening

Keep Good
Posture & Healthy
Life Style
 Pose.
Erector Spine Membantu
Sacroilliac Joint
mobilisasi
tulang
belakang dan
bantalannya (
Untuk HNP
Ringan )
QL, Gluteal, And
Hamsting
Stretching Contoh Untuk Q
Lumborum Kiri
bagian kanan
menukar posisi k
gerakan sebal
Teknik Mengangkat