Curriculum Vitae

Dr.dr. Tirza Z. Tamin, SpKFR-K

Birth Place / Date : Medan, March 14th 1964
Home Address : Jl. Tanimbar Blok H No. 228 Cinere Megapolitan,
Depok. Phone number : 087885176141
Office Address : Medical Rehabilitation Department
RSUPN.Dr Cipto Mangunkusumo
Phone number / Fax number : 021. 3915593 /
3907561
Curriculum Vitae
Educational Background :
 2006 – 2009 : Doctoral Program, Medical Faculty University of
Indonesia, Jakarta
 1994 – 1998 : Physical Medicine and Rehabilitation Specialist,
Medical Faculty University of Indonesia, Jakarta
 1983 – 1989 : General Practitioner, North Sumatera University,
Medan
Position :
 Januari 2002 – Now : Head Division of Sport Injury, Welness clinic and Obesity
Clinic Physical Medicine and Rehabilitation Department,
RSUPN Cipto Mangunkusumo, Jakarta
 November 2007 – 2013: Secretary of Specialist Program Physical Medicine and
Rehabilitation RSUPN Cipto Mangunkusumo, Jakarta/
Medical Faculty University of Indonesia
 December 2013 - Now : Coordinator of Vokasi and Undergraduate (S0 –S1)
Program RSUPN Cipto Mangunkusumo, Jakarta / Medical
Faculty University of Indonesia
Organization :
> IDI > PEROSI
> PERDOSRI
 General Rehabilitation Principles of
Sports – Related Musculoskeletal Injuries

Dr.dr. Tirza Z Tamin SpKFR (K)

Department of Medical Rehabilitation

Cipto Mangunkusumo Hospital/
Faculty of Medicine University of Indonesia
The body’s response to injury & the role of
rehabilitation
Injury

Greater risk Bleeding Damage Reduced risk

of reinjury Tissue of reinjury
Pain
Inadequate Adequate
Inflammation

Repair
Regeneration

Atrophy

Rehabilitation
 Rehabilitation
The process of applying stress to healing tissue in
accordance with the specific stresses that it will face upon
return to a specific activity.
Rehabilitation involves reconditioning injured tissue. Once
the healing tissue is mature, the emphasis to more
aggressive conditioning for the athlete to re-enter the
sports.
Ultimate goal of rehabilitation of sport specific injuries :
maximal restoration of function for an anatomic area or a
specific athletic activity.
 Goals of Rehabilitation
Decrease pain
Decrease inflammatory response to trauma
Return of full active & pain-free range of motion
Decrease effusion
Regaining balance and postural control
Return full muscular strength, power & endurance
Maintaining cardiorespiratory endurance
Return to full asymptomatic functional activities at the pre-
injury level
 Adverse Effects of Immobility
(Unilateral Limbs Suspension or Absolute Bed Rest)
Muscle atrophy and loss of strength
General deconditioning
Structural changes of articular capsule connective tissue,
causing decreased range of motion
Articular cartilage degeneration
Cardiovascular deconditioning
Reduced stimulus of bone mineral depositing, possibly
contributing to diminished bone density
 Allowed for Proper Healing
Healing Rates for Various Tissue Types
Time to Return to (approximately)
Tissue Normal Strength
Bone 12 weeks
Ligament 40 – 50 weeks
Muscle 6 weeks up to 6 months
Tendon 40 – 50 weeks

Depends on the athlete’s age, health, and

nutritional status and the magnitude of injury
 Healing Process – Ligament Sprain
1. Inflammatory phase : 72 hours-6weeks
2. Proliferation phase : 6 weeks-12 months
3. Remodelling phase : more than 12 months

Depends on the athlete’s age, health, and nutritional

status and the magnitude of injury
 Goals should be met to achieve
maximum results
1. Establishment of a complete and accurate diagnosis
2. Minimization of a deleterious local effects of the acute
injury
3. Allowance for proper healing
4. Maintenance of other components of athletic fitness
5. Return to normal athletic function
Establishment of Complete & Accurate Diagnosis
1. History (Subjective)
2. Examination of specific systems :
a. Musculoskeletal : range of motion/flexibility, strength,
coordination, agility, special tests and functional
performance tests
b. Neuromuscular,
c. Cardiopulmonary,
d. Integumentary.
Establishment of Complete & Accurate Diagnosis
3. Assessment :
a. Problem list
b. Short term goals (1 to 2 weeks), long term goals
(functional goals), rehabilitation potential
c. Summarized evaluation

4. Plan : specify interventions and the frequency and duration

of treatment
 Musculoskeletal Injury Types

Fracture Sprain
Broken bone Joint injury with
tearing of ligaments
Dislocation
Disruption of a
Strain
joint Stretching or tearing
of a muscle
 Developing a Rehabilitative Plan
Must be carefully designed
Must have complete understanding of the injury :
 How it was sustained

 Major anatomical structures involved

 The grade of trauma

 The severity of injury

 Stage or phase of healing

 Adherence to a Rehabilitation Program
Athlete must comply to be successful
To enhance adherence :
 Provide encouragement
 Be creative
 Support from peers and coaches
 Provide a positive attitude
 Design clear plan and instructions
 Coach must support the rehabilitation process
 Make an effort to fit the program to the athlete’s
schedule
 Rehabilitation should be pain free
Common Mistakes in Rehabilitation
Look for the culprit not the victim
Focusing on one single muscle group
Not moving on until injured limb is equal or
superior to the uninjured side
Proprioception is often forgotten
Postural defects, anatomical malalignment and
biomechanical imbalances are neglected
Sports specific skills are not incorporated
SAID principle not incorporated
Integrated of Individual Components into a
Progressive Rehabilitation Program
 Stages of Rehabilitation
Stage Functional Sport Management
level
Initial Poor Nil RICE
Substitute activities Electrotherapeutic modalities
(e.g. swimming, cycling) Stretch/range of motion exercise
Isometric exercise

Intermediate Good Isolated skills (e.g. Electrotheraphy (less)

basketball shooting) Stretch/range of motion exercises
Strength
Proprioception
Advanced Good Commence agility work Strength, especially power
Skills Proprioception
Game drills Functional activity
Return to Good Full Continue strength/power work, flexibility
sport
Electrotherapeutic Modalities

ES TENS
 Thermal Modalities

Ultrasound diathermy Shortwaves diathermy

 Thermal Modalities

Microwaves diathermy Low laser therapy

 Cryotherapy

Ice Massage Ice Packs

Vapocoolant Spray
Intermittent Compression Devices
 Manual Therapy
A

Mobilization
Techniques
 Soft Tissue Massage
EBM :
Sullivan  reduced
triceps surae H-reflex
amplitudes among
subjects who received
ipsilateral petrissage
compared with control
subjects
 Muscles Conditioning
Muscle strength
Muscle power
Muscle endurance
Motor re-education

Isometric
Isotonic
Isokinetic
Core Stabilization Training Exercises
 Core Stabilization Training
 Important component of all strengthening and
comprehensive injury prevention program
 Will improve dynamic postural control, ensure
appropriate muscular balance, allow for expression of
dynamic functional strength, improve neuromuscular
efficiency
 Body’s stabilization system has to function optimally to
effectively utilize the strength of prime movers
 A weak core is a fundamental problem of inefficient
movements which leads to injury
 Facilitates balanced muscular functioning of the entire kinetic
chain - offers biomechanically efficient position for the entire
kinetic chain, allowing optimal neuromuscular efficiency
 Program should be systematic, progressive and functional
 Program should be safe, challenging, stress multiple planes
and incorporate a variety of resistance equipment, be derived
from fundamental movement skills, and be activity specific
Core Stabilization Exercises
 Regaining Balance
Involves complex integration of muscular forces,
neurological sensory information from mechanoreceptors
and biomechanical information
Entails positioning center of gravity (CoG) w/in the base of
support
If CoG extends beyond this base, the limits of stability have
been exceeded and a corrective step or stumble will be
necessary to prevent
Even when “motionless” body is constantly undergoing
constant postural sway w/ reflexive muscle contractions
which correct and maintain dynamic equilibrium in an upright
posture
 Flexibility
Continous passive motion
Passive mobilization
Active assistive exercises
Active exercises
Stretching:
 Static
 Ballistic
 Proprioceptive neuro-
muscular facilitation
Proprioception Exercise
When balanced is challenged the response is reflexive and
automatic
The primary mechanism for controlling balance occurs in the
joints of the lower extremity
The ability to balance and maintain it is critical for athletes
If an athlete lacks balance or postural stability following
injury, they may also lack proprioceptive and kinesthetic
information or muscular strength which may limit their ability
to generate an adequate response to disequilibrium
A rehabilitation plan must incorporate functional activities that
incorporate balance and proprioceptive training
Balance Equipment
Sport Skills
Agility training
Sports specific drills
Correction of Biomechanical Abnormalities
Aerobic Exercise
Hydrotherapy
 Joint Mobilization and Traction
Used to improve joint mobility or decrease
pain by restoring accessory motion -allowing
for non-restricted pain free ROM
Mobilization may be used to
 Reduce pain
 Decrease muscle guarding
 Stretch or lengthen tissue surrounding a joint
 Produce reflexogenic effects that either inhibit or
facilitate muscle tone or stretch reflex
 For proprioceptive effects that improve postural
and kinesthetic awareness
Mobilization Techniques
 Used to increase accessory motion about a joint
 Involve small amplitude movements (glides) w/in a
specific range
 Should be performed w/ athlete and athletic trainer in
comfortable position
 Joint should be stabilized as near one articulating
surface as possible; other should be held firmly
 Treatment occurs in parallel treatment plane
 Maitland Grading System
 Grade I (for pain) - small amplitude at beginning
of range
 Grade II (for pain) - large range at midrange

 Grade III (treating stiffness) - large amplitude to

pathological limit
 Grade IV (treating stiffness) - small amplitude at
end range
 Grade V (manipulation) - quick, short thrust
Mobilization based on concave-convex rule
 When concave surface is stationary, convex surfaces is
glided in opposite direction of bone movement
 When convex surface is stationary, concave surface is
glided in direction of movement
Mobilization can also be used in conjunction w/
traction
Traction
 Pull articulating segments apart (joint separation)
 Occurs in perpendicular treatment plane
 Used to treat pain or joint hypomobility
Joint Mobilization Techniques
 Positional Release Therapy
PRT is based on the strain/counterstrain technique
Difference is the use of a facilitating force
(compression) to enhance the effect of positioning
Osteopathic mobilization technique
Technique follows same procedure as
strain/counterstrain however, contact is maintained
and pressure is exerted
 Maintaining contact has therapeutic effect
Positional Release Therapy
 Active Release Therapy
ART is relatively new type of therapy used to correct soft
tissue problems caused by formation of fibrotic adhesions
 Result of acute injury and repetitive overuse injuries or
constant pressure/tension
 Disrupt normal muscle function affecting biomechanics of
joint complex leading to pain and dysfunction
 Way to diagnose and treat underlying causes of
cumulative trauma disorders
Deep tissue technique used for breaking down scarring and
adhesions
 Locate point and trap affected muscle by applying
pressure over lesion
 Athlete actively moves body part to elongate muscle

 Repeat 3-5 times/treatment

 Uncomfortable treatment but will gradually soften and

stretch scar tissue, increase ROM, strength, and
improve circulation, optimizing healing
 Must follow up w/ activity modification, stretching and
exercise
Active Release Therapy
Medical Rehabilitation Program in Acute Phase
 Criteria for Progressive Out
the Initial/Acute Phase
Include :
Progression of tissue healing where the tissue is healed or
sufficiently stabilized for active motion
Passive range of motion to 75% of the opposite side
Minimal pain or tenderness less than level II
Manual muscle test strength in non pathologic area 4+ to 5
Control of the particular regions
Continued kinetic chain function
Medical Rehabilitation Program in Sub-Acute Phase
 Criteria for Progressive Out
the Intermediate/Recovery Phase
Include :
Full, non painful active and passive range of motion of
the joint
No pain on tenderness
Strength at 80% of the opposite site with good force
couple balance
A normal kinetic chain
 Criteria for Progressive Out
Advanced/ Functional Phase into Full Competition
Normal arthrokinetics and multiple-plane activities
Isokinetic strength balance and work at 90% of normal
Completion of functional progressions and satisfactory
clinical examinations
 Return to Sport
Time constraints for soft tissue healing have been
observed
Pain-free full range of movement
No persistent swelling
Adequate strength and endurance
Good flexibility
Good proprioception
Adequate cardiovascular fitness
Good regional skill
No persistent biomechanical abnormality
Athlete physiologically ready
Coach satisfied with training form
 Psychology and Rehabilitation of Injury

The factors that effect rehabilitation:

 Type of injury
 Circumstances of the injury
 External pressure (eq : fear of
losing position on the team)
 Pain tolerance
 Psychological attributes of the player
 Player-player and coach-player support system
 Conclusion
Rehabilitation of the injured athlete requires carefull
assessment and subsequent correction of the athlete’s
deficit
The rehabilitation program should be individualized for the
athlete’s need
Functional and sport-specific activities should form a major
part of the program
The injured athlete should be able to return to sport
without functional deficit and with any predisposing factors
to injury corrected