INTRODUKSI

MANUAL TERAPI
Oleh: Sugijanto

Disampaikan pada Kuliah Penyegaran

Esa Unggul 2020

Sugijanto, 2020
 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 prioritas masalah 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.
 Mampu mengikuti perkembangan pengetahuan dan meningkatkan serta mengembangkan diri dalam
kemampuan inovasi teknologi

Sugijanto, 2020
 KAJIAN KEILMUAN KLINIS
MANUAL TERAPI
 Merujuk ICD:
 Mampu menjelaskan dan menganalisis ilmu dasar patologi
terhadap kasus terbanyak ditangani fisioterapi
 Merujuk ICF:
 Menganalisis anatomi terapan dan gangguan (impairment) terkait
patologi
 Menganalisis fisiologi dan biomekanik terapan dan gangguan
terkait patologi
 Menganalisis aktivitas individual dan ketrbatasannya serta partisipasi
sosial dan hambatannya

Sugijanto, 2020
CLINICAL REASONING APPROACH

Merupakan proses berfikir logis dan kritis utk

memaknai temuan klinis (Higgs J and Jones M,
1995)
Metode: hipotetico-deduktif, algoritma, pattern
recognition dan gejala-tanda patognomonis.

Sugijanto, 2020
 CLINICAL
REASONING
 Clinical reasoning adalah proses cognitive atau proses berfikir yang
digunakan dalam evaluasi dan pengelolaan pasien (Mark A Jone, 1992).
 Clinical reasoning adalah proses berfikir dan membuat
keputusan klinis yang digunakan dalam praktek klinik.
 Menurut Higgs and Jones (1990), Clinical reasoning adalah proses dalam
interaksi antara terapis dan pasien dan yang lain terkait (mis family atau
penyelenggara pelayanan yg lain), membantu pasien memahami arti, goals,
dan health management strategies based on clinical data, patient choices,
and professional judgment and knowledge

Sugijanto, 2020
Andersen, Linde &
Broberg, 2014 Sugijanto, 2020
 CLINICAL
REASONING
Clinical reasoning
Clinical prediction rule
Clinical decision making

JANGAN
BERFIKIR
TERBALIK

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

Salah Benar
Sugijanto, 2020
Body structure Client complain
(anatomic) Activities
impairment Non Pathologi/ Limitation
Pathologi
Body Function Participation
(biomechanic) Restriction
impairment Gangguan Gerak-
Fungsi
Critical thinking

HOAC 2 Assessment E B(C)P

Clinical
reasoning Diagnosis and Clinical
prognosis prediction r
Clinical
decision m
Analisis Strategi
perencanaan
Prosedur intervensi
Evaluasi dan
penilaian hasil
Sugijanto, 2020
Kata kunci

 Fahami patologi (juga non patologis)

penyebab gangguan fungsi
 Buat hipotesis (dugaan kuat) sakit dlm ICD
 Lakukan tes menggunakan EBCP utk
pembuktian hipotesis awal
 Bila negative, ganti hipotesis lain
 Bila positif lanjutkan pemeriksaan detail sesuai ranah
ICF

Sugijanto, 2020
Kata kunci …… lanjutan
 Lakukan tes orientasi (regional screening) utk
menegakkan regio asal impairment
 Lakukan tes menggunakan EBCP utk
pembuktian body function impairment
 Bila negative, ganti hipotesis lain
 Lakukan identiivikasi dan pemeriksaan red flag pada
regio tersebut
 Bila positif, lakukan konsultasi dengan dokter
yang kompeten

Sugijanto, 2020
Kata kunci …… lanjutan
 Bila tidak ada red flag lanjutkan pemeriksaan body
function and structure impairment
 Lanjutkan pemeriksaan activity limitation dan
participation restriction
 Lanjutkan pemeriksaan contextual factor
(prognosis factors)

Sugijanto, 2020
Kata kunci …… lanjutan
 Buat penegakan diagnosis fungsional dlm ICF yg
dikaitkan patologi dlm ICD
 Lakukan penetapan prognosis sesuai diagnosis dan
problema yg ditemukan
 Lakukan analisis body structure impairment
target dan body function impairment target
 Lanjutkan disability target
 Lanjutkan pembuatan rekomendasi sesuai
prognosis factors

Sugijanto, 2020
 MENGANALISIS DARI ICD KE
ICF,
Contoh: Shoulder impingement
Jaringan apa yg Fungsi (mekanik) (ICD)
Keterbatasan Hambatan
terganggu? apa yg terganggu? aktivitas berpartisipasi
(sosial)
Inflamasi pd cuff ? ? ?
dan/subacromial
bursa
Hypertrophy-tight ? ? ?
m.supraspinatus
Capsular/ligame nt ? ?
laxity
Tigthness/weakn ?
ess pd otot scapula

Sugijanto, 2020
 MENGANALISIS DARI ICD KE
ICF,
Jaringan apa ygContoh: Shoulder C impingement
K eterbatasan
apa yg terganggu? ( aktivitas
D)
Fungsi (mekanik) Hambatan
terganggu? berpartisipasi
(sosial)
Inflamasi pd cuff Nyeri gerak Abd/ I ? ?
dan/subacromial lainnya
bursa
Hypertrophy-tight Kesalahan posisi ? ?
m.supraspinatus head of humerus
tinggi
Capsular/ligame nt Glenohumeral joint ?
laxity instability
Tigthness/weakne ss Scapular dyskinetic
pd otot scapula

Sugijanto, 2020
 MENGANALISIS DARI ICD KE
ICF,
Jaringan apa ygContoh: Shoulder C impingement
K eterbatasan
apa yg terganggu? ( aktivitas
D)
Fungsi (mekanik) Hambatan
terganggu? berpartisipasi
(sosial)
Inflamasi pd cuff Nyeri gerak Abd/ I Nyeri meraih ?
dan/subacromial lainnya benda pd mid
bursa position
Hypertrophy-tight Kesalahan posisi Nyeri aktivitas ?
m.supraspinatus head of humerus angkat lengan
tinggi
Capsular/ligame nt Glenohumeral joint Nyeri aktivitas
laxity instability tertentu pd posisi
lengan tertentu
Tigthness/weakne ss Scapular dyskinetic
pd otot scapula

Sugijanto, 2020
 MENGANALISIS DARI ICD KE
ICF,
Jaringan apa ygContoh: Shoulder C impingement
K eterbatasan
apa yg terganggu? ( aktivitas
D)
Fungsi (mekanik) Hambatan
terganggu? berpartisipasi
(sosial)
Inflamasi pd cuff Nyeri gerak Abd/ I Nyeri meraih Bekerja dgn
dan/subacromial lainnya benda pd mid tangan didepan
bursa position
Hypertrophy-tight Kesalahan posisi Nyeri aktivitas Bekerja, olah raga
m.supraspinatus head of humerus angkat lengan ataupun rekreasi
tinggi menggunakan tangan
Capsular/ligame nt Glenohumeral joint Nyeri aktivitas
laxity instability tertentu pd posisi
lengan tertentu
Tigthness/weakne ss Scapular dyskinetic
pd otot scapula

Sugijanto, 2020
Sugijanto, 2020
 CLINICAL Nyeri pada bahu
REASONING Impingement syndrome
Contextual
Fungsi dan disabilitas
factors
Internal External
Anatomic factors factors
impairment
SLAP
Cuff muscle
Lesion
AC Bursa Functional
Joint subacromial Pectoralis minor,
Capsule/ Participatio
levator scapulae impairment
lig laxity n restriction
osteophyt
e Serratus anterior
Activity
Inflamation- Tightness limitation
Supraspinatus GH
calc formation
Instability
Weakness
Subscapularis, Over head
infraspinatus, Internal Work
impingement
activity
Inflamation Scapular
dyskinesis Carrying Sport
Inflamatio
n
Tight- Lifting Recreation
hypertroph
y
External The used of
impingement arm in ADL
Shoulder pain
Sugijanto, 2020
 MENGANALISIS DARI ICD KE ICF,
: CARPAL TUNNEL SYNDROME
Jaringan apa yg
terganggu? apa yg terganggu? (
Fungsi (biomekanik) C
D)Keterbatasan aktivitas Hambatan
berpartisipasi (sosial)

I
? ? ? Terganggu saat
bekerja dengan
tangan karena
semutan
? ? ? Terganggu saat olah
raga karena semutan/
nyeri
? ? ? Saat rekreasi sering
tersa kaku/ semutan
? ? ?

Sugijanto, 2020
 MENGANALISIS DARI ICD KE ICF,
Jaringan apa yg
: CARPAL
Fungsi (biomekanik)
TUNNEL SYNDROME
Keterbatasan aktivitas Hambatan
terganggu? apa yg terganggu? (ICD) berpartisipasi (sosial)
? ? Nyeri/paresthesia saat Terganggu saat
tangan menekan telapak bekerja dengan
tangan tangan karena
semutan
? ? Nyeri/paresthesia saat Terganggu saat olah raga
menggenggam karena semutan/ nyeri
? ? Aktivita tangan Saat rekreasi sering
kaku/terbatas tersa kaku/ semutan
? ? Semutan permukaan Saat pemenuhan
palmar saat menjijing/ kualitas keluarga
mendorong barang, karena keluhan
tangan

Sugijanto

, 2020
 MENGANALISIS DARI ICD KE ICF,
: CARPAL TUNNEL SYNDROME
apa yg terganggu? (ICD)
Jaringan apa yg Fungsi (biomekanik) Keterbatasan aktivitas Hambatan
terganggu?
? Carpal arch dalam,
carpat tunnel sempit
? Dorsal fleksi jari lurus
desakan kuat isi tunnel
? Hypomobilitas dari
wrist
? Semutan permukaan
palmar jari 1; 2; 3 dan
sisi medial jari 4
berpartisipasi (sosial)
Nyeri/paresthesia saat Terganggu saat
tangan menekan telapak bekerja dengan
tangan tangan karena
semutan
Nyeri/paresthesia saat Terganggu saat olah raga
menggenggam karena semutan/ nyeri
Aktivita tangan Saat rekreasi sering
kaku/terbatas tersa kaku/ semutan
Semutan permukaan Saat pemenuhan
palmar saat menjijing/ kualitas keluarga
mendorong barang, karena keluhan
tangan

Sugijanto,

2020
 MENGANALISIS DARI ICD KE ICF,
: CARPAL TUNNEL SYNDROME
D Keterbatasan
Fungsi (biomekanik )
Jaringan apa yg
terganggu? (IC aktivitas
apa yg terganggu? ) Hambatan
berpartisipasi (sosial)

Lig. Carpi Carpal arch dalam, Nyeri/paresthesia Terganggu saat

transversum carpat tunnel sempit saat tangan menekan bekerja dengan
contracture telapak tangan tangan karena
semutan
Penebalan Dorsal fleksi jari lurus Nyeri/paresthesia Terganggu saat olah
tendon fleksor jari desakan kuat isi tunnel saat menggenggam raga karena semutan/
nyeri
Intercarpal joint Hypomobilitas dari Aktivita tangan Saat rekreasi sering
contracture wrist kaku/terbatas tersa kaku/ semutan
n. Medianus Semutan permukaan Semutan permukaan Saat pemenuhan kualitas
entrapment palmar jari 1; 2; 3 dan palmar saat menjijing/ keluarga karena keluhan
sisi medial jari 4 mendorong barang, tangan
Sugijant o, 2020
 CLINICAL Nyeri dan paraesthesia sc CTS
REASONING
Functioning, and disability Contextual factors

Anatomic impairment
Internal External
Tendon flexor Lig. Carpi Lunatum
factors factors
dig transversum n. Medianus

Inflamasi- Contracture Subluxate

odema
Penyempitan CT

Entrapment Kompresi-
dlm CT Functional
entrapment
impairmen t Activity
inflamation Anoxia Muscle
limitation
weakness Participatio
Neural Parestesia
adhesion Carrying
n restriction

Dressing Work

Dll
Pain & Muscle paresis Sport
Paresthesias
Recreation
Sugijanto, 2020
ANATOMIC DAN KINETIC
IMPAIRMENT SEBAGAI PUSAT
KAJIAN
Contoh:  Jalan pincang akibat nyeri
permukaan sendi
 Nyeri akibat inflamasi tulang
permukaan sendi  Tidak dapat jongkok akibat
kontraktur sendi
 Hipomobilitas akibat hambatan
kapsul kontraktur  Tidak dapat bekerja dalam konstruksi
akibat kaku sendi dan lemah otot
 Tidak mampu olahraga akibat nyeri
lutut dan kelemahan otot

Sugijanto, 2020
SPECIFIC BODY STRUCTURE PENYEBAB
KELUHAN

Gangguan fungsi Jaringan

tertentu

Penyimpangan fungsi
(mekanis)

Menimbulkan
patologi tertentu

NYERI
Gang Keseimbangan
Sugijanto, 2020
NYERI BERASAL DARI
JARINGAN SPESIFIK
Nyeri: Wound healing process
Inflammation
Nyeri: Nosisensoric sensitization

SPECIFI Hypoxia Nyeri: necrosis

C Ischemic
TISSUE Nyeri: Wound
Inflammation
healing process

Contracture Collagen adhesion Nyeri regang

Fatique Acedosis Nyeri kimiawi

Sugijanto, 2020
CIDERA-INFLAMASI JAR.
SARAF
Neuritis: Neropraxia, Nyeri pd distribusi
axonotmesis, Neurotmesis saraf, paraesthesia,
neurofibrosis hypoaesthesia

Triad symptom pd Reflex. MMT, Sensoric

lesi saraf perifer test, Neurodynamic test

spesifik

Sugijanto, 2020
NYERI DARI SARAF
PERIFER
Paresthesia intermittent →
Anoxia
tinnel test & neural tension test

Neuropathic pain → tinnel test

Inflamation & neural tension test
Entrapment
Paresthesia menetap
Fibrosis → n e r v e gliding test

NERVE Inflamation Neuropathic pain →

neural tension test

Systemic Paresthesia menetap →

sensoric, motorik & reflex test

Sugijanto, 2020
Kata kunci
Bila diduga impairment saraf tepi?
 Test sensorik area dermatome (pd radiks) dan area nervina
(pd saraf spinalis)
 Test motoric (myotome)
 Neural tension test (tightness) dan nerve gliding test
(adhesion)

Sugijanto, 2020
 CIDERA JAR. DISC (tanpa inflamasi)
4 tingkat disc lesion: Disc
Beban meningkat bila fleksi, terberat:
bulging; Disc herniated; Disc
duduk bungkuk, ringan: Psoas position
extruded; disc fragmented

Nyeri akibat kompresi Central –

jar. Sensitif sekitarnya peripheral pain

spesifik

Sugijanto, 2020
 PAIN FROM PERIPHERAL
NERVE
Inflamasi Central pain
Iritasi lig
Longitudinal Iritasi Bilateral
Stenosis hamstrings pain
Duramater

Paresthesia
Anoxia intermittent

Neuropathic
Inflamation
DISC Iritasi radiks /radicular pain

Paresthesia
Fibrosis menetap

Iritasi saraf Triage

Inflamation
spinalis Sugijanto, 2020
symptoms
 Skema umum assessment Disc

? ?
Disc ? ?
? ?

Disc ? ?
Nerve ? ?
? ?

Sugijanto, 2020
 Skema umum assessment Disc

Spurlings test ?
(compression in flx)
Disc Traction test ?
Valsava maneouvre ?

Disc Tinnel test ?

Nerve Sensoric, motoric and ?
Reflex
Upper limb tension test ?

Sugijanto, 2020
 Skema umum assessment Disc

Spurlings test Pain, central –

(compression in flx) peripheral sensation
Disc Traction test No pain
Valsava maneouvre Pain

Disc Tinnel test Pain - referred

Nerve Sensoric, motoric and Pain, or Paresthesia,
Reflex weakness and hypo
reflexia
Upper limb tension test Pain and/or
paresthesia
Sugijanto, 2020
Kata kunci

Bila diduga impairment discus intervertebralis?

 Springing test / Rosert test (Lokasi impairment)

 Spurling’s test (posisi fleksi)

 Traction test (posisi ekstensi)

Sugijanto, 2020
 CAPSULOLIGAMENTAI
R
T.a. srbt collagen sejajar Ligament penebalan tunica Mrpk stabilisator sendi
silang, elastin; cell capsel / berdiri sendiri. pasif fs arahkan gerak
fibroblast, dan matrix Terdapat meniscoide sendi

spesifik

Sugijanto, 2020
NYERI DARI
CAPSULE
Nyeri pasca aktifitas
Instability → stability test

Sprain/ Inflamation Nyeri diam →

rupture passive test

Nyeri regang →
Capsule Contracture
passive & JPM test

Immuno Effusion Acidosis Nyeri & hydrops →

reaction palpasi & ballotement

Intercollagen Nyeri regang →

Immobilzation Adhesion space passive & JPM test

Sugijanto, 2020
 Kata kunci
Bila diduga impairment Kapsul sendi:
Lakukan pemeriksaan capsules dgn passive test dilanjutkan joint play
movement test:
 Bila nyeri → rasakan end feel nya:
 Springy oleh tahanan otot yg tegang → mulai intervensi relaksasi atau traksi
osilasi dlm MLPP
 Elastic end feel oleh tahanan capsule yg masih cukup lentur →
mobilisasi pd pembatasan ROM
 Nyeri pd akhir ROM → manipulasi sendi
 Keterbatasan gerak dlm capsular pattern → seluruh capsule contracture
→ mobilisasi sendi semua arah

Sugijanto, 2020
 Kata kunci

 Bila terasa empty end feel ROM lebih besar dari normal karena
hypermobility → stability program
 Bila joint play movement juga berlebihan dan empty end feel
oleh instability → passive stability program diikuti active
stability

Sugijanto, 2020
INFLAMASI JOINT
SURFACE
 Injury, arthritis, iritasi osteophyte, RA.
 Sprain, capsulitis/arthritis, spondyloarthrosis
 Compression pain, Pseudoradicular pain.
 Diikuti capsular pattern hypomobility.
 Nyeri gerak segmental

Sugijanto, 2020
 NYERI DARI
CAPSULE
Nyeri pasca aktifitas →
Instability stability test

Sprain/ Inflamation Nyeri diam →

rupture passive test

Nyeri regang →
Capsule Contracture
passive & JPM test

Immuno Effusion Acidosis Nyeri & hydrops →

reaction palpasi & ballotement

Intercollagen Nyeri regang →

Immobilzation Adhesion space passive & JPM test

Sugijanto, 2020
Kata kunci
Bila diduga impairment Kapsul sendi:
Lakukan pemeriksaan capsules dgn passive test dilanjutkan joint play
movement test:
 Bila nyeri → rasakan end feel nya:
 Springy oleh tahanan otot yg tegang → mulai intervensi relaksasi
atau traksi osilasi dlm MLPP
 Elastic end feel oleh tahanan capsule yg masih cukup
lentur → mobilisasi pd pembatasan ROM
 Nyeri pd akhir ROM → manipulasi sendi
 Keterbatasan gerak dlm capsular pattern → seluruh capsule
contracture → mobilisasi sendi semua arah

Sugijanto, 2020
Kata kunci

 Bila terasa empty end feel ROM lebih besar dari normal
karena hypermobility → stability program
 Bila joint play movement juga berlebihan dan empty end
feel oleh instability → passive stability program diikuti
active stability

Sugijanto, 2020
 CIDERA - INFLAMASI JAR
OTOT-
TENDO
Strain, rupture, Myositis, tendinitis, myotendinosis,
Navulsion myofascial syndrome

Spasm/guarding Isometrik, palpasi

spasm, taut & CRS
band/twisting
spesifik

Sugijanto, 2020
 NYERI DARI
OTOT
Atrophy → palpasi &
Weakness strength test

Strain/ Inflammation Nyeri diam

rupture
Muscle Nyeri kontraksi →
spasm isometric test
MUSCLE
Tightness/ Nyeri regang →
contract relax
Contracture stretch test

Immobilisation Adhesion
Myofascial Nyeri regang →
contracture palpasi & stretch test
Sugijanto, 2020
 Skema umum Muscle
assessment

Myofibrile ? ?
? ?
Fascia ? ?
Muscle
α motoneuron ? ?
? ?

Sugijanto, 2020
 Skema umum Muscle
assessment

Myofibrile Isometric test ?

Palpasi ?
Fascia CRS test ?
Muscle
α motoneuron Isomtric ?
MMT ?

Sugijanto, 2020
 Skema umum Muscle
assessment

Myofibrile Isometric test Pain/Clicking/crepitation

Palpasi Pain and No pain
Fascia CRS test Tightnes or shorteningl
Muscle
α motoneuron Isomtric Weakness/paralytic
MMT Pain and strength

Sugijanto, 2020
 Kata kunci

• Bila diduga impairment otot:

• Lakukan pemeriksaa otot dengan isometric test (/isotonic)
 Bila nyeri lakukan palpasi, temukan tender/trigger point, taut band/twisting
 Intervensi dengan ischemic compression technique, atau transverse friction, myofascial
release atau manipulasi otot
 Bila lemah lakukan tes lanjut:
• Penyanggaan sendi utk memilahkan lemah karena nyeri
• Pengukuran kekuatan otot bila murni kelemahan otot
 Intervensi blok nyeri atau stabilization/strengthening exc
 Intervensi melepas perlengketan

Sugijanto, 2020
 Kata kunci

Bila otot hipertonik (tegang) lakukan contract relax stretching test

 Bila pasca kontraksi otot menjadi lentur → tegang saja
→ intervensi teknik relaksasi
 Bila pasca kontraksi tetap tegang → kontraktur → internensi etknki
peregangan
Bila otot lemah (weakness)
 Strength test / active stability test → strengthening programs / stability programs

Sugijanto, 2020
FUNCTIONAL
IMPAIRMENT
 Pain  Balance
 Pain in rest
◦ Sitting disbalance
 Pain in movement
◦ Standing disbalance
 Referred pain etc ◦ Walking disbalance, etc
 Joint mobility:  Gait:
 Ankylosing
◦ Antalgic gait
 Hypomobility
◦ Duchene gait
 Joint blockade ◦ Trendelen burg gait, etc
 Joint stability:  Hand function:
 Hypermobility
◦ Grip weakness
 Instability ◦ Prehension disability,
 Muscle performance: etc
 Muscle weakness
 Muscle paresis
Sugijanto, 2020
 JOINT MOTIONS
IMPAIRMENT Capsular pattern →
ROM in passive test
Contracture
Non capsular pattern →
Capsular ROM in passive test

Ossification Blockade → passive

test & JPM test

Hypo- Inert Loose body Blockade →

mobility structure passive & NAGs test

Tightness → contract
Tendomuscular relax stretch test
Contracted → contract
relax stretch test
Sugijanto, 2020
 JOINT
MOTIONS
Joint hypermobility →
Laxity JPM Test elastic end feel
Ligamenter
-Capsular
Instability → J P M Test
Rupture
empty end feel
Hypermobility & Bony- Deformity →
instability structure Measurement

Weakness
Active instability →
Tendomuscular
Active stability test
Rupture
Sugijanto, 2020
 PEMAHAMAN DAN KETRAMPILAN
MENENTUKAN REG FLAG

Mampu melakukan Simple Medical Screening pada

kasus Patologi Serius (Red Flag)
Mampu melakukan System screening

Sugijanto, 2020
ASSESSMENT
MANUAL THERAPY
Temu 2

Sugijanto, 2020
 Proses pengelolaan Fisioterapi
1. HISTORY TAKING Profesi
2. INSPEKSI

3. REGIONAL
SCREENING & QUICK
TEST

4. REVIEW OF SYSTEM
& RED FLAG
5. ASSESSMENT
EVIDENCE BASE
CLINICAL PRACTICE
6. DIAGNOSIS AND
FUNCTIONAL PROGNOSIS
7. PLANNING
8. INTERVENTION

9. EVALUATION

10. DOCUMENTATION
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
making Analisis Strategi
perencanaan
Prosedur intervensi

Evaluasi dan
penilaian hasil
Sugijanto, 2020
 HYPOTHESIS ORIENTED
ALGORYTHM DALAM ASSESSMENT

Dalam pemeriksaan selalu dibuat hipotesis yg harus diuji (tes)

kebenarannya
Mahasiswa memiliki dasar keilmuan yang kuat
Body structure
Body function
Impairment and Pathology
Individual activity
Sosial participation
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
 DIAGNOSIS
 Dihasilkan dari pemeriksaan & evaluasi & merupakan hasil dari alasan-
alasan klinis.
 Menunjukkan adanya difungsi gerak atau mencakup kategori gangguan,
keterbatasan fungsi, ketidakmampuan atau sindrom.
 Diagnosis: proses keputusan klinis terkait patologi.
 Mengacu ICF dalam menganalisis patologi (ICD)
 Meliputi Body function & structure impairment
 Activity limitation & participation restriction of disability
 Akibat Patologi (ICD) tertentu.
 Memperhitungkan factor hambatan atau fasilitasi dari personal dan
lingkungan,

Sugijanto, 2020
Diagnosis Medis Vs Diagnosis FT

 ICD Vs ICF

Sugijanto, 2020
The International Classification of Functioning, Disability and Health by the World Health Organization 2001(p. 18)
 Diagnosis Terkait Treatmen &
Prognosis

 Proses evaluasi terkait penyebab disfungsi gerak & system

klasifikasi berdasarkan clinical decision rules.
 Terkait dengan pertimbangan patologi.
 Mengarah kepada tissue-specific diagnosis.
 Mampu mengidentifikasi keterkaitan gangguan, dengan
keterbatasan aktifitas & partisipasi.
 Pertimbangkan faktor internal & eksternal
(konseptual).

Sugijanto, 2020
 Diagnostic Reasoning

 Salah satu komponen alasan klinis.

“…formasi diagnosis terkait disabilitas fisik &
gangguan dengan pertimbangan terkait
mekanisme nyeri, patologi jaringan. . .”.
Review system berdasarkan struktur
anatomi & fisiologi.
 Menentukan ada/tidak red flag.

Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical
therapy. Phys Ther. 2004;84(4):312–330; discussion 331–335
Sugijanto, 2020
 Hierarchy of Evidence for
Treatment

Penggunaan Evidence Systematic

Base Reviews &
Meta- analyses
of RCTs
Multiple RCTs

Randomized Controlled Trial (RCT)

Systematic Review of the studies

below
Observational Cohort or Case Control
Studies, Large Case Series

Case Reports, Small Case Series

Unsystematic Clinical Observations
Sugijanto, 2020
 PENGGUNAAN EVIDENCE
BASE CLINICAL PRACTICE
DALAM PEMERIKSAAN
FISIOTERAPI

 Merujuk HOAC
 Pemeriksaan cepat, akurat
 Memerlukan dasar pengetahuan yg baik

Sugijanto, 2020
 INTERVENTIO
N
Mampu menjelaskan dan mendemontrasikan target intervensi
 Anatomic Impairment target:
 Topografik target
 Tissue specific target
 Specific impairment target
 Kinetic Impairment target:
 Positional vault/Postural deformity
 Hypomobility/hypermobility/unstability
 Weakness/imbalance
 Movement incoordination
 Dll
 Disability target
Sugijanto, 2020
PENGATURAN DOSIS
FITT
ditentukan:
 Jenis pendekatan:  Waktu dan Frekwensi:
Tissue specific Aktualitas patologi
impairment target Kronisitas
Kinetic impairment Disabilitas
target
 Intensitas:
Aktualitas
patologi/impairment
Tujuan intervensi

Sugijanto, 2020
Contoh Fisioterapi pada kasus
ortopaedi/Musculoskeletal

Sugijanto, 2020
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
Case 1: 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
Case 2: 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
Case 3: 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
 Case 4: 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
 Case 5: 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
REGIONAL
SCREENING & QUICK
TES Case 6: IDENTIFICATION TO
T
LUMBAR SPINE PROBLEMS

 The other Client complain of low back pain refer to

gluteal area, but sometimes refer to hamstrings area
 Test trunk flexion-extension in standing
 Trunk 3 D extension to the right and left in
siting position
 Ad ‘over pressure’ on lumbar spine process

Sugijanto, 2020
REGIONAL
SCREENING & QUICK
TES
Case 7: IDENTIFICATION OF
T
LOWER THORACIC
SPINE ORIGINE
 Client complain of lateral lumbar
area refer
to iliac crest sometimes to
trochanter area.
 Be sure that pain at lateral lumbar area – iliac’s
crest – gluteus medius - trochanter
 Trunk flexion - extension
 PACVP/LPAVP test on spine process and facet
 Extension while give over pressure on lower
thoracic spine process

Sugijanto, 2020
 Case 8: SACROILIAC JOINT
IMPAIRMENT
 Other client complain of pain at gluteal area, and gluteal
fold
 Be sure that pain at sacral area to gluteal fold
 Found asymmetry of PSIS when standing position and
trunk flexion
 Screening:
 Sacral trust test
 Thigh trust test
 Gaenslen test

Sugijanto, 2020
REGIONAL
SCREENIN & QUICK
Case 9: THE EXAMINATION TO
G TEST IDENTIFY HIP JOINT
PROBLEM

 Be sure that pain lies on inguinal area

(groin) to trochantor
 Gait analysis has seen duchene gait
 Contra Patric’s test
 Patric’s test

Sugijanto, 2020
REGIONAL
SCREENING & QUICK
TEST
Case 10: PIRIFORMIS
SYNDROME
Pain felt on gluteal region referred to one
side of hamstring region and provocates
by siting on hard chair
Screening:
◦ Palpate on piriform muscle
◦ Thigh cross test
◦ Contract relax stretch test to piriformis
positive
Slump test if there was nerve
irritation
Sugijanto, 2020
REGIONAL
SCREENING & QUICK
TEST
Case 11: Assumption of
Lysthesis

 Be sure that pain/tingling on bilateral

hamstring regions and sometimes feel
clicking,
 Screening:
 Palpate on spine process to identified step off or
step on (L4)
 Passive stability test:
 Active lumbosacral stability test (Prone position
at the edge of bed) with fixation and without
fixation

Sugijanto, 2020
 PROCEDURE TESTS AFTER
REGIONAL SCREENING

REVIEW OF SYSTEM &

• Review of Systems
RED FLAG
• Serious pathology (Red Flag)

Sugijanto, 2020
 KASUS LAIN …Berasal dari regio
manakah impairment nya?
A. Nyeri samping paha dari trocantor mayor ke atas lutut
B. Pasien lain mengeluh terasa baal (anesthesia} daerah anus dan
kelamin, disertai gangguan buang air kecil dan kadang gangguan
buang air besar juga.
C. Pasien lainnya lagi datang dengan keluhan nyeri
pedas/panas pada inguinal menyebar ke paha depan,
D. Seorang pasien lain mengeluh nyeri pada perut bawah kanan,
kadang nyeri hebat tak tertahankan.

Sugijanto, 2020
 PROCEDURE TESTS AFTER
REGIONAL SCREENING

REVIEW OF SYSTEM &

• Review of Systems
RED FLAG
• Serious pathology (Red Flag)

Sugijanto, 2020
RED
FLAG

Sugijanto, 2020
Sugijanto, 2020
 REVIEW OF SYSTEM (Guide-APTA)

 To support the hypotheses of serious
pathology (red flag)
 Anatomic dan physiologic assessment
of cardiovascular/pulmonary,
integumentary, musculoskeletal,
neuromuscular systems
• Checklist general symptomps that support the
spectrum of an impairment in the specific
body parts using interview
• ROS as a part of history taking
• Purpose: to identify potential problem
related to PT intervention
• Depends on medical records and
location/pain characteristics

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG Test for Red flag: Vertebral
Artery Test (VBI)

 Cervical rotation hold in 30 second

Dizziness, nausea and nystagmus
 Differentiate to vestibular symptoms

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG Red flag: Upper cervical complex
Instability Sharp –Purser Test

 Index finger on spine proc of C2

 Apply compression to PA
 Posterior slide: + AA
instability
 Note:
Aware to sign of instability:
VBI sign
Cord sign
Neck pain and stiffness
Hypoaesthesia on face, lips and
tounge
Sugijanto, 2020
 REVIEW OF SYSTEM
&
Red flag: Upper cervical
RED FLAG
Red flag: Upper complex Instability
cervical complex Tectorial Membrane
Instability Alar lig laxity (PLL)

 Lateral flexion of • Fix on spine proc of

occiput through the C7
contralateral • Traction to the head in
transverse process neutral than flexed
of the atlas position

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG
CLINICAL EXAMINATION
FOR PANCOAST SYNDROME
 Man age >50 years
 Chronic coughing and history of
smoking
 Paresthesia at along of ulnar
nerve distribution
 ULTT for ulnar and then deep
breathing

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG Red flag:
Myocardial infark

 Damage of myocardial tissue due to coronary arterial block for a short

period of time caused byspasme or thrombus, heart muscle
dysfunction/infark.
 Angina
 Palpitation
 Intermitent Claudication
 Risk of coroner heart disease: Cholesterol abobe 180 mg/dl on the age
of <30, or above 200 mg/dl on the age of >30, supposed to have a risk
of coronary arterial disease.

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG
RED FLAG:
PLEURISY

 Sharp pain in inspiration

 History of lung disease
 Dypsnea, chest expansion very limited

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG APENDICITIS Red flag
examination
 Abdominal rigidity:
Rebound tenderness
Mc Burney point +
Psoas and Obturator sign +

Nyeri
ekstensi Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG
Red Flag:
PYELONEPHRITIS

 Kidney Infection
 Pain felt bilateral posterior low back and
unilateral abdomen, position or movement have
no effect
 Test with clap on dorsal lower thoracic spine

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

 Inconsistent of complain. disorder

Deep constant pain, worst in
 Constant pain unchanged on
weight bearing
position/activities; getting worst
Fever, malaise, and edema
in the night.
Spine rigidity

Sugijanto, 2020
REVIEW OF SYSTEM
& RED FLAG
RED FLAG: CAUDA
EQUINA
SYNDROME
 Retention uri or incontinence uri / alvi
 Saddle anesthesia
 Weakness of the inferior extremity increase
progressive
 Test to sensory deficit (L4, L5, S1)
 Quick test: Ankle dorsiflexion, toe extension, and
ankle plantarflexion weakness

Sugijanto, 2020
PT MANAGEMENT ON
SPINE PROBLEMS
 Comparison of CPG’s for diagnosis,
prognosis and management of non
specific neck pain.

Pulak Parikh , et al, 2019

 The effect of manual therapy and

stabilizing exercise on FHRSP
Kiana Fatholahnejad, et al,
2019 Sugijanto, 2020
PROSEDUR
PEMERIKSAAN
History taking:
 Pertanyaan utk pembuktian hipótesis awal (ICD)
 Dugaan HNP cervical: Nyeri ngilu cervical
hingga sisi kepala atau lengan pd area
dermatome, Terpicu posisi menunduk lama/gerak
menunduk
 Dugaan artritis: Nyeri – kaku bangun tidur; Posisi
tengadah & grk rotasi cervical nyeri/ nyeri
meningkat ekstensi

Sugijanto, 2020
PROSEDUR
PEMERIKSAAN
Observasi:
 Forward head position; Flat neck atau
deviasi

Tes orientasi:
 Dugaan artritis: Gerak ekstensi cervical nyeri,
atau + kompresi posisi ekstensi nyeri;
 Gerak esktensi 3 D cervical limitasi gerak dan
nyeri leher, interscapular dan paresthesia hingga
lengan
 Dugaan HNP: Gerak fleksi cervical nyeri,
atau + kompresi nyeri
Sugijanto, 2020
PROSEDUR SPECIFIC
TEST
Spurling test (test 1)
 Tes kompresi saraf dgn bertahap: 3D-
extension
 Tahapan:
1. Kompresi posisi fleksi
2. Kompresi posisi ekstensi
3. Kompresi posisi 3D ekstensi
Hasil
 Test + nyeri timbul mulai dr leher dan
menyebar ke sisi kepala atau sisi dorsal bahu,
dorsolateral lengan atas,
Sugijanto, 2020
PROSEDUR SPECIFIC
TEST
 Traction and distraction test (test 2)
 Pasien terlentang
 Lakukan traction leher

Hasil:
Test + bila nyeri hilang oleh traksi dan
timbul saat dilepaskan

Sugijanto, 2020
 Cervicogenic headache (CH). IHS 1999
Flexion-rotation test
(Hall 2004, Ogince 2006)

Flexion-rotation test: Nyeri leher dan kepala

unilateral. Occipital
Flexion rotation test: positive more than 10
degrees in limitation

Sugijanto, 2020
Prosedur pemeriksaan

Tes khusus (Evidence base approach)

 Joint play movement lateral gapping test atau
 3 dimentional flexion terbatas firm end feel.
 Tes dengan PACVP nyeri segmental

Sugijanto, 2020
TEST
KHUSUS
 PALPASI POSTERIOR
Spinous proc. C2,6,7, C3-4-5
Proc transversus
 Trapezius m.

 PALPASI ANTERIOR
◼ Carotis tub -> Stelate gln
 Sternocleido mastoid m
 Supra clavicular fossa
Sugijanto, 2020
Shoulder Abduction Sign

Kompresi radix C5-6

Penurunan symptoms berarti
positive

Sugijanto, 2020
Upper Limb Tension Testing A

Scapular Depression
Shoulder Abduction and External
Rotation
Elbow Extension
Forearm Supination
Wrist and Finger Extension

Sugijanto, 2020
Upper Limb Tension Testing B

Supine in 30º Abd

Scapular Depression
Shoulder Internal Rotation
Elbow Extension
Wrist and Finger Flexion
Opposite Cervical SB and Rot

Sugijanto, 2020
 Upper Limb Tension Test (ULTT)
Lateral fleksi-rotasi kontralateral,
diikuti gerakan bertahap sbb:
 Depresi dr girdle
 Abduksi bahu
 Lateral rotasi bahu
 Ekstensi siku
 Supinasi lengan bawah
 Ekstensi perg tangan
 Ekstensi jari2

Hasil:
Test + bila muncul nyeri
radiks.
Sugijanto, 2020
Ulnar Nerve Testing

Shoulder Retraction
Shoulerd Extension and External
Rotation
Elbow Flexion
Forearm Supination
Wrist Extension and Radial Deviation
Finger Extension
Cervical Side Banding and Rotation away

Sugijanto, 2020
NEURAL TENSION
TEST
 LLTT: Slump test; N. tibialis dan N. Peroneus
suerficial
 Lower limb tension test
Tes ketegangan saraf
 Nerve gliding test
Tes mobilitas saraf

Sugijanto, 2020
T1 Nerve Root Stretch

Abduct to 90º
Flex pronated arms to 90º
Flex elbows and place behind the neck
Pain in scapular area is T1- Pain in
Ulnar distribution is Ulnar

Sugijanto, 2020
 TEST
KHUSUS
Segmental CO-C1
Self test: Active Flexion seluruh cervical:
Gerak Fleksi-ekstensi kepala
Pasif: Translasi Occyput ke dorsocranial

Segmental C1-C2
Self test: Active Flexion seluruh cervical dan
ekstensi kepala, gerak rotasi kepala.
Pasif: Posisi CPP, kepala ekstensi, Rotasi
melalui proc. Transversus C1

Sugijanto, 2020
Test khusus LOWER CERVICAL

Segmental Lat.flexion test: C2-3, C3-4, C4-5, C5-6, C6-7

dan C7-Th1.
Tekanan proc transversus kontralat gerak ipsilat
Gapping uncinate joint dan facet kontralateral

Sugijanto, 2020
SPECIFIC
TEST
• P.A.C.V.P TEST C2 sd. C7
– Provokasi segmental
– Hanya untuk tes
• 3D Flexion test
– Tes Capsel sisi kontra lateral
• SEGMENTAL GAPPING TEST
– Segment tertentu
– Rotasi ipsilat, fleksi lat kontralat
dan fleksi
• Perhatikan: pain, (range), dan
end feel.
Sugijanto, 2020
SPECIFIC
TEST
 UPPER THORACAL VERT:
 Terkait faktor mekanik dan vegetative
 LPAVP
 Unilateral facet gapping test

 NAG test
 Arah 600 ventrokranisl

 Catat: Nyeri, range dan end feel. Firm end feel indikasi
hypomobility.
 Costo Vertebral-Transversal Joint
 Mobilizarion test costovert dan gapping test costotransversal
 Nyeri dan firm end feel indikasi adanya Hypomobility
Sugijanto, 2020
Stabilization test:
tes stabilisasi lumbosacrale fiksasi pd
lumbale dan mendorong femur ke
posterior.

Sugijanto, 2020
SPECIFIC
TEST
MUSCLE LENGTH TEST
Contract relax stretch test
 UPPER TRAPEZIUS M
 Fleksi lateral cervical kontralat, depresi girdle ipsilat

 LEVATOR SCAPULAR M

 Posisi dan pelaksanaan spt Upper trapezius m. tangan belakang kepala

SCALENUS M
 Cervical fleksi lateral kontralat, CostaI depresi dan rotasi kepala
 Perhatikan bila clicking costa I

Sugijanto, 2020
MUSCLE LENGTH TEST
 Contract relax stretch test
PECTORALIS MAYOR M.
Posisi glenohumeral Abduction -horizontal
abduction.
Expiration dan horizontal abd.

PECTORALIS MINOR M.
Posisi girdle retraction
Expiration dan girdle retraction

Sugijanto, 2020
 TenNeduroolonsigrcehfolnedxreeozse,k with reflex hammer
-Biceps reflex (C5-6). Compare left and right
- Triceps reflex (C6-7), compare left
and
right

-Outcome/result
-Test + by hyporeflex – areflex of one or
more reflexs

-Babinski reflex, compare left and right

Demonstration in
supine position

Sugijanto, 2020
SPECIFIC
TEST

Sugijanto, 2020
DERMATOM DAN TES
REFLEX

Sugijanto, 2020
 DATA
PENUNJANG

X Ray AP, MRI, CT SCAN,

ATHROSCOPY.
Data dr Orthopaedi, bedah, bedah
rahang, internist, dll

Sugijanto, 2020
 DIAGNOSIS

 Gangguan neuro-musculoskeletal-
vegetative mechanism atau gerak dan
fungsi :
 Body structure and body function

impairment:
 Disability:

Sugijanto, 2020
INTERVENSI
MANUAL TERAPI
Temu 3

Sugijanto, 2020
Konsep mobilisasi otot
 Mobilisasi myofibrile (serabut otot)
Teknik relaksasi otot
Static stretching
 Mobilisasi Myofascial (pembungkus otot)
Contract relax stretching
Myofascial release
Muscle Energy Technique
 Mobilisasi tendon
Eccentric stretching
 Mobilissi tendoperiosteal
Sugijanto, 2020
INTERVENSION
TECHNIQUES
MANUAL MUSCLE STRETCHING
 Ischaemic compression
technique
 Muscle mobilization utk
melepas collagen adhesion
 Myofascial release
 Transverse
stretching
manipulation

Sugijanto, 2020
INTERVENSION
TECHNIQUES
 MUSCLE LENGTHENING/STRETCHING
Muscle Energy Technique
Contract relax stretching
Gabungan relaxation-stretching
Lengthening position  Agonist isometric
Contract  Relaxation  Agonist Stretching

Sugijanto, 2020
 Konsep Mobilization

Ditambahkan gerak passive ROM

beberapa derajad The anatomic
barrier ctidak dapat
dilewati tanpa
kerusakan integritas
sendi
Sugijanto, 2020
 Konsep Mobilization

Gerak fisiologis dibatasi oleh

physiologic barrier
Tegan
gan
munc
ul Sugijanto, 2020
 INTERVENSIO
N

JOINT MOBILIZATION
Meningkatkan mobilitas dan kemampuan gerak
 Intensitas: Grade I; II; III; IV dan IV force.

Restrict
I
I Normal ROM
I

II
I I
V mani
p

Sugijanto, 2020
Konsep Concave-convex

 Traksi (traction): tarikan tegak lurus

permukaan sendi
 Translasi (glide): gerak luncur sejajar
permukaan sendi
 Roll glide: gerak fisiologis terdiri dari gerak
arthrokinematics berpasangan antara gerak
gelinding (roll) dan luncur (glide) sesuai
dengan hokum cekung-cembung.

Sugijanto, 2020
Konsep Mobilization

 Mobilization
 Mobilization vs. manipulation
(thrust)
 Self-mobilization /
automobilization
 Mobilization with movement
(Mulligan’s techniques / natural
apophyseal glides)

Sugijanto, 2020
Konsep mobilisasi serabut saraf

 Dilakukan setelah entrapment di be

 baskan
 Nerve tightness → neural mobilization
 Nerve Adhesion → nerve gliding
 Regional neural mobilization:
Proximal
Distal

Sugijanto, 2020
Konsep mobilisasi venosus & lymphatic
drainiage
 Venous edeme → Elevation; Elastic bandaging
massage; pumping exc
 Lymphatic edeme → lymph drainage;
compression technique; taping

Sugijanto, 2020
INTERVENSI
MT
MOBILISASI SEGMENTAL C0-1
Posisi head flexion (atlanto occypitalis)
→ traksi occyput dan translasi kearah
dorsocranial.

MOBILISASI SEGMENTAL C1-2

Posisi netral: head traction kmd rotation
dan kembali posisi semula
Mendorong transverse proc atlas ke
rotation.
Sugijanto, 2020
INTERVENSI
MT

MOBILISASI SEGMENTAL C2-3, C3-4, C4-5, C5-6,

C6-7 dan C7-Th1.
Lateral flexion dg mendorong transverse proc arah
contra lat.
Rotation dg mendorong transverse proc arah rotasi
bersama head-neck rotation

Sugijanto, 2020
NAGS AND SNAGS

 Auto mobilization

Sugijanto, 2020
INTERVENSI
MT
 CERVICAL TRACTION
 INDIKASI:
Manual
Seluruh cervical spine
Segmental
Dengan alat
Posisi lordosis sudut traksi lurus : utk disc
problem
Posisi fleksi sudut traksi tertentu : utk facet
problem
Posisi fleksi lateral sudut traksi tertentu utk
uncinate joint.

Sugijanto, 2020
Prosedur Intervensi
1. Cervical oscillated traction in lordotic position.
2. Natural apophyseal glides technique (NAGs:
Mulligan concept)
3. Mobilisasi nucleus grk segmental extension
4. Mc. Kenzie Extension exc
5. Neural mobilization / nerve gliding technique
6. Postural correction & proper neck
mechanic/ergonomic

Sugijanto, 2020
 Prosedur Intervensi
• Intermittent lumbar pd Disc problems: traction
posisi lumbar lordosis
• Intermittent lumbar pd Facet problems: traction posisi
lumbar fllexion
• Mobilisasi discus gerak ekstensi: Ekstensi lumbale
dengan PACVP
• Extension program (Mc. Kenzie); Muscle
strengthening untuk stabilisasi

Sugijanto, 2020
 Joint mobilization
 Joint mobilization:
3D flexion (capsular target)
 NAGs and SNAGs
Extension SNAGs (disc target)
Flexion SNAGS (facet tasget)
 Gapping manipulation (facet target)

Sugijanto, 2020
INTERVENSI
MT
 GAPPING MANIPULATION LOWER CERVICAL
FACET
Posisi cervical rotation homolat, lateral flexion
contralat dan flexion
Manipulasi dengan mendorong transverse proc
kearah rotation homolat.

Sugijanto, 2020
 Joint mobilization
 Mulligan concept: NAGS, SNAGS, MWM, SMWAMS, dan
Fist Traction Upper thoracic joint Mobilization With
movement (MWM)
Rotasi bersamaan gerak cervical rotation
 Thoracic Mobilization
Extension dengan NAGs dan SNAGs
 NAGS: 600 ventrocranial glide
 SNAGS sambil gerak fleksi, ekstensi, rotasi dan
lateral fleksi
 LPAVP : unilateral segmental mobilization

Sugijanto, 2020
Joint mobilization

 Costovertebral manipulation
 Lower thoracic traction manipulation

Sugijanto, 2020
MANIPULATION

 Thoracal spine Gapping manipulation

(minimal hypomobility/blockade)
2 or 3dimentional manipulation
NAGs and SNAGs

Sugijanto, 2020
 INTERVENSI
MT

•  NELSON TRACTION
• Sand back pd spinous proc upper thoracal.
• Manipulasi dgn menarik bahu pasien dan
• mendorong sand bag keventral.
• Utk minimal capsular pattern

Sugijanto, 2020
 Intervention

3 Thrust Manipulations
2 reps of each
Seated Distraction

Sugijanto, 2020
Myofascial pain para vertebral
muscle thoracal spine

 Ischemic compression technique:

kompresi lokal >30”
 Transverse manual stretching
 Longitudinal manual stretching

Sugijanto, 2020
PROSEDUR
INTERVENSI

Intervensi Scalenus Syndrome

 Contract relax stretching m.
scalenus
 Mobilisasi costa1

 Neural mobilization nerve trunk

via:
N. radialis
N. Medianus
 Postural correction retraksi cervical
(scalenus)Sugijanto, 2020
SELF THORACIC
MOBILIZATION
 Latihan mobilisasi ekstensi thoracal dgn foam roller
 Crawl exercise
 Unilateral stretching

Sugijanto, 2020
 INTERVENSI
MT

 TERAPI LATIHAN
POSTURAL CORRECTION
Posisi neck retraction
STABILIZATION
Pd posisi terkoreksi
MOBILISATION
Mobilisasi cervical hati-hati
Dlm full ROM kecuali extension.
Sugijanto, 2020
INTERVENSI
MT

 STABILISASI PASIF
Neck collar : soft, semi rigid atau
rigid.

 STABILISASI AKTIF
Neck stabilizing exercise

Sugijanto, 2020
Terapi latihan cervical spine

 Latihan
Postural correction
Isometric contraction
Stretching

Sugijanto, 2020
Terapi latihan thoracal spine

Latihan
Postural correction
Stretching
Mobilization

Sugijanto, 2020
INTERVENSI
MT

PROPER NECK MECHANIC

Posisi berdiri, duduk dan bekerja
Penempatan alat kerja yg tepat
Penyesuaian kacamata

Sugijanto, 2020
INSTRUME
NT
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
 Nyeri pada bahu Relevance &
CLINICAL Impingement syndrome contextual
REASONING
Contextual
Fungsi dan disabilitas
factors
Internal External
Anatomic factors factors
impairment
Cuff muscle SLAP
Lesion
AC Bursa Functional
Joint subacromial Pectoralis minor, Participatio
levator scapulae Capsule/ impairment
lig laxity n restriction
osteophyte Serratus anterior
Activity
Inflamation- Tightness limitation
Supraspinatus GH
calc formation
Instability

Subscapularis, Weakness
Over head Work
infraspinatus, Internal
impingement
activity
Inflamation Scapular
dyskinesis Carrying Sport
Inflamation
Tight- Lifting Recreation
hypertroph
y

External The used of

impingement arm in ADL
Shoulder pain
Sugijanto, 2020
 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
paiful arc humeroscapular rhythm, Ganti hipotesis
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

EXTERNAL SHOULDER IMPINGEMENT

Glenohumeral INTERNAL SHOULDER IMPINGEMENT
H1: Superior capsel
instability

H1: Supraspinatus H2: Subacromial

H3: Infraspinatus H4: Subscapularis H8: SLAP lesion
Traksi caudal: no pain bursa
and No sulcus sign Abdominal press
Empty can test, External rot
Neer-Hawkin test, Internal rot
Abduksi isometric isometric,
test, Crepitasi isometric, palpasi
dan Palpasi Palpasi posisi
dan palpasi posisi netral
posisi borgol posisi sphynx
Superior capsule
contracture penyebab ekstensi
impingement Tendinitis Subacromial Tendinitis Tendinitis
supraspinatus akibat bursitis akibat infraspinatus akibat subscapularis
impimgement impimgement impimgement
impimgement
Scapulothoracal
dyskinetic

Scapular tiping Scapular shrugging Scapular winging Sugijanto, 2020

 Shoulder External Competency base
impingement approach

Penyebab Akibat
impingement impingement

Subacromial GH
space Instability (a) Tendinitis
sempit Scapular Supraspinatus
Bursitis (b) Tendinitis
dyskinesis
subacromial Subscapularis, (c)
1. Traksi statik ke infraspinatus
1. Anteroposition: Strenghtening ,
caudal
/MWM in posterocaudal
2. Roll glide Abd +
correction 1. Transverse friction pss
rotasi eksternal/ 1. Transverse friction pss
2. Instability: Glenohumeral ekstensi
internal (a) borgol/ (b) netral/
functional stabilization exc 2. Traksi statik ke caudal
3. Mobilization under (c) sphynx
caudal traction 3. Mobilization under 2. Contract relax
caudal traction stretching
1. Tipping: pectoralis
minor stretching
2. Shrugging: levator
scapula stretcjhing
3. Winging: Serratus 1. Edukasi proper
anterior strength hand activity
2. Stretching
3. Stabilization exc

1. Edukasi: Postural correction

2. Joint stabilization exc Sugijanto, 2020
EVALUATION

ALAT UKUR/EVALUASI FISIOTERAPI

YG DIBUTUHKAN
 Pengukuran nyeri: VAS/VDS/dll
 Pengukuran Stability: Endurance test
 Pengukuran ROM: Goniometer
 Analisis scapulohumeral rhytm
 Analisis scapulothoracal rhytm
 Pengukuran movement disfunction
 Pengukuran disabilitas: SPADI, DASH

Sugijanto, 2020
 Resume Clinical pathway
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
4 Nyeri dan Pemeriksaan US/SWD Ringan: 3x/ Nyeri
disabilitas bahu Impingement (5): subacromial, traksi – mgg, 1 sesi berukrang tiap
akibat Painful arc translasi static caudal, Sedang: : kunjungan
external Jobe’s test Mobilisasi saat caudal 3x/ mgg, 2 Fungsi normal
impingement Neer test traction, MWM sesi Berat: : <2-4 mgg
syndrome Hawkin Kennedy test 2x/ mgg, 4
External rotation sesi
isometric test

+subacromial Bursa subacromial Neer mobilization under idem idem

bursitis & Hawkin test Palpasi caudal traction,
+supraspinatu s pisisi ekstensi Contract relax
tendinitis M Supraspinatus stretching
Jobe’s/Empty can test
Isometric Abd pada
MLPP
Palpation posisi borgol

Sugijanto, 2020
 Relevance
Lumbar disc herniated
&
contextual Functioning and disability Constextual factors

Anatomic impairment
Internal External
factors factors
Disc Nerves Capsels Facet
Muscle
Annulus Motoric Chronic
rupture Autonom inflamation

Paretic Weak-
Nocisensoric Blockade
atrphy
Sympathic Spasm Inter fiber Functional
Nucleus
herniation
hyperactivity adhesion impairment
Vascular Activity
Sensitive Capsel contracture limitation Participation
tissue restriction
Micro circular Capsular
Neuropathic constriction pattern
pain
Sitting
Work
Radicular pain Stretched Muscle Lifting
Low back pain
pain imbalance Sport
Driving
Postural Recreatio
deformity n
Pain Sugijanto, 2020
 Klien dengan keluhan nyeri pinggang
menjalar hingga punggung kaki.

ya Buat hipotesis awal HNP

Nyeri duduk. Membungkuk, Pemeriksaan red flag:

History taking: Acute herniated, myelitis dll
(Ha: HNP) berkuranhg bila jalan
tdk
ya

Observasi: Lumbar deviation.

ya
ya Konsul dokter spesialis
yang kompeten
Pemeriksaan Tes orientasi Lumbarl: fleksi trunki nyeri &
Algoritme
fungsi terbatas, tetapi ekstensi tidak nyeri,
pemeriksaan lain
gerak: 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

Annulus rupture, Iritasi jaringan Lumbar straight

nucleus migrate Lumbar disability
dorsal discus posture

Sensitive tissue Nerve

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

1. Corset Sugijanto, 2020

EVALUATION
ALAT UKUR/EVALUASI
FISIOTERAPI YG DIBUTUHKAN

 Pengukuran nyeri: VAS, VRS,

 Pengukuran fleksibilitas/ekstensibilitas otot:
 Pengukuran mobilitas
 ROM: Goniometer, Inclinometer, Schober
 Pengukuran disabilitas
 Oswestry

Sugijanto, 2020
 Resume Clinical pathway
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
2 Low back pain Pemeriksaan Discus: SWD, oscillated traction Disc bulging: 3x Nyeri hilang,
and nerve • Springing test pss extension, oscillated (3x/mgg) dan 4x ROM dan fungsi
irritation/ • Spurling’s test POLD method, NAGs (2x/mgg) pulih
adhesion • Distraction test extension mobilization,
•Extension test Cobra exercises, Disc herniated: Nyeri kurang,
Pemeriksaan stability: 6x (2x/mgg) ROM & fungsi
• Core stability test pulih

Extruded- Nyeri menurun,

fragmented: ROM meningkat
Preoperative PT Fungsi membaik

Pemeriksaan Neural mobilization Idem

Integritas radix: Nerve gliding idem
Dengan iritasi • Dermatome test
radix • Kenn muscle test
• Lower Limb Tension
Test (LLTT)

Sugijanto, 2020
 OA Lutut Relevance &
CLINICAL
contextual
REASONING
Functioning, and disability Contextual
factor
Anatomic impairment
Internal External
Rawan Capsul factor factor
Otot/ Vascular
Sendi Ligamen Tendo
n Micro
Laxity Spasme Circulation
Erosi
Kontraktur
Inflamasi tl Penumpukan Functional Participation
Subchondral zat iritan restriction
impairment
Immobilisasi Nyeri Activity
Osteofit Deformitas
limitation
pagi
Iritasi Tightness/
Kontraktur Antalgic
Jaringan gait Work Recreation
Lemah
Capsular
Inflamasi Pattern Nyeri naik
Kronis Sport
tangga
Nyeri
kompresi Nyeri Nyeri jongkok
Regang
Hypomobility Sugijanto, 2020
 Nyeri inguinal dan kaku sendi
Anamnesis utk panggul akibat osteo atritis,
menegakkan ICD Ha: Contraktur akibat
Ya OA panggul
Nyeri dan kaku panggul bangun
tidur, krepitasi, internal rotasi Ganti hipotesis
sangat terbatas Tdk
Ya
Patologi serius/
Posisi sendi: Red flag?
Inspeksi Tdk
Ya
Duchene gait; Posisi Tengkurap,
rotasi internal terbatas
Tes Cepat:
Ya ALGORITMA
Red flag: PEMERIKSAAN
Test Gerak Pasif FISIOTERAPI PADA
:Nyeri & terbatas (rotasi internal < abduksi
CAPSULAR PATTERN
Muskular?
< Fleksi dengan Elastic - Firm End Feel)? Tdk HYPOMOBILITY SENDI
Ya PANGGUL AKIBAT
Isometric test dan
Joint Play Movement (Nyeri, Elastic - Firm
End Feel), Traksi pembatasan ROM abduksi, palpasi OSTEO ARTRITIS
Tes khusus
rotasi internal dan rotasi eksternal
Penunjang: X-Ray

Diagnosis CAPSULAR PATTERN HYPOMOBILITY OF

THE HIP AKIBAT OSTEOARTRITIS

Problem: Contracture lutut aibat OA

Body structure impairment: Joint surface/capsules
Body function impaitmen: Capsular pattern Hypomobility
Disabilitas: Sugijanto, 2020
 Competency base
approach

OA LUTUT
Anatomic Kinetic
impairment target
impairment
Muscle
Joint surface weakness/tightnes s
inflammation/erosi Tibial lateral
Capsular glide
Mal Tibial medial
pattern posture
alignment glide
position
1. Traksi osilasi inferior 1. Active stabilization
2. Pengurangan berat 2. Contract relax
badan stretching otot MWM dengan
3. Olah raga dalam contracture/tegang medial glide
kolam 3. Muscle strengthening reposition
& Functional exc

Penggunaan AFO MWM dengan

1. Traksi osilasi MLPP Penggunaan
2. Mobilisasi pada akhir lateral glide
orthopaedic shoes reposition
pembatanan rom
3. Roll glide Sugijanto, 2020
EVALUATION

ALAT UKUR/EVALUASI
FISIOTERAPI
 Pengukuran nyeri:
 VRS, VDS, NRS.
 Pengukuran stabilitas sendi:
 One Leg Standing Test,
 Pengukuran mobilitas sendi:
 ROM: Goniometer
 Analisis berjalan
 Gait Analysis
 Pengukuran movement
disfunction:
 Agility test
 Pengukuran disabilitas:
 KOOS, Womac, Sugijanto, 2020
 Resume Clinical pathway
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
Knee joint Capsular Pemeriksaan alignment: SWD/US, tibiofemoral Kellgren 1: 3x Nyeri hilang,
pattern • Deformitas/Alignment: joint and patellofemoral (3x/mgg) dan ROM dan fungsi
hypomobility valgus/ varus/ recurvatum joint oscillated mob. in 4x (2x/mgg) pulih
akibat knee Pemeriksaan rawan sendi: MLPP, end range joint
osteoarthritis • Crepitasi mobilization, MWM and Kellgren 2: 6x Nyeri kurang,
• Compression nyeri active mobilization exc, (2x/mgg) ROM & fungsi
• Traction test nyeri - MWM pulih
Pemeriksaan Capsul:
• Passive test: capsular Kellgren 3-4: pre Capsules-
pattern; elastic e f. operatif 3x muscle-Nerve
• Joint play movement nyeri (seminggu) lentur
dan elastic/firm end feel Rehabilitatif 6x Fungsi membaik
• Stability test: ligament (2x/mgg)
laxity

Dengan knee + medial glide varus idem idem

valgus mobilization

Dengan knee + medial glide varus

varus mobilization
Sugijanto, 2020
Sugijanto, 2020