INTERVENSI MANUAL TERAPI CERVICAL SPINE

INTERVENSI MANUAL TERAPI INTERVENSI MANUAL TERAPI CERVICAL SPINECERVICAL SPINE

OlehOlehSugijantoSugijanto

DisampaikanDisampaikan padapada: : KuliahKuliah MK MK ManualterapiManualterapi III III FakultasFakultas FisioterapiFisioterapi Univ. Univ. IndonusaIndonusa EsaEsa UnggulUnggul

Jakarta, Jakarta, JuliJuli 20072007

TUJUAN INSTRUKSIONALTUJUAN INSTRUKSIONAL

Mahasiswa memahami Intervensi pd Mahasiswa memahami Intervensi pd kasus Cervical spine dgn cara:kasus Cervical spine dgn cara:•• Mampu menjelaskan metodaMampu menjelaskan metoda--teknik dan teknik dan

dosis intervensi manualterapi kasus dosis intervensi manualterapi kasus Cervical spine Cervical spine

•• Mampu membedakan indikasi antara Mampu membedakan indikasi antara metoda dengan assessment manual metoda dengan assessment manual terapi terutama pemeriksaan khusus.terapi terutama pemeriksaan khusus.

•• MampuMampu mempraktekmempraktek intervensiintervensimanualterapimanualterapi kasuskasus Cervical spine Cervical spine

•• MampuMampu menilaimenilai tentangtentang hasilhasil intervensiintervensimanualterapimanualterapi kasuskasus Cervical spine Cervical spine

PERTANYAAN STUDIPERTANYAAN STUDIJelaskanJelaskan indikasiindikasi intervensiintervensi metodametodamanualterapimanualterapi kaitannyakaitannya dgndgn hasilhasilassessment assessment bilabila dijumpaidijumpai patologipatologi::•• Cervical pain/neck arm pain Cervical pain/neck arm pain akibatakibat Cervical disc Cervical disc

bulging/HNP, cervical bulging/HNP, cervical spondyloarthrosisspondyloarthrosis, , MyofascialMyofascial pain, thoracic outlet syndrome, upper pain, thoracic outlet syndrome, upper thoracalthoracal spine pathology, shoulder pathology.spine pathology, shoulder pathology.

JelaskanJelaskan dandan praktekkanpraktekkan manipulasimanipulasi cervical cervical spinespineUraikanUraikan dandan praktekkanpraktekkan mobilisasimobilisasi otototot dandancontract relax stretching contract relax stretching padapadatightness/contracture cervical spinetightness/contracture cervical spineJelaskanJelaskan dandan praktekkanpraktekkan terapiterapi latihanlatihan padapadaJelaskanJelaskan dandan praktekkanpraktekkan pengukuranpengukuran hasilhasilpadapada intervensiintervensi

MASSAGE MASSAGE DiterapkanDiterapkan pd depressor TMJ:pd depressor TMJ:•• M. M. MasseterMasseter•• M. M. TemporalisTemporalis•• Mm. Mm. PterigoideusPterigoideus

OtotOtot--otototot elevator TMJ:elevator TMJ:•• M. M. DigastricusDigastricus•• M. M. StyloideusStyloideus•• M. M. MilohyoideusMilohyoideus•• M. M. GeniohyoideusGeniohyoideus•• M. M. InfrahyoideusInfrahyoideus

INTERVENSI MT :INTERVENSI MT :MOBILISASI OTOT TMJ MOBILISASI OTOT TMJ dandan

CERVICAL SPINE CERVICAL SPINE MANUAL STRETCHINGMANUAL STRETCHING•• PereganganPeregangan otototot langsunglangsung scrscr

manual individualmanual individual..•• Pd Pd otototot besarbesar: : FiksasiFiksasi dekatdekat origoorigo

dandan insersioinsersio, , reganganregangan transversal transversal tengahtengah otototot..

•• Manual transverse stretching / Manual transverse stretching / manual longitudinal stretchingmanual longitudinal stretching

•• KasusKasus myofascialmyofascial painpain

TRANSVERSE FRICTIONTRANSVERSE FRICTION

•• GGerusanerusan ibuibu jarijari atauatau jarijari tangantangan•• TujuanTujuan: :

MengurangiMengurangi nyerinyeri; ; MeningkatkanMeningkatkan sirkulasisirkulasi; ; MelepasMelepas abnormal cross links abnormal cross links antaraantara cells cells otototot..

•• GerusanGerusan menyilangmenyilang jarijari tegaktegak luruslurus..

MOBILISASI OTOT CERVICAL MOBILISASI OTOT CERVICAL SPINESPINE

MUSCLE CONTRACT RELAX MUSCLE CONTRACT RELAX STRETCHINGSTRETCHING•• MetodaMetoda V. V. JandaJanda atauatau contract contract

relax PNF relax PNF pereganganperegangan ototototmemanfaatkanmemanfaatkan post post exitatoryexitatoryrelaxation reflex.relaxation reflex.

•• PosisiPosisi sub stretched + deep breath sub stretched + deep breath + isometric + isometric contrcontr 6 6 dtkdtk

•• Expiration + stretching 9 Expiration + stretching 9 dtkdtk

Upper Upper parapara cervical musclescervical muscles

TranversTranvers stretching pd stretching pd otototot bawahbawah occyputoccyput dgndgnibuibu jarijari atauatau jarijari--jarijari..

FleksiFleksi pasifpasif sendisendi atlantoatlantooccypitalisoccypitalis bersamaanbersamaantraksitraksi pd pd occyputoccyput dandandorongandorongan pd pd mandibulaemandibulae..

Contract relax stretchingContract relax stretching

Upper Upper trapeziustrapezius musclemuscle

Pd Pd posturpostur neck protracted neck protracted atauataudeviation deviation →→ hypertonehypertone →→myosismyosis →→ myofascialmyofascial trigger trigger point.point.Longitudinal stretching dg Longitudinal stretching dg keduakedua tangantanganTranversTranvers stretching dg stretching dg keduakeduatangantangan..TranversTranvers friction.friction.Contract relax stretchingContract relax stretching

cervical rotator musclescervical rotator musclesNocisensoric spasm reflex / psychologic stress →hypertone/spasm -tightness. Pd spondyloarthrosis cervRelaxing massageContract relax stretching.Torticolis: Sternocleidomastoideus + traction.

LevatorLevator scapular mscapular m

Sering tegang/memendek, myofascial pain atau tendinitis. Tranvers friction.Contract relax stretching,

MyofascialMyofascial pain pain parapara vertebral vertebral muscle muscle thoracalthoracal spinespine

Ischemic Ischemic techgniquetechgnique: : kompresikompresi lokallokal >8>8””Transverse manual Transverse manual stretchingstretchingLongitudinal manual Longitudinal manual stretchingstretching

SupraspinatusSupraspinatus mm•• PosisiPosisi AddAdd--Internal rot Internal rot penuhpenuh lenganlengan

bawahbawah belakangbelakang punggungpunggung..

InfraspinatusInfraspinatus m. m. •• PosisiPosisi SphynxSphynx, friction , friction tuberculumtuberculum minus minus

araharah craniocranio--caudal.caudal.

SubscapularisSubscapularis m. m. •• PosisiPosisi netralnetral sedikitsedikit external external rotasirotasi, ,

friction medial friction medial tuberculumtuberculum minusminus

Long head Biceps mLong head Biceps m•• Friction Friction sulcussulcus bicipitalisbicipitalis sambilsambil grkgrk

externalexternal--internal rotinternal rot

Bursa Bursa subdeltoideasubdeltoidea•• PosisiPosisi lenganlengan ekstensiekstensi, friction pd inferior , friction pd inferior

acromionacromion..

TRANSVERSE FRICTION

JOINT MOBILIZATIONJOINT MOBILIZATIONGLENOHUMERAL JOINTGLENOHUMERAL JOINT

Traction in MLPPTraction in MLPP•• PosisiPosisi bonnet, traction bonnet, traction keke laterallateral•• Oscillated traction Oscillated traction →→ pain pain

release & release & awalawal mobilisasimobilisasi

Longitudinal tractionLongitudinal traction•• PosisiPosisi netralnetral, , araharah kaudalkaudal•• Oscillated traction Oscillated traction →→ pain pain

release & release & patologipatologi surahumeralsurahumeral

INTERVENSI MTINTERVENSI MT

MOBILISASI SEGMENTAL C0-1Posisi head flexion (atlanto occypitalis) traksi occyput dantranslasi kearahdorsocranial.


MOBILISASI SEGMENTAL C1-2

• Posisi netral: head traction kmd rotation dankembali posisi semula

• Mendorong transverse proc atlas ke rotation.


MOBILISASI SEGMENTAL CMOBILISASI SEGMENTAL C22--33, , CC33--44, C, C44--55, C, C55--66, C, C66--77 dandan CC77--ThTh11..• Lateral flexion dg mendorong

transverse proc arah contra lat.

• Rotation dg mendorongtransverse proc arah rotasibersama head-neck rotation


MOBILISASI SEGM UPPER MOBILISASI SEGM UPPER THORACAL SPINE THORACAL SPINE INDIKASI:INDIKASI:•• PACVP PACVP padapada spinousspinousproc proc vertvert. . ThoracalisThoracalisybsybs..

•• UtamakanUtamakan apex apex kyphosiskyphosis


MOBILISASI MOBILISASI

COSTOVERTEBRALCOSTOVERTEBRAL--

TRANSVERSAL 1TRANSVERSAL 1-- 44

•• MendorongMendorong costacosta 1 1 kecaudalkecaudal

•• MendorongMendorong costacosta 2 2 -- 4 4 keke

ventroventro laterolatero caudal.caudal.

INTERVENSI MTINTERVENSI MTCERVICAL TRACTIONCERVICAL TRACTIONINDIKASI:INDIKASI:•• ManualManual

SeluruhSeluruh cervical spinecervical spineSegmentalSegmental

•• DenganDengan alatalatPosisiPosisi lordosislordosis sudutsudut traksitraksiluruslurus : : utkutk disc problemdisc problemPosisiPosisi fleksifleksi sudutsudut traksitraksitertentutertentu : : utkutk facet problemfacet problemPosisiPosisi fleksifleksi lateral lateral sudutsuduttraksitraksi tertentutertentu utkutk uncinateuncinatejoint.joint.

INTERVENSI MTINTERVENSI MTGAPPING MANIPULATION LOWER CERVICAL FACET• Posisi cervical rotation

homolat, lateral flexion contralat dan flexion

• Manipulasi denganmendorong transverse proc kearah rotation homolat.


GAPPING GAPPING MANIPULATION MANIPULATION THORACAL FACETTHORACAL FACET•• Lateral Lateral posteroanteriorposteroanterior

pressure pressure diaplikasikandiaplikasikanpadapada transverse proc transverse proc ybsybs..

•• UtkUtk capsular / capsular / ligamentairligamentair stretchingstretching


NELSON TRACTIONNELSON TRACTION•• Sand back pd Sand back pd spinousspinous proc proc

upper upper thoracalthoracal..•• ManipulasiManipulasi dgndgn menarikmenarik

bahubahu pasienpasien dandanmendorongmendorong sand bag sand bag keventralkeventral. .

•• UtkUtk minimal capsular minimal capsular patternpattern


TERAPI LATIHANTERAPI LATIHAN•• POSTURAL CORRECTIONPOSTURAL CORRECTION

PosisiPosisi neck retractionneck retraction

•• STABILIZATIONSTABILIZATIONPd Pd posisiposisi terkoreksiterkoreksi

•• MOBILISATIONMOBILISATIONMobilisasiMobilisasi cervical cervical hatihati--hatihatiDlmDlm full ROM full ROM kecualikecuali extension.extension.


STABILISASI PASIFSTABILISASI PASIF•• Neck collar : soft, Neck collar : soft,

semi rigid semi rigid atauatau rigid.rigid.

STABILISASI AKTIFSTABILISASI AKTIF•• Neck stabilizing Neck stabilizing

exerciseexercise

TAPPING & BRACINGTAPPING & BRACING

PadaPada kasuskasus scoliosisscoliosisKyphosisKyphosisHyper Hyper lordosislordosis

TerapiTerapi latihanlatihan cervical spinecervical spine

LatihanLatihan•• Postural correctionPostural correction•• Isometric contractionIsometric contraction•• StretchingStretching

TerapiTerapi latihanlatihan thoracalthoracal spinespine

LatihanLatihan•• Postural correctionPostural correction•• StretchingStretching•• MobilizationMobilization

MOBILIZATION EXERCISEMOBILIZATION EXERCISESHOULDER JOINTSHOULDER JOINT

•• CODMANNCODMANN’’S PENDULAR S PENDULAR EXERCISEEXERCISE

•• OVERHEAD PULLEY EXC OVERHEAD PULLEY EXC FINGE LADDER, ETC.FINGE LADDER, ETC.

STABILIZING EXCSTABILIZING EXC•• PNFPNF•• BUGNET BUGNET •• DLLDLL


PROPER NECK MECHANICPROPER NECK MECHANIC•• PosisiPosisi berdiriberdiri, , dudukduduk dandan

bekerjabekerja•• PenempatanPenempatan alatalat kerjakerja ygyg

tepattepat•• PenyesuaianPenyesuaian kacamatakacamata

EVALUATIONEVALUATION

INPUT REEVALUALITIONINPUT REEVALUALITION•• ReevaluasiReevaluasi data data dandan hasilhasil

assessmentassessment

PROCESS REEVALUATIONPROCESS REEVALUATION•• ReevaluasiReevaluasi metodametoda dandan

teknikteknik intervensiintervensi

OUTPUT REEVALUATIONOUTPUT REEVALUATION•• ReevaluasiReevaluasi hasilhasil intervensiintervensi

dengandengan instrument instrument pengukuranpengukuran

INSTRUMENTINSTRUMENTNYERI (VAS, VRS, VDS, NYERI (VAS, VRS, VDS, dlldll))ROM (ROM (GoniometerGoniometer, tip , tip measure), MOBILITY measure), MOBILITY (elasticity) , END FEEL (elasticity) , END FEEL (quality)(quality)STABILISATION STABILISATION MUSCLE PERFORMANCE (MMT, MUSCLE PERFORMANCE (MMT, HHD, HHD, SpygmomanometerSpygmomanometer))MUSCLE TONE MUSCLE TONE ((myotonometermyotonometer), LENGTH (tip ), LENGTH (tip measure)measure)

MEKANISME NYERI NECK ARMMEKANISME NYERI NECK ARM

Nyeri leher dan lengan

Cervical spine Shoulder Thoracal spine Thoracic outlet/inlet

discligament tendomusclcostovertefacet &

uncinatebursae

iritasi radix

radicularpsudoradicular

osteofitnyeri lokal/referal Inflamasi

neurovege

microsorculation

ischemic hipertone

spasm

fibrosis

contractbrachial nerve entrapment

posture

muscle tightness

nerve ischemiccalcification

NECK ARM PAINNECK ARM PAINNeck arm pain Neck arm pain seringsering dijumpaidijumpaidlmdlm klinisklinis

JenisJenis patologipatologi: : PseudoradicularPseudoradicularsec. sec. SpondyloSpondylo arthrosisarthrosis, Spasm , Spasm TorticolisTorticolis sec. disc migration, sec. disc migration, radicularradicular pain sec. disc pain sec. disc bulging/HNP, postural disorder, bulging/HNP, postural disorder, shouldershoulder--arm pain and arm pain and paresthesiaparesthesia sec. TOS, neck arm sec. TOS, neck arm pain pain sec.myofascialsec.myofascial syndrome syndrome dandan shoulder arm pain shoulder arm pain sec.suprahumeralsec.suprahumeral pathology.pathology.

NECK ARM PAINNECK ARM PAINNyeriNyeri leherleher menyebarmenyebar keke lenganlengan..Radikuler/pseudoradikuler/lokalRadikuler/pseudoradikuler/lokal..NyeriNyeri drdr jaringanjaringan spesifikspesifik tertentutertentuoleholeh patologipatologi tertentutertentu. . DiperlukanDiperlukan KajianKajian anatomianatomiterapanterapan; ; patologipatologi morfologismorfologis/ / fungsionalfungsional; ; terampilterampil pengkajianpengkajiansistematiksistematik maupunmaupun metodametoda/ / teknikteknik interversiinterversi khususkhusus; ; dandanpengukuranpengukuran hasilhasil ygyg tepattepat..DiniDini dibatasidibatasi pd pd patologipatologi: : SpondyloSpondylo arthrosisarthrosis cervcerv, disc , disc bulging/HNP bulging/HNP cervcerv, TOS, neck , TOS, neck shoulder m. shoulder m. myofascialmyofascial pain pain dandansuprahumeralsuprahumeral pathology.pathology.

Pain problem

SpondyloarthrosisSpondyloarthrosis cervicaliscervicalisDiawaliDiawali discosisdiscosis ((pemipihanpemipihan, , pengerasanpengerasan disc)disc)TerjadiTerjadi arthrosisarthrosis ((penipisanpenipisan, , pengerasanpengerasan hyaline cartilage hyaline cartilage dandanerosierosi facets)facets)MulaiMulai instabilitasinstabilitas →→ iritasiiritasi jar. jar. LunakLunak→→ psudoradicularpsudoradicular painpainCapsuleCapsule--ligaments ligaments contracturecontractureMuscle Muscle tight and contractedtight and contractedPembentukanPembentukan osteofitosteofit tepitepi facets facets dandan corpuscorpusPenyempitanPenyempitan foramentforamentintervertebraleintervertebraleIritasiIritasi radix radix →→ RadicularRadicular painpain

Cervical disc migrationCervical disc migration

AkibatAkibat posisiposisi menetap/deviasimenetap/deviasiNucleusNucleus terdorongterdorong kesatukesatu sisisisi dandanterjebakterjebak tanpatanpa kerusakankerusakan annulus.annulus.Dengan/tanpaDengan/tanpa inflamasiinflamasi; Acute/chronic; Acute/chronicMuscleMuscle spasm, tightness spasm, tightness atauataucontractedcontractedLigamentLigament contracture pd std contracture pd std lanjutlanjutPosturalPostural deformitydeformityPseudo Pseudo radikulerradikuler atauatau radicularradicular

Cervical disc bulging/HNPCervical disc bulging/HNPRusakRusak bag bag dalamdalam annulusannulusNucleus Nucleus terdorongterdorong posterior/ posterior/ posterolatposterolat kadangkadang anterioranteriorPenekananPenekanan isiisi foramentforamentintervertintervert/ / inflamasiinflamasi radix/ radix/ stenosisstenosis spinal canalspinal canalMuscle guarding spasm, tight, Muscle guarding spasm, tight, contractedcontractedFlat neck/deviation.Flat neck/deviation.IritasiIritasi radix radix →→ RadicularRadicular painpain((BrachialgiaBrachialgia))IritasiIritasi spinal spinal canalcanal→→HemiHemi/tetra /tetra parestesiaparestesia/pain /pain

ScalenusScalenus vsvs pectoralispectoralis minor minor syndrome TOSsyndrome TOS

GanggGangg somestesia/brachialgiasomestesia/brachialgiaGejalaGejala terbalikterbalik hiperhiper abduksiabduksilenganlenganKompresi/neuropraksiaKompresi/neuropraksia posisiposisi ttttttGangguanGangguan somestesiasomestesia dandan/ / protopatikprotopatik pd pd posisiposisi vsvs menetapmenetapForward head position Forward head position vsvs girdle girdle protractedprotracted→→ pseudoradicularpseudoradicular painpain

NeckNeck--shoulder shoulder MyofascialMyofascialpainpain

AkibatAkibat ischemic pd ischemic pd otototot, , timbultimbulinflamasiinflamasi dgndgn abnormal cross links abnormal cross links myofibrilemyofibrile--fasciafasciaDptDpt pd erector spine cervical, girdle, pd erector spine cervical, girdle, upper upper thoracalthoracalMuscle taut band /twisting Muscle taut band /twisting dgndgntrigger point trigger point Local Local dandan referred pain referred pain polapoladermatome/dermatome/--vegetative.vegetative.AllodyniaAllodynia →→ psudoradicularpsudoradicular painpain

SUPRAHUMERAL PATHOLOGYSUPRAHUMERAL PATHOLOGY

SubdetoidSubdetoid bursitis, bursitis, tendinitistendinitis m. m. supraspinatussupraspinatus, m. , m. infraspinatusinfraspinatus, , m. m. subscapulaeissubscapulaeis dandan m. bicep m. bicep caput caput longuslongus..AktualitasAktualitas tinggitinggi →→ referred pain referred pain (C(C44))--CC55––(C(C66) )

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INTERVENSI MANUAL TERAPI CERVICAL SPINE