FISIOTERAPI PROBLEM LUMBOPELVIC

HIP COMPLEX

Oleh: Sugijanto
Disampaikan pada:
Internship training Fisioterapi
RSUP Dr. Wahidin, Makassar
19-20 Desember 2019
Sugijanto, 2019
Movement system impairment

• Postural impairment:
• Round back and/ kyphosis
• Joint positional vault
• Movement impairment:
• Ankylosis, Hypomobility, Joint blockage,
Hypermobility, Instability
• Imbalance:
• Muscle imbalance, siting-standing imbalance
• Gait problems:
• Pathological gait

Sugijanto, 2019
SPECIFIC BODY STRUCTURE OF COMPLAIN
Specific/Non specific
Pathology

Tissue specific impairment

Kinetic/physiologic
impairment

PAIN

Dysbalance
Sugijanto, 2019
LUMBO-PELVIC-HIP PROBLEMS
Back and neck pain as a highest musculoskeletal complain
Difficult to identify and solve: because of complicated anatomic,
biomechanic and function. Which causing a high risk
Many pathologies: from simple pathology such as acute complains
(acute back pain) to chronic complain such as Bamboo spine (back
stiffness).
Funtional analysis as Upper/Lower quarter, segmental and regional,
including; TMJ, Upper-Mid-Lower cervical, Upper Thoracal-Costae,
Shoulder complex, and arm. Also lower thoracic, lumbar, pelvic, hip
and leg.

Sugijanto, 2019
 REVIEW OF THORACIC SPINE
• The normal apex of Kyphosis T4-5,
• Low range of movement, the lowest at
apex
• Spine process on the under vertebral
body
• The thoracic facet surface lies at frontal
plane
• There are costovertebral-transversal
joint
REVIEW OF LUMBAR SPINE
• The vertebral bodies and the discs
are bigger
• The lumbar spine kinesiology have a
specific character, and the highest
structure – relation with pelvic hip
complex and lower thoracic spine
Sugijanto, 2019
Facets surface (degree)

Lower cervical spine

• Joint surface , Joint movement:
• Transverse plane: 450 • Sagital plane: primary movement Flexion
• Frontal plane: parallel - extension

Thoracic spine • Frontal plane: primary movement

Abduction - Adduction
• Transverse plane: 600 • Transversal plane: primary movement
• Frontal plane: 200 Rotation

Lumbar spine • Capsule system have a

• Transverse plane: 900 meniscoide/disc
• Frontal plane: 450

Sugijanto, 2019
REFERRED PAIN PATTERN
• Vertebral impairment have a referred pain pattern in
dermatome zone
• The pattern follows innervation segmental facet pattern in
overlapping dermatome
• The other hand, peripheral nerve pattern in nervinal zones

Sugijanto, 2019
 PAIN FROM SPECIFIC TISSUE
Pain : Wound healing process
Inflammation
Pain : Nosisensoric sensitization

Hypoxia Pain: necrosis

SPECIFIC TISSUE Ischemic
Pain: Wound
Inflammation
healing process

Contracture Collagen adhesion Stretch

reflex/pain
Fatique Acidosis Chemical pain

How to explain central sensitization to patients with

‘unexplained’ chronic
musculoskeletal pain: Practice guidelines; Nijs J et al, 2011 Sugijanto, 2019
 CELLS

DISCRIPTIVE – HISTOLOGY - FUNCTION –

TOPOGRAPHY – INTERACTION TO OTHER

SPECIFIC TISSUE TARGET Sugijanto, 2019

CIDERA - INFLAMASI JAR OTOT-
TENDON
Strain, rupture, Myositis, tendinitis, myotendinosis,
avulsion myofascial syndrome

Spasm/guarding spasm, taut

band/twisting

spesifik

Sugijanto, 2019
 NYERI DARI OTOT
Atrophy → palpation &
Weakness strength test

Strain/
Inflammation Resting pain
rupture
Muscle Contraction pain → isometric
spasm test

MUSCLE
Tightness/ Stretch pain → contract
Contracture relax stretch test

Immobilisation Adhesion
Myofascial Stretch/contraction pain →
contracture palpation & stretch test

Sugijanto, 2019
 General scheme of muscle
assessment

Myofibril

Fascia
Muscle
α motoneuron

Sugijanto, 2019
 General scheme of muscle
assessment

Myofibril Isometric test

Palpation
Fascia Contract Relax
Stretch test
Muscle
α motoneuron Isometric
MMT

Sugijanto, 2019
 General scheme of muscle
assessment

Myofibril Isometric test Pain/Clicking/crepitation

Palpation Pain and No pain
Fascia Contract Relax Tightness or shortening
Stretch test
Muscle
α motoneuron Isometric Weakness/paralytic
MMT Pain and end feel

Sugijanto, 2019
INJURY-INFLAMATION OF CAPSULE-
LIGAMENT
Injury, arthritis, irritated Sprain, capsulitis/ arthritis, -
osteophyte, RA arthrosis

Compression pain, capsular pattern

Pseudoradicular pain hypomobility

spesifik

Sugijanto, 2019
 PAIN FROM CAPSULES
Post activity pain →
Instability stability test

Sprain/ Resting pain→

Inflammation
rupture palpation; passive test

Tight pain →
Contracture
Capsules passive & JPM test

Immuno Pain & hydrops →

Effusion Acidosis
reaction palpation & ballotement

Intercollagen Stretch pain →

Immobilzation Adhesion
space passive & JPM test

Sugijanto, 2019
 FACETS
Meniscoid on the capsular system
Transisi Th12 facet inferior sagital, superior frontal
L5-S1 43% deviation
Iritated by extension movement
Fraktur proc artic → lysis → lysthesis

Sugijanto, 2019
 PAIN FROM JOINT SURFACE
Nyeri kompresi sendi →
Kompresi prmk
Compression-traction test
tulang

JOINT Penglupasn Inflamasi tlg

SURFACE rawan sendi subchondrale

Tumbuh Nyeri bl gerak →

osteophyte compression-tractin test

Lepasan Penguncian Nyeri bl gerak ROM tertentu

fragmentasi grk sendi → Osclilated traction

Sugijanto, 2019
 General scheme of facet joint
assessment

? ?
Joint surface ? ?

?
Facet

Capsule - ligament ? ?

Sugijanto, 2019
 General scheme of facet joint
assessment

Passive test ?
Joint surface Compression & ?
traction test
NAGs test ?
Facet

Capsule - ligament Passive ?

Joint play ?
movement test
Sugijanto, 2019
 General scheme of facet joint
assessment

Passive test Pain/Clicking/crepitation

Joint surface Compression & Pain and No pain
traction test
NAGs test Pain and end feel
Facet

Capsule - ligament Passive Pain, end feel and ROM

Joint play Pain and end feel

movement test
Sugijanto, 2019
 INJURY-INFLAMATION OF NERVE
Neuritis: Neropraxia, axonotmesis, Pain along the nerve
Neurotmesis neurofibrosis distribution, paraesthesia,
hypoaesthesia

Triad symptom in
peripheral nerve
lesion

spesifik

Sugijanto, 2019
 PAIN FROM PERIPHERAL NERVE

Anoxia Paresthesia intermittent → tinnel

test & neural tension test

Neuropathic pain → tinnel

Inflammation test & neural tension test
Entrapment
Constant Paresthesia
Fibrosis →nerve gliding test

NERVES Inflamation Neuropathic pain →

neural tension test

Systemic Constant Paresthesia →

sensoric, motorik & reflex test

Sugijanto, 2019
Disc
• Nucleus as mucopolysacharide →
hydrophil
• Annulus fibrosus → dens connective
tissue with cross layer aranged
• Function: as a shock absorber; create
free segmental motion; and self
stabilization mechanism

Sugijanto, 2019
DISC INJURY (without inflammation)
4 level disc lesion: Disc bulging; Disc
herniated; Disc extruded; disc fragmented

Pain secondary to Sensitive Central – peripheral

tissue compression pain

spesifik

Sugijanto, 2019
 PAIN FROM PERIPHERAL NERVE
Inflamasi Central pain
Iritasi lig
Longitudinal Iritasi Bilateral
Stenosis hamstrings pain
Duramater

Paresthesia
Anoxia intermittent

Neuropathic
DISC Iritasi radiks Inflamation /radicular pain

Paresthesia
Fibrosis menetap

Iritasi saraf Triage

Inflamation
spinalis symptoms
Sugijanto, 2019
General Scheme of Disc Assessment

? ?
Disc ? ?
? ?
Disc
? ?
Nerve ? ?
? ?

Sugijanto, 2019
 General Scheme of Disc Assessment

Spurlings test (compression in ?

flx)
Disc Traction test ?
Valsava maneouvre ?
Disc
Tinnel test ?
Nerve Sensoric, motoric and Reflex ?
Lower limb tension test ?

Sugijanto, 2019
 General Scheme of Disc Assessment

Spurlings test (compression in Pain, central – peripheral

flx) sensation
Disc Traction test No pain
Valsava maneouvre Pain and end feel
Disc
Tinnel test Pain
Nerve Sensoric, motoric and Reflex Pain, or Paresthesia,
weakness and hypo reflexia
Lower limb tension test Pain and/or paresthesia

Sugijanto, 2019
FUNCTIONAL IMPAIRMENT
• Pain  Balance
• Pain in rest ◦ Sitting imbalance
• Pain in movement
◦ Standing imbalance
• Referred pain etc
◦ Walking imbalance, etc
• Joint mobility:
• Ankylosing
 Gait:
• Hypomobility
◦ Antalgic gait
• Joint blockade ◦ Duchene gait
• Joint stability: ◦ Trendelen’s burg gait,
etc
• Hypermobility
• Instability
 Hand function:
◦ Grip weakness
• Muscle performance:
◦ Prehension disability,
• Muscle weakness
etc
• Muscle paresis
Sugijanto, 2019
A TYPICAL LUMBOPELVIC KINEMATIC
• In LBP found ROM of lumbar and pelvic were
decreased, slow trunk movement and delay of
pelvic movement,

Robert A Laird et al, 2019

Sugijanto, 2019
 JOINT MOTIONS IMPAIRMENT
Capsular pattern →
ROM in passive test
Contracture Non capsular pattern →
ROM in passive test
Capsular
Blockade → passive test &
Ossification
JPM test

Inert Loose body Blockade → passive

structure & NAGs test
Hypo-
mobility Tightness → contract relax
stretch test
Tendomuscular
Contracted → contract relax
stretch test

Pattern impairment Deviation → movement pattern

Movement
system Misalignment → Positional /
Positional Fault Postural correction Sugijanto, 2019
 JOINT MOTIONS
Joint hypermobility →
Laxity JPM Test elastic end feel
Ligamenter-
Capsular
Rupture Instability →JPM Test
empty end feel
Hypermobility & Bony-
Deformity →
instability structure Measurement

Weakness
Tendomuscular Active instability →
Active stability test
Rupture
Sugijanto, 2019
 MOVEMENT IMPAIRMENT
Joint hypermobility →
Laxity JPM Test elastic end feel
Medial
collat lig Instability →JPM Test
Rupture
empty end feel

Medial ankle Bony- Fracture → Ottawa

movement pain structure knee & ankle rule
Faulty position →
Compression test
Medial talotibial Impingement
compartment Active correction
mobility → Half squat
Optimization of Movement: A Dynamical Systems
Approach to Movement Systems as Emergent Phenomena; in corrected test
Andrew A. et al, 2019 Sugijanto, 2019
 GIRD as a movement impairment
Anterior capsular tight
Anterior → Dorsal glide test
positional fault
Posterior capsular laxity
→ Active stability test
Shoulder pain & Protracted
internal rotation Corrected girdle position →
positional
deficit Active scapular stabilization test
vault

Muscle Corrected GH position →

Impingement Stability test
imbalance

Sugijanto, 2019
Postural Malalignments

Sugijanto, 2019
 McKenzie’s Three Syndromes
Postural Syndrome
• Umumnya usia <30 th
• Gejala sekitar pinggang dan tdk menjalar
• Nyeri akibat mechanical stress jaringan scr statik dlm waktu lama; Nyeri membaik bila tidak
ada stress
• Inflamasi tidak akut, shg nyeri tidak konstan tetapi terprovokasi oleh gerakan
• Nyeri positif provokasi akhir ROM,
• Dapat diobati dgn koreksi kesalahan postural alignment saat timbul nyeri, misal tiduran,
duduk, berdiri atau jalan. Perlu pemeriksaan ergonomic/ living space
Dysfunction Syndrome
• Bila postural syndrome tidak terobati
• Patologi pemendekan/kelemahan jar. ikat normal, akibat faulty alignment dan
musculoskeletal imbalances
• Terkait kerja dan/atau aktivitas rumah tangga
• Nyeri muncul pd provokasi akhir ROM, tidak selama gerak. Nyeri intermittent (spt postural
syndrome) ttp jar. lunak yg normal menjadi tight.
• Nyeri tdk menjalar ke bawah.
• Nyeri akan muncul bila jar yg memendek diulur.
Derangement syndrome
Sugijanto, 2019
REVIEW OF SYSTEM AND UNDERSTANDING
OF RED FLAG
• Able to review of system (ROS) on serious
pathology (Red Flag)

Sugijanto, 2019
 Client complain
Body structure Activities
(anatomic) impairment Non Pathology/ Limitation
Pathology
Body Function Participation
(biomechanic) impairment Movement-function Restriction
problems

Critical thinking

HOAC 2 Assessment E B(C)P

Clinical
reasoning
Diagnosis and Clinical
Clinical decision prognosis prediction rule
making

Strategic analysis planning

Procedural intervention

Evaluation and
result analysis Sugijanto, 2019
HYPOTHESIS ORIENTED ALGORITHM ON
ASSESSMENT

• In PT assessment always created hypothesis first then do

the specific evidence tests
• PTs must have good knowledge
• Body structure Impairment
• Body function Impairment
• Pathology
• Individual activity limitation
• Social participation restriction
• Internal and external contextual factors

Sugijanto, 2019
Physical Therapy Assessment The HOAC is a tool to
structure YOUR
clincal reasoning

Hypothesis-Oriented
Algorithm for Clinicians II
(HOAC II – PART 1)
Rothstein et al., 2002

Sugijanto, 2019
 DIAGNOSIS
• Diagnosis: the clinical decision related to pathology, impairment
and disability.
• Within ICF criteria as a complement to pathology (ICD) including of:
• Body function & structure impairment
• Activity limitation & participation restriction of disability
• Secondary to definitive Pathology (ICD).
• Relation to inhibited dan facilitated factors from personal and
environment,

Sugijanto, 2019
Diagnosis Medis Vs Diagnosis FT
❑ICD Vs ICF

The International Classification of Functioning, Disability and Health by the World Health Organization 2001(p. 18) Sugijanto, 2019
THE PLAN OF INTERVENTION
PROGRAME
• Based on diagnosis and prognosis as the result of
assessment.
• Based on analysis and synthesis related to
diagnosis
• Code of ethic and law
• Depend on facilities, finance etc

Sugijanto, 2019
 PT MANAGEMENT
1. HISTORY TAKING

2. INSPECTION
More cost-effective management of patient with
3. REGIONAL SCREENING musculoskeletal disorder in primary care after
& QUICK TEST direct triaging to physiotherapist for initial
assessment compare to initial general practitioner
4. REVIEW OF SYSTEM & assessment. (Lena Bornhoft, 2019)
RED FLAG

5. ASSESSMENT EVIDENCE BASE

CLINICAL PRACTICE
6. DIAGNOSIS AND
FUNCTIONAL PROGNOSIS

7. PLANING

8. INTERVENTION

9. EVALUATION

10. DOCUMENTATION Sugijanto, 2019

REGIONAL SCREENING &
QUICK TEST
Case 1: Hypothesis of 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, 2019
REGIONAL SCREENING &
QUICK TEST
Case 2: Hypothesis of 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, 2019
 Case 3: Hypothesis of
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, 2019
REGIONAL SCREENING &

Case 4: Hypothesis of
QUICK TEST

HIP JOINT ORIGIN

• Be sure that pain lies on inguinal area (groin)
to trochanter
• Gait analysis has seen duchene gait
• Contra Patric’s test
• Patric’s test

Sugijanto, 2019
REGIONAL SCREENING &
QUICK TEST
Case 6: Hypothesis of
PIRIFORMIS SYNDROME
 Pain felt on gluteal region referred to one
side of hamstring region and provocate 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, 2019
REGIONAL SCREENING &
QUICK TEST
Case 7: Hypothesis of Hip
Joint Problems
• Be sure that pain on groin to medial thigh
and getting worst as siting on the ground,
• Screening:
• Patric’s test
• Contra patric’s test:
• Passive test near full ROM

Sugijanto, 2019
REGIONAL SCREENING &
QUICK TEST
Case 8: Hypothesis of Lumbar 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, 2019
 OTHER CASES…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, 2019
 PROCEDURE TESTS AFTER REGIONAL
SCREENING

REVIEW OF SYSTEM & • Review of Systems

RED FLAG
• Serious pathology (Red Flag)

Sugijanto, 2019
Sugijanto, 2019
 REVIEW OF SYSTEM (Guide-APTA)

• To support the hypotheses of serious • Checklist general symptomps that

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

Sugijanto, 2019
REVIEW OF SYSTEM &

APENDICITIS Red flag examination

RED FLAG

• Abdominal rigidity:
• Rebound tenderness
• Mc Burney point +
• Psoas and Obturator sign +

Nyeri ekstensi
Sugijanto, 2019
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, 2019
 Red flag: Back cancer/infection
REVIEW OF SYSTEM &
RED FLAG

(osteomyelitis)
• Age >50 year, with history of
cancer
• High body weight lost
• Fail in conservative treatment
• Inconsistent of complain.
• Constant pain unchanged on
position/activities; getting worst in
the night.
 History of resent infection
 The used of intravenous
medication
 Concurrent immunosuppressive
disorder
 Deep constant pain, worst in
weight bearing
 Fever, malaise, and edema
 Spine rigidity

Sugijanto, 2019
 RED FLAG: CAUDA
REVIEW OF SYSTEM &
RED FLAG

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, 2019
PT MANAGEMENT ON LUMBO-
PELVIC–HIP 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, 2019
 Hipotesis: NYERI RADICULAR –
LUMBAR DISC BULGING/HNP

Degeneratif + injury → Intermittent lumbar

annulus fibrosus robek
Pergeseran nucleus → disc
menonjol ke
posterolateral/posterior
traction pss lordosis
penonjolan menekan lig.
longit posterior/ dural Nucleus pulposus
sleeve → inflamasi mobilization
Neuropathic pain
Mc. Kenzie extension
exc

Iritasi jar lunak radix → Lumbar corset utk

inflamasi → radicular pain actualitas tinggi

Proper body mechanic

Sugijanto, 2019
 Lumbar disc herniated

Functioning and disability Constextual factors

Anatomic impairment
Internal External
factors factors
Disc Nerves Muscle Capsels Facet

Annulus Motoric Chronic

rupture Autonom inflamation

Paretic Weak-
Nocisensoric Blockade
atrphy

Sympathic Spasm Inter fiber Functional

Nucleus
hyperactivity adhesion impairment
herniation
Vascular Activity
Capsular
Sensitive contracture limitation Participation
tissue restriction
Micro circular Capsular
Neuropathic constriction pattern
pain Sitting Work
Radicular pain Lifting
Stretched Muscle Sport
Low back pain pain imbalance Driving
Recreation
Postural
Pain deformity Sugijanto, 2019
 Klien dengan keluhan nyeri pinggang menjalar
hingga punggung kaki.
ya Buat hipotesis awal HNP

History taking: Nyeri duduk. Membungkuk, berkuranhg Pemeriksaan red flag:

Acute herniated, myelitis dll
(Ha: HNP) bila jalan tdk
ya
ya
Observasi: Lumbar deviation.
Konsul dokter spesialis
ya yang kompeten

Pemeriksaan Tes orientasi Lumbarl: fleksi trunki nyeri & terbatas, Algoritme
fungsi gerak:
tetapi ekstensi tidak nyeri, pemeriksaan lain
tdk
ya Algorithm of PT
Springing test positif, Spurling’s test positif, traction posisi
Tes khusus: disc
ekstensi nyeri menurun, valsava maneouvre positif Assessment for
ya
Radicular pain sec.
Sensoric test dermatome positif, Lasegue positif, Lower Limb Tension
Lumbar Disc
Tes khusus: radiks
HIPOTESIS
Test positif. Kenn muscle bisa positif LAIN herniation
ya tdk

MRI untuk melihat tingkat HNP dan Nyeri tekan dgn MRI
Pemeriksaan Penunjang
Dan Pengukuran
algometer/VAS; Kenn muscle dengan MMT

Diagnosis Nyeri Pinggang menjalar ke kaki akibatHNP lumbale

Identifikaasi Body structure Impairment: Discus and Nerve root

problem dlm ICF Body Function Impairment:
Disabilitas: Sugijanto, 2019
 PEMERIKSAAN FISIOTERAPI
Diutamakan pemilihan evidence untuk:
• Tes cepat utk menentukan hipotesis Discogenic LBP
• Pemeriksaan Discus:
• Springing test
• Spurling’s test
• Distraction test
• Extension test
• Pemeriksaan Integritas radix:
• Dermatome test
• Kenn muscle test
• Lower Limb Tension Test (LLTT)
• Pemeriksaan stability:
• Core stability test
Sugijanto, 2019
 Competency base approach

Lumbar disc
herniated

Annulus rupture, Iritasi jaringan Lumbar straight Lumbar disability

nucleus migrate dorsal discus posture

Sensitive tissue Nerve

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

1. Corset
Sugijanto, 2019
 PT Intervention
• Intermittent lumbar traction posisi lumbar lordosis
• Mobilisasi discus gerak ekstensi: Ekstensi lumbale dengan PACVP
• Extension program (Mc. Kenzie); Muscle strengthening untuk
stabilisasi
• Proper body mechanics:
• Posisi tidur, duduk, berdiri, kerja dan lifting technique

Sugijanto, 2019
ALAT UKUR/EVALUASI FISIOTERAPI

• Pengukuran nyeri
• Pengukuran fleksibilitas/ekstensibilitas otot
• Pengukuran mobilitas
• ROM,
• Pengukuran disabilitas
• Oswestry

Sugijanto, 2019
 Clinical pathway for Lumbar disc herniated
No Problem fisioterapi Assessment Intervensi Jumlah Kondisi yang
kedatangan diharapkan
Low back pain and Pemeriksaan Discus: SWD, oscillated traction Disc bulging: 3x Nyeri hilang, ROM
nerve irritation/ • Springing test pss extension, oscillated (3x/mgg) dan 4x dan fungsi pulih
adhesion • Spurling’s test POLD method, NAGs (2x/mgg)
• Distraction test extension mobilization, Nyeri kurang, ROM
• Extension test Cobra exercises, Disc herniated: 6x & fungsi pulih
Pemeriksaan stability: (2x/mgg)
• Core stability test Nyeri menurun,
ROM meningkat
Extruded- Fungsi membaik
fragmented:
Preoperative PT Idem
Dengan iritasi radix Pemeriksaan Integritas Neural mobilization
radix: Nerve gliding Idem
• Dermatome test
• Kenn muscle test
• Lower Limb Tension Test
(LLTT)
Diagnosis ICF terkait ICD
Sugijanto, 2019

SPONDYLO-ARTHROSIS LUMBALIS
Osteoarthrosis → iritasi tl
subchondral & osteofit →
iritasi jar sekitar
Variasi bentuk facet L5-S1 →
grk traumatis
Osteofit→ foramen
intervert sempit; iritasi jar
lunak sekitar → inflamasi
→pseudoradicular pain.
Hipotesis: NYERI PINGGANG –
Iritasi jar akibat untable
Iritasi jar lunak oleh osteofit
Iritasi radix oleh osteofit
Correlation of leg-length
discrepancy among meat cutter.
RCT (Satu Ranisto, et al, 2019)
Abdominal trunk muscle weakness
and its associated with chronic LBP
and risk fallingini older women
(Satosi Kato, et al, 2019)
Efficacy of manual therapy versus
conventional physical therapy in
chronic lbp due to lumbar
spondylosis (Art Sarma, et al, 2015)
Sugijanto, 2019
 Lumbar spondylo arthrosis
Functioning and disability
Constextual factors

Anatomic impairment
Internal factors External factors
Disc Facet Capsels Muscle Nerves

Erosi Chronic Nocisensoric

inflamation Weak-
Pipih &
rapuh atrophy
Corpus
Inter fiber Autonom
libera
adhesion system
Instability Sympathic
Blockade Spasm-
Vascular hyperactivity
tightness
Inflamasi
Capsel Functional Activity
Iritasi Micro circular Participation
contract impairment limitation
jar.sensitif constriction restriction

Stretched
Capsular pain Standing Work
Muscle
pattern
imbalance
Walking Sport

Pain Postural Recreation

deformity Sugijanto, 2019
 Klien dengan keluhan nyeri pinggang
menjalar ke pantat atau paha.
ya

History taking: Nyeri kaku pinggang banngun tidur, Pemeriksaan red flag:
(Ha: SAL) Pancoast tumor, Cervical
duduk lama. tdk instability/disc lesion, dll
ya ya
Observasi Flat back, cervical
Konsul dokter spesialis
deviation, yang kompeten

ya
Tes orientasi fleksi-ekstensi trunki: ekstensi nyeri & fleksi
Pemeriksaan
fungsi gerak: tidak nyeri/ tegang, 3D ekstensi nyeri
Algoritme
pemeriksaan lain
Algorithm of PT
tdk
ya Assessment for
Tes khusus:
Tes pasif: lumbale fleksi & rotasi tegang/nyeri & Capsular pattern
springy, Ekstensi: nyeri dorsal hard end feel
ya
hypomobility sec. lumbar
Joint Play Movement Test: Nyeri dan elastic end feel spondyloarthrosis
pada saat gapping. 3D flexion test nyeri regang
ya
Pemeriksaan Penunjang
Dan Pengukuran X Ray dan Nyeri tekan dgn algometer/VAS;
X Ray
Postur dgn plumb line
ya

Diagnosis Nyeri dan kaku pinggang disertai capsular pattern

hypomobility akibat spondyloarthrosis lumbalis
ya
Body structure Impairment: Facet dan capsules
Identifikaasi
problem dlm ICF Body Function Impairment: Nyeri leher dan hypomobility
dalam capsular pattern Sugijanto, 2019
 Clinical pathway of Lumbar Spondyloathritis
No Problem Assessment Intervensi Jumlah Kondisi yang
fisioterapi kedatangan diharapkan
Pain and Lumbar Tes cepat artrosis Facet joint surface: Flat Awal: 3x (3x/mgg) Nyeri
spine capsular • Extension pain back exercise, NAGs- Lanjut 6x (2x/mgg) berkurang/hilang
pattern Pemeriksaan Facet: SNAGs ROM meningkat
hypomobility sec. • PACVP Capsules: 3 D flexion
Lumbar • Spurling test mobilization
spondyloarthrosis • Traction in flexion Gapping manipulation
Pemeriksaan capsule sendi Muscles: Massage;
facet: Contract relax
• 3D flexion test stretching
• Gapping test Williams flexion
Pemeriksaan otot: exercises
• Contract relax stretch test
• Palpasi
Diagnosis Dalam ICF: terkait
ICD:
Kasus berat (dgn Idem + back corset Lanjutan 6x Deformitas
osteoporosis dan Intensive home (2x/mgg) dikoreksi/
deformitas) exercises dipertahannkan
Sugijanto, 2019
PEMERIKSAAN FISIOTERAPI YG
DIBUTUHKAN
• Tes cepat untuk menentukan artrosis
• Extension pain
• Pemeriksaan Facet:
• PACVP
• Spurling test
• Traction in flexion
• Pemeriksaan capsul sendi facet:
• 3D flexion test
• Gapping test
• Pemeriksaan otot: Subjective and clinical assessment criteria
suggestive for five clinical patterns
• Contract relax stretch test discernible in nonspecific neck pain patients. A
• Palpasi Delphi-survey of clinical experts; Dewitte V, 2016
Sugijanto, 2019
 Assessment
• ROM terbatas dgn/tanpa nyeri, firm end feel
• Tes: kompresi posisi ekstensi, dan traksi posisi fleksi
• 3 D flexion test
• Gapping test
• Muscle length test

Classification characteristics of a chronic low

back pain population using a combined
McKenzie and patho-anatomical assessment;
Flavell C A, et al, 2016
Sugijanto, 2019
 INTERVENSI FISIOTERAPI

MODALITAS DAN METODA

• Anatomic Impairment target:
• Disc degenerated: Extension exercise
• Facet joint surface: Flat back exercise
• Capsels: 3 D flexion mobilization
• Gapping manipulation
• Muscles: Massage; Contract relax stretching
• Functional Impairment target: What do patients value about spinal
• Postural correction manipulation and home exercise for
back-related leg pain? A qualitative
• Proper body mechanic study within a controlled clinical
• Disability target trial; Maiers M et al, 2016
Sugijanto, 2019
 Intervensi
• Static lumbar traction posisi lumbar flat
– Joint mobilization 3D flexion atau gapping technique
– Contract relax stretching (muscle energy technique)

Sugijanto, 2019
 Williams flexion exercise.
• Trunk flexion & Lumbar flatting
• Abdominal strengthening
• Iliospoas stretching
• Lumbar flat posture
Proper body mechanics:
Posisi tidur, duduk, berdiri, kerja dan lifting
technique

Sugijanto, 2019
ALAT UKUR/EVALUASI FISIOTERAPI

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

Sugijanto, 2019
 LOW BACK PAIN & BILATERAL
HAMSTRINGS SEC. SPONDYLOLISTHESIS
Pasca injury → rusakan
proc. articularis
Vertebral subluxatio
Micro/repetitive injury Iritasi cauda equina
→ rusak proc. artic Postural deficit &
active unstable
Spondylolysis → erosi
(lisis) proc. Articularis
→ subluxatio antar
corpus vertebrae
Iritasi cauda equina

Active unstable
Sugijanto, 2019
 Process of Manualtherapy
for Instability

ROM>norma
l-empty
Nyeri & JPM test: Bila
gerak Range >> negatif →
clicking Bila
elastic ganti
positif
hipotesis
lain
Active
Stability test:

Are stability and instability relevant concepts for back pain?

Reeves N. P. Et al, 2019
Sugijanto, 2019
 Spondylolisthesis lumbalis

Function & disability Constextual

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

Driving Recreation

Pain Postural
deformity Sugijanto, 2019
 Klien dengan nyeri pinggang menjalar hingga gluteal
atau kedua belah paha belakang. Hhipotesis awal Lysthesis
ya

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

Pemeriksaan Tes orientasi Lumbar: fleksi –ekstensi trunki Algoritme

fungsi gerak:
nyeri & bunyi clicking pemeriksaan lain

ya
tdk Algorithm of PT
Tes khusus Palpasi → step off/on; Gapping test early clicking, assessment for
lumbar lysthesis Stability test → thigh trust nyeri & clicking. Active
stability test +
ya
Gluteal/hamstrings
Tes khusus: sayaf
Slump test , LLTT HIPOTESIS
pain sec
Bladder funtion test LAIN
perifer
ya tdk
Spondylolysthesis
Pemeriksaan Penunjang
X Ray untuk mengukur besarnya lysthesis, tekan dgn MRI
Dan Pengukuran algometer/VAS; Kenn muscle dengan MMT

Diagnosis
Nyeri Pinggang menjalar ke hamstrings akibat sondylolysthesis

Identifikaasi
Body structure Impairment: Facet & Cauda equina
problem dlm ICF Body Function Impairment: Pain & Instability
Disabilitas: Sugijanto, 2019
 Clinical pathway for Spondylolysthesis
No Problem fisioterapi Assessment Intervensi Jumlah Kondisi yang
kedatangan diharapkan
Pain and Lumbar Tes cepat Spondylolisthesis Pain management, Awal: 3x Nyeri berkurang/
spine instability sec. • Palpasi: step off Hip and core stability (3x/mgg) hilang Stabilitas
Lumbar • Clicking saat fleksi-ekstensi exercises meningkat
spondylolisthesis Pemeriksaan lumbopelvic hip Flexion strengthening Lanjut 6x
Grade 1 complex: exercises (2x/mgg)
• Stability test backcorset
• Gapping test
• Active prone stability test
Pemeriksaan capsul sendi
facet:
• Gapping test
Pemeriksaan otot:
• Core stability test
Diagnosis ICF terkait ICD
Grade 2 Idem Idem + idem
+ TLSO Lanjut 6x
Grade 3 dan 4 Dibawah supervise dr (1x/mgg)
orthopaedic
Sugijanto, 2019
PT ASSESSMENT

• Orientation test for Spondylolisthesis

• Antalgic position
• Clicking when trunk flexion-extension
• Movement test of lumbopelvic hip complex:
• Stability test
• Gapping test
• Active stability test
• Muscle performance test:
• Core stability test
Sugijanto, 2019
• Palpation: identivication of ‘step off / step on’
• Segmental test :
• 2 or 3 dimentional segment test
• Passive stability test and active prone stability
test
• Lumbar segment gapping test: segmental/
regional intervertebral gapping

Sugijanto, 2019
INTERVENSI FISIOTERAPI
MODALITAS DAN METODA
• Anatomic Impairment target:
• Disc degenerated: Extension exercise
• Facet joint Lysis: Core stabilization exercise
• Functional Impairment target:
• Postural correction with stabilization
• Proper body mechanic
• Disability target:
• Bracing/Taping
MAINTAINING LUMBAR SPINE STABILITY: A STUDY OF THE SPECIFIC AND 1
COMBINED EFFECTS OF ABDOMINAL ACTIVATION AND LUMBOSACRAL 2
ORTHOSIS ON LUMBAR INTRINSIC STIFFNESS, Larivière C, et al, 2019 Sugijanto, 2019
PROCEDURE
• Core stabilization exercise
• Prone plank
• Supine plank
• Side plank
• With swiss ball

Sugijanto, 2019
Stabilization
– Passive stabilization dg lumbar corset
(hypermobility/unstable)
• Tapping
• Belt
• Corset
• Bracing
• Internal fixation

Sugijanto, 2019
 SACROILIAC JOINT DYSFUNCTION

Functioning, and disability Constextual factors

Anatomic impairment
Internal External
factors factors
Capsels & Joint Muscle Nerves
ligament surface

Chronic Tight - Nocisensoric

inflamation contracture

Inter fiber Weak- Sympathic Musculoskeletal

Blockade hyperactivity pain
adhesion atrophy
Functional
Capsel & lig Referred pain Activity
impairment Participation
contracture limitation restriction
Stretched
pain Muscle
Capsular imbalance
pattern Work
Walking
Pain Sport
Lifting
Recreation
Stair
climbing
Pelvic torsion antalgic gait
posture
Sugijanto, 2019
 Keluhan nyeri gluteus atau
gluteal fold.
ya Ha: Sacroiliac joint paint

History taking: Nyeri saat bersila, bersimpuh Pemeriksaan red flag:

atau naik sepeda motor Acute herniated, myelitis dll
tdk
ya ya

Observasi:
Pelvic inclination Asymmetry Konsul dokter spesialis
ya yang kompeten

Orientasi: Trunki fleksi-ekstensi SIPS-SIAS Algoritme Algoritme

Asymmetry positif pemeriksaan lain
ya
tdk pemeriksaan
Pemeriksaan
fungsi gerak:
Hip extension test: positif SIJ problem fisioterapi pada
Tes khusus: SIJ
ya
ya Sacroiliac joint pain
Sacral thust, Gainslan, compression dan gapping
test, dan thight thrust test positif
ya
Pemeriksaan Penunjang X Ray untuk mengetahui Identivikasi deficit gerak: Anterior/posterior
Dan Pengukuran
adanya sacroiliitis rotation; up/down slip; anterior/posterior shear
ya
Diagnosis Nyeri gluteus dan penguncian gerak (mis anterior
rotation) akibat sacroiliac arthritis/blockade

Identifikaasi Body structure Impairment: Sacroiliac joint

problem dlm ICF
Body Function Impairment: Blockade/hypomobility
Disabilitas: Sugijanto, 2019
PEMERIKSAAN FISIOTERAPI
Diutamakan pemilihan evidence untuk:
• Tes cepat untuk menentukan Sacroiliac
joint
• Sacral thrust
• Thigh thrust
• Gaenslen test
• Pemeriksaan capsul sendi facet:
• Gapping test
• Pemeriksaan lain:

Sugijanto, 2019
SACROILIAC JOINT TEST I

• Palpasi SIAS dan SIPS → pelvic torsion

• SLR test nyeri

• SLR + fiksasi pelvis tanpa nyeri

Sugijanto, 2019
SACROILIAC JOINT TEST II

• Distraction test (anterior SIJ gapping test)

• Tight trust, fixation on the sacrum.
• Sacral thrust test, compression on the sacrum.

Sugijanto, 2019
INTERVENSI FISIOTERAPI
MODALITAS DAN METODA
• Anatomic Impairment target:
• Sacroiliac Joint mobilization
• Stretching
• Functional Impairment target:
• Functional position in driving, sitting
etc
• Disability target

Sugijanto, 2019
 INTERVENSI
• Joint mobilization:
• Anterior (-posterior) pelvic mobilization
• Down (-up) slip mobilization
• Gapping mobilization
• Active mobilization

Sugijanto, 2019
 INTERVENSI

• Passive stabilisation →Pelvic belt

• Active stabilization → Strength Pelvic-hip
muscles & Pelvic floor.

Sugijanto, 2019
ALAT UKUR/EVALUASI FISIOTERAPI

• Pengukuran nyeri
• Pengukuran fleksibilitas/ekstensibilitas otot
• Pengukuran ROM,
• Pengukuran disabilitas

Sugijanto, 2019
 CLINICAL PATHWAY: NYERI LIPAT PANTAT
AKIBAT SACROILIAC JOINT SYNDROME
No Problem fisioterapi Assessment Intervensi Jumlah Kondisi yang
kedatangan diharapkan
Pelvic-glutel fold Inspeksi dinamis: Ringan: 3x (3x/mgg) Nyeri hilang
pain (SIJ rotation/ • Level SIPS dan SIAS Sacroiliac joint gapping Fungsi normal
up-slip blockage • Level malleolus posisi Sacroiliac joint (counter)
sec sacroiliac joint terlentang dan duduk selonjor mobilization
pain syndrome Tes cepat Sacroiliac joint Active (counter) joint
• Sacral thrust mobility exercise
• Thigh thrust Pada unstable joint:
• Gaenslen test Stability exercise
Pemeriksaan capsul sendi facet: Pelvic belt
• Gapping test
Pemeriksaan lain:

Moderate: idem + joint 6x (3x/mgg) idem

manipulation
Sugijanto, 2019
NYERI LATERAL PANGGUL HINGGA
INGUINAL

• Hipotesis awal:
• Osteoartitis Coxae
• Dilakukan pemeriksaan secara
algoritme dengan menggunakan
evidence base practice untuk
menegakkan atau menolak

Sugijanto, 2019
 Hip Osteo Arthritis

Functioning and disability Contextual

factor
Anatomic impairment

Internal Lexternal
Rawan Capsul Otot/ Vascular
factor factor
Sendi Ligamen Tendon
Micro
Erosi Sirculation
Laxity Kontraktur

Inflamasi tl Spasme Penumpukan

Subchondral Deformitas zat iritasi
Functional Activity Participation
impairment limitation restriction
Osteofit Immobilisasi
Nyeri
Iritasi Capsular pagi
Jaringan Pattern Work
Tightness/
Kontraktur
Nyeri Sport
Inflamasi Lemah
Nyeri bersila
Kronis Recreation
Regang
Antalgic gait
Nyeri Hypomobility
kompresi Stair climbing
Nyeri Inguinal Sugijanto, 2019
 Nyeri inguinal dan kaku sendi
Anamnesis utk panggul akibat osteo atritis,
menegakkan ICD
Ya Ha: Contraktur
akibat OA panggul
Nyeri dan kaku panggul bangun
tidur, krepitasi, internal rotasi
sangat terbatas Ganti hipotesis

Ya Tdk

Patologi serius/
Inspeksi Posisi sendi:
Red flag?
Tdk
Ya
Duchene gait; Posisi Tengkurap,
ALGORITMA
Tes Cepat: rotasi internal terbatas
PEMERIKSAAN
Ya FISIOTERAPI PADA
:Nyeri & terbatas (rotasi internal <
Test Gerak Pasif abduksi < Fleksi dengan Elastic -
Firm End Feel)? Tdk
Muskular?
CAPSULAR PATTERN
Ya Isometric test dan
HYPOMOBILITY SENDI
Joint Play Movement (Nyeri, Elastic - Firm palpasi PANGGUL AKIBAT OSTEO
Tes khusus End Feel), Traksi pembatasan ROM abduksi,
rotasi internal dan rotasi eksternal ARTRITIS
Penunjang: X-Ray

CAPSULAR PATTERN HYPOMOBILITY OF

Diagnosis THE HIP AKIBAT OSTEOARTRITIS

Problem: Contracture lutut aibat OA

Body structure impairment: Joint surface/capsules
Body function impaitmen: Capsular pattern Hypomobility
Disabilitas:
Sugijanto, 2019
 Competency base approach

OA HIP JOINT

Anatomic
Kinetic
impairment target
impairment
Joint surface Muscle
inflammation/erosi weakness/tightness
Mal Femoro Acetabular
Capsular pattern Impingement
alignment

1. Active stabilization
1. Traksi osilasi inferior
2. Contract relax stretching MWM dgn lateral
2. Pengurangan berat badan
otot contracture/tegang glide reposition
3. Olah raga dalam kolam Joint stabilization
3. Muscle strengthening &
Functional exc

1. Traksi osilasi MLPP Penggunaan AFO

2. Mobilisasi pada akhir Penggunaan
pembatasan ROM orthopaedic shoes
3. Roll glide
Sugijanto, 2019
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, 2019
 Nyeri dan disabilitas akibat Osteoartritis
sendi panggul
No Problem Assessment Diagnosis & Intervensi Kondisi yg Jumlah
fisioterapi Prognosis diharapkan kedatangan
Nyeri dan Pemeriksaan alignment: Hip joint SWD,hip joint Nyeri hilang, ROM Kellgren 1: 3x
kaku panggul • Deformitas/Alignment: Capsular oscillated mob. in dan fungsi pulih (3x/mgg) dan 4x
terutama valgus/ varus/ internal pattern MLPP, end range joint (2x/mgg)
bangun tidur rotation hypomobility mobilization, MWM Nyeri kurang, ROM
Pemeriksaan rawan sendi: akibat hip and active & fungsi pulih Kellgren 2: 6x
• Crepitasi osteoarthritis mobilization exc, (2x/mgg)
• Compression nyeri ICD: MWM Capsules-muscle-
• Traction test nyeri - ICF: Nerve lentur
Pemeriksaan Capsul: Fungsi membaik Kellgren 3-4: pre
• Passive test: capsular operatif 3x
pattern; elastic e f. (seminggu)
• Joint play movement nyeri Rehabilitatif 6x
dan elastic/firm end feel (2x/mgg)
• Stability test: ligament laxity
Dengan • Tes positional fault Dengan knee + medial glide varus idem idem
perubahan • Pengukuran alignment valgus mobilization
alignment Dengan knee + medial glide varus
varus mobilization
Sugijanto, 2019
PEMERIKSAAN FISIOTERAPI
Diutamakan pemilihan evidence untuk:
• Pemeriksaan gait:
• Gait analysis
• Pemeriksaan permukaan sendi:
• Passive test; compression-traction test
• Pemeriksaan Capsels:
• Passive, JPM test
• Pemeriksaan otot:
• Palpasi, Contract relax stretch test
• Pemeriksaan alignment panggul
• Pemeriksaan disabilitas
Sugijanto, 2019
PROSEDUR PEMERIKSAAN
• Gait analysis:
• Duchene gait?
• Passive test:
• ROM, pain dan End feel
• Tes fungsi
– Nyeri dan terbatas dengan crepitasi pada gerak pasif hip joint
– internal rotasi<abduksi<fleksi firm end feel → Capsular pattern
• Tes khusus
– JPM test
– Posisi fleksi, ekstensi, abduksi, rotasi internal dan rotasi eksternal dari
Hip joint, elastic-firm end feel.
– Muscle length test:
– Hip adductor, Iliospoas, Il;iotibial band, Hamstrings, Rectus femoris dan
m. piriformis.

Sugijanto, 2019
PROSEDUR PEMERIKSAAN

• Pemeriksaan penunjang
– X ray: penyempitan sela sendi; penebalan tulang
subchondrale; osteophyte.
• Diagnosis
– Nyeri inginal dan keterbatasan gerak sendi panggul dalam
Capsular pattern akibat Hip Joint Osteoarthrosis

Sugijanto, 2019
INTERVENSI FISIOTERAPI
MODALITAS DAN METODA
• Anatomic Impairment target:
• Joint surface: direct traction
• Capsule : Joint mobilization
• Muscle : contract relax stretching
• Functional Impairment target:
• Gait training
• Disability target

Sugijanto, 2019
PROSEDUR INTERVENSI
• Joint mobilization: taction →
• Mulai direct traction dalam MLPP
• Indirect traction posisi netral dan ekstensi
• Traction at end range position
• Joint mobilization: Roll glide →
• Anterior capsule
• Inferior capsule
• Posterior capsule

Sugijanto, 2019
 MULLIGAN CONCEPT
MWM utk:
• Hip Flexion dgn medial glides atau lateral
traction
• Hip extension dgn lateral traction
• Hip Abduction dgn inferior glides
• Hip Int rotation dgn lateral traction
• Hip Ext rotation dgn lateral traction

Sugijanto, 2019
PROSEDUR INTERVENSI

• Stabilization:
• Stabilization exercise
• Non weight bearing – mobilization/-
stabilization exc
• Postural correction:

Sugijanto, 2019
ALAT UKUR/EVALUASI FISIOTERAPI YG
DIBUTUHKAN
• Pengukuran nyeri
• Pengukuran fleksibilitas/ekstensibilitas dan
panjang otot
• Pengukuran mobilitas sendi /ROM,
• Analisis berjalan
• Pengukuran disabilitas

Sugijanto, 2019
Sugijanto, 2019