Terapi Manipulasi

Joseph Mikhael Husin

Siti Nurul Badriyah

Narasumber:
Dr. dr. Tirza Z. Tamin, Sp.K.F.R., M.S.(K)
 Table of Contents
1. Joint Mobilization
2. Barriers
3. Types of Joint Motion
4. Procedures
5. Peripheral Joint Mobilization Techniques
 01
Joint Mobilization
 Joint Mobilization
Manipulation, refers to manual therapy techniques: used to modulate pain and treat joint
impairments that limit range of motion (ROM) by specifically addressing the altered
mechanics of the joint
Dysfunctions of joints and vertebral motion segments fall into two categories:
hypermobility and restricted mobility; manipulative therapy is concerned only with
restricted mobility.

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
Wi s e and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
 02
The Barrier
 The Barrier
•The anatomical barrier, created by the bony structures
•The physiological barrier, which is clinically significant and is found at that point in
the examination where the first, minute degree of resistance is felt; the barrier yields
slightly with a sense of ‘springing.’
•The pathological barrier, which restricts motion and is felt as a hard, abrupt stop,
lacking the sense of spring.

Lewi t K, Ma nipulative Therapy. Mus culoskeletal Medicine. Churchill Livi ngstone, Elvesier, 2007
 Principle of Joint Mobilization/Manipulation
Mobilization/ Passive, skilled manual therapy techniques applied, to joints and related soft tissues at varying speeds and amplitudes
Manipulation using physiological or accessory motions for therapeutic purposes

Thrust manipulation Thrust refers to high-velocity, short-amplitude techniques

Self- Mobilization Self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule

Mobilization with Concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement
Movement (MWM) to end-range applied by the patient

Physiological Movement Movements the patient can do voluntarily (e.g., the classic or traditional movements, such as flexion, abduction, and
rotation)

Accessory Movement Movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively
performed by the patient
Component motion
Joint play

Resting Position The position of the joint where the greatest mobility is possible

Manipulation under Procedure used to restore full ROM by breaking adhesions around a joint while the patient is anesthetized.
anesthesia

Muscle Energy Active contraction of deep muscles that attach near the joint and whose line of pull can cause the desired accessory
motion
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
 Arthrokinematics

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
Wi s e and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
 03
Types of Joint Motion
 Type of Joint Motion (Roll, Slide, Spin)
Roll Slide

Spin

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
Grade of Joint Mobilization

Wi s e and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
Effect of Joint Mobilization

Wi s e and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
 Compression and Traction
Compression Traction
• Compression is the decrease in the joint Traction and distraction are not
space between bony partners synonymous. Traction is a longitudinal pull
• Compression normally occurs in the
extremity and spinal joints when weight
bearing.

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
Wi s e and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
 When to use?
Indication Contraindication

Lewi t K, Ma nipulative Therapy. Mus culoskeletal Medicine. Churchill Livi ngstone, Elvesier, 2007
Painful Joint, Reflex Muscle Guarding and Muscle Spasm

• May be treated by gentle mobilization/joint play

• Neurophysiological effect
o Small-amplitude distraction à stimulate the
mechanoreceptors that may inhibit the transmission of
nociceptive stimuli at the spinal cord or brain stem levels
• Mechanical effect
o Small-amplitude distraction or gliding movements of the
joint are used to cause synovial fluid motion, which is the
vehicle for bringing nutrients to the avascular portions of
the articular cartilage
o Nutrients: prevent painful and degenerative effects
 04
Procedures
Procedure of Manipulation Therapy

1. Examination and Evaluation

o Quality of pain
o Capsular Restriction
o Subluxation/Dislocation
2. Grades or Dosages of Movement
3. Positioning and Stabilization
4. Direction or Target of Treatment Force
5. Initial and progression of treatment
6. Patient Response
Grades or Dosages of Movement for Non-Thrust
Techniques

• Oscillation Technique: using ostheokinematic or arthrokinematic

• Grade I. Small-amplitude rhythmic oscillations are performed at the
beginning of the range. Usually rapid oscillations, like manual vibrations.
• Grade II. Large-amplitude rhythmic oscillations are performed within the
range, not reaching the limit. Usually performed at 2 or 3 per second for 1 to
2 minutes.
• Grade III. Large-amplitude rhythmic oscillations are performed up to the limit
of the available motion and are stressed into the tissue resistance. Usually
performed at 2 or 3 per second for 1 to 2 minutes.
• Grade IV. Small-amplitude rhythmic oscillations are performed at the limit of
the available motion and stressed into the tissue resistance. Usually rapid
oscillations, like manual vibrations.

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
Lewi t K, Ma nipulative Therapy. Mus culoskeletal Medicine. Churchill Livi ngstone, Elvesier, 2007
 Dosage of Movement
• Non-Thrust Sustained Joint-Play Techniques
This grading system describes only joint-play techniques that separate
(distract) or glide/translate (slide) the joint surfaces.
• SUSTAINED (several seconds) Joint-Play Technique
• Grading only for slide and distract technique
• Grade I (loosen); to relieve pain, apply intermittent small ampiltudo for 7-
10 seconds with few seconds of rest in between for several cycles.
• Grade II (tighten); enough distraction/glide to tighten the tissue. Initial
treatment to determine sensitivity of the joint.
• Grade III (stretch); to stretch joint structure, 6-second stretch followed by
partial release (grade I or II), then repeat with slow, intermittent stretches
at 3- to 4-second intervals.

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
 Thrust Manipulation/
High Velocity Thrust (HVT)
Application Indication
• Prior to application, the joint is moved HVT is used to snap adhesions or
to the limit of the motion so that all is applied to a dislocated structure to
slack is taken out of the tissue, then a reposition the joint surfaces
quick thrust is applied to the
restricting tissue
• HVT is applied with one repetition
only

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
HVLA (High Velocity Low Amplitudo)

• Rotation mobilization or manipulation

with the patient side-lying in a neutral
position, with the leg underneath
• The practitioner stabilizes the patient’s
pelvis at the greater trochanter while
using his fingers to fix the spinous
process of the lower vertebra of the
segment being treated

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
Direction and Target of Treatment Force

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017. P.119-56
 05
Peripheral Joint Motion
Techniques
Shoulder Girdle Complex
Glenohumeral Joint
 Glenohumeral Distraction Glenohumeral Caudal Glide
Glenohumeral Caudal Glide in Resting Position
Progression

Indication: initial treatment, pain control, and

Indication: increase abduction, humeral head reposition
general mobility
Indication: increase abduction

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017.
 Glenohumeral Elevation Progression Glenohumeral Posterior Glide, Glenohumeral Posterior Glide
Resting Position Progression

Indication: increase elevation beyond 90°

abduction Indication: increase flexion and internal
rotation Indication: increase posterior gliding when
flexion approaches 90°; increase horizontal
adduction

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6th ed. Philadelphia: F. A. Davis Company;
2017.
 Glenohumeral Anterior Glide, Resting Glenohumeral External Rotation
Position Progression

DO NOT LIFT THE ARM AT

THE ELBOW!!

Indication: increase extension, external rotation Indication: increase external rotation

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6th ed. Philadelphia: F. A. Davis Company; 2017. p.119-56.
Wise and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
Elbow Complex
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017.
 Wrist Complex

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2012. p.119-56.
 Carpal Mobilization

MCP Distraction

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Davis Company; 2017.
 Radiocarpal Distraction Radiocarpal Volar Glide

Indication: Testing, initial treatment, pain control, and general

To increase extension
mobility

Radiocarpal Dorsal Glide Ulnar Glide

to increase flexion to increase radial deviation

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6th ed. Philadelphia: F. A. Davis Company; 2017.
 Hip Joint

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
 Hip Posterior Glide Hip Anterior Glide
Hip Distraction of The Weight-Bearing Surface, Caudal Glide

Indication: Testing, initial treatment, pain control, and general mobility Indication: increase hip flexion, internal rotation Indication: increase hip extension, external rotation

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
Knee Joint
 Tibiofemoral Articulation

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
 Tibiofemoral distraction Tibiofemoral Anterior Glide

Tibiofemoral Posterior Glide

Indication: Testing, initial treatment, pain control,

Indication: Increase Flexion Indication: Increase Extension
and general mobility

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6th ed. Philadelphia: F. A. Davis Company; 2017. p.119-56.
Wise and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Davis Company
 Patellofemoral Joint

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
Ankle and Foot
 Talocrural Distraction
Distal Tibiofibular Posterior Glide

Indication: Testing, initial treatment, pain

control, and general mobility

Talocrural Posterior Glide

Indication: Increase dorsiflexion

Indication: increase mortise mobility when it is restricting ankle

dorsiflexion

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
 Talocrural Anterior Glide Subtalar Lateral Glide

Indication: Increase plantarflexion

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
Wise and Gulick. Mobilization Notes A Rehabilitation Specialist’s Pocket Guide. 2009. Dav is Company
Subtalar Joint (Talocalcaneal),
Posterior Compartment
Subtalar Distraction

Subtalar Medial/Lateral Glide

Indication: Testing, initial treatment, pain control, and general mobility for Indication: Medial glide to increase eversion; lateral glide to
inversion/eversion increase inversion

Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6 th ed. Philadelphia: F. A. Dav is Company ; 2017. p.119-56.
 General Recommendation for
Performance of Joint Mobilization
• Selecting benefit
• Begin in area & direction of greatest
restriction
• Monitor symptoms over 24-hour period
immediately following intervention &
base next intervention on tolerance
• If substantial improvement in mobility is
noted in response to an intervention,
do not be greedy. Wait until the next
visit to do more.
• Add a second technique or intervention
only after effects of the first technique
have been determined
• Use as little force as possible to produce
the desired effect
• Use the relationship between pain &
resistance to determine aggressiveness
• Allow individuals to take responsibility for
their own care; initiate active interventions
ASAP
• The best way to assess the effect of each
technique is to continually re-examine
throughout each session by following the
process of examination/ intervention/re-
examination
• Do not enter into examination with bias;
let the patient’s presentation guide your
evaluation & plan of care
• Perform each technique at least twice
before abandoning it
• Do not feel the need to complete
the entire exam & initiate
intervention on first day; you
need only enough information to
educate & advise. The pt’s
response to intervention on the
first day may be confounded by
effects from examination
• Symptomatic response to
movement as a guide for
intervention, & as a dependent
variable upon which to confirm
efficacy of chosen interventions
Terima Kasih