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FISIOTERAPI PADA GANGGUAN
MUSCULOSKELETAL :
“PENDEKATAN FISIOPRAKSI PADA
GANGGUAN CERVICAL SPINE”
Safrin Arifin
Anatomi Fungsional
 Struktur anatomis paling kompleks dgn ciri beda:
C0-C1; C1-C2; C2-3-4-5-6-7 dan C7-T1
 Analisis fungsi quadrant, regional dan segmental,
terkait dng TMJ, Shoulder complex, Upper Thoracal
dan Upper Costae
 Mobilitas cervical sangat besar dan spesifik
 Diperlukan stabilitas yg besar dan spesifik pula
 Pemahaman struktur jar spesifik sbb:
Cervical spine
• Spine Fleksibel thd force, stretch, copression,
shear, tilt maupun rotation.
• Cervical spine mrpk bag tubuh yg paling
kompleks,  pemeriksaan hrs akurat
• Gang gerak dan fungsi cervical berkaitan dgn
temporo mandibular joint, shoulder complex,
upper thoracal joint dan upper costae.
• Patologi cervical spine meliputi trauma,
inflammation process, degeneration, neplasma dll
Zygapophysial joint
 Merespon terhadap berbagai sudut
beban (Clark CR, Ducker TB, Dvorak J, 1998)
 Bersama dgn discus menahan daya
kompresi subaxial pada cervical
spine (Kumaresan S, Yoganandan N, Pintar FA.1998)

Menahan beban kompresi dan
disebarkan secara merata kepada
kedua sendi zygapophysial
 Melengkapi peran discus
 Dilengkapi oleh struktur yang peka
nyeri (Tobias D, Ziv I, Maroudas A,1992)
Facet joint
POE
1/3 of superior nuchal line
Ligamentum nuchae
Spinous process of C7-T12
Otot-otot vertebrae
Cont…
Cont…
Otot – otot vertebrae
Uncovertebral (Luschka’s) Joint
Ligaments within cervical spine
 Ligamentum
Nuchae
 Interspinous
Ligament
 Ligamentum Flava
 Posterior Atlantooccipital membrane
 Intertransverse
Ligament
Ligamen
 Upper Cervical Spine
 Occipitoatlantal Joint (OA)  Yes Joint (The Atlas)
 Alar Ligament (fig. 1a)  membantu kontrol grkn
extensi (stretch) & rotasi (opposite side stretch)
 Cruciform Lig. (fig. 1a)
 Atlantoaxial Joint (AA) - No Joint (The Axis)
 Cruciform Lig. (fig. 1a)
Arterial Circulation
 VA masuk ke C6 , kadang C5
 Selecki¹ Observed setelah
Rotasi 30°  Ketegangan VA
sisi contralateral thdp
transverse foramina. 45° sisi
ipsilateral.
 Fx : supply darah ke brain stem
 Ciri : Pusing, g3 penglihatan &
Mual
Articulations within cervical
spine
 Body-to-body
articulation
 Fibrocartilogenous
Intervertebral Disk
 Annulos fibrosis
 Nucleus puplosis
Upper thoracic Spine
 Harus ikut dalam pembahasan cervical spine 
grkn cervical bawah selalu diikuti oleh Thoracic
spine.
 Splenius, longissimus, semispinalis cervicis &
semispinalis capitis muscle  T6
 Thoracic vertebra have no Uncovertebral joint, bifid
spinous processes, or intertransverse foramina.
Ribs (Costae)
 Kedua costae I  one facet
 Costae I Paling convex & pendek
 Costovertebral (transversal plane) Pump-handle
effect (superior-inferior), Bucket-handle mov
(medial-lateral)
Thoracic Inlet
Thoracic Inlet
 Superior opening of the rib
cage, posterior ( Th1),
anterior (manubrium
sterni), lateral Costa 1
 Inferior portion of the rib
cage & diaphragma
 Structures sternohyoid m,
sternothyroid m, thymus,
trachea, esophagus &
thoracic ducts, longus colli
& lig longitudinal anterior.
Lateral, upper lung &
neurovascular structure
Term Thoracic inlet ( outlet) syndrome  compression of neurovascular
structures : arteries veins &/or the upper or lower trunk of the brachial
plexus¹
Occipitoatlantal &
Atlantoaxial Active range of
Motion
Vertebral
Unit
Flexi
Extensi
Side flexi
Rotasi
Co-C1
0-15°
0 – 20°
5°-0-5°
8°-0-8°
C1-C2
0-10°
0-10°
3°-0-3°
30°-0-30°
N. Bogduk, S. Mercer / Clinical Biomechanics 15 (2000) hal. 633 - 648
Motion of Middle & Lower
Cervical
Tes kompresi untuk menilai kelenturan
diskus (N. Yoganandan et al. / Clinical
Biomechanics 16 (2001) 1 - 27 )
Tes Penguluran Ligamen
3-D Geometry: mengukur
beban C4-C5-C6
Hasil penelitian :
Daerah ventral dari disk
mengalami gaya aksial yang
lebih tinggi dalam semua
model beban
Wilayah dorsal mengalami
gaya geser yang lebih
tinggi
Tekanan intradiscal paling
tinggi pada saat beban
kompresi diberikan dalam
posisi flexi
Hattori S, Oda H, Kawai S, 1981
Pospiech J, Stolke D, Wilke H, Claes L. 1999.
Hukum pergerakan
vertebrae
 Sebuah gerak vertebra selalu digambarkan oleh
arah gerakan corpus vertebral dan bukan gerakan
processus spinosus (PS). Akibatnya, gerakan pasif
dari PS Th 11 ke kiri, dapat menyebabkan rotasi
vertebral ke kanan.
Biomechanics of cervical
Flexion
Rotation
Lateral Flexion
Data Biomekanik Kapsul
Sendi
Yoganandan N, Kumaresan S, Pintar FA. Geometrical and mechanical
properties of human cervical spine ligaments. J Biomech Eng 2000;
Upper crossed syndrome (Janda, 1994)
Forward head posture. (Watson 1994)
Cervical Loads
 Kapandji: ↑ inci forward head  ↑ 10
pounds
Area Dermatomes
Myotomes (Grieve, 1991)
ROOT
JOINT ACTION
REFLEX
C1
Fleksi Upper cervical
C2
Extensi Upper cervical
C3
Lateral fleksi Cervical
C4
Shoulder girdle elevation
C5
Shoulder abduction
Biceps
C6
Fleksi Elbow
Biceps
C7
Extensi Elbow
Triceps & Brachioradialis
C8
Extensi ibu jari, fleksi jari2
QUICK TEST:Cervical flexion –
extension dan 3 dimension
 Flexion
 Compression pada anterior pilar (Disc & corpus)dan
traction posterior pilar.
 Extension
 Compression pada posterior pilar (facets) dan
traction anterior pilar.
 3 dimension provocation
 Compression facets dan uncovertebral serta
penyempitan foramen intervertebral sisi
homolateral. Regangan sisi sebaliknya.
QUICK TEST Shoulder
abduction – elevation
 Scapulo humeral rhythm:
 Painful arc (Patologi supra humeral)
 Reverse humero scapular rhythm (contracture
sendi glenohumeral)
 Pain pattern
 ROM dan End feel
 Bunyi
Active movement
Fungsional active atlanto-occipital joint : A. Extensi ; B, Flexi
Fungsional active testing Atlantoaxial joint
Jackson’s test (nerve root
compression test
 PROSEDUR: Pasien duduk, lateral flexi leher, tekan leher
kebawah, lakukan kedua sisi

DASAR PEMIKIRAN:
 The pertimbangan biomekanik berikut berlangsung
penyempitan foramen intervertebralis di sisi unilateral.
 Kompresi sendi facet pada sisi unilateral
 Kompresi diskus intervertebralis sisi unilateral.
 Nyeri Localised mengindikasikan gangguan foraminal
tanpa tekanan akar saraf atau patologi sendi apophyseal
 Nyeri radikuler dapat menunjukkan tekanan pada akar
saraf
Sharp-Purser Test
A positive Sharp-Purser test  AA instability in
patients with rheumatoid arthritis (RA) at a specificity
of 96% and predictive value of 85%.69
Positive Sharp-Purser test results indicate AA
instability, which is a contraindication to cervical
manipulation techniques that place strain through the
craniovertebral region. Atlantoaxial instability is
common in RA from weakening of the transverse
portion of the cruciate ligament that stabilizes the
dens to the anterior arch of the atlas.
Spurling’s Test
 The procedure for Spurling’s test B combines cervical extension and
rotation with ipsilateral lateral flexion.
 Application of overpressure for Spurling’s test B is the same as in
Spurling’s test A.
 Wainner et al, reported 255 patients who were referred for
electrodiagnosis of the upper extremity nerve disorders.
 The Spurling’s test had a sensitivity of 30% and a specificity of 93%,
which means that it is not a very useful screening tool but that it is
clinically useful to help confirm cervical radiculopathy.
Shoulder abd-elevation test
 Tujuan : + jika posisi tersebut dapat
mengurangi nyeri yg menjalar sepanjang
lengan.
Midle & upper cervical foraminal closure test
Cervical compression &
distraction test
Pump & bucket – handle
motion
Tree-minute elevated arm
exercise test for thoracic inlet
syndrom
Vertebral artery test
Bilateral PACVP
Unilateral PACVP
Pemeriksaan Tambahan :
X-Ray
Pemeriksaan Tambahan :
MRI
Neutral position
Elastic barrier
of resistance (crack)
Active movement
Passive movement
Limit of anatomical
Integrity (sprain)
Paraphysiological
space
Mobilization (physiotherapy)
Adjustment
Model of beneficial effect of
Manipulative therapy
Z joint hypomobility
Hypomobility Result in
degenarive changes & adhesion
Neurophysiologic
effects
Gapping/movement stimulated
mechanoreceptors in either Z joint
capsule & or small muscles of the spine
Afferent to spinal cord & higher centers
decrease pain & influence somatic &/or
viceral efferents improving function
Anatomic /
biomechanical effects
Gapping breaks up adhesions &
re-establishes joint motion
Increased joint motion to normal
ranges slows (reverses)
degenerative changes
Theoretical mechanism of cavitation
production
Theoretical mechanism of cavitation
production
 Fibrous Adhesion
Break up of adhesion
Pain-Relief Mobilization
 P’s Has severe pain/symptoms (spasm,
paraesthesia)
 Grade I – II slack zone - intermittent traction
movement  help normalize joint fluid viscosities
& improve joint mov by shortened periarticular
tissues.
 Intermittent Traction Mobilization – vibration &
oscillation.
Relaxation Mobilization
 Apply relaxation joint mobilizations as intermittent
Grade I and II movements in the actual resting position
to relax muscles, decrease pain and facilitate ease of
movement.
 Relaxation mobilizations are also useful as
preparation for more intensive treatments (for
example, a Grade III stretch mobilization) which can
be more effective when the patient's muscles are
fully relaxed.
Manipulation
 high velocity, small amplitude, low force, linear
movement in the actual resting position, applied with a
quick impulse ("thrust," or "quick mobilization") to a
joint showing suitable end-feel, to effect joint
separation and restore translatoric glide.
Avoiding high-risk manual
treatment
 Rotation mobilization
General spinal rotation mobilization is one of the most potentially
dangerous techniques for the patient
 Joint compression
While some practitioners believe that passive
manual joint compression can stimulate
cartilage nutrition and regeneration and
apply it for that purpose, particularly in
certain extremity joints, we do not teach it.
Red Flag
(Cartwright and Godlee 2003, Hawkes 2002
 Vascular tumour/aneurysm.
 Headache progresif
 Headaches > 50 tahun.
 Perubahan tingkat kesadaran.
 Head/cervical trauma baru.
 Neurological deficits-focal.
 Meningitis.
 Tender temporal arteries.
 Cough headache.
 Upper cervical instability.
Red Flag
 Subarachnoid hemorrhage –ischemic stroke.
(Hiroki O, Hidefumi T, Suzuki S, Islam S 2003; Hong YH, Lee YS, Park S 2003)
 VBI.(Grad A, Baloh RW 1989;Szirmai A 2001;Silbert PT, Bahram M, Schievink WI 1995)
 Mild traumatic brain injury–subdural
hematoma. (Sobri M, Lamont AC, Alias NA, Win MN 2003; Borg J, Holm L,
Cassidy JD, et al 2004)
Cervical segment C2 to C5 :
Translatoric Joint play
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Cervicothoracic segment :
flexion with sidebending &
rotation (stretch mobilization)
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Thumb Technique
Finger Technique
Skin Rolling Technique
Exercise
 Cervical active
stabilization
 Cervical passive
stabilization
TERIMA KASIH