materi kuliah dasar dasar terapi
1/1/2002
Langkah-langkah Terapi
PROSES TERAPI
dr Rachmah Laksmi Ambardini
FIK Universitas Negeri Yogyakarta
Anamnesis (history): informasi terkait keluhan
pasien
Identitas
Keluhan utama
Riwayat Penyakit Sekarang (RPS)
Riwayat Penyakit Dahulu
Email: rachmah_la@uny.ac.id
Pemeriksaan Fisik
Inspeksi (observasi)
Palpasi cek, misal tanda radang, krepitasi,
ROM (range of motion) rentang gerak sendi
berkurang atau tidak?
Perkusi
Auskultasi
Diagnosis
Diagnosis utama/ Diagnosis pasti
Diagnosis banding (diagnosis alternatif)
Pemeriksaan Penunjang/Tambahan
Laboratorium periksa darah, urine
Radiologi Foto Rontgen, CT Scan, MRI
(magnetic Resonance Imaging), USG
Terapi
Non farmakologi
Farmakologi: NSAID (obat anti rasa sakit, antiradang, dll).
Non Farmakologi:
- RICE pd cedera akut
- Berbagai modalitas terapi
- Terapi Latihan (Physical Therapy): Loosening,
Stretching, Strengthening, latihan untuk kembali
ke aktivitas semula
1
1/1/2002
Follow up
Mengevaluasi hasil terapi
2
1/1/2002
Tujuan
Anamnesis
Keluhan Nyeri Bahu
dr Rachmah Laksmi Ambardini
FIK Universitas Negeri Yogyakarta
Email: rachmah_la@uny.ac.id
Memahami anatomi sendi bahu
Memahami bagaimana mengevaluasi keluhan nyeri
bahu
Mendiskusikan tes provokasi yg digunakan untuk
evaluasi nyeri bahu.
Menguasai temuan anamnesis dan pemeriksaan fisik
yg dapat membantu diagnosis masalah-masalah
pada bahu.
Mendiskusikan kelainan yg umum terjadi pada bahu
dan penanganannya.
Shoulder Anatomy
Reference 1
Anatomi Bahu
Bahu mrp salah satu sendi yg paling kommpleks.
Terdiri atas:
1.Struktur Tulang:
Humerus
Glenoid
Acromion
Clavicle
2. Struktur Jaringan Lunak:
Otot-otot Rotator cuff dan elemen penyokongnya.
3. 4 Sendi :
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
Scapulothoracic joint/pseudoarticulation
Sendi Glenohumeral (GH)
Bagian sendi yg paling sering mengalami dislokasi.
Prinsip-Prinsip Dasar:
– GH joint a ball and socket joint
– Fossa glenoid datar dan jauh lebih kecil daripada caput
humeri yg melekat padanya (persentuhan hanya 25-30%).
– Cartilaginous labrum menyediakan fungsi socket, tetapi
bukan stabilitas.
– Stabilitas didapat dari struktur yg menstabilkan sendi
bahu.
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1/1/2002
Static Stabilizers
• Terdiri atas:
• Terdiri atas:
•
•
•
•
Dynamic Stabilizers
Struktur Tulang
Labrum
GH ligaments (superior, middle, inferior)
Kapsul sendi
• Membantu menjaga harmoni
• Tetap berfungsi walaupun ada gangguan saraf
maupun otot intrinsik.
– Rotator cuff
– Scapular stabilizers (teres major, rhomboids, serratus
anterior,trapezius and levator scapula)
• Tidak bisa berfungsi jika terjadi cedera
neuromuskular dan kerusakan otot intrinsik.
• Malfungsi menyebabkan kelonggaran sendi GH dan
nyeri bahu.
The Rotator Cuff
•
•
•
Anamnesis
Main function- depress the humeral head
against the glenoid & stabilize
• Tanyakan umur pasien, tangan yg dominan,
olahraga, pekerjaan.
Composed of 4 muscles:
1.
Supraspinatus- abduction helper to
deltoid, pulls humeral head towards
glenoid
2.
Infraspinatus- external rotation helper,
pulls humeral head inferiorly
3.
Teres minor-external rotation helper, pulls
humeral head inferiorly
4.
Subscapularis-internal rotation helper to
pectoralis and latismus dorsi
When damaged, humeral had can move
upward within the joint 2/2 to unopposed
deltoid action
• Tentukan keluhan utama pasien (mis. Nyeri,
kelemahan, instabilitas, ROM yg terbatas).
• Bagaimana & kapan masalah dimulai?
• Apakah gejala yg dirasakan terkait dg
cedera/kejadian tertentu sebelum gejala
timbul?
• Apakah aktivitas/gerakan lengan tertentu
menyebabkan gejala timbul?
Anamnesis
• Gejala yg terkait:
– Instability/longgar (mis. Instabilitas sendi GH di segala arah)
– Menurunnya kekuatan otot (mis. Impingment, gangguan pd rotator
cuff).
– Bengkak (mis. Trauma akut, robekan pd rotator cuff)
– Mati rasa/kesemutan (misal gangg pd tl cervical)
– Hilangnya gerakan/kekakuan (mis. Adhesive capsulitis, dislokasi atau
instabilitas sendi GH)
• Terapi apa yg sebelumnya sudah dilakukan, mis: es, panas, obat-obatan.
Pemeriksaan Fisik
• Dilakukan secara sistematis
• Jangan mengabaikan bahu yg sehat (krn hal ini akan
memberi informasi sisi normal pasien).
• Perhatikan kedua bahu dan lakukan:
–
–
–
–
–
Inspeksi
Palpasi
Periksa ROM: pasif dan aktif
Tes kekuatan
Tes khusus sesuai indikasi
• Tindakan Intervensi sebelumnya, mis terapi fisik, suntikan, pembedahan.
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Inspeksi
Inspeksi
• Cari adanya:
–
–
–
–
–
• Look for:
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
–
–
–
–
–
–
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
Dsitensi vena
Inspeksi
Inspeksi
• Look for:
–
–
–
–
–
–
Ant. Shoulder Dislocation
• Look for:
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
Distensi vena
Ant. Shoulder Dislocation
AC joint separation
–
–
–
–
–
–
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
Distensi vena
Ant. Shoulder Dislocation
AC joint separation
Supraspinatus and
infraspinatus atrophy
Palpasi
Palpasi
•
•
•
•
•
•
Sendi Sternoclavicular
Clavicula
Prosesus Coracoid
Acromion
Sendi Acromioclavicular
Scapula
• Tendon biceps
Subacromial Bursa
• Spina Cervical
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1/1/2002
Fraktur Clavicula (patah tulang)
•
Umum terjadi, paling sering di bag
tengah 1/3 clavicula
Anamnesis:
•
Pemeriksaan fisik:
•
Kelainan Akut dan Kronis Pada
Sendi Bahu
– Jatuh dg menumpu pd tangan atau
benturan langsung.
– Nyeri tajamP dan/ ada deformitas
(gangg.bentuk).
– Selalu lakukan uji neurovascular.
•
Foto Rontgen:
•
Penanganan: siku difiksasi bentuk
angka 8 selama 2-4 minggu
Follow up: lihat dlm 4-6 minggu dg
foto rontgen
Rujuk ke dokter bedah tulang:
– Xray- AP and cephalic tilt views
•
•
– Jika fungsi bag distal clavicula
terganggu (kena lig sendi AC)
Proximal Humeral Fractures
•
•
•
•
•
Anamnesis:
– Jatuh menumpu pd tangan atau
benturan langsung
Pemeriksaan fisik
– Crepitus pd sisi yg terkena
– Ecchymosis dalam 48 jam setelah
cedera.
Foto Rontgen:
– AP and Lateral Xray.
Penanganan:
– Imobilisasi bahu utk mencegah
rotasi eksternal dan abduksi.
Rujuk ke dokter bedah jika:
– Fraktur komplels
– Melibatkan bag leher
– Pergeseran lebih dari 1 cm
– Evaluasi cedera neurovascular
Glenohumeral Dislocation
• Most dislocations are anterior
• Ant. Dislocation:
– pt holds arm in external
rotation/abduction
– Humeral head palpable
anteriorly/ dimple below
acromion
• Posterior Dislocation:
– Arm in abduction/internal
rotation
– Dx often delayed
AP
• Imaging
– Need two views:
• AP- can miss posterior
dislocation
• Axillary or Y view
Y view
Dislokasi Glenohumeral
• Komplikasi:
– Dislokasi GH berulang:
– Cedera Tulang:
• >50 % ada deformitasgangg di posterolateral
caput humeri.
– Robekan Rotator Cuff
• 50% usia 60
• Penanganan:
– Reposisi
– Latihan ROM exercises lebih
awal
– Operasi jika diperlukan.
Sprain Sendi AC
•
•
Cedera yg biasa tjd pada atlet atau pasien yg
aktif.
Mekanisme:
– Benturan langsung pd aspek superior
bahu.
– Benturan di sisi samping daerah
deltoid
– Jatuh menumpu pd tangan
•
Pemeriksaan Fisik:
•
– Bengkak terlokalisir & nyeri di atas
sendi AC.
– Selalu periksa pasien dalam posisi
duduk.
– Palpasi deformitas antara acromion &
clavicula mengindikasikan cedera yg
lebih berat.
Rontgen:
– Xray:
• AP- confirms dx
• Axillary- if suspect grade 4-6
injury
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Robekan Rotator Cuff
Klasifikasi Cedera AC
•
Grade 3 atau lebih besar rujuk ke dokter bedah utk perbaikan
lebih lanjut.
• Paling sering dialami pd usia di atas 40 tahun. Anamnesis:
Ligaments or joint
Grade
1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Acromioclavicular
Ligaments
Sprained
Disrupted
Disrupted
Disrupted
Disrupted
Disrupted
Acromioclavicular
joint
Intact
Disrupted
or slight
vertical
separation
Disrupted
Disrupted
Separate
d
Ruptured
Coracoclavicular
Ligament
Intact
Sprained
Disrupted
or slight
vertical
separation
Disrupted
Disrupted
Disrupted
• Rontgen:
Impingement Syndrome
• Mekanisme:
Imaging:
• Fase akut: NSAIDS, Injeksi, es, istirahat
• Mengatasi nyeri: latihan penguatan Rotator cuff
– Xrays- get if 2-3 mo of conservative Rx fails- may show hooked
acromion, AC spurring.
– MRI sesuai indikasi
– Pembedahan Operasi jika terapi konservatif gagal.
– Pain and tenderness in bicipital groove
– Often associated with impingement syndrome or rotator
cuff tear
– X-rays- normal
– Arthography- constriction of joint
capsule
• PE: +Yergason s, +Speeds
• Rx:
Penanganan:
–
–
–
–
Physical therapy
Terapi nyeri (NSAIDS)
Corticosteroids occasionally
Surgical referral if conservative fails
Biceps Tendonitis
• Inflammation of sheath around long head of biceps
• Hx:
– Imobilitas (operasi, nyeri)
– Autoimun
•
Impingement Syndrome
– Konservatif:
Frozen Shoulder
•
– Surgical repair in young and selected older patients within 3 weeks
of injury preferably
– Rehabilitasi pasien yg tidak perlu operasi.
• PE: +Hawkins, + Neer
• Penanganan:
– Primer
• Pasien lebih tua, overuse
kronis dan degenerasi
– Sekunder
• Usia lebih muda, atlet
pelempar, instabilitas GH
menyebabkan impingment.
Mekanisme: penebalan dan
kontraktur kapsul di sekitar sendi GH.
Etiologi:
• Penanganan:
– Nyeri di atas bahu anterolateral, bisa menjalar ke siku.
– Dipicu karena aktivitas yg melibatkan gerakan overhead, terasa
memburuk di malam hari.
• Supraspinatus paling sering
terganggu.
• Ada 2 jenis:
•
– AP view GH joint- may show calcific tendonitis of cuff +/- superior
migration of humeral head- should be f/u with further imaging
– MRI= gold standard
• Anamnesis:
– Tendon rotator cuff terkena
impinged antara lengkung
coracoacromial dan abduksi
humerus.
•
– Pasien yg lebih muda terkait dg trauma
– Usia pertengahanimpingment kronik mengakibatkan ruptur
rotator cuff.
The Origin of Acupuncture
– Conservative: Rest, ice, NSAIDs, Injection
– Surgical: Transfer of tendon
5
1/1/2002
Osteolysis of Distal Clavicle
Labral injury
• SLAP lesion (Superior Labrum Anterior Posterior)
common in throwing athletes
• HX: Painful shoulder that clicks or pops with motion
• PE: +clunk test, +O'Brien's, +/-laxity signs
• Rx:
•
•
•
If atraumatic, most common in
weight lifters
Begins as stress fx & bone
remodeling cannot occur due to
continual stress on joint
Hx:
– Dull Pain over AC joint
– worst in beginning of exercise period
– Aggravated by abduction of shoulder
•
Dx:
•
RX:
– Xrays- osteopenia and lucency of
distal clavicle
– Often will need surgical repair, especially if athlete.
– D/C load-bearing activity
– Surgical: Resection of distal clavicle
Case 1
• 42 yo Male comes to your office complaining of Rt shoulder pain. He does
not remember any specific injury, but has been playing tennis a lot over
the past 4 months and tells you that opposing players no longer fear his
serve . It is difficult and painful for him to reach overhead and behind
him. Even rolling onto his shoulder in bed is painful.
• PE shows full ROM, but with discomfort at end ranges of Flexion,
abduction and internal rotation. There is significant pain when you place
the shoulder in position of 90 degrees of flexion and then internally rotate.
There is also moderate weakness on abduction and external rotation. The
rest of the MS exam is normal.
1. The most likely diagnosis is:
a)
b)
c)
d)
e)
Acromioclavicular sprain
Rotator Cuff tear
Adhesive Capsulitis
Rotator Cuff impingement
Cervical Radiculopathy
1. The most likely diagnosis is:
a)
b)
c)
d)
e)
Acromioclavicular sprain
Rotator Cuff tear
Adhesive Capsulitis
Rotator Cuff impingement
Cervical Radiculopathy
2. The best initial treatment is:
a)
b)
c)
d)
e)
Corticosteroid injection
Arthroscopic subacromial decompression
Strengthening and ROM exercises
Elbow sling
Cervical collar
6
1/1/2002
2. The best initial treatment is:
a)
b)
c)
d)
e)
3. Predisposing factors for this problem
include:
a) Repetitive motion of the shoulder above the
horizontal plane
b) Hooked acromion
c) Acromioclavicular spurring
d) Shoulder instability
e) All of the above
Corticosteroid injection
Arthroscopic subacromial decompression
Strengthening and ROM exercises
Elbow sling
Cervical collar
References
3. Predisposing factors for this problem
include:
a) Repetitive motion of the shoulder above the
horizontal plane
b) Hooked acromion
c) Acromioclavicular spurring
d) Shoulder instability
e) All of the above
1.
2.
3.
4.
Woodward, T.W & Best, T.M; The Painful Shoulder: Part I. Clinical
Evaluation. American Family Physician. May, 15 2006;60:3079-88.
Woodward, T.W & Best, T.M; The Painful Shoulder: Part II. Acute and
Chronic Disorders. American Family Physcian. June 1, 2000; 61:3291300. http://www.aafp.org/afp/20000601/3291.html
Hoppenfield, M. Physical Examination of the Spine and Extremities. New
Jersey:Prentice Hall 1976.
Thompson, J.C. Netter s Concise Atlas of Orthopedic Anatomy.
Philadelphia:Elselvier Inc 2002
???
7
7
•
•
•
•
8 #* 9 #
:, ; (/
120 degrees
Aduksi- 45 degrees
Flexi- 90 degrees
Selalu bandingkan kedua ekstremitas.
Isolasi kelompok otot rotator cuff
Masalah rotator cuff adalah nyeri disertai
kelemahan otot.
Kelemahan otot yg sebenarnya harus dibedakan
dengan kelemahan otot karena nyeri.
Extensi- 45 degrees
Internal Rotation- 55 deg
External Rotation- 40-45 deg.
I
MNMNOPPO
Supraspinatus
Infraspinatus dan Teres Minor
The Empty can test:
abduksikan sendi bahu
90 degrees dalam
posisi flexi, dg ibu jari
menunjuk ke bawah.
Pasien mencoba
mngelevasikan lengan
melawan tahanan
pemeriksa.
Posis lengan pasien di
sisi badan, flexi kedua
siku 90 derajat
sementara pemeriksa
menahan melawan
gerakan rotasi
eksternal.
Subscapularis
Tes Provocative
Fokuskan evaluasi pd
Lift off test:
Patient rests dorsum of
the hand on the back in
the lumbar area.
Inability to move hand
off the back by further
internal rotation of the
arm, suggests injury to
subscapularis muscle
masalah khusus yg
diduga dialami pasien
berdasarkan anamnesis
& pemeriksaan fisik.
Termasuk:
Impingment signs:
Neer s Sign,
Hawkin s Test
Rotator cuff tear
Drop Arm Test
AC joint Arthritis:
Cross-arm test
Impingement Signs
Rotator Cuff Tear
Neer Sign
Arm in full flexion with arm fully
pronated
Stabilize scapula
Pain= subacromial impingmentRotator cuff tendons pinched
under coracoacromial arch
Hawkins Test
Drop Arm Test:
Passively abduct patient s
NeerNeer
Forward Flex shoulder to 90
deg., elbow@ 90 deg., then
IR
Pain= suprapinatus tendon
impingement or tendonitis
? More sensitive for
impingement than Neer s
Cervical Nerve
disorder:
Spurling s
Maneuver
GH instability:
Apprehension test,
Relocation (Jobe),
Sulcus Sign
Biceps Tendon
instabillity/tendonitis:
Yergason test,
Speed s maneuver
Labral Disorders
Clunk Test, O
Brien s
shoulder to 90 degrees & have
patient lower slowly to waist
Weakness or arm drop indicates
rotator cuff tear/dysfunction
Note: the patient may be able to
lower the arm slowly to 90
degrees (deltoid fxn) but will be
unable to do so as far as the
waist
Hawkins
O
QRQRSTTS
AC joint pathology
Cervical Nerve Pathology
Cross Arm Test:
Shoulder in 90 degrees
Pain that originates from the
neck or radiates past elbow, is
suspicious for neck disorder
forward flexion, then abduct
arm across body
Pain indicates AC joint
pathology
Decreased ROM indicates
tight posterior capsule
AC Shear
Cup hands over
Spurling Maneuver
Extend neck and rotate head
Cross Arm Test
clavicle/scapula: then
squeeze
Pain/movement= AC
pathology
of patient to affected
shoulder. Then apply axial
load.
Reproduction of sx indicates
cervical disk pathology
Biceps Tendonitis
Labral Disorders
Yergason s
Patient s elbow flexed at 90 deg with
Clunk Test
thumb up
Examiner grasps wrist, & resists
patient attempt to supinate the arm
and flex elbow
Pain= biceps tendonitis
Speed s Maneuver
Flex pt s elbow to 20-30 degrees w/
forearm in supination and arm in 60
degrees of flexion
Examiner resists forward flexion and
palpates biceps tendon
Patient supine
Patient s arm is rotated &
loaded from extension thru
forward flexion.
clunk sound or clicking
sensation, may indicate labral
tear
OBrien s
90 deg FF, max IR, then
adduct and flex
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ÄÅÆÇÅÈÉÊË
Qigong
Reiki
Therapeutic touch
Dasar Terapi Energi
Terapi Energi didasarkan atas
kepercayaan bahwa perubahan dalam
life force tubuh, termasuk medan
listrik, magnetik dan electromagnetic ,
mempengaruhi kesehatan manusia dan
dapat mendorong penyembuhan.
Acupuncture
Jarum ditusukkan pd titik kritis (meridian).
Butuh kualifikasi tertentu
Acupressure
Menggunakan tekanan sbg pengganti jarum
Apa yg dimaksud dg terapi energi?
Terapi Energi termasuk domain pengobatan
komplementer & alternatif yg berdasar pd
interaksi medan energi manusia dg medan
energi lain (manusia atau non-manusia).
Berbagai medan energi dikaitkan dg tubuh
manusia, termasuk listrik, magnetik, cahaya, dll.
Perubahan medan energi ini dapat
mempengaruhi kesehatan manusia dan
mendorong kesembuhan.
Mind-body medicine
Psychoneuroimmunology (PNI)
Stres berlebihan dapat menurunkan
kekebalan tubuh.
Aktivitas yg dpt menenangkan pikiran.
Penamaan inner energy
Qi-Traditional Chinese Medicine
Ki-Japanese Kampo system
Doshas-Ayurvedic medicine
Etheric energy
Fohat
Orgone
Odic Force
Mana
Homeopathic Resonance
Prana
Mind-body medicine
Mind-body medicine fokus pd interaksi
antara otak, pikiran, tubuh, serta
perilaku dan faktor emosional, mental,
spiritual, serta perilaku dpt secara
langsung mempengaruhi kesehatan.
¹
ÌÍÌÍÎÏÏÎ
Teknik mind-body medicine
Cognitive-behavioral therapies
Relaxation
Hypnosis
Imagery
Meditation
Yoga
Biofeedback
Tai Chi
Qigong
Group Support
Autogenic Training
Spirituality
Meditasi
Latihan kewapadaan & konsentrasi
Deep relaxation
Mind-body medicine
Ada bukti bhw intervensi mind-body
berefek positif thd fungsi psikologis &
kualitas hidup.
Risiko fisik & emosional minimal.
Mind-body interventions can be taught
easily
Mind-body medicine harus digunakan
bersamaan dg pengobatan modern sbg
pendekatan terpadu utk meningkatkan
kesehatan.
Biologically based practised
Most controversial
Many claims do not have evidence
Herbal remedies
Gelombang otak berubah-ubah
Tinctures
sepanjang waktu
Memperpanjang usia, meningkatkan
kualitas hidup, mengatasi nyeri,
kecemasan dll
Ginkgo biloba
St. John s wort
Echinacea
Ginseng
Green tea
Ephedra (Ma Huang)
Biologically based practised
Special supplements
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Biologically based practised
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◦ Plant sterol
◦ Oat fiber
◦ Sunflower
◦ Soy protein
◦ Garlic
◦ Ginger
◦ Yogurt
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1234567356, 89:;? @A
D5:EE65 FA:>
Langkah-langkah Terapi
PROSES TERAPI
dr Rachmah Laksmi Ambardini
FIK Universitas Negeri Yogyakarta
Anamnesis (history): informasi terkait keluhan
pasien
Identitas
Keluhan utama
Riwayat Penyakit Sekarang (RPS)
Riwayat Penyakit Dahulu
Email: rachmah_la@uny.ac.id
Pemeriksaan Fisik
Inspeksi (observasi)
Palpasi cek, misal tanda radang, krepitasi,
ROM (range of motion) rentang gerak sendi
berkurang atau tidak?
Perkusi
Auskultasi
Diagnosis
Diagnosis utama/ Diagnosis pasti
Diagnosis banding (diagnosis alternatif)
Pemeriksaan Penunjang/Tambahan
Laboratorium periksa darah, urine
Radiologi Foto Rontgen, CT Scan, MRI
(magnetic Resonance Imaging), USG
Terapi
Non farmakologi
Farmakologi: NSAID (obat anti rasa sakit, antiradang, dll).
Non Farmakologi:
- RICE pd cedera akut
- Berbagai modalitas terapi
- Terapi Latihan (Physical Therapy): Loosening,
Stretching, Strengthening, latihan untuk kembali
ke aktivitas semula
1
1/1/2002
Follow up
Mengevaluasi hasil terapi
2
1/1/2002
Tujuan
Anamnesis
Keluhan Nyeri Bahu
dr Rachmah Laksmi Ambardini
FIK Universitas Negeri Yogyakarta
Email: rachmah_la@uny.ac.id
Memahami anatomi sendi bahu
Memahami bagaimana mengevaluasi keluhan nyeri
bahu
Mendiskusikan tes provokasi yg digunakan untuk
evaluasi nyeri bahu.
Menguasai temuan anamnesis dan pemeriksaan fisik
yg dapat membantu diagnosis masalah-masalah
pada bahu.
Mendiskusikan kelainan yg umum terjadi pada bahu
dan penanganannya.
Shoulder Anatomy
Reference 1
Anatomi Bahu
Bahu mrp salah satu sendi yg paling kommpleks.
Terdiri atas:
1.Struktur Tulang:
Humerus
Glenoid
Acromion
Clavicle
2. Struktur Jaringan Lunak:
Otot-otot Rotator cuff dan elemen penyokongnya.
3. 4 Sendi :
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
Scapulothoracic joint/pseudoarticulation
Sendi Glenohumeral (GH)
Bagian sendi yg paling sering mengalami dislokasi.
Prinsip-Prinsip Dasar:
– GH joint a ball and socket joint
– Fossa glenoid datar dan jauh lebih kecil daripada caput
humeri yg melekat padanya (persentuhan hanya 25-30%).
– Cartilaginous labrum menyediakan fungsi socket, tetapi
bukan stabilitas.
– Stabilitas didapat dari struktur yg menstabilkan sendi
bahu.
1
1/1/2002
Static Stabilizers
• Terdiri atas:
• Terdiri atas:
•
•
•
•
Dynamic Stabilizers
Struktur Tulang
Labrum
GH ligaments (superior, middle, inferior)
Kapsul sendi
• Membantu menjaga harmoni
• Tetap berfungsi walaupun ada gangguan saraf
maupun otot intrinsik.
– Rotator cuff
– Scapular stabilizers (teres major, rhomboids, serratus
anterior,trapezius and levator scapula)
• Tidak bisa berfungsi jika terjadi cedera
neuromuskular dan kerusakan otot intrinsik.
• Malfungsi menyebabkan kelonggaran sendi GH dan
nyeri bahu.
The Rotator Cuff
•
•
•
Anamnesis
Main function- depress the humeral head
against the glenoid & stabilize
• Tanyakan umur pasien, tangan yg dominan,
olahraga, pekerjaan.
Composed of 4 muscles:
1.
Supraspinatus- abduction helper to
deltoid, pulls humeral head towards
glenoid
2.
Infraspinatus- external rotation helper,
pulls humeral head inferiorly
3.
Teres minor-external rotation helper, pulls
humeral head inferiorly
4.
Subscapularis-internal rotation helper to
pectoralis and latismus dorsi
When damaged, humeral had can move
upward within the joint 2/2 to unopposed
deltoid action
• Tentukan keluhan utama pasien (mis. Nyeri,
kelemahan, instabilitas, ROM yg terbatas).
• Bagaimana & kapan masalah dimulai?
• Apakah gejala yg dirasakan terkait dg
cedera/kejadian tertentu sebelum gejala
timbul?
• Apakah aktivitas/gerakan lengan tertentu
menyebabkan gejala timbul?
Anamnesis
• Gejala yg terkait:
– Instability/longgar (mis. Instabilitas sendi GH di segala arah)
– Menurunnya kekuatan otot (mis. Impingment, gangguan pd rotator
cuff).
– Bengkak (mis. Trauma akut, robekan pd rotator cuff)
– Mati rasa/kesemutan (misal gangg pd tl cervical)
– Hilangnya gerakan/kekakuan (mis. Adhesive capsulitis, dislokasi atau
instabilitas sendi GH)
• Terapi apa yg sebelumnya sudah dilakukan, mis: es, panas, obat-obatan.
Pemeriksaan Fisik
• Dilakukan secara sistematis
• Jangan mengabaikan bahu yg sehat (krn hal ini akan
memberi informasi sisi normal pasien).
• Perhatikan kedua bahu dan lakukan:
–
–
–
–
–
Inspeksi
Palpasi
Periksa ROM: pasif dan aktif
Tes kekuatan
Tes khusus sesuai indikasi
• Tindakan Intervensi sebelumnya, mis terapi fisik, suntikan, pembedahan.
2
1/1/2002
Inspeksi
Inspeksi
• Cari adanya:
–
–
–
–
–
• Look for:
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
–
–
–
–
–
–
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
Dsitensi vena
Inspeksi
Inspeksi
• Look for:
–
–
–
–
–
–
Ant. Shoulder Dislocation
• Look for:
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
Distensi vena
Ant. Shoulder Dislocation
AC joint separation
–
–
–
–
–
–
Bengkak
Asimetri
Atrofi Otot
Adanya bekas luka
Ecchymosis
Distensi vena
Ant. Shoulder Dislocation
AC joint separation
Supraspinatus and
infraspinatus atrophy
Palpasi
Palpasi
•
•
•
•
•
•
Sendi Sternoclavicular
Clavicula
Prosesus Coracoid
Acromion
Sendi Acromioclavicular
Scapula
• Tendon biceps
Subacromial Bursa
• Spina Cervical
3
1/1/2002
Fraktur Clavicula (patah tulang)
•
Umum terjadi, paling sering di bag
tengah 1/3 clavicula
Anamnesis:
•
Pemeriksaan fisik:
•
Kelainan Akut dan Kronis Pada
Sendi Bahu
– Jatuh dg menumpu pd tangan atau
benturan langsung.
– Nyeri tajamP dan/ ada deformitas
(gangg.bentuk).
– Selalu lakukan uji neurovascular.
•
Foto Rontgen:
•
Penanganan: siku difiksasi bentuk
angka 8 selama 2-4 minggu
Follow up: lihat dlm 4-6 minggu dg
foto rontgen
Rujuk ke dokter bedah tulang:
– Xray- AP and cephalic tilt views
•
•
– Jika fungsi bag distal clavicula
terganggu (kena lig sendi AC)
Proximal Humeral Fractures
•
•
•
•
•
Anamnesis:
– Jatuh menumpu pd tangan atau
benturan langsung
Pemeriksaan fisik
– Crepitus pd sisi yg terkena
– Ecchymosis dalam 48 jam setelah
cedera.
Foto Rontgen:
– AP and Lateral Xray.
Penanganan:
– Imobilisasi bahu utk mencegah
rotasi eksternal dan abduksi.
Rujuk ke dokter bedah jika:
– Fraktur komplels
– Melibatkan bag leher
– Pergeseran lebih dari 1 cm
– Evaluasi cedera neurovascular
Glenohumeral Dislocation
• Most dislocations are anterior
• Ant. Dislocation:
– pt holds arm in external
rotation/abduction
– Humeral head palpable
anteriorly/ dimple below
acromion
• Posterior Dislocation:
– Arm in abduction/internal
rotation
– Dx often delayed
AP
• Imaging
– Need two views:
• AP- can miss posterior
dislocation
• Axillary or Y view
Y view
Dislokasi Glenohumeral
• Komplikasi:
– Dislokasi GH berulang:
– Cedera Tulang:
• >50 % ada deformitasgangg di posterolateral
caput humeri.
– Robekan Rotator Cuff
• 50% usia 60
• Penanganan:
– Reposisi
– Latihan ROM exercises lebih
awal
– Operasi jika diperlukan.
Sprain Sendi AC
•
•
Cedera yg biasa tjd pada atlet atau pasien yg
aktif.
Mekanisme:
– Benturan langsung pd aspek superior
bahu.
– Benturan di sisi samping daerah
deltoid
– Jatuh menumpu pd tangan
•
Pemeriksaan Fisik:
•
– Bengkak terlokalisir & nyeri di atas
sendi AC.
– Selalu periksa pasien dalam posisi
duduk.
– Palpasi deformitas antara acromion &
clavicula mengindikasikan cedera yg
lebih berat.
Rontgen:
– Xray:
• AP- confirms dx
• Axillary- if suspect grade 4-6
injury
4
1/1/2002
Robekan Rotator Cuff
Klasifikasi Cedera AC
•
Grade 3 atau lebih besar rujuk ke dokter bedah utk perbaikan
lebih lanjut.
• Paling sering dialami pd usia di atas 40 tahun. Anamnesis:
Ligaments or joint
Grade
1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Acromioclavicular
Ligaments
Sprained
Disrupted
Disrupted
Disrupted
Disrupted
Disrupted
Acromioclavicular
joint
Intact
Disrupted
or slight
vertical
separation
Disrupted
Disrupted
Separate
d
Ruptured
Coracoclavicular
Ligament
Intact
Sprained
Disrupted
or slight
vertical
separation
Disrupted
Disrupted
Disrupted
• Rontgen:
Impingement Syndrome
• Mekanisme:
Imaging:
• Fase akut: NSAIDS, Injeksi, es, istirahat
• Mengatasi nyeri: latihan penguatan Rotator cuff
– Xrays- get if 2-3 mo of conservative Rx fails- may show hooked
acromion, AC spurring.
– MRI sesuai indikasi
– Pembedahan Operasi jika terapi konservatif gagal.
– Pain and tenderness in bicipital groove
– Often associated with impingement syndrome or rotator
cuff tear
– X-rays- normal
– Arthography- constriction of joint
capsule
• PE: +Yergason s, +Speeds
• Rx:
Penanganan:
–
–
–
–
Physical therapy
Terapi nyeri (NSAIDS)
Corticosteroids occasionally
Surgical referral if conservative fails
Biceps Tendonitis
• Inflammation of sheath around long head of biceps
• Hx:
– Imobilitas (operasi, nyeri)
– Autoimun
•
Impingement Syndrome
– Konservatif:
Frozen Shoulder
•
– Surgical repair in young and selected older patients within 3 weeks
of injury preferably
– Rehabilitasi pasien yg tidak perlu operasi.
• PE: +Hawkins, + Neer
• Penanganan:
– Primer
• Pasien lebih tua, overuse
kronis dan degenerasi
– Sekunder
• Usia lebih muda, atlet
pelempar, instabilitas GH
menyebabkan impingment.
Mekanisme: penebalan dan
kontraktur kapsul di sekitar sendi GH.
Etiologi:
• Penanganan:
– Nyeri di atas bahu anterolateral, bisa menjalar ke siku.
– Dipicu karena aktivitas yg melibatkan gerakan overhead, terasa
memburuk di malam hari.
• Supraspinatus paling sering
terganggu.
• Ada 2 jenis:
•
– AP view GH joint- may show calcific tendonitis of cuff +/- superior
migration of humeral head- should be f/u with further imaging
– MRI= gold standard
• Anamnesis:
– Tendon rotator cuff terkena
impinged antara lengkung
coracoacromial dan abduksi
humerus.
•
– Pasien yg lebih muda terkait dg trauma
– Usia pertengahanimpingment kronik mengakibatkan ruptur
rotator cuff.
The Origin of Acupuncture
– Conservative: Rest, ice, NSAIDs, Injection
– Surgical: Transfer of tendon
5
1/1/2002
Osteolysis of Distal Clavicle
Labral injury
• SLAP lesion (Superior Labrum Anterior Posterior)
common in throwing athletes
• HX: Painful shoulder that clicks or pops with motion
• PE: +clunk test, +O'Brien's, +/-laxity signs
• Rx:
•
•
•
If atraumatic, most common in
weight lifters
Begins as stress fx & bone
remodeling cannot occur due to
continual stress on joint
Hx:
– Dull Pain over AC joint
– worst in beginning of exercise period
– Aggravated by abduction of shoulder
•
Dx:
•
RX:
– Xrays- osteopenia and lucency of
distal clavicle
– Often will need surgical repair, especially if athlete.
– D/C load-bearing activity
– Surgical: Resection of distal clavicle
Case 1
• 42 yo Male comes to your office complaining of Rt shoulder pain. He does
not remember any specific injury, but has been playing tennis a lot over
the past 4 months and tells you that opposing players no longer fear his
serve . It is difficult and painful for him to reach overhead and behind
him. Even rolling onto his shoulder in bed is painful.
• PE shows full ROM, but with discomfort at end ranges of Flexion,
abduction and internal rotation. There is significant pain when you place
the shoulder in position of 90 degrees of flexion and then internally rotate.
There is also moderate weakness on abduction and external rotation. The
rest of the MS exam is normal.
1. The most likely diagnosis is:
a)
b)
c)
d)
e)
Acromioclavicular sprain
Rotator Cuff tear
Adhesive Capsulitis
Rotator Cuff impingement
Cervical Radiculopathy
1. The most likely diagnosis is:
a)
b)
c)
d)
e)
Acromioclavicular sprain
Rotator Cuff tear
Adhesive Capsulitis
Rotator Cuff impingement
Cervical Radiculopathy
2. The best initial treatment is:
a)
b)
c)
d)
e)
Corticosteroid injection
Arthroscopic subacromial decompression
Strengthening and ROM exercises
Elbow sling
Cervical collar
6
1/1/2002
2. The best initial treatment is:
a)
b)
c)
d)
e)
3. Predisposing factors for this problem
include:
a) Repetitive motion of the shoulder above the
horizontal plane
b) Hooked acromion
c) Acromioclavicular spurring
d) Shoulder instability
e) All of the above
Corticosteroid injection
Arthroscopic subacromial decompression
Strengthening and ROM exercises
Elbow sling
Cervical collar
References
3. Predisposing factors for this problem
include:
a) Repetitive motion of the shoulder above the
horizontal plane
b) Hooked acromion
c) Acromioclavicular spurring
d) Shoulder instability
e) All of the above
1.
2.
3.
4.
Woodward, T.W & Best, T.M; The Painful Shoulder: Part I. Clinical
Evaluation. American Family Physician. May, 15 2006;60:3079-88.
Woodward, T.W & Best, T.M; The Painful Shoulder: Part II. Acute and
Chronic Disorders. American Family Physcian. June 1, 2000; 61:3291300. http://www.aafp.org/afp/20000601/3291.html
Hoppenfield, M. Physical Examination of the Spine and Extremities. New
Jersey:Prentice Hall 1976.
Thompson, J.C. Netter s Concise Atlas of Orthopedic Anatomy.
Philadelphia:Elselvier Inc 2002
???
7
7
•
•
•
•
8 #* 9 #
:, ; (/
120 degrees
Aduksi- 45 degrees
Flexi- 90 degrees
Selalu bandingkan kedua ekstremitas.
Isolasi kelompok otot rotator cuff
Masalah rotator cuff adalah nyeri disertai
kelemahan otot.
Kelemahan otot yg sebenarnya harus dibedakan
dengan kelemahan otot karena nyeri.
Extensi- 45 degrees
Internal Rotation- 55 deg
External Rotation- 40-45 deg.
I
MNMNOPPO
Supraspinatus
Infraspinatus dan Teres Minor
The Empty can test:
abduksikan sendi bahu
90 degrees dalam
posisi flexi, dg ibu jari
menunjuk ke bawah.
Pasien mencoba
mngelevasikan lengan
melawan tahanan
pemeriksa.
Posis lengan pasien di
sisi badan, flexi kedua
siku 90 derajat
sementara pemeriksa
menahan melawan
gerakan rotasi
eksternal.
Subscapularis
Tes Provocative
Fokuskan evaluasi pd
Lift off test:
Patient rests dorsum of
the hand on the back in
the lumbar area.
Inability to move hand
off the back by further
internal rotation of the
arm, suggests injury to
subscapularis muscle
masalah khusus yg
diduga dialami pasien
berdasarkan anamnesis
& pemeriksaan fisik.
Termasuk:
Impingment signs:
Neer s Sign,
Hawkin s Test
Rotator cuff tear
Drop Arm Test
AC joint Arthritis:
Cross-arm test
Impingement Signs
Rotator Cuff Tear
Neer Sign
Arm in full flexion with arm fully
pronated
Stabilize scapula
Pain= subacromial impingmentRotator cuff tendons pinched
under coracoacromial arch
Hawkins Test
Drop Arm Test:
Passively abduct patient s
NeerNeer
Forward Flex shoulder to 90
deg., elbow@ 90 deg., then
IR
Pain= suprapinatus tendon
impingement or tendonitis
? More sensitive for
impingement than Neer s
Cervical Nerve
disorder:
Spurling s
Maneuver
GH instability:
Apprehension test,
Relocation (Jobe),
Sulcus Sign
Biceps Tendon
instabillity/tendonitis:
Yergason test,
Speed s maneuver
Labral Disorders
Clunk Test, O
Brien s
shoulder to 90 degrees & have
patient lower slowly to waist
Weakness or arm drop indicates
rotator cuff tear/dysfunction
Note: the patient may be able to
lower the arm slowly to 90
degrees (deltoid fxn) but will be
unable to do so as far as the
waist
Hawkins
O
QRQRSTTS
AC joint pathology
Cervical Nerve Pathology
Cross Arm Test:
Shoulder in 90 degrees
Pain that originates from the
neck or radiates past elbow, is
suspicious for neck disorder
forward flexion, then abduct
arm across body
Pain indicates AC joint
pathology
Decreased ROM indicates
tight posterior capsule
AC Shear
Cup hands over
Spurling Maneuver
Extend neck and rotate head
Cross Arm Test
clavicle/scapula: then
squeeze
Pain/movement= AC
pathology
of patient to affected
shoulder. Then apply axial
load.
Reproduction of sx indicates
cervical disk pathology
Biceps Tendonitis
Labral Disorders
Yergason s
Patient s elbow flexed at 90 deg with
Clunk Test
thumb up
Examiner grasps wrist, & resists
patient attempt to supinate the arm
and flex elbow
Pain= biceps tendonitis
Speed s Maneuver
Flex pt s elbow to 20-30 degrees w/
forearm in supination and arm in 60
degrees of flexion
Examiner resists forward flexion and
palpates biceps tendon
Patient supine
Patient s arm is rotated &
loaded from extension thru
forward flexion.
clunk sound or clicking
sensation, may indicate labral
tear
OBrien s
90 deg FF, max IR, then
adduct and flex
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·¸·¸¹ºº¹
»¼½¾¿À Á¼½ÃÀ
ÄÅÆÇÅÈÉÊË
Qigong
Reiki
Therapeutic touch
Dasar Terapi Energi
Terapi Energi didasarkan atas
kepercayaan bahwa perubahan dalam
life force tubuh, termasuk medan
listrik, magnetik dan electromagnetic ,
mempengaruhi kesehatan manusia dan
dapat mendorong penyembuhan.
Acupuncture
Jarum ditusukkan pd titik kritis (meridian).
Butuh kualifikasi tertentu
Acupressure
Menggunakan tekanan sbg pengganti jarum
Apa yg dimaksud dg terapi energi?
Terapi Energi termasuk domain pengobatan
komplementer & alternatif yg berdasar pd
interaksi medan energi manusia dg medan
energi lain (manusia atau non-manusia).
Berbagai medan energi dikaitkan dg tubuh
manusia, termasuk listrik, magnetik, cahaya, dll.
Perubahan medan energi ini dapat
mempengaruhi kesehatan manusia dan
mendorong kesembuhan.
Mind-body medicine
Psychoneuroimmunology (PNI)
Stres berlebihan dapat menurunkan
kekebalan tubuh.
Aktivitas yg dpt menenangkan pikiran.
Penamaan inner energy
Qi-Traditional Chinese Medicine
Ki-Japanese Kampo system
Doshas-Ayurvedic medicine
Etheric energy
Fohat
Orgone
Odic Force
Mana
Homeopathic Resonance
Prana
Mind-body medicine
Mind-body medicine fokus pd interaksi
antara otak, pikiran, tubuh, serta
perilaku dan faktor emosional, mental,
spiritual, serta perilaku dpt secara
langsung mempengaruhi kesehatan.
¹
ÌÍÌÍÎÏÏÎ
Teknik mind-body medicine
Cognitive-behavioral therapies
Relaxation
Hypnosis
Imagery
Meditation
Yoga
Biofeedback
Tai Chi
Qigong
Group Support
Autogenic Training
Spirituality
Meditasi
Latihan kewapadaan & konsentrasi
Deep relaxation
Mind-body medicine
Ada bukti bhw intervensi mind-body
berefek positif thd fungsi psikologis &
kualitas hidup.
Risiko fisik & emosional minimal.
Mind-body interventions can be taught
easily
Mind-body medicine harus digunakan
bersamaan dg pengobatan modern sbg
pendekatan terpadu utk meningkatkan
kesehatan.
Biologically based practised
Most controversial
Many claims do not have evidence
Herbal remedies
Gelombang otak berubah-ubah
Tinctures
sepanjang waktu
Memperpanjang usia, meningkatkan
kualitas hidup, mengatasi nyeri,
kecemasan dll
Ginkgo biloba
St. John s wort
Echinacea
Ginseng
Green tea
Ephedra (Ma Huang)
Biologically based practised
Special supplements
Muscle enhancers
Glucosamine
Antioxidants
Foods as healing agents
Functional foods
Nutraceuticals
Biologically based practised
Common healing foods
◦ Plant sterol
◦ Oat fiber
◦ Sunflower
◦ Soy protein
◦ Garlic
◦ Ginger
◦ Yogurt
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