Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Exercise
Presentan :
Setia Wati Astri Arifin
Pembimbing :
Prof. Dr. dr. Angela B.M. Tulaar, SpKFR-K
Introduction
Vertebra
Cervical
Foramen transversum
Processus articularis
pendek
Foramen vertebra
segitiga, lebih besar dari
corpus
Processus spinosus pendek
dan bercabang
Cervical
Vertebral
Column
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
C1= Atlas
Bagian superior ada
faset luas,
(berartikulasi dengan
occipital)
Tidak memiliki corpus
& processus spinosus
Gerakan rocking
YES Joint (fleksi
ekstensi)
C2= Axis
Bentuk seperti gigi
proc.
odontoid (dens)
Bersendi dengan
atlas
C 7 Vertebra Prominens
Processus spinosus : panjang, tebal,
hampir horizontal, tidak bifida
Processus transversus lebih luas
Foramen transverum lebih kecil
Membentuk 5 persendian :
Vertebra-diskus (true joint)
Sepasang Sendi Luschka (false
joint)
Sepasang articulasi posterior faset
Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
Arunachalam Kumar VK. UNCO VERTEBRAL JOINTS OF LUSCHKA: AN OSTEOLOGICAL STUDY. Nitte Univ J Health Sci. 2012;2(4):579
A paired of
Luschka
Joints (uncovertebral
joints)
important in
the
pathology of
neck pain
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
Superficia
l
http://www.slideshare.net/ananthatiger/muscles-of-the-neck-1
Superficia
l
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Flexors
Scalenus
SCM
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Flexors
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Extensors
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Extensors
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Extensors
Spinalis
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Kinesiologi
Faset pada prosesus articularis cervikal
berorientasi pada :
Bidang oblique 45
Arah kemiringan dari atas depan ke
bawah-belakang
Membentuk sadel joint
Gerakan
Fleksi
Ekstensi
Lateral fleksi
Rotasi
C4 s/d C6
WHIPLASH
FORAMEN
INTERVERTEBRALIS
Fleksi
membuka
Ekstensi menyempit
Lateral fleksi Foramina
ipsilateral mengecil &
foramina kontralateral
membesar dan sebaliknya
CANALIS
CERVICALIS
Fleksi
Memanjang
Ekstensi
Memendek
Tetapi
syaraf/medulla
spinalis tidak
memanjang/meme
ndek
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
Cervical
ROM
Degree ()
Movement
Tota
l
AOJ
AAJ
C2C7
Flexion
60
10
45
Extension
80
25
10
45
75
45
30
45
10
30
www.healthtap.com
Sumber :
Diunduh dari http://www.coreconcepts.com.sg/mcr/wp-content/uploads/2008/06/stretched-disc.jpg
Flexion
Extension
Lateral
Flexion
XXX
X (upper)
XXX
XXX (CL)
Scalenus anterior
XX
XXX
X (CL)
Scalenus medius
XXX
Scalenus posterior
XX
Longus colli
XX
XX
Longus capitis
XX
XX
XX (AOJ)
X (AOJ)
XX (AOJ)
Splenius capitis
XXX
XX
XXX (IL)
Splenius cervicis
XXX
XX
XXX (IL)
XX (AOJ)
XX (IL) (AAJ)
XX (AOJ)
X (AOJ)
XX (AAJ)
XXX (AOJ)
XXX (AOJ)
Muscles
Sternocleidomastoideus
Keterangan:
AOJ : atlanto-oksipital joint
AA J : atlanto-aksial joint
Axial
Rotation
CL : contralateral
IL : ipsilateral
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
NECK PAIN
Definition
Epidemiolog
y
Classification by
Onset
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180
Mechanic
al
Etiology
The most common neck pain is
non-specific mechanical neck
pain caused by muscle strain,
ligament sprain, spasm, or a
combination
No specific lesions, or findings
Usually caused by daily activities
Philip D. Sloan, Essentials of the family medicine , Chapter 37 Introduction , Wolters Kluwer , 6th edition
Patophysiology
The nociceptive sites on
cervical area are:
1. Anterior & Posterior
Longitudinal Ligament
2. Outer Annulus
Fibrosus
3. Duramater
4. Spinal Nerve Root
5. Facet Joint Capsule
6. Muscles
Irritation or
inflammation
on cervical
tissue can
produce pain
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Patophysiology
Two major mechanisms of neck pain
are trauma and arthritis
Trauma:
1.External
trauma
2.Postural
trauma
3.Tension
Arthritis:
1.Degenerative
arthritis
2.Sequelae of
acute
inflammation
arthritis
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Patophysiology
External Trauma:
The neck received external forces that cause
abnormal cervical vertebrae position or
movement that leading to injury and pain
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Patophysiology
Postural
Trauma:
Wrong posture
can cause
various trauma
to the
musculoskeletal
system,
especially the
vertebral
column:
1.Forward head
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Patophysiology
Tension Trauma:
Emotional factor hypothalamic
limbic system physiologic &
neuromuscular system
Tension within the neuromuscular
system manifest as a sustained
isometric muscular contraction No
period of relaxation
Clinical Manifestation
Pain on neck or pain
from neck, with or
without radiation to
the head, back,
shoulder and upper
extremity
Fatigue
Sleep disturbance
Headache
Pain with movement
Limited ROM
Palpated trigger point
Radicular pain:
Sharp or dull,
burning sensation
or shocking pain
depend on ventral
or dorsal nerve
root involvement
Distributes
according to the
dermatomal or
myotomal area
Neurologic
symptoms such as
tingling sensation,
paresthesia, numb
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180
Differential Diagnoses
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180
Neck Cailliet
Exercises
Kontraindikas
i
Tha
nk
You
Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion.
Axial (C2)
Odontoid Process / Dens, Tooth-like projection
Articulates with anterior arch of atlas
rotation in longitudinal plane Act as a
PIVOT
Called NO Joints
Greatest motion of neck rotation 50% total
neck rotation
Motion
Atlanto
Axial
Flexion
Extension
10
Rotation (each
side)
45
Lateral flexion
(each side)
10
NO joint
Atlas (C1)
No vertebral body
2 large concave facets
on upper surface
occipital condyles
Motion
Atlanto Occipital
Flexion
10
Extension
25
Lateral flexion
(each side)
YES joint
Kontraindikasi
Myelopathy
Fracture
Dislocation
Acute Injury
Vascular injury
Infection
Malignancy
Ligamentous
instability
Joint Instability
Diseases Affecting
the Tissues Being
Stretched
Excessive Pain
When Stretching
Inflammation or
Joint Effusion
Severe
degenerative
changes
Vertebrobasilar
insufficiency
Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion.
Cervical Movement
Major movement in range and amplitude occurs
between skull C3.
Movement of C4 C7 depend upon ligament
laxity, distortion and compressibility of
intervertebral disc
Facet joints in coronal plane, slanted backward
45
Flexion cervical canal lengthens,
intervertebral foramina open
Extension cervical canal shortens,
intervertebral foramina narrowed
Lateral bending close on the side the head
turns and vice versa
Cervical Movement
Motion
Flexion
Extension
Rotation
(each
side)
Lateral
flexion
Atlant
Atlanto
o
Occipital
Axial
C2
C7
Total
cervic
al
10
25
5
10
45 60
45 80
45
30 75
Vertebra Servikal
Mempunyai foramen
tranversum
Prosesus artikularis pendek
Membentuk 5 persendian
dengan vertebra terdekat:
Sisi akhir vertebra dengan
diskus (true joint)
Sepasang joint of luschka (false
joint)
Sepasang artikulasi posterior
faset (true joint)
Joint of Luschka /
Uncovertables joint
dibentuk oleh proyeksi
tulang
( prosessus uncinatus)
Faset pada prosesus
artikularis cervikal
Orientasi pada bidang oblik:
miring dari atas depan ke
bawah belakang
Membentuk saddle joints,
3th degree freedom of motion
Gerakan: fleksi, ekstensi,
lateral fleksi
Trauma tanpa fraktur sering
terjadi: whiplash injury
Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
C1 = atlas
No body
Bagian superior ada
faset luas, bersendi
dengan occipital
Gerakan rocking=YES
joint
C2 = axis
Bentuk seperti gigi =
prosesus odontoid
Bersendi dengan arkus
Gerak=rotasi=NO joint
Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
C7 = Prominens
Processus
spinosus :
panjang, tebal,
hampir
horizontal, tidak
bifida
Processus
transversus lebih
luas
Foramen
Reyes,
Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
transversum
Retroauricula
rNodes
Superficial
Cervical
Lymph
Nodes
Deep
Cervical
Lymph
Jugular
Trunk
Cervical Spinal
Nerves
Cervical Spinal
Nerves
Classification by
ICD-10
Classification by
ICF
Precautions
(McMillin)
Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of Neck Pain and Its Associated Disorders. Eur
Spine J. 2008 Feb 29;17(1):10122.
Evaluation
Physical Examination:
Palpation of trigger point & tenderness
Cervical Range of Movement (CROM)
Manual Muscle Testing (MMT)
Pain Perception:
Visual Analog Scale (VAS)
Functional Assessment:
Neck Disability Index (NDI)46,47
Cervical
ROM
Examinatio
n
Image Source:
INTERVERTEBRAL DISKS
Intervertebral Disks
The chief structural unit between adjacent
vertebral bodies
25% of the total length of the spinal
column
Function:
To bind vertebrae together & allow motion
Contributes to the formation of spinal curves
(cervical & lumbar)
A self-contained fluid elastic system that
absorbs shock during vertical loading &
permits transient compression
Intervertebral Disks
Allowing fluid displacements within its
elastic container, distributes pressure
equally
The compressive force is not
concentrated on the edge of the vertebral
body toward which the spine bends
Permits movement, equalizes pressure
and forces on the column & disperses the
forces.
Intervertebral Disks
The cartilaginous plate
Hyaline cartilage
Covers the bony
surfaces of the
opposed vertebral
bodies
Act as semipermeable
membrane
Anchors the
attachment of the
annulus fibrosus
Nucleus pulposus
40% of cross section
Between middle &
posterior third of the
disk
80% water
Pascals Law of fluid
under pressure
The external forces
that applied to any
point is transmitted
to every unit area of
the interior of the
containing vessel
Karakter Diskus
Area Servikalis
Ukuran besar : diskus > korpus vetebra
Ketebalan : bagian anterior > bagian posterior
(membentuk kurva lordosis)
Lebar diskus sedikit lebih kecil dibandingkan korpus vertebra
Lokasi nukleus lebih anterior dibandingkan dengan di area lain
Area Thorakalis
Ketebalan : bagian anterior = bagian posterior
(bentuk kurva kifosis lebih dikarenakan struktur korpus vertebra
dibandingkan diskus intervertebralisnya)
Ukuran diskus lebih tipis dibandingkan pada area lainnya
Ukuran lebih kecil dibandingkan dengan korpus vertebra
Area Lumbalis
Ketebalan : bagian anterior > bagian posterior
(membentuk kurva lordosis)
Paling terlihat pada intervertebralis L5
Gambar diunduh dari http://www.corpshumain.ca/en/images/Squelette_colonne_(FF )_en.jpg
Beban
(Kg)
Standing
100
Sitting
140
190
270
Reclining
70
Supine
16
300
Anterior ALL
Posteromedial PLL
Organ
Sensitif
1.
2.
3.
Ligamentum flavum
4.
Serabut saraf
5.
Anulus fibrosus
6.
7.
Korpus vertebra
8.
Ligamentum interspinosus
9.
Otot-otot trunkus
Resisten
Rule of Thumb:
When the disk protruded is small, it will usually affects the spinal nerve
below correspondent vertebra.
If there are symptoms of sensory motor loss as referred to spinal
involvement, the disk number is one above the vertebra
Sumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.
Normal Dehydration
Dehydration during days activity
loss of 2cm height in an adult
During the rest in bed & sleep
pressure << water absorbed from
blood by the disk original height is
regained
Aging
Decreased ability to
absorbs water << 20%
fluid deability of the
disk to trasmit the
pressure prone to
rupture
Calcification of
cartilagenous plate & gel
part of the nucleus
pulposus
nonproductive collagen
tissue space between
vertebrae narrows & the
annulus bulges new
collagen tissues
proliferate on the lips &
vertebral bodies
ossification & osteophytes
Ligamen
Ligamen Longitudinal
anterior
& posterior
Ligamen transversum
Ligamen Flavum
Lig. Atlanto-occipital
Lig. Cruciate proc.
odontoid & occiput
Lig. Alar proc
odontoid & anterior
atlas
Ligamentum nuchae
LIGAMENTS
1. Longitudinal Intersegmental Ligament
a) Anterior Longitudinal Ligament
b) Posterior Longitudinal Ligament
c) Supraspinous Ligament
Interspinous Ligament
Intertransverse Ligaments
Ligamentum Flavum
Reinforcing ligaments of atlanto-occipital
and atlanto-axial joints
LIGAMENTS
1. Longitudinal Intersegmental Ligament
a) Anterior Longitudinal Ligament
b) Posterior Longitudinal Ligament
c) Supraspinous Ligament
Interspinous Ligament
Intertransverse Ligaments
Ligamentum Flavum
Reinforcing ligaments of atlanto-occipital
and atlanto-axial joints
Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.