How to Find & Fix Musculoskeletal,

8/9/2019 How to Find & Fix Musculoskeletal,

1/79

HOW TO FIND & FIXMUSCULOSKELETAL

ORIGIN OF BACKPAIN

Pagan PambudiSMF Neurologi FK UNLAM/RSUD Ulin Banjarmasin

Property of dr. Pagan Pambudi, M.Si, Sp.S.


2/79

Epidemiology of Backpain



3/79

Indian Journal of Occupational and Environmental Me

Vol. 15, No. 2, May-August, 2011, pp. 59-63 Property of dr. Pagan Pambudi, M.Si, Sp.S.


4/79

What Physician thinksabout Backpain

Patophysiology

Nerve Compresion

Vertebrae pathology

Kidney & Organs problems



5/79

SARAF KECEPIT !!



6/79

The Fact and What expert

says• 56% of adults have disc bulging

• MRI scans show that between 20% & 35% of

working age adults have asymptomatic discherniation

• There is lifetime incidence of 2% for symptomatic

disc herniation

• 80% of general population will experience back

pain but only 2-3% will have sciatica

• Most cases of back pain aren't caused by serious

damage or disease but by minor sprains, strains or

injuries, or a pinched or irritated nerve.



7/79

Our Traditional Approach toPatientwith Chronic Backpain



8/79

What’s the results

• The Backpain soften…But:

• I can’t works because I’m to sleepy

• I feel clumpsy in the morning can not work

• The headache come when the drug goes

• NSAIDs side effects:

• Cardiovascular risks

• GI effects

• Drugs overuse

• Transquilizer effect

• Dependency or abuse

• To expensive..I can not continue



9/79

The Fact is spinal surgery rarely needed

There is no choice, You shouldundergo spinal surgery Upps…I’m afraid doc, My

neighbor did spinal surgery lastmonth and he is paralyzed now,

I don’t have money doc, doBPJS cover it thoroughly??



10/79

What next we usually do…

• Ok..its up to you…take your pills at your own

risks..continue your life

• Refers to

• Pain Specialist Physician

• Rehabilitation

• Complimentary Alternative Medicine



11/79

What are Usually Forgot to

treat adequately in Backpain• Muscle stiffness & Trigger point• Patient posture

•Sedentary lifestyle

• Working behavior and environment

• Diet



12/79

• Muscle accounts for 50% ofhuman body mass, and somost human pathologicalconditions involve softtissue dysfunction, whetherin the case of physical

injuries such as musclesdamaged by overuse in dailylife or in sporting activity, orin cases like Parkinson’sdisease, drug addiction,

stroke, or cancer.



13/79

Muskuloskeletal influence in

Backpain



14/79

PAIN In the Muscle

• Muscle bands are usually pain-free, but canbecome tender and painful, possibly bycompressing intramuscular nociceptors ormicroneuromas Focal areas of tendernessand pain are often referred to as "triggerpoints".



15/79

What is Trigger Point

• A trigger point (TrP) is a focal area ofhyperirritability that is locally sensitive to pressureand can refer symptoms (usually pain) to other

areas of the body• located within a taut band of skeletal muscle tissue



16/79

TrP Patophysiology



17/79



18/79



19/79



20/79



21/79



22/79



23/79

Stretch The Muscle usuallyResolve the Problems

• Stretch Technique

• Trp injection/Dry needling

• Rehabilitation device

• Muscle relaxan is not effective sometimesharmfull

• NSAID Helps but have limitation



24/79

Myofascial Dx

1-2

• Take a carefull history

• Find Biomechanical injury

3-4

• Palpate a taut band

• Identify a tender nodule

5-6• Identify patient pain recognition• Identify pain in ROM



25/79

Myofascial Dx

7-8

• Identify LTR

• Identify refered pain pattern

9-10

• Identify muscle weakness

• Corelate with Neurologic & orthopedic exam

11• Diagnosis made



26/79

How to Fix?

• Find which muscle involve

• Find the Trigger Point

• Find the problems and correct it

• Bad posture• Works environment

• Habit

• Sleep disorders

• Obesity

• Deactivate trigger

• Stretch

• Strengthen



27/79

Finding the Trigger

• Palpation is important

• Do not focus on area noted by patient, It could beonly a refered area not the muscle has trigger

• Knowledge of refered pattern for each muscletrigger is important



28/79


t f d b d M


29/79

Trigger point confirmation

• A nodul in taut band that:

• Elicited pain when pressed, referred to another area

• LTR observed when needling

• Grity…hard on needling



30/79

Palpation Technique

Pincer palpation Flat palpation



31/79

Identify the Problems and

Fix


f


32/79



33/79



34/79

Culture effect on Posture


P t f d P P b di M Si S S


35/79

Common Trigger point inBackpain• Quadratus Lumborum (QL)

• Multifidus (Mfd) & erector Spinae

• Pyriformis (Pr)

• Gluteus Medius an external rotator complex (GM)

• Tensor Fascia Latae (TFL)



36/79

f d d


37/79


t f d b d M


38/79

Posture Correction


P t f d P P b di M Si S S


39/79

Let’s check Our Posture

• Stand tall with your feet a comfortable ten inchesapart

• your toes pointing straight forward.

•Put your hands on buttocks and tighten buttocks

• Move hands to lower stomach muscles and suck instomach muscles.

• Move hands up to lower rib cage, stretch up spineand lift rib cage up.

• Move hands to upper chest; lift chest up•


Property of dr Pagan Pambudi M Si Sp S


40/79

Let’s check Our Posture

• Move hands to shoulders; lift them up and slightly back

• Put right hand under chin and lift chin up

• Now line body up straight, nose plumb-line to bellybutton

• drop hands heavy to sides, swinging themeasily back and forth

• Look in the mirror to see if the shoulders are level. Youmay have to lift one shoulder up a little to equalize andlevel them.




41/79

The Simple Posture Principle

•Stand Tall

•Sit Tall

•Walk Tall


Property of dr Pagan Pambudi, M Si, Sp S


42/79

Stretching

• stretching is a method of physical bodyworkthat lengthens and elongates soft tissues:

• Muscle• Tendon• ligamen• Joint capsule

• the client's body is moved into a position thatcreates a line of tension that pulls on the target

tissues, placing a stretch upon them•




43/79

Stretching

• Stretching is done because soft tissues may increase intensionand become shortened and contracted.

• Shortened and contracted soft tissues resist

lengthening and limit mobility of the joint that theycross

• If the stretch is effective, the tissues will be lengthened.

P pe y f d Pagan Pambudi, M i, p



44/79

g



45/79

How to Stretch(Learn from Trapezius)

• Warmed up

• recall the actions that were learned for thetarget muscle,

• the right upper trapezius, given that its actions are extension, right lateralflexion, and left rotation of the neck at the spinal joints.

• do the opposite of one or more of its actions.• flexion, left lateral flexion, and/or right

rotation of the head and neck at the spinal joints.

• never be done too quickly; stretching shouldalways be done slowly and rhythmically.




46/79

How to Stretch(Learn from Trapezius) • The principle awareness through movement should

be considered

• always without pain

• Hold for 10 – 30 second, can be adjusted wisely,

• Repeat 3 times

• Or Hold for 3 second..repeat 10 times

g



47/79

p y g , , p


48/79

• Imprudent stretching may notonly set back the progress of the client's

treatment program but may also cause

damage that is difficult to reverse.

e s x e acProperty of dr. Pagan Pambudi, M.Si, Sp.S.


49/79

e s x e acPain



50/79

g



51/79



52/79



53/79

Symptoms of QL Problems

• Persisten deep aching in the rest

• excruciating in the unsupported upright position and in sitting orstanding that increasesweight bearing or requires stabilization of the lumbar spine.

• A minimal movement of the lower part of the torso may precipitate a

burst of sharp pain with a knifelike cutting quality,• Painfull when:

• restrict forward bending;

• turning or leaning to the opposite side and

• climbing stairs

• Rolling onto either side from the supine position is painful and difficult



54/79




55/79

p g p



56/79

How to Find QL



57/79



58/79

How to Stretch

• See QL Stretch Video

g



59/79

p g p



60/79

Symptoms and Sign

• restlessness anddiscomfort

• when sitting,• lateral rotation of the thigh at the hip joint resulting in turn-out of

the foot,

• Restricted medial rotation of the thigh at the hip joint, andsacroiliac joint dysfunction

• are often incorrectly assessed assacroiliac joint dysfunction, herniated disc compressionupon spinal nerves L5 or SI ,



61/79

Piriformis Trp Refered Pattern



62/79

HOW TO FIND ?



63/79

p g p



64/79

Piriformis Stretch

• See the Pr Stretch Video

p g p



65/79

Sleep postition

E t S i M ltifid Property of dr. Pagan Pambudi, M.Si, Sp.S.


66/79

Erector Spinae, Multifidus



67/79

Symptom & Sign

• Deep persisten low back pain

• Reduced back ROM

• Vertebral alignment problems

• Paraspinal spasmcoccydynia



68/79



69/79



70/79



71/79



72/79

How to Stretch



73/79

Iliopsoas



74/79

Symptom & Sign

• Back pain

• Groin pain

• Increased hyperlordosis of lumbar spine

• Pain prominent in lying to sitting up

• Pelvis asymetri



75/79



76/79

How to Find



77/79



78/79

How to Stretch

Get your back pain freeProperty of dr. Pagan Pambudi, M.Si, Sp.S.


79/79

Get your back pain free

• You will behealthier.younger,stronger,

happier• and life

longer

Documents

How to Find & Fix Musculoskeletal,