Ilmu Kedokteran Fisik dan Rehabilitasi - 4. dr. Nur Ahlina Damayanti, SpKFR, CPS

Ilmu Kedokteran Fisik

dan Rehabilitasi - 4

MODUL PEMBELAJARAN

Sesi 1 : Pendahuluan, Basic Rehab Sesi 2 : Musculoskeletal, Sports Sesi 3 : Neuromuscular, Pediatric

Sesi 4

: Geriatric, Cardiorespiration

-

Geriatri

-

Parkinson

-

Deconditioning

-

Low Back Pain

-

Palliative Care

-

Cardiac Rehab

Soal

Semua keadaan berikut ini berkaitan dengan geriatric, kecuali …

a.

Mudah lelah

b.

Kecepatan hantaran zat meningkat

c.

Respon rangsang turun

d.

Kemampuan motorik menurun

e.

Gangguan keseimbangan

Perubahan

Fisiologis

pada Usia

Lanjut

Soal

The statement(s) below is/are correct about Parkinson disease:

a.

Most of cases happen in elderly

b.

One complaint that the patient often share is tremor

c.

Mask like face expression

d.

Rigidity and postural instability

e.

All of the above

Parkinson Disease

▪

PD affects 1% of the population older than 60 years of age

▪

Idiopathic PD is a disorder of the basal ganglia due to loss of cells in the

substantia nigra (SN) and locus coeruleus (LC), where dopamine is produced, and degeneration of the nigrostriatal pathway (from SN to the corpus striatum). This results in a decrease in dopamine content in the corpus striatum.

▪

Dopamine plays a part in controlling the movements a person makes, as well as their emotional responses. The right balance of dopamine is vital for both

physical and mental wellbeing.

Sign Symptoms

▪

Resting tremor (“pill-rolling”) usually at 3 to 5 Hz

▪

Bradykinesia/hypokinesia (slowness of movements)

▪

“Cogwheel” rigidity = tremor superimposed on muscular rigidity

▪

Masked facies (hypomimia = expressionless face)

▪

Festinating (shuffling) gait

▪

Postural instability/loss of postural reflexes (with tendency to fall to the side or backward)

▪

“Freezing” phenomena—transient inability to perform or restart certain task

▪

Depression (seen in 1/3 of patients)

▪

Dementia (seen in 1/3 of patients)

▪

Orthostatic hypotension

Disability

▪

Social isolation

▪

Manual dexterity

▪

Walking

▪

Speech impairment

▪

Dysphagia

▪

Drooling

8

Deconditioning Syndrome

▪

Deconditioning : perubahan multipel dalam fisiologi dan anatomi yg

diinduksi oleh inaktifitas fisik dan kondisi ini dapat dibalik melalui aktifitas fisik

▪

Imobilisasi menggambarkan sindroma degenerasi fisiologik → menurunnya aktivitas dan deconditioning

▪

Imobilisasi/tirah baring lama: keadaan tidak bergerak/tirah baring selama 3 hari atau lebih, dengan gerak anatomik tubuh menghilang sebagai akibat

perubahan fisiologik

•Massa otot •Kekuatan

•Fungsi kardiovaskular •Total blood volume •Heart volume

•Toleransi orthostatik •Toleransi latihan

Sindroma dekondisi merupakan

kumpulan gejala :

1.Kelemahan dan atrofi otot 2.Kontraktur

3.Disuse osteoporosis

4.Gangguan Kardiovaskuler 5.Gangguan Respirasi

6.Gangguan pada kulit

7.Gangguan pada sistem gastrointestinal 8.Gangguan pada sistem urinari

9.Perubahan Metabolik dan Nutrisi 10.Komplikasi Psikososial

Soal

Komplikasi bed rest lama, kecuali …

a.

Kelemahan otot

b.

Keterbatasan lingkup gerak sendi

c.

Ulkus dekubitus

d.

Osteoporosis

e.

Semua benar

Soal

One of the statements below are true for deconditioning syndromes, that is :

a.

As blood pools in the legs venous return increased, stroke volume increased

b.

There may be reduced flexibility in joints that lead to joint contractures

c.

With prolonged bed rest in may lead to diuresis and increase in blood and plasma volume

d.

Cardiac output is increased

e.

All of the above

Soal

Untuk mencegah hipotensi ortostatik pada pasien dengan tirah baring lama dilakukan …

a.

Mobilisasi bertahap

b.

Cek tensi tiap 1 jam

c.

Ankle pumping

d.

Latihan LGS

e.

Breathing exrcise

Narasi Soal

LK, 60 th mengeluh nyeri punggung bawah kanan, terasa hingga ke bokong dan tungkai kanan. Nyeri membaik apabila pasien membungkuk. Pada pemeriksaan fisik, didapatkan nyeri tekan pada regio lumbosacral kanan dan nyeri sepanjang tungkai posterior kanan. Pasien mengeluh adanya kesemutan yang menjalar dari

punggung sampai kaki. BAB dan BAK tidak ada keluhan.

Soal

Apakah diagnosa etiologis yang tepat pada pasien tsb?

a.

Traumatic brain injury

b.

Spinal cord injury

c.

Spondilitis tuberculosis

d.

Stenosis canalis

e.

Hernia nucleus pulposus

Soal

Pilih pernyataan yang benar tentang diskus intervertebralis

dibawah ini, kecuali :

a.

Protusi sering kearah postero lateral

b.

Terdiri dari nucleus pulposus dan annulus fibrosus

c.

Annulus fibrosus bagian posterior lebih tebal

d.

Semua pernyataan diatas benar

Post menopausal women with low spine BMD have a greater incidence of compression fractures if the perform :

A.

Walking Exercises

B.

Trunk Flexion Exercises

C.

Trunk Extension Exercises

D.

Stair Climbing

Anamnesis

▪

Lokasi

▪

Sifat

▪

Beratnya nyeri

▪

Waktu : onset, durasi, & frekuensi

▪

Faktor pemicu & pemberat

Soal

The most common cause of falls in the elderly is / are :

a.

Postural hypotension

b.

Weakness

c.

Environmental hazards

d.

Vertigo

e.

Paraparese

26

Risk Factors of Fall

Intrinsic • Advanced age • Previous falls • Muscle weakness

• Gait & balance problems • Poor vision

• Postural hypotension

• Chronic conditions including arthritis, stroke,

incontinence, diabetes, Parkinson’s, dementia

• Fear of falling

Extrinsic • Lack of stair handrails • Poor stair design

• Lack of bathroom grab bars • Dim lighting or glare

• Obstacles & tripping hazards • Slippery or uneven surfaces • Psychoactive medications • Improper use of assistive device

Soal

The role of medical rehabilitation in palliative care are

a.

Psychological support

b.

Physiotherapy, occupational therapy, speech therapy

c.

Spiritual support

d.

All of the above are true

e.

None of above

PALLIATIVE CARE

▪

The goal of palliative care is to improve the quality of life of patients and their families who are facing serious illness, through symptom alleviation, prevention, and relief of suffering.

▪

Rehabilitation goals are changed from return to prior level of function to address issues of mobility, independence, quality of life, and reduced burden of care

Soal

Cardiac output merupakan jumlah darah yang dipompakan jantung

per menit ke seluruh tubuh, komponen yang terlibat pada cardiac

output adalah :

a.

Sistolik

b.

Diastolik

c.

Heart rate

d.

Kontraksi miokard

31

Soal

Latihan aerobik adalah latihan yang membutuhkan :

A.

Metabolisme energi anaerobik

B.

Mengubah molekul glukosa → 2 molekul ATP + asam piruvat / asam laktat

C.

Metabolisme terjadi di luar mitokondria

D.

Bukan salah satu diatas

METABOLISME

ENERGI SAAT

LATIHAN

Glikolisis (Phase I) Glikolisis (Phase II) Siklus Kreb’s Transport Elektron

GLIKOLISIS FASE I

▪

Energy investment phase

▪

ATP yang tersimpan digunakan

untuk membentuk Glyceraldehyde – 3 – phosphate (sugar phosphates)

▪

Digunakan dalam glikolisis fase II

Soal

Cabang arteri koronia kanan memberikan suplai darah ke area berikut ini kecuali :

a.

Dinding lateral ventrikel kiri

b.

Atrium kanan

c.

Ventrikel kanan

d.

Dinding inferior ventrikel kiri

Vascularisation

•

Left Coronary Artery

–

Left Circumflex Artery

→ lateral wall of left ventricle

–

Left Anterior Descending Artery

→

Anterior wall and apex of the left ventricle

→

Most of inter ventricular septum

•

Right Coronary artery

–

Majority of right ventricular wall

–

Inferior left ventricular wall

–

Right Atrium

–

Posterior Descending Artery • interventricular septum

→60% → dominant right coronary

→30 % → equal from right and left circumflex arteries

Soal

Untuk pasien jantung selama latihan yang harus diperhatikan adalah …

a.

Keluhan pasien

b.

Nadi

c.

Pernapasan

d.

A dan B Benar

e.

Semua Benar

39

Soal

Unmodifiable risk pada penyakit jantung koroner adalah

A.

Kolesterol

B.

Hypertensi

C.

Diabetes mellitus

D.

Usia tua

Soal

Untuk mengetahui kemampuan penderita gagal jantung, biasanya dites dengan …

a.

Uji jalan 6 menit

b.

Bicycle

c.

Treadmill

d.

Spirometri

e.

Latihan napas

Uji Latih/ Exercise Testing

▪

Assessment of exercise capacity provides valuable information to guide exercise prescription. This includes subjective assessment of an

individual’s exercise tolerance, and objective exercise test results, which can be used to calculate exercise intensity based on an equation or

algorithm.

▪

When deciding on the most appropriate exercise test, consider:

•

The workload intensity achieved during the assessment and its

implication for risk

•

The clinical risk of patients you are likely to manage within your service

Uji Latih:

Exercise capacity can be assessed by the following tests depending on the facilities available and the level of medical support:

Maximal Test

• _{Laboratory: Cardiopulmonary}

exercise test (CPET)

• _{Field: Incremental shuttle walk test}

(ISWT)

Submaximal Test

• _{Laboratory: submaximal treadmill}

test

• _{Field: Six minute walking test}

6 Minutes Walk Test (6MWT)

•

The 6MWT is a practical simple test to assesses the submaximal level of functional capacity.

•

This test measures the distance that a patient can quickly walk on a 100-ft hallway flat and hard surface in a period of 6 minutes. Subject allowed to choose their own walking speed, also to stop and rest during the test.

Adverse Response to Exercise Leading to Exercise

Discontinuation

SOAL

Pasca infark miokard, setelah hemodinamik stabil:

a.

Tidak boleh memulai latihan terlebih dahulu khawatir eksaserbasi

b.

Paling baik tirah baring untuk mencegah angina berulang

c.

Menunggu 1 bulan untuk keamanan memulai latihan

d.

Segera dilatih secara bertahap

e.

A, C, dan D benar

INFARK MIOKARD

• Aliran darah koroner

menurun secara

mendadak setelah oklusi thrombus pada plak

aterosklerotik yang sudah ada sebelumnya

Goals of cardiac rehabilitation

• Restore and improve cardiac function • Reduce disability

• Identify and improve cardiac risk factors • Increase cardiac conditioning

→Able to resume activities of normal life without significant

cardiac symptomatology

→Specific cardiac conditions will require refinements of the

Stable Condition

• No new/ recurrent chest pain in 8 hours • Neither CK nor troponin levels are rising

• No new signs of uncompensated failure (dyspnea at rest with

bibasilar rales)

• No new significant, abnormal rhythm or ECG changes in past 8

Cardiac Rehabilitation of the post MI

• Acute phase (Phase I) : in hospital period immediately following

the MI, leading up to discharge → early mobilization

• Training phase (Phase II) : after healing is completed, intense

education and aerobic conditioning → desired results of exercise

• Final phase (Phase III) : maintenance of the aerobic

Soal

Program cardiac rehabilitation dapat dimulai pada pasien dengan kondisi di bawah ini, kecuali

a. post myocardial infarc

b. post coronary artery bypass graft c. chronic heart congestive

d. severe arrythmia

Soal

Male, 60 years old, post cardiac insufficiency also has osteoarthritis at right knee. What exercise that can be prescribed as a maintenance exercise for this patient ?

a. running b. walking c. jogging

d. static cycling

Respirasi

Semua proses yang menyebabkan pergerakan

pasif O

₂

dari atmosfer ke jaringan untuk

menunjang metabolism sel, serta pergerakan

pasif CO

₂

selanjutnya yang merupakan produk

Pengukuran pada Pernapasan

▪

Pengukuran volume pernapasan

▪

→Spirometri ( gold standar untuk

diagnosis dan monitor PPOK dan Asma, screening awal untuk deteksi PPOK pada perokok)

Obstructive vs Restrictive

Obstructive Lung Disease

• Chronic obstructive pulmonary

disease (COPD), which includes emphysema and chronic

bronchitis

• Asthma

• Bronchiectasis • Cystic fibrosis

Restrictive Lung Disease

• Interstitial lung disease, such as

idiopathic pulmonary fibrosis

• Sarcoidosis, an autoimmune

disease

• Obesity, including obesity

hypoventilation syndrome

• Scoliosis

• Neuromuscular disease, such as

muscular dystrophy or

amyotrophic lateral sclerosis (ALS)

Soal

The true about breathing mechanism is

a.

Movement of air occurs via bulk flow in which movement of molecules due to pressure difference

b.

While inspiration, intrapulmonary pressure is raised

c.

While inspiration, diaphragm pushes upward, ribs lift outward

d.

While expiration, intrapulmonary pressure is lowered

e.

While expiration, diaphragm contracts, ribs pulled downward

Soal

Yang merupakan otot inspirasi :

a.

Otot – otot interkostal eksternal

b.

Otot – otot interkostal internal

c.

Otot rektus abdominis

d.

Otot transversus abdominis

Soal

Cervical segments that innervates the diaphragm is

a.

C2 – C4

b.

C3 – C5

c.

C1 – C3

d.

C4 – C5

e.

C3 – C6

63

Soal

Pada spirometry, gambaran PPOK adalah

a.

Meningkatnya kapasitas vital

b.

Menurunnya volume ekspirasi paksa

c.

Meningkatny Max voluntary ventilation

d.

Menurunnya frekuensi napas

Soal

Pada penyakit paru restriktif terjadi

a.

Peningkatan FVC yang disertai penurunan FEV1

b.

Penurunan FEV1/FVC yang didahului oleh penurunan FVC

c.

Penurunan FVC dengan FEV1 normal atau menurun

d.

FVC normal dan FEV1 meningkat

e.

Penurunan FEV1%

Sering didapatkan problem lendir paru berlebih sehingga memerlukan postural drainage

a.

Tirah baring lama

b.

PPOK

c.

Dekompensasi kordis

d.

A dan B benar

e.

A, B, dan C benar

POSTURAL DRAINAGE

▪

Intervention for airway clearance

▪

•means of mobilizing secretions in one or more lung segments to the central airways by placing the patient in various positions so gravity assists in drainage process →cleared by coughing or endotracheal suction

Includes the use of manual techniques:

▪

Percussion

▪

Shaking

▪

Vibration

▪

Coupled with voluntary coughing

Indications

Prevent Accumulations of secretions

• Mucus production and

viscosity ↑

• Prolonged bed rest • Patients with general

anaesthesia with painful incisions that restrict deep breathing

• Patients on ventilator

Remove Accumulated Secretions

• Patients with acute or

chronic lung disease

• Patients who are generally

very weak or elderly

• Patients with artificial

airways

69

Thank You!