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

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

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

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)

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

•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

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

SOAL

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

▪

Osteoporosis is a bone disease in which the amount of bone is

decreased and the structural integrity of trabecular bone is impaired.

▪

Cortical bone becomes more porous and thinner. This makes the bone weaker and more likely to fracture.

SOAL

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

a.

Postural hypotension

b.

Weakness

c.

Environmental hazards

d.

Vertigo

20 • 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 Extrinsic

• 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 Intrinsic

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

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

Mini Mental State Test, didisain untuk menilai

A.

Kemampuan fungsi kognitif

B.

Adanya afasia atau tidak

C.

Kemampuan fungsional / aktivitas kehidupan sehari-hari

D.

Adanya gangguan visuospasial

MOCA-INA

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

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

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)

GLIKOLISIS FASE II

▪

Energy generation phase

▪

Hasil akhir: + 2 – 3 ATP

▪

Piruvat yang terbentuk diubah menjadi laktat atau transfer ke mitokondria

▪

Latihan intensitas tinggi → piruvat diproduksi lebih cepat dibandingkan kecepatan memasuki mitokondria → banyak piruvat yang diubah menjadi laktat → kadar laktat darah tinggi

SIKLUS KREB’S

▪

Melengkapi oksidasi karbohidrat (piruvat), asam lemak, atau asam amino, menghasilkan CO2

▪

Untuk menyediakan energi untuk produksi ATP secara aerobik

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

SOAL

Untuk pasien jantung selama latihan yang harus diperhatikan adalah …

a.

Keluhan pasien

b.

Nadi

c.

Pernapasan

d.

A dan B Benar

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

UJI LATIH

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

•

Maximal test (exercise stress test; EST)

•

Cardiopulmonary exercise test (CPET)

•

Submaximal test (six-minute walk test; 6MWT)

•

Submaximal treadmill test

•

Incremental shuttle walk test (ISWT)

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

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

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

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 hour

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

SOAL

Yang harus diperhatikan saat pemeriksaan fisik paru dalam menunjang perencanaan program rehabilitasi paru adalah:

a.

Penilaian fungsi

b.

Penilaian musculoskeletal

c.

Penilaian neurologi

d.

Pemeriksaan umum

e.

Semua benar 50

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

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 sisa metabolism

dari jaringan ke atmosfer

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

SOAL

Which of the following cannot be measured with a simple spirometer and stopwatch?

a.

Vital capacity

b.

Tidal volume

c.

Total ventilation

d.

Residual volume

e.

Force vital capacity

SOAL

Pada spirometry, gambaran PPOK adalah

a.

Meningkatnya kapasitas vital

b.

Menurunnya volume ekspirasi paksa

c.

Meningkatny Max voluntary ventilation

PENGUKURAN PADA PERNAPASAN

▪

Pengukuran volume pernapasan

▪

→Spirometri ( gold standar untuk diagnosis dan monitor PPOK dan Asma, screening awal untuk deteksi PPOK pada perokok)

• Interstitial lung disease, such as idiopathic pulmonary fibrosis

• Sarcoidosis, an autoimmune disease

• Obesity, including obesity hypoventilation syndrome

• Scoliosis

• Neuromuscular disease, such as

Restrictive Lung Disease

• Chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis

• Asthma

• Bronchiectasis

• Cystic fibrosis

Obstructive Lung Disease

SOAL

Pada penyakit paru restriktif terjadi

a.

Peningkatan FVC yang disertai penurunan FEV1

b.

Penurunan FEV1/FVC yang didahului oleh penurunan FVC

c.

Penurunan FV 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

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

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

• Patients with acute or chronic lung disease

• Patients who are generally very weak or elderly

• Patients with artificial airways

REMOVE ACCUMULATED SECRETIONS

SOAL

In patient with prolonged ventilator, the most common cause of death is..

a. Pulmonary emboli b. Pneumothorax c. Pneumonia d. Flail chest e. Renal failure 68

COMPLICATION OF VENTILATION

Complications associated with mechanical ventilation can be divided into:

1. Infection (Ventilator-associated pneumonia)

2. Lung Damage (Ventilator-associated lung injury)

VAP

• Ventilator-associated pneumonia (VAP) is a life threatening complication with mortality rate of 33 – 50%. The risk of VAP is highest immediately after intubation.

VALI

• If the force or amount of air is too much, or if your lungs are too weak, it can damage your lung tissue

• Pneumothorax

• Pulmonary edema

OTHER RISKS

• Delirium

• Immobility

• Vocal cord problems