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

Ilmu Kedokteran Fisik dan Rehabilitasi - 4

dr. Nur Ahlina Damayanti, SpKFR, CPS

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Sesi 1 : Pendahuluan, Basic Rehab Sesi 2 : Musculoskeletal, Sports

Sesi 3 : Neuromuscular, Pediatric Sesi 4 : Geriatric, Cardiorespiration

MODUL PEMBELAJARAN

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.

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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

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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

•Kepadatan mineral tulang

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

11.Gangguan Susunan Saraf Pusat dan Perifer

Soal

Komplikasi bed rest lama, kecuali …

a.

Kelemahan otot

b.

Keterbatasan lingkup gerak sendi

c.

Ulkus dekubitus

d.

Osteoporosis

e.

Inkontinensia urin

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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

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

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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

d.

Stair Climbing



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.

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Wedging

Soal

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

a.

Postural hypotension

b.

^Weakness

c.

Environmental hazards

d.

^Vertigo

e.

^Paraparese

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 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

Risk Factors of Fall

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



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

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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

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MMSE

Moca-Ina

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Soal

The following are walking aid that commonly used by elderly people, except

a.

Bilateral axillaty crutch

b.

^Tripod

c.

^Cane

d.

^Walker

e.

^Quadripod

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

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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

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METABOLISME ENERGI SAAT LATIHAN

Glikolisis (Phase I)

Glikolisis (Phase II)

Siklus Kreb’s

GLIKOLISIS FASE I



Energy investment phase



ATP yang tersimpan digunakan

untuk membentuk Glyceraldehyde – 3 – phosphate (sugar phosphates)



Digunakan dalam glikolisis fase II



Hasil akhir: - 1 sampai 2 ATP

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



CO2Untuk menyediakan energi untuk produksi ATP secara aerobik



Hasil akhir: + 36 ATP

Soal

Kegiatan berikut ini berkaitan dengan rehabilitasi medik usia lanjut pada kasus kardiorespirasi, kecuali …

a.

Latihan napas

b.

Hemat energy

c.

Kegiatan anaerob

d.

Kegiatan respirasi dan sepeda

e.

Menghindari latihan berat dan cepat

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

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•

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

Vascularisation

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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

Soal

Unmodifiable risk pada penyakit jantung koroner adalah

A.

^Kolesterol

B.

^Hypertensi

C.

Diabetes mellitus

D.

^{Usia tua}

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Soal

Untuk mengetahui kemampuan penderita gagal jantung, biasanya dites dengan …

a.

Uji jalan 6 menit

b.

^Bicycle

c.

^Treadmill

d.

^Spirometri

e.

Latihan napas

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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 (exercise stress test; EST)

•

Cardiopulmonary exercise test (CPET)

•

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

•

Submaximal treadmill test

•

Incremental shuttle walk test (ISWT)

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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.

1.

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

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Aliran darah koroner menurun secara

mendadak setelah oklusi thrombus pada plak aterosklerotik yang sudah ada sebelumnya

INFARK MIOKARD

 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 exercise prescription

Goals of cardiac rehabilitation

 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 conditioning gains → program of regular exercise

Cardiac Rehabilitation of the post MI

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

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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

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

Muscles

Inspirasi dan Ekspirasi

Soal

Yang merupakan otot inspirasi :

a.

Otot – otot interkostal eksternal

b.

Otot – otot interkostal internal

c.

Otot rektus abdominis

d.

Otot transversus abdominis

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Soal

1.

Cervical segments that innervates the diaphragm is

a.

^{C2 – C4}

b.

^{C3 – C5}

c.

^{C1 – C3}

d.

^{C4 – C5}

e.

^{C3 – C6}

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

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Soal

Pada spirometry, gambaran PPOK adalah

a.

Meningkatnya kapasitas vital

b.

Menurunnya volume ekspirasi paksa

c.

Meningkatny Max voluntary ventilation

d.

Menurunnya frekuensi napas

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 muscular dystrophy or

Restrictive Lung Disease

 Chronic obstructive

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

 Asthma

 Bronchiectasis

 Cystic fibrosis

Obstructive Lung Disease

Obstructive vs Restrictive

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%

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Thank You!