Ilmu Kedokteran Fisik dan Rehabilitasi - 2. dr. Nur Ahlina Damayanti, SpKFR, CPS

Ilmu Kedokteran Fisik dan

Rehabilitasi - 2

MODUL PEMBELAJARAN

Sesi 1

: Pendahuluan, Basic Rehab

Sesi 2

:

-

Modalities,

-

Basic Anatomy,

-

Osteoarthritis,

-

Capsulitis Adhesiva,

-

Elbow, Knee, Ankle Injury

Sesi 3

: Neuromuscular, Pediatric

Sesi 4

: Geriatric, Cardiorespiration

Definisi Modalitas

▪

Agen fisik yang digunakan untuk

menghasilkan respon terapi

pada jaringan

▪

Terdiri dari panas, dingin, air, suara, listrik, dan

gelombang elektromagnetik (infrared, cahaya

tampak, atau ultraviolet, shortwave, dan

microwave)

▪

Merupakan terapi tambahan untuk membantu

intervensi kuratif primer

W.E. Prentice,Therapeutic Modalities in Rehabilitation, 4th Ed

Classification Of Therapeutic Modalities Under The Various Forms Of Energy

ELECTROMAGNETIC ENERGY MODALITIES

- Shortwave diathermy - Microwave diathermy - Infrared lamps

- Ultraviolet therapy - Low power Laser

THERMAL ENERGY MODALITIES

- Thermotherapy - Cryotherapy

ELECTRICAL ENERGY MODALITIES

- Electrical Stimulating Currents

- Biofeedback - Iontophoresis

SOUND ENERGY MODALITIES

- Ultrasound

- Extracorporal Shockwave Therapy

MECHANICAL ENERGY MODALITIES

- Intermittent Compression

Terapi Panas

Panas superfisial

Panas dalam

Panas superfisial

Botol air panas

Lampu biasa

Hot pack

Parafin bath

Infra merah

▪

Micro wave diathermy (MWD)

▪

Short wave diathermy (SWD)

▪

Ultrasound diathermy (USD)

Panas dalam

Efek panas

▪

Memperbaiki sirkulasi darah di daerah nyeri

▪

↑

metabolisme daerah terapi

▪

Membantu produksi keringat → eliminasi metabolit

▪

↑

ambang rangsang ujung saraf sensorik →nyeri ↓

Efek Fisiologis Panas

Hemodinamik :

Vasodilatasi, ↑ aliran

darah

•↑ nutrisi, leukosit, antibodi

•↑ produk akhir metabolik dan debris •Memfasilitasi resolusi kondisi

inflamasi

→Inflamasi kronik cenderung

mendapatkan manfaat dari panas

•↑ perdarahan,

•↑ terbentuknya edema

•Kondisi inflamasi eksaserbasi akut •Inflamasi akut → diperburuk

dengan panas

Sendi dan Jaringan Ikat : • Memaksimalkan regangan tendon (dikombinasikan dengan latihan) • ↓ kekakuan sendi • ↑ aktivitas enzim

(kolagenase) _{Efek lain-lain:}

• Mengurangi nyeri iskemik,

menghilangkan mediator nyeri, dan ↑ambang batas nyeri

• Relaksasi menyeluruh

Electrotherapy

▪

Electrotherapy is the use of different electric currents (low frequency currents) to stimulate peripheral nervous system to control pain or cause muscle

contraction.

▪

Clinical uses for electrotherapy include pain management, muscle stimulation/re-education, and

▪

medication delivery. The main types of electrotherapy that will be discussed are:

▪

1. Transcutaneous nerve stimulation (TENS)

▪

2. Neuromuscular electrical stimulation (NMES)

▪

3. Iontophoresis

▪

A TENS unit uses a pocket-size programmable device to apply an electrical signal through lead wires and electrodes attached to the patient’s skin. It stimulates nerve fibers for the symptomatic relief of pain.

▪

NMES refers to the process of applying electrical

stimulation above the motor threshold to cause a muscle contraction.

The Gate Control Theory by Melzack and Wall (1965)

Electrical Stimulating Currents

Fungsi:

•

Memodulasi nyeri, stimulasi saraf sensori kulit

menggunakan frekuensi tinggi

•

Menghasilkan kontraksi dan relaksasi otot

•

Memfasilitasi jaringan lunak dan penyembuhan

tulang

•

Menghasilkan gerakan ion melalui arus langsung

yang terus-menerus → menimbulkan perubahan

kimiawi jaringan (iontophoresis)

Soal

Manfaat modalitas fisioterapi :

a.

Mengurangi inflamasi

b.

Mengurangi nyeri

c.

Meningkatkan sirkulasi pembuluh darah

d.

A dan C Benar

e.

A, B, dan C Benar

Soal

A physical therapy that used gait control theory to reduce pain

a.

Heat therapy

b.

TENS

c.

cold therapy

d.

Ultrasound

Soal

Yang termasuk pemanasan dalam

a.

Infrared

b.

Kompres panas

c.

Diathermy

d.

A dan B benar

e.

A, B, dan C benar

17

Soal

Pemanasan dalam sebaiknya tidak diberikan pada penderita:

a.

Cedera tendon akut

b.

Kanker

c.

Nyeri sendi kronik

d.

A dan B benar

e.

A, B, dan C benar

Soal

Quadriceps femoris muscles has a double function of the lower

extremities:

a.

Flexor hip – flexor knee

b.

Flexor hip – extensor knee

c.

Extensor hip – extensor knee

d.

Flexor hip – rotator knee

e.

Extensor hip – extensor knee

Soal

Struktur yang terdapat pada insersi otot sartorius, gracilis semitendinosus dan colateral medial ligamen adalah

a.

baker cyst

b.

Pes anserinus

c.

Posterior bursa

d.

infrapatellar bursa

Rectus

Femoris MedialisVastus IntermediusVastus LateralisVastus

O Anterior inferior iliac spine Medial aspect of the linea aspera Anterior, lateral, and medial surfaces of the femur Lateral aspect of the linea aspera I Tibial

tuberosity Tibialtuberosity Tibialtuberosity Tibialtuberosity A Hip flexion, knee extension Hip flexion, knee extension Hip flexion,

knee extension Hip flexion, knee extension

N Femoral

Bursa

•

Bursa secara struktural mirip dan biasanya lanjutan ruang synovial sendi.

▪

Normalnya berada di sisi gerak jaringan.

▪

Fungsinya mencegah friksi dan mengurangi peradangan diantara kedua permukaan

Bi-articular Muscle

▪

These muscles generally cross two joints and influence movement at both.

▪

A direct head and a reflected head form its proximal attachments. The direct attachment arises from the anterior inferior iliac spine (AIIS) of the pelvis, while the reflected attachment emerges from the rim of the acetabulum and the fibrous capsule of the hip joint. The two proximal attachments quickly blend into a common belly that coalesces into the quadriceps tendon and, in conjunction with the vasti muscles, then inserts on the tibial tuberosity

▪

The knee extension work of the quadriceps group is widely known and well documented with a 60 - 90° knee angle appearing optimal.

▪

Although the function of the RF as a hip flexor is largely unknown, anatomists have traditionally included it with the hip flexor group

Soal

Serabut Otot tipe I:

a.

Kontraksi cepat

b.

Kaya glikogen

c.

Metabolisme tergantung aerobic

d.

Diameter besar

Muscle

Type

RHEUMATOLOGY

ACR Criteria Knee OA

33

Clinical and Labaratory Clinical and Radiographic Clinical

Knee pain + at least 5 of 9 - Age > 50 yo - Stiffness < 30 min - Crepitus - Bony tenderness - Bony enlargement - No palpable warmth - ESR < 40 mm/h - RF < 1:40

- Synovial fluid consisten with OA

Knee pain + at least 1 of 3 - Age > 50 yo

- Stiffness < 30 min - Crepitus + osteophytes

Knee pain + at least 3 of 6 - Age > 50 yo - Stiffness < 30 min - Crepitus - Bony tenderness - Bony enlargement - No palpable warmth

Sensitivity 92% Sensitivity 91% Sensitivity 95%

Pathology

• Early → Hypercellularity of chondrocytes.

–– Cartilage breakdown: Swelling and loosening of collagen framework. –– Increased proteoglycan synthesis.

–– Minimal inflammation.

• Later → Cartilage fissuring, pitting, and destruction. –– Hypocellularity of chondrocytes.

–– Inflammation secondary to synovitis.

–– Osteophytes spur formation—seen at the joint margins. –– Subchondral bone sclerosis (eburnation).

–– Cyst formation in the juxta-articular bone. –– Loss of proteoglycans.

–– Increased water content of OA cartilage leads to damage of the collagen network (increased

Radiological

Findings

Narasi Soal

Seorang ibu rumah tangga berusia 55 tahun dengan indeks massa tubuh

32kg/m2 mengeluh nyeri lutut kanan. Nyeri dirasakan sejak dua tahun yang

lalu, namun hilang timbul. Nyeri timbul apabila pasien berjalan jauh, berdiri

lama, atau sering naik turun tangga. Apabila merasakan nyeri, ia berobat ke

dokter praktek di dekat rumahnya, diberikan obat penghilang rasa nyeri, dan nyeri menghilang. Namun 1 bulan ini nyeri yang dirasakan lebih berat, dan

tidak menghilang walaupun minum obat anti nyeri. Pada pemeriksaan fisik ekstremitas inferior dekstra tidak menunjukkan adanya gangguan neurologis.

Status lokalis genu dekstra tidak didapatkan tanda-tanda inflamasi (merah, eodem, hangat), dan krepitasi. Pemeriksaan radiologis right knee joint

menunjukkan adanya osteofit dan penyempitan celah sendi.

Soal

Characteristic of OA, except:

a.

Bone tenderness

b.

Stiffness < 30 minutes

c.

Bone spur/ Osteophytes

d.

Pain at night

Soal

Dasar teori apa yang berkaitan dengan diagnosa etiologis

pasien tersebut diatas?

a.

Degeneratif

b.

Inflamasi

c.

Weight bearing associated mechanical stress

d.

A, B, dan C benar

e.

A, B, dan C salah

Soal

Characteristic of osteoarthritis of the hands, except

a.

osteopenia

b.

subchondral sclerosis

c.

narrowing joint space

d.

Cartilage breakdown

Soal

Based on Kellgren Lawrence classification, osteoarthritis is differentiated into how many grades

a.

6

b.

5

c.

4

d.

3

e.

2

40

Soal

Jika tanda- tanda akut tidak ada, exercise jenis apa yang paling

baik diberikan pada pasien tersebut?

a.

Swimming

b.

Jogging

c.

Cycling

d.

A dan b benar

e.

A dan C benar

41

Soal

Criteria for Rheumatoid Arthritis according to American College of Rheumatology guidelines, except

a.

> 3 small joints

b.

nodule

c.

asymmetrical

d.

morning stiffness

Soal

A Boutinnere deformity is a deformed position of finger joint resulting a hyperextention of

a.

Rheumatoid Arthritis - distal interphalanges

b.

Rheumatoid Arthritis - proximal interphalanges

c.

Osteo Arthritis - distal interphalanges

d.

Osteo Arthritis - proximal interphalanges

Rheumatoid Arthritis

Joints commonly involved

-

Hands and wrist

-

Cervical spine – C1 to C2 → atlanto-axial subluxation

-

Feet and ankles

-

Hips and knees

ACR Classification Criteria for RA

1. Morning joint stiffness:

• In and around the joints. Must last at least 1 hour before maximal improvement. 2. Arthritis of three or more joints:

• Three or more joint areas simultaneously affected with soft-tissue swelling or fluid 3. Arthritis of the hand joints:

4. Symmetric arthritis: 5. Rheumatoid nodules:

• Subcutaneous nodules over extensor surfaces, bony prominences, or in juxta-articular regions, observed by a physician.

6. Rheumatoid factor (RF) positive 7. Radiographic changes:

• Erosions, bony decalcification, and symmetric joint-space narrowing seen on hand and wrist X-rays

Boutonniere Deformity

• _{Weakness or rupture of the}

terminal portion of the extensor hood (tendon or central slip) at the PIP joint, which holds the lateral bands in place.

• MCP hyperextension

• _{PIP flexion}

• DIP hyperextension

Note: Positioning of the finger as if

you were buttoning a button (Boutonnière = “buttonhole”)

Swan Neck Deformity

• _{due to synovitis at the MCP,}

PIP, or DIP (rare) joint.

• Flexor tenosynovitis -> MCP flexion contracture.

• _{Contracture of the intrinsic}

(lumbricals, interosseous) → PIP hyperextension.

• _{Contracture of deep finger}

flexor muscles and tendons → DIP flexion.

Ulnar Deviation of the Fingers

• _{Weakening of the extensor}

carpi ulnaris, ulnar, and radial collateral ligaments.

• _{Wrist deviates radially.}

• _{Increases the torque of the}

stronger ulnar finger flexors.

• _{Flexor/extensor mismatch}

causes ulnar deviation of the fingers as the patient tries to extend the joint.

SHOULDER

FUNCTIONAL ANATOMY (SHOULDER)

Ranges of Motion of the Shoulder

▪

Shoulder flexion: 180°

▪

Shoulder extension: 60°

▪

Shoulder abduction: 180°

–– Shoulder abduction of 120° is seen in normals with the thumb pointed down.

▪

Shoulder adduction: 60°

▪

Shoulder internal rotation: 90° (with arm abducted)

Shoulder Joint Stability

Dynamic Stabilizers

▪

Surround the humeral head and help to approximate it into the glenoid fossa.

▪

Rotator cuff muscles: “Minor S.I.T.S.” –– Supraspinatus

–– Infraspinatus –– Teres minor –– Subscapularis

• Long head of the biceps tendon, deltoid, and teres major, latissimus dorsi.

SHOULDER

SPECIAL

ADHESIVE CAPSULITIS (FROZEN SHOULDER)

▪

Painful shoulder with restricted glenohumeral motion.

▪

Contracture of the shoulder joint.

▪

Unclear etiology may be autoimmune, trauma, inflammatory.

▪

More common in women over the age of 40 years. Stages

▪

Painful stage: Progressive vague pain lasting roughly 8 months.

▪

Stiffening stage: Decreasing ROM lasting roughly 8 months.

▪

Thawing stage: Increasing ROM with decrease of shoulder pain. Pathology

Treatment

▪

Rehabilitation

–– Restoring PROM and AROM. –– Decreasing pain.

–– Corticosteroid injection: Subacromial and glenohumeral will decrease pain to maximize therapy.

–– Home program: Stretches in all ranges of motion. –– Modalities: Ultrasound and electrical stimulation.

▪

Surgical

–– Manipulation under anesthesia may be indicated if there is no substantial progress after 12 weeks of conservative treatment.

–– Arthroscopic lysis of adhesions—usually reserved for patients with IDDM who do not respond to manipulation.

Narasi Soal

Ny. A, seorang guru berusia 39 tahun mengeluh nyeri dan kesulitan

menggerakkan bahu kanan. Nyeri yang dirasakan pertama kali terjadi pada

bahu bagian anterior sejak 5 bulan yang lalu setelah mengangkat tangannya secara berlebihan karena hendak menulis di bagian papan tulis yang terlampau

tinggi. Sejak saat itu, ia mulai merasakan nyeri jika melakukan gerakan fleksi

dan abduksi pada bahu sehingga mulai membatasi gerakan bahunya. Saat ini nyeri terus menerus terjadi walaupun tanpa digerakkan. Pada pemeriksaan

fisik regio bahu kanan terdapat nyeri tekan pada tendon proksimal m. biceps

dektra. Tes provokasi Yergason test (+). Luas gerak sendi terbatas ke semua arah baik aktif maupun pasif.

Soal

Apakah diagnosis klinis yang tepat pada pasien diatas?

a.

OA shoulder dekstra

b.

Capsulitis adhesiva dekstra

c.

Shoulder impigement syndrome

d.

Degenerative joint disease of shoulder

e.

Glenohumeral joint injuries

Soal

Berapa fase dan urutan dari perjalanan penyakit tersebut?

a.

2 fase ; painful stage – stiffening stage

b.

2 fase ; painful stage – thawing stage

c.

2 fase ; stiffening stage – thawing stage

d.

3 fase ; painfull stage – stiffening stage – thawing stage

e.

3 fase ; painfull stage – thawing stage – stiffening stage

Soal

Terapi apa yang paling tepat diberikan pada pasien tersebut?

a.

Decreasing pain medication

b.

Ultrasound diathermy and TENS

c.

Restoring active and passive movement exercise

d.

Semua salah

e.

Semua benar

Soal

Otot – otot rotator cuff dibawah ini mempunyai insersi pada tuberositas mayor, kecuali :

a.

M. Supraspinatus

b.

M. Infraspinatus

c.

M. Subscapularis

d.

M. Teres Minor

Soal

If the drop arm test is positive (pada rotater cuff tear), injury of all the following muscles,except:

a.

Infraspinatus

b.

Teres minor

c.

Supraspinatus

d.

Teres mayor

62

Soal

Muscle for shoulder abduction is….

a.

Teres minor

b.

Infraspinatus

c.

Supraspinatus

d.

Subscapularis

e.

Deltoid posterior

63

ELBOW

Soal

Penyakit Tennis Elbow disebabkan peradangan pada :

a.

Epicondylus lateralis

b.

Epicondylus medialis

c.

Pergelangan tangan

d.

Insertio Tendon Brachialis

Inflammation of the common flexor tendon at the elbow is called

a.

Tennis Elbow

b.

Golfer’s Elbow

c.

Lateral epicondylitis

d.

Olecranon Bursitis

e.

Distal biceps tendinitis

Introduction

▪

The elbow complex is made of three bones, three ligaments, two joints : humeroulnar and humeroradial joints (another joint, the proximal radioulnar articulation, is the third joint of the elbow complex) and one capsule

Bones

▪

The most distinct palpable bony landmarks are the epicondyles (medial and lateral)

▪

The medial epicondyle serves as the proximal attachment site for a primary forearm

pronator (pronator teres), for a major stabilizing ligament (the ulnar collateral ligament), and for most of the wrist and finger flexor muscles.

▪

The lateral epicondyle : attachment for many of the wrist and finger/thumb extensors and the forearm supinator.

▪

Lateral supracondylar ridge, a landmark that is palpable between the lateral head of the triceps posteriorly and the brachioradialis muscle anteriorly.

Common Elbow Pathologies

▪

Lateral epicondylitis, also know as tennis elbow, is a very common overuse condition of the common extensor tendon where it inserts into the lateral epicondyle of the humerus.

▪

Medial epicondylitis, also know as golfer’s elbow, is an inflammation of the common flexor tendon that inserts into the medial epicondyle.

▪

Volkmann’s ischemic contracture is the result of ischemic necrosis of the forearm muscles caused by trauma to the brachial artery.

ANKLE SPRAINS

Soal

The weakest ligament on the ankle is:

a.

The calcaneo fibular ligament

b.

The anterior talofibular ligament

c.

The posterior talofibular ligament

d.

The strong medial deltoid ligament

SPRAINS VS STRAINS

• Ankle sprains are caused by

direct or indirect trauma to the ankle ligaments

STRAINS

• ankle strain is an injury that occurs

when ankle muscles and/or their connecting tendons are either

stretched beyond their normal limits or torn outright

Ankle Sprains

Mechanism of Injury

▪

Inversion of a plantar-flexed foot places the foot in the most vulnerable position to cause ligamentous injury.

▪

History of “rolling over” the

ankle.

▪

A sprained ankle is the single most

common injury among badmi nton players.

Anterior drawer stress view of ankle. This technique detects anterior

talofibular ligament insufficiency. Cross-table lateral views of the ankle both at rest (A) and with vertical stress applied (B) are taken with the heel elevated on a support. A positive examination shows greater than 4 mm anterior displacement (arrow) of the talus when vertical stress is applied, illustrated in images C and D

ANTERIOR

CRUCIATE

LIGAMENT

Soal

Special test for anterior cruciate ligament injury is

a.

Distraction test

b.

Drawer test

c.

Pivot test

d.

Lachmann test

ACL injury

▪

Patients typically develop a rapidly developing effusion (hemarthrosis) and ‘‘pop’’ sign, usually during a pivot motion. The most common tests are the Lachman, anterior drawer sign, and pivot shift test

▪

Lachman test: Patient lies supine. Knee is flexed approximately 20 degrees and the proximal tibia is pulled forward to assess excessive translation (more than 5 mm).

▪

Anterior drawer test: Patient lies supine. Knee is flexed at 90 degrees and the hip is flexed at 45 degrees. The proximal tibia is pulled anteriorly to assess excessive translation (more than 5 mm).

▪

Pivot shift test: Patient lies supine. Knee is placed in extension. The examiner supports the leg by

the upper tibia and flexes the knee while applying a slight valgus stress to the knee (pushing the knee toward the midline) and internal rotation stress about the femur. In a knee with an ACL injury, the femur sags backward on the tibia (or conversely, the tibia moves forward on the femur),

Ligaments of the Knee

▪

Anterior cruciate ligament (ACL): Prevents anterior displacement of the tibia over the femur and provides rotational (torsional) stability

▪

Posterior cruciate ligament (PCL): Prevents the femur from sliding forward on the tibia (or the tibia from sliding backward on the femur)

▪

Medial collateral ligament (MCL): Connects the femur to the tibia and stabilizes the medial side of the knee

▪

Lateral collateral ligament (LCL): Connects the femur to the fibula and stabilizes the lateral side of the knee

Soal

Therapies used in the treatment of sports injuries, except

a.

Icing

b.

ROM exercise

c.

Elevation the injured area

d.

Compression

83

Thank You!