Ilmu Kedokteran Fisik dan Rehabilitasi - 4

dr. Nur Ahlina Damayanti, SpKFR, CPS

MODUL PEMBELAJARAN

Sesi 1 : Pendahuluan, Basic Rehab

Sesi 2 : Musculoskeletal, Sports

Sesi 3 : Neuromuscular, Pediatric

Sesi 4 : Geriatric, Cardiorespiration

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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

3

PerubahanFisiologispada UsiaLanjut

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

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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)

▪ Orthostatic hypotension

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Disability

▪ Social isolation

▪ Manual dexterity

▪ Walking

▪ Speech impairment

▪ Dysphagia

▪ Drooling

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Deconditioning Syndrome

▪ Deconditioning : perubahan multipeldalam fisiologi dan anatomi ygdiinduksi oleh inaktifitas fisik dan kondisi ini dapat dibalik melaluiaktifitas fisik

▪ Imobilisasi menggambarkan sindromadegenerasi fisiologik → menurunnyaaktivitas dan deconditioning

▪ Imobilisasi/tirah baring lama: keadaantidak bergerak/tirah baring selama 3 hari atau lebih, dengan gerak anatomiktubuh menghilang sebagai akibatperubahan 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

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Soal

Komplikasi bed rest lama, kecuali …

a. Kelemahan otot

b. Keterbatasan lingkup gerak sendi

c. Ulkus dekubitus

d. Osteoporosis

e. Semua benar

12

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 above13

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

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▪ 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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17

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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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

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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

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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

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23

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

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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28

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

Transport

Elektron

GLIKOLISIS FASE I

▪ Energy investment phase

▪ ATP yang tersimpan digunakanuntuk 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 diubahmenjadi laktat atau transfer kemitokondria

▪ Latihan intensitas tinggi→ piruvatdiproduksi lebih cepat dibandingkankecepatan memasuki mitokondria→ banyak piruvat yang diubahmenjadi laktat→ kadar laktatdarah tinggi

SIKLUS KREB’S▪ Melengkapi oksidasi karbohidrat (piruvat),

asam lemak, atau asam amino, menghasilkanCO2

▪ Untuk menyediakan energi untuk produksiATP secara aerobik

▪ Hasil akhir: + 36 ATP

Soal

Cabang arteri koronia kanan memberikan suplai darah ke area berikutini kecuali :

a. Dinding lateral ventrikel kiri

b. Atrium kanan

c. Ventrikel kanan

d. Dinding inferior ventrikel kiri

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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

→10 % → dominant form left circumflex arteri

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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

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Soal

Unmodifiable risk pada penyakit jantung koroner adalah

A. Kolesterol

B. Hypertensi

C. Diabetes mellitus

D. Usia tua

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39

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

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

Maximal Test

• Labaratory: Cardiopulmonary exercise test (CPET)

• Field: Incremental shuttle walk test (ISWT)

Submaximal Test

• Labaratory: submaximal treadmill test

• Field: Six minute walking test

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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.

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

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INFARK MIOKARD

• Aliran darah koronermenurun secaramendadak setelah oklusithrombus pada plakaterosklerotik yang sudahada sebelumnya

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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 exercise prescription

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

• Final phase (Phase III) : maintenance of the aerobic conditioning gains → program of regular 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

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Respirasi

Semua proses yang menyebabkan pergerakanpasif O2 dari atmosfer ke jaringan untuk

menunjang metabolism sel, serta pergerakanpasif CO2 selanjutnya yang merupakan produk

sisa metabolism dari jaringan ke atmosfer

Muscles

Pengukuran pada Pernapasan

▪ Pengukuran volume pernapasan

▪ →Spirometri ( gold standar untukdiagnosis dan monitor PPOK danAsma, screening awal untuk deteksiPPOK 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

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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

Cervical segments that innervates the diaphragm is

a. C2 – C4

b. C3 – C5

c. C1 – C3

d. C4 – C5

e. C3 – C6

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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 capacity61

Soal

Pada spirometry, gambaran PPOK adalah

a. Meningkatnya kapasitas vital

b. Menurunnya volume ekspirasi paksa

c. Meningkatny Max voluntary ventilation

d. Menurunnya frekuensi napas

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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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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

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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 coughing65

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

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Indications

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

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Complication of ventilationComplications associated with mechanical ventilation can be divided into:

1. Infection (Ventilator-associated pneumonia)

2. Lung Damage (Ventilator-associated lung injury)

3. Other Risks

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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.

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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

• Hypoxemia

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OTHER RISKS

• Delirium

• Immobility

• Vocal cord problems

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Thank You!

NADH