Ilmu Kedokteran Fisik dan Rehabilitasi - 2

dr. Nur Ahlina Damayanti, SpKFR, CPS

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, Cardiorespiration2

Definisi Modalitas

▪ Agen fisik yang digunakan untukmenghasilkan respon terapi pada jaringan

▪ Terdiri dari panas, dingin, air, suara, listrik, dan gelombang elektromagnetik (infrared, cahayatampak, atau ultraviolet, shortwave, dan microwave)

▪ Merupakan terapi tambahan untuk membantuintervensi 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

- Traction

- Massage

Terapi Panas

Panas superfisial Panas dalam

Dry heat Moist heat

Panas superfisial

Botol air panas

Lampu biasa

Hot pack

Parafin bath

Infra merah

Kompres sederhana

▪ 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 pskis → rasa nyaman & relaksasi psikis

Efek Fisiologis Panas

Hemodinamik :

Vasodilatasi, ↑ aliran

darah

•↑ nutrisi, leukosit, antibodi•↑ produk akhir metabolik dan debris•Memfasilitasi resolusi kondisiinflamasi→ Inflamasi kronik cenderungmendapatkan manfaat dari panas

•↑ perdarahan,

•↑ terbentuknya edema

•Kondisi inflamasi eksaserbasi akut

•Inflamasi akut → diperburuk

dengan panas

Sendi dan Jaringan Ikat :• Memaksimalkanregangan tendon (dikombinasikan denganlatihan)• ↓ kekakuan sendi• ↑ aktivitas enzim(kolagenase) Efek lain-lain:

• Mengurangi nyeri iskemik, menghilangkan mediator nyeri, dan↑ambang batas nyeri• Relaksasi menyeluruh• Endorphin mediated responsed

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

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▪ 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.

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The Gate Control Theory by Melzack and Wall (1965)

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Electrical Stimulating Currents

Fungsi:

• Memodulasi nyeri, stimulasi saraf sensori kulitmenggunakan frekuensi tinggi

• Menghasilkan kontraksi dan relaksasi otot

• Memfasilitasi jaringan lunak dan penyembuhantulang

• Menghasilkan gerakan ion melalui arus langsungyang terus-menerus → menimbulkan perubahankimiawi 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

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Soal

A physical therapy that used gait control theory to reduce pain

a. Heat therapy

b. TENS

c. cold therapy

d. Ultrasound

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Soal

Yang termasuk pemanasan dalam

a. Infrared

b. Kompres panas

c. Diathermy

d. A dan B benar

e. A, B, dan C benar

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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

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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

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Rectus

Femoris

Vastus

Medialis

Vastus

Intermedius

Vastus

Lateralis

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

ITibial

tuberosity

Tibial

tuberosity

Tibial

tuberosity

Tibial

tuberosity

A Hip

flexion,

knee

extension

Hip flexion,

knee

extension

Hip flexion,

knee extension

Hip flexion,

knee extension

N Femoral

nerve

Femoral

nerve

Femoral nerve Femoral nerve

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

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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

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Bursa

• Bursa secara struktural mirip dan biasanya lanjutan ruang synovial sendi.

▪ Normalnya berada di sisi gerak jaringan.

▪ Fungsinya mencegah friksi dan mengurangi peradangan diantarakedua permukaan

Bursa (2)

Soal

Serabut Otot tipe I:

a. Kontraksi cepat

b. Kaya glikogen

c. Metabolisme tergantung aerobic

d. Diameter besar

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MuscleType

RHEUMATOLOGY

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ACR Criteria Knee OA

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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%

Specificity 75% Specificity 86% Specificity 69%

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 chondrocytes, collagen, and enzymes). 34

RadiologicalFindings

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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 jointmenunjukkan adanya osteofit dan penyempitan celah sendi.

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Soal

Characteristic of OA, except:

a. Bone tenderness

b. Stiffness < 30 minutes

c. Bone spur/ Osteophytes

d. Pain at night

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Soal

Dasar teori apa yang berkaitan dengan diagnosa etiologispasien tersebut diatas?

a. Degeneratif

b. Inflamasi

c. Weight bearing associated mechanical stress

d. A, B, dan C benar

e. A, B, dan C salah

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Soal

Characteristic of osteoarthritis of the hands, except

a. osteopenia

b. subchondral sclerosis

c. narrowing joint space

d. Cartilage breakdown

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Soal

Based on Kellgren Lawrence classification, osteoarthritis is

differentiated into how many grades

a. 6

b. 5

c. 4

d. 3

e. 2

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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

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Soal

Criteria for Rheumatoid Arthritis according to American College of

Rheumatology guidelines, except

a. > 3 small joints

b. nodule

c. asymmetrical

d. morning stiffness

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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

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Rheumatoid Arthritis

Joints commonly involved

- Hands and wrist

- Cervical spine – C1 to C2 → atlanto-axial subluxation

- Feet and ankles

- Hips and knees

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ACR Classification Criteria for RA1. 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

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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”)

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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.

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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.

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SHOULDER

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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 external 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.

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SHOULDER SPECIAL TESTS

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

▪ Synovial tissue of the capsule and bursa become adherent.

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 SoalNy. 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. bicepsdektra. Tes provokasi Yergason test (+). Luas gerak sendi terbatas ke semua

arah baik aktif maupun pasif.

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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

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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

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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

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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

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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

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Soal

Muscle for shoulder abduction is….

a. Teres minor

b. Infraspinatus

c. Supraspinatus

d. Subscapularis

e. Deltoid posterior

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ELBOW

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Soal

Penyakit Tennis Elbow disebabkan peradangan pada :

a. Epicondylus lateralis

b. Epicondylus medialis

c. Pergelangan tangan

d. Insertio Tendon Brachialis

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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

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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

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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

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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

SPRAIN

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 badminton 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

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Soal

Special test for anterior cruciate ligament injury is

a. Distraction test

b. Drawer test

c. Pivot test

d. Lachmann test

e. Mc Murray 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), creating a subluxation of the lateral tibiofemoral compartment.

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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

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Thank You!

NADH