Management in Rheumatic

Conditions
(OA, RA, AS)
Angela BM Tulaar
 Definitions
Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis
• A type of arthritis caused The most common form of • Ankylosing spondylitis (AS) is
by inflammation, inflammatory arthropaties a complex and debilitating
breakdown, and eventual and diagnosis is often disease with a worldwide
loss of cartilage in the difficult in the early stage. prevalence ranging up to
joints. Also known as 0.9%. 1 Its aetiology and
• Systemic Rheumatic
degenerative arthritis. pathogenesis are not yet fully
Disease as the result of understood, and its diagnosis
• degeneration of joint acute inflammatory
cartilage and the is difficult.
response
underlying bone, most • Involvement of the axial
common from middle age • Unknown aetiology skeleton, enthesopathy and
onward. It causes pain although the mechanism of extraarticular manifestations (
and stiffness, especially tissue damage is related to skin rashes,psoriasis, uveitis,
in the hip, knee, and immune system and aortitis)
thumb joints. mediators of inflammation
 Osteoarthritis Rheumatoid Arthritis
OA Varians Types :
• OA inflamatorik erosif • A self-limited Polyarthritis;
• Ankylosing hyperostosis meets ACR criteria for RA on
atau difuse presentation; no patients meet
criteria 2-5 yrs later
• idiopthatic skeletal
hyperostosis (DISH) • Persistent disease;
management by conservative
• OA sekunder
treatment; few significant long
. is difficult.
term consequences
• Progressive disease with
radiologic damage; functional
decline; premature morbidity
• Younger age of onset
Ankylosing Spondylitis
• Ankylosing spondylitis (AS) is
a complex and debilitating
disease with a worldwide
prevalence ranging up to
0.9%.1 Its aetiology and
pathogenesis are not yet fully
understood, and its diagnosis
• Involvement of the axial
skeleton, enthesopathy and
extraarticular manifestations (
skin rashes,psoriasis, uveitis,
aortitis)
• Predominantly male
 Sites of involvement

Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis

 Anamnesis
Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis
• Pain • Pain • Pain :
• Deep pain, • Joint Stiffness - The most common symptom
excruciating, difficult (Morning stiffness (back pain), initially mild that
to localize >30 minutes) gradually becomes worse;
• Early OA : pain when • Symmetrical - Arthritis of the hip joint is
joint is used common,causing pain and
• Rheumatoid nodule
• Advanced OA: pain difficulty of walking
• Weakness / Fatique - Pain felt in the sacroiliac region
even during resting • Depression could be unilateral or bilateral, and
• Joint stiffness (morning • Sleep disturbance coughing may worsen the pain
<30 minutes) - Rest does not relieve the pain,
• Joint enlargement and it may wake the patient from
• Weakness & Disability sleep
 Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis
4 functional classes:
• Sacroiliitis is the earliest
• may have an Class I – Completely able to
recognised manifestation
asymmetrical onset, but perform usual activities of daily of AS, but peripheral joints
it has a tendency to living and extra-articular
become symetrical and Class II – Able to perform usual structures may also be
affect joints on both sides self-care and vocational activities affected.
of the body with time
but limited in avocational activities • Stiffness
• Mono, pauci or Class III – Able to perform usual
polyarticular • Inflammation of tendons &
self-care activities but limited in ligaments
vocational and avocational
• Bone mineral loss 
activities
fracture
Class IV – Limited in ability to
perform usual self-care, vocational, • Tiredness / Depression
and avocational activities • Breathing problems
 Osteoarthritis Rheumatoid Arthritis
• Distribusi kelainan sendi:• Joints affected: glenohumeral, • Subchondral tissues become
• Predileksi pada DIP, PIP, distal III clavicula and around
CMC I, Vertebra, Coxae, bursa, capsule, and ligament.
Lutut dan MTP I • 20- 65% cases
• Jarang mengenai MCP, • May have Staphylococcus
pergelangan tangan, infection of the bursa (Bursitis)
siku, bahu dan • Ulnar Deviation at MCP
pergelangan kaki. • 3 types of finger deformities:
• crepitus Tipe I : boutonniere of IP;
Tipe II : volar subluksation at
• ROM limitation
CMC during adductor pollicis
• Typical Hand Deformities
contraction;
Tipe III: in advanced disease,
adduction CMC I at DIP
Ankylosing Spondylitis
granulomatous and infiltrated with
plasma cells, lymphocytes, mast cells,
macrophages, and chondrocytes. The
affected joints show irregular erosion
and sclerosis. Tissue is gradually
replaced by fibrocartilage and then
becomes ossified : in the spine, the
junction of the annulus fibrosus of the
disc cartilage and the margin of the
vertebral bone undergo irreversible
damage. The outer annular fibres are
replaced by bone and the vertebrae
become fused. In advanced stages of
the disease the fusion typically
ascends the spine, forming a long bony
column referred to as “bamboo spine.”
 Criteria
Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis
Kriteria Klinis • Morning stiffness (> 30 Modified New York Classification
Nyeri Lutut minutes) criteria for AS Definitive:
Diperlukan 3 dari 6 kriteria • Arthritis in 3 areas • Low back pain for at least 3
months improved by exercise
di bawah ini: • Arthritis of the wrist and not relieved by rest
• Krepitus • Symmetrical arthritis • Limitation of lumbar spine in
• Usia > 50 tahun • Rheumatoid nodule sagittal and frontal planes
• Kekakuan sendi 15-30 • Positive serum • Chest expansion decreased
menit rheumatoid factor relative to normal values for
• Pembesaran tepi tulang • Characteristic changes age and sex
• Bilateral sacroiliitis grades 2
• Nyeri tekan tepi tulang in Radiological pictures to 4
• Perabaan kulit tidak • Unilateral sacroiliitis grades 3
hangat
to 4
Juvenile Idiopathic Arthritis
• Penyebab tersering artritis pada anak
• Penyakit inflamasi sistemik kronis, penyebabnya tidak
diketahui (diduga autoimun) terutama mengenai membran
sinovial dari multipel sendi
• Symptoms:
• joint warmth or tenderness
• pain or stiffness when moving joints
• limited range of motion
• stiffness after sleep or rest
• swelling in the joints
• Clinical subtipes:
• systemic , polyarticular ,
dan pauciarticular

Delisa et al. Physical Medicine and Rehabilitation 4th edition Vol1. Lippincott Williams & Wilkins. 2005
Delisa et al. Physical Medicine and Rehabilitation 4th edition Vol1. Lippincott Williams & Wilkins. 2005
CLASSIFICATION CRITERIA FOR
OSTEOARTHRITIS OF THE HIP
• Hip pain
and
• At least two of the following three features:
- ESR = 20 mm/hour
- Radiographic femoral or acetabular
osteophytes
- Radiographic joint space narrowing
(superior, axial, and/or medial)
 KRITERIA KLINIS OA LUTUT
(Altman. 1986)
NYERI LUTUT, ditambah salah satu dari :
1. Usia  50 tahun 6. Tidak teraba panas
2. Kekakuan  30 menit 7. Laju Endap Darah
 40 mm/jam
3. Krepitus
8. Faktor Reumatoid
4. Nyeri tulang
 1 : 40
5. Pembesaran tulang
9. Cairan sendi : OA
 CRITERIA FOR CLASSIFICATION OF
OSTEOARTHRITIS (OA) OF THE KNEE
• Clinical and laboratory :
Knee pain plus at least five of nine:
- Age >50 years
- Stiffness <30 minutes
- Crepitus
- Bony tenderness
- Bony enlargement
- No palpable warmth SF OA
92% sensitive
- ESR <40 mm/hour 75% specific
- RF <1 : 40
 CRITERIA FOR CLASSIFICATION OF
OSTEOARTHRITIS (OA) OF THE KNEE
• Clinical and radiographic :
Knee pain plus at least one of three:
- Age >50 years
- Stiffness <30 minutes
- Crepitus
+ 91% sensitive
- Osteophytes 86% specific
 CRITERIA FOR CLASSIFICATION OF
OSTEOARTHRITIS (OA) OF THE KNEE
• Clinical* :
Knee pain plus at least three of six:
- Age >50 years
- Stiffness <30 minutes
- Crepitus
- Bony tenderness
95% sensitive
- Bony enlargement
69% specific
- No palpable warmth
Criteria diagnosis RA
(American College of Rheumatology, 1988) Dari 7 kriteria, diperlukan 4 untuk
menentukan diagnosis. Kriteria 1-4 harus didapatkan sekurangnya 6 minggu

• Kaku pagi hari (morning stiffness) sekurangnya 1 jam sebelum timbul

perbaikan
• Arthritis pada 3 atau lebih sendi pada masing-masing sisi tubuh (simetris):
MCP, PIP, pergelangan tangan, siku, lutut, pergelangan kaki, MTP
• Arthritis pada tangan, sekurangnya satu daerah pembengkakan pada
pergelangan tangan, MCP atau PIP
• Pembengkakan sendi yang sama pada kedua sisi tubuh (simetris) atau
pembengkakan sendi (tidak harus sendi yang sama) pada kedua sisi
tubuh, pada sendi PIP, MCP atau MTP.
Modified New York Classification Criteria for AS Definite

http://en.wikipedia.org/wiki/File:Ankylosing_process.jpg
 Classification of spondyloarthropathies using ESSG criteria
(European Spondylarthropathy Study Group )
Sensitivity 87%; specificity 87%.
Inflammatory spinal (back) pain
OR
Synovitis (asymmetric, predominantly in lower extremities)
PLUS at least one of the following:
Alternating buttock pain
Sacroiliitis
Heel pain (enthesitis)
Positive family history
Psoriasis
IBD (Inflammatory Bowel Disease ; Crohn’s disease, ulcerative colitis)
Urethritis/acute diarrhoea in preceding 4 weeks
 Physical Examination
Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis
• Observable signs of • Observable signs of • Observation on Posture
Inflammation and Inflammation and • Palpation of tenderness :
Deformities Deformities enthesis (tendons/ligaments)
• Palpable signs of • Palpable signs of • Limitation of movement (lumbar
inflammation, inflammation, spine)
Tenderness / Pain on Tenderness / Pain on
palpation and on palpation and on
movement movement • Bone mineral loss  fracture
• Joint Range of Motion • Joint Range of Motion • Tiredness / Depression
• Muscle Strength • Muscle Strength • Breathing problems
• Special examinations on • Special examinations on
pertinent joints pertinent joints
Pemeriksaan Fisik: look
pembengkakan / swelling ; perubahan kulit
(kemerahan, psoriasis, fenomena Raynaud, tukak, ruam)

OA

SLE RA
 Physical examination: look contractures /
muscle wasting around loints Deformities
swan-neck
deformity
hyperextension
PIP, flexion DIP

Boutonnière deformity: Bouchard’s node

Genu valgus ; varus ; recurvatum
flexion PIP extension DIP Heberden’s node
Pemeriksaan Fisik: feel Move

warm
Active ; Passive ;
tenderness Against resistance
 Pemeriksaan fisik AS: harus mencakup ukuran
panjang tungkai dan penilaian kesimetrisan pelvis.
• Tiga atau lebih temuan positif pada tes provokasi 85% sensitif dan 79% spesifik
untuk penyakit sendi sakroiliak. Berbagai tes provokasi adalah : (Isaac)
Gaenslen test. Dengan pasien berbaring
terlentang, di dekat pinggiran meja periksa
dengan bokong sisi yang diperiksa pada pinggiran
meja periksa dan tungkai dijatuhkan sehingga
panggul dan paha dalam hiperekstensi. Lutut di
kontralateral difleksikan maksimal. Adanya Nyeri
atau tidak nyaman menyarankan suatu penyakit
sendi sakroiliaka, walaupun positif semu dapat terlihat pada pasien dengan lesi
akar saraf L2-4, spondilolisthesis, fraktur tulang sakrum, fraktur kompresi lumbal,
atau stenosis spinal.
 2. Patrick test. Dengan pasien terlentang pada
permukaan yang rata, paha difleksikan dan
pergelangan kaki diletakkan di atas patela
tungkai yang lain yang dalam ekstensi.
Tekanan ke bawah pada lutut yang fleksi
bersamaan dengan tekanan pada spina iliaka
anterior superior sisi yang lain sambil posisi
kaki dipertahankan di atas lutut.
Nyeri atau tidak nyaman di daerah gluteus merefleksikan gangguan sakroiliaka, nyeri
di daerah selangkangan / paha menandakan gangguan sendi panggul.

Tes Provokasi : Tekanan pada Sulkus Sacrum. Aplikasi tekanan pada regio
gluteal yang menyebabkan nyeri daerah otot gluteus dapat
dipertimbangkan sebagai disfungsi sendi sakroiliaka. Tanda ini sering
ditemukan tetapi tidak spesifik, sering terlihat pada nyeri aksial diskogenik,
nyeri radikuler, fraktur sakrum, sindroma facet dan sindroma piriformis.
Distraction test Pasien berbaring terlentang,
(Gapping test).
diberi tekanan ke bawah dan
lateral pada kedua spina iliaka
anterior superior. Manuver ini
meregangkan ligamen
sakroiliaka ventral (depan) dan
simpai (kapsul) sendi serta
memberi tekanan pada ligamen
sakroiliaka dorsal.

Pasien berbaring miring,

pemeriksa di belakang pasien,
serta memberi tekanan ke
bawah pada iliac crest
Compression test).
 Mc Murray

Patellar grinding
Appley

Laksitas medio-
lateral

Drawer’s
Pergelangan kaki / Kaki
Schober test

Ankylosing Spondylitis:
Chest expansion
Pemeriksaan penunjang : foto polos
• Beratnya OA Panggul dapat dikategorisasi
berdasarkan sela sendi minimal (minimal joint space =
MJS) yaitu jarak terdekat pada foto polos antara tepi
kaput femur (femoral head margin) dan tepi
asetabulum (acetabular edge).
• MJS ditentukan oleh 4 (empat) pengukuran sela
sendi, dari medial, lateral, superior dan aksial.
• Gradasi MJS menurut Croft adalah :
0 = MJS > 2,5 mm;
1 = MJS >1,5mm dan  2,5mm;
2 = MJS  1,5mm.
(Reijman M, Hazes JM, Pols HA, et al. Validity and reliability of three definitions
of hip osteoarthritis: cross sectional and longitudinal approach.
Ann Rheum Dis 2004;63:1427-1433.)
To determine the progression of RA, patients are categorized by
clinical and radiologic criteria into 4 stages, as follows:
• Stage I (early RA) – No destructive changes observed upon
radiographic examination; radiographic evidence of osteoporosis is
possible
• Stage II (moderate progression) – Radiographic evidence of
periarticular osteoporosis, with or without slight subchondral bone
destruction; slight cartilage destruction is possible; joint mobility is
possibly limited, but no joint deformities are observed; adjacent
muscle atrophy is present; extra-articular soft tissue lesions (eg,
nodules and tenosynovitis) are possible
• Stage III (severe progression) – Radiographic evidence of cartilage
and bone destruction in addition to periarticular osteoporosis; joint
deformity (eg, subluxation, ulnar deviation, or hyperextension)
without fibrous or bony ankylosis; muscle atrophy is extensive; extra-
articular soft tissue lesions (eg, nodules, tenosynovitis) are possible
• Stage IV (terminal progression) – Presence of fibrous or bony
ankylosis, along with criteria of stage III
Rheumatoid
Arthritis
Normal

1 erosions

1 sclerosis
1 squaring
2 obvious
2 syndesmophytes

3 total bony
3 bridges
Delisa et al. Physical Medicine and Rehabilitation 4th edition Vol1. Lippincott Williams & Wilkins. 2005
Delisa et al. Physical Medicine and Rehabilitation 4th edition Vol1. Lippincott Williams & Wilkins. 2005
modalities
Exercises : Muscles, joints,
mobility, flexibility, etc
Exercise in Ankylosing spondylitis
Maintenance or improvement of
flexibility and mobility
Maintenance or improvement of muscle
strength and endurance
Maintenance or improvement of
coordination and balance
Maintenance or improvement of
cardiovascular & pulmonary fitness

Prevention of spinal deformity

Types of exercise Range of Motion
& Stretching : to
maintain mobility,
flexibility & joint
motion
Stretching
FLEXIBILITY
Ballistic stretching seemed to
have the same effects as static
stretching without any
perceived negative effects.

Although there was an

increased range of motion
due to stretching, there was
no change in muscle soreness

(LaRoche and Connolly 1000-1007)

 Types of exercise

• Good Posture Techniques

Arthritis Research Campaign

Types of exercise
• Strengthening erector spinae

• Prevent thoracic kyphosis

Types of exercise
• Strengthening gluteus maximus muscle
• Reverse kyphosis
Types of exercise

Pelvic tilt: - relax back muscles

- prevent lumbar hyperlordosis
Types of exercise
Coordination & Balance
• Hydrotherapy

Swimming is
one of the most
effective exercises
for ankylosing spondylitis :
strengthen muscles &
keep body supple;
increases lung capacity;
involves all muscles &
joints in a low gravity environment
General Guidelines

Exercise program can be Warming-up and cooling-

individually designed or down exercises are
group exercise mandatory to avoid injury

Heat therapy should be given with precautions and

attention to conditions accompanying Ankylosing
Spondylitis that may be contraindications to heat
therapy
Proteksi sendi dalam ADL (Activities of Daily Living) (Lorig, 1980)

Prinsip 1 GUNAKAN SENDI TERBESAR / TERKUAT

MUNGKIN UNTUK MELAKUKAN PEKERJAAN
Contoh: membuka pintu (lemari es) menggunakan sabuk yang diikat
pada gagang pintu dan ditarik dengan lengan bawah; menggunakan
extender pada tombol pintu atau pada kran air, agar dapat
dibuka dengan seluruh telapak tangan
Prinsip 2 MENDISTRIBUSIKAN BEBAN PADA BEBERAPA SENDI
Contoh : gunakan kedua lengan/tangan untuk menurunkan /
menggantungkan pakaian di lemari ; memegang
mangkuk dengan kedua tangan;
mengangkat piring dengan kedua telapak tangan.
Prinsip 3 GUNAKAN SETIAP SENDI PADA POSISI FUNGSIONAL YANG PALING STABIL
Contoh : pada waktu berdiri dari kursi duduk, kedua kaki penuh menapak lantai dan
menghadap ke depan; berdiri lurus; hindari mendorong hanya dengan satu tangan agar tidak
miring ke satu sisi yang dapat menyebabkan stres memutar pada lutut.
Proteksi sendi dalam ADL (Activities of Daily Living) (Lorig, 1980)

Prinsip 4 GUNAKAN MEKANISME TUBUH YANG

TEPAT DAN BAIK
Contoh : - menekuk lutut pada waktu mengangkat barang dari
lantai atau tempat yang rendah, angkat barang sedekat mungkin
dengan tubuh sebelum bangkit berdiri.
Prinsip 5 KURANGI TENAGA YANG DIPERLUKAN UNTUK
UNTUK MELAKUKAN PEKERJAAN
Contoh : - menggunakan peralatan adaptif; menerapkan sistim
leverage; hindari mengangkat, tetapi obyek didorong atau digeser
Prinsip 6 HINDARI POSISI SENDI YANG SAMA UNTUK WAKTU LAMA
Contoh : - berganti posisi berdiri dan duduk; apabila duduk, ganti posisi kaki sehingga lutut
dapat diluruskan; gerakkan kaki ke atas dan bawah; hindari menggenggam terlalu lama
Proteksi sendi dalam ADL (Activities of Daily Living) Lorig, 1980)

Prinsip 7 USAHAKAN GERAKAN PENUH DAN LENGKAP

SELAMA KEGIATAN SEHARI-HARI
Contoh : - pada saat menyetrika pakaian atau menyapu, luruskan
lengan dan lakukan gerakan bahu luas
Prinsip 8 HINDARI POSISI DAN AKTIVITAS YANG DAPAT
MENGAKIBATKAN DEFORMITAS SENDI
Contoh : - hindari bantal di bawah lutut
- luruskan lengan pada saat tidur
Prinsip 8A HINDARI TEKANAN BERLEBIHAN PADA
IBUJARI/JARI TANGAN BAGIAN BELAKANG, BANTALAN &
SISI RADIAL
Contoh : - waktu berdiri dari duduk, tetap mendorong dengan
telapak tangan; saat duduk, telapak tangan menyangga dagu
Prinsip 8B HINDARI GENGGAMAN KUAT PADA BENDA &
TANGAN AGAR TETAP TERBUKA
Contoh : - mencuci piring dengan scrubber
Proteksi sendi dalam ADL (Activities of Daily Living) (Lorig, 1980)

Prinsip 9 PENGORGANISASIAN PEKERJAAN

Contoh : - Merencanakan pekerjaan dengan
matang sebelum bekerja agar
menghemat energi. Benar Salah
Prinsip 10 SEIMBANGKAN KERJA DENGAN
ISTIRAHAT
Contoh : - Menjadwalkan waktu istirahat di
antara pekerjaan.
Prinsip 11 GUNAKAN TEMPAT
PENYIMPANAN YANG EFISIEN Benar Salah
Contoh : - Perencanaan tempat penyimpanan
yang efisien akan mengurangi tenaga &
membatasi gerak dlm bekerja.
Prinsip 12 HILANGKAN TUGAS YANG TIDAK
DIPERLUKAN / TIDAK PENTING
Benar Salah
 Rehabilitasi pada THR
• Pra-bedah :
- latihan napas dan batuk
- penguatan dan endurance otot sekitar panggul
- latihan ambulasi dengan walker termasuk
penguatan otot-otot untuk ambulasi tongkat (crutch-walking
muscles)
- latihan transfer
- pemeliharaan kekuatan otot dan gerak sendi yang lain
terutama untuk ambulasi
Rehabilitasi pada THR
• Pasca bedah
- positioning
- menghindari hiperfleksi, adduksi dan rotasi interna
- ankle pumping, heel slides, gluteal squeezes, quadriceps
setting
- active-assisted ROM and strengthening exercises
- early protected ambulation with weight-bearing restrictions
using ambulatory aids
- raised toilet seats or commodes
Tujuan akhir pasca THR
• Keberhasilan tatalaksana nyeri pasca bedah
• Mempertahankan stabilisasi medis
• Pencapaian penyembuhan luka operasi
• Pengawasan akan dislokasi implant
• Pencegahan akibat buruk tirah baring (thrombophlebitis,
emboli paru, dekubitus, pneumonia)
• Pencapaian lingkup gerak sendi bebas-nyeri dalam batas-
batas kehati-hatian
Komplikasi
• Proses degeneratif berlanjut
• Nyeri hebat, kekakuan, keterbatasan fungsi dan ancaman
penurunan kualitas hidup
• Penurunan mobilitas menyebabkan kelemahan, osteoporosis,
obesitas dan dekondisi kardiovaskular
• Efek samping obat terutama anti nyeri dan anti-inflamasi serta
infeksi akibat injeksi intra- articular
• Komplikasi pasca bedah
• Penguatan otot-otot panggul dan lutut
• Peningkatan kekuatan fungsional
• Pembelajaran transfer dan ambulasi dengan alat bantu / asistif
• Keberhasilan progres ke situasi hidup sebelumnya
Modified from Cameron H, Brotzman SB, Boolos M. Rehabilitation after total joint arthroplasty.
In Brotzman SB, ed. Clinical Orthopaedic Rehabilitation. St.Louis, Mosby, 1997:284-311.
Total Knee Replacement (TKR)
• 3 jenis Total Knee Arthroplasty (TKA):
1. constrained; 2. semiconstrained; 3. totally unconstrained
Jumlah constraint yang dibentuk pada sendi artificial menunjukkan
besar stabilitas yang diberikan  totally constrained mempunyai
bagian femur yang secara fisik dilekatkan pada komponen tibia dan
tidak memerlukan support ligamen maupun jaringan lunak
Prognosis pasca-bedah
• Profil pra-bedah dengan risiko pemulihan lokomotor buruk pasca-bedah
adalah: - wanita dengan BMI tinggi; - banyak ko-morbiditas
- nyeri lutut intensitas tinggi; - keterbatasan dalam besar fleksi
- kurang kekuatan lutut; - kemampuan lokomotor pra-bedah
buruk
 Tatalaksana
▪ intervensi terapi medik: - profilaksis untuk DVT (Deep Vein
Thrombosis) :
- selain heparinoids (Warfarin)
- sequential pneumatic compression devices of the lower limb
▪ tatalaksana nyeri pasca-bedah:
- controlled analgesia therapy melalui intravena atau epidural
▪ perawatan luka: kasa steril kering selama ada salir (drain); jahitan /
staples dikeluarkan 10-14 hari pasca-bedah
▪ bengkak pasca-bedah: - thigh-high elastic compression stockings
- continuous passive motion (CPM)
- cryotherapy lokal
▪ anemia pasca-bedah harus diperhatikan
Tatalaksana TKR
▪ tahap I : segera pasca bedah: - hari 0 :
latihan napas, incentive spirometer, quadriceps & gluteal sets, straight-
leg raise, hip abduction, ankle pumps; mobilitas transfer duduk;
CPM  fleksi lutut dinaikkan 5-10 derajat setiap hari tergantung
toleransi
▪ hari 1 :
deep breathing, lower extremity static resistance exercises, ankle pumps
and circles, CPM, lanjutkan exercise hari 0,
mobilitas tempat tidur dan transfer tempat tidur ke kursi memakai knee
immobilizer
• Assess adaptive equipment reachers, long-handed sponges & shoehorns
Tatalaksana TKR
▪ hari 2 : lanjutkan exercise hari 0,1, :
short arc quads, straight-leg raise with knee immobilizer, upper
extremity strengthening; mulai mobilitas tempat tidur dan transfer,
grooming & dressing well while seated; toilet transfers  raised
toilet seat;
assisted ambulation in room, partial weight bearing or weight
bearing as tolerated with knee immobilizer
• hari 3 : lanjutkan exercise hari 0-2 : sitting full arc motion:
flexion and extension in conjunction with supine passive flexion and
extension; decreased assistance in basic transfers, independent toileting
& grooming; Independent ambulation with walker or crutches in room,
partial weight bearing or weight bearing as tolerated w/ knee
immobilizer, trial of ambulation in corridor, possibly practice 2-4 stairs;
Education on joint protection & energy conservation techniques
Tatalaksana TKR
▪ hari 4 : lanjutkan exercise hari 0-3 with increased intensity:
• Initiate active assistive ROM exercise and quadriceps & hamstrings
self-stretch
• independent in basic transfers
• Gait training to improve pattern and endurance, discontinue knee
immobilize continue previously described activity of daily living
▪ hari 5-6 : lanjutkan exercise hari 0-4 :
• Transition from passive to active ROM exercises
• Independent ambulation with assistive device, begin stairs with
railing, cane as needed
• Independent dressing with tapered use of adaptive equipment
Tatalaksana TKR : tahap II (mg 1-4)
▪ patient progresses to low-resistance dynamic exercise therapy for the
involved lower extremity  stationary bicycle  aquatic based exercise
▪ Independent in ambulating w/ 2-handed or single-handed device, fully
weight bearing on level surfaces up to 500 feet
▪ ES for Quadriceps (inhibited recruitment)
▪ Soft tissue mobilization for patellar glide
Tatalaksana TKR : tahap III (mg 4-8)
▪ available ROM should reach 0-115 
▪ Patient able to advance dynamic resistance exercise regimen  open &
closed kinetic chain & dynamic balance exercise
▪ Independent in ambulating w/ single-handed or no device, at different
speeds & on different terrain
▪ Independence in instrumental ADL
 Tatalaksana TKR: tahap akhir (mg 8-12)

▪ patients return to pre-operative exercise regimens

and recreation activities and kneeling, low impact
sport activities
▪Return to sedentary, light, and medium work
categories
▪Contact sports are advice against
 The joints most commonly affected by
arthritis in the lower extremity include:
•The ankle (tibiotalar joint);
•The three joints of the hindfoot.
These three joints include:
◦The subtalar or talocalcaneal joint;
◦The talonavicular joint;);
◦The calcaneocuboid joint.
•The midfoot (metatarsocunieform joint).
•The great toe (first metatarsophalangeal joint).
 The Canadian Orthopaedic Foot and Ankle Society have developed a
classification of the complexity of ankle osteoarthritis pre-operatively
(Krause 2010) and for the procedures required postoperatively
(Krause 2012). Krause (2010) reported inter-observer kappa of 0.62
and intra-observer 0.72 for the pre-operative classification
• Pre-operative classification
• Type 1 – isolated ankle arthritis (52% of cases (Krause 2010))
• Type 2 - ankle arthritis with intra-articular deformity, ankle instability or a tight heel
cord (12%)
• Type 3 – ankle arthritis with extra-articular deformity (8%)
• Type 4 – any of the above with subtalar, talonavicular or calcaneocuboid arthritis,
as defined by pain, limitation of movement or radiographic change (28%)
The Canadian Orthopaedic Foot and Ankle Society
(Krause 2012) for the post-operative classification
0.89 and 0.87.
• Post-operative classification
• Type 1 – ankle fusion or replacement with no additional procedure other
than syndesmosis fusion (to allow for the Agility replacement)
• Type 2 - ankle fusion or replacement with additional soft tissue procedure
requiring a second incision
• Type 3 - ankle fusion or replacement with additional osteotomy or midfoot
fusion
• Type 4 - ankle fusion or replacement with additional hindfoot fusion
 LOWER LIMB ORTHOSIS
PRINCIPLES :
- Use only as indicated and not for as long as necessary.
- Allow joint movement wherever possible and appropriate.
- Orthoses should be functional throughout all phases of gait.
- Orthotic knee joint should be centered over prominence of medial
femoral condyle.
- Patient compliance will be enhanced if orthosis is comfortable,
cosmetic, and functional.
• Valgus or unloader braces are thought Knee
to assist patients with medial
compartment osteoarthritis with a Braces
significant varus deformity.
• Cochrane Review 2004:
• Based on one brace study we conclude
there is limited evidence that: a brace
has additional beneficial effect (WOMAC,
MACTAR, function tests) for knee
osteoarthritis compared with medical
treatment alone.
 COUNTERFORCE
CHARACTERISTICS
• Adjustable multilateral condyle
• Triangular design
• Light alluminium alloy material
INDICATION
• Unicompartmental OA
• Meniscal repair
• Prevention of deformity
• To halt progress of OA
Breg’s Functional Knee Brace
PATELLA TRACKING
ORTHOSIS (PTO) Knee Braces
CHARACTERISTICS
• Rigid lateral part
• The more extension, the higher SHORTRUNNER WAOB
pressure on the lateral
• Extension stops at 10°
CHARACTERISTICS
INDICATION
• “wraparound” design
• Chronic dislocation of the
• Hinge with full range of flexion –
patella
extension control
• Patellofemoral syndrome
• Contoured condyle pads
• Chondromalacia patella
INDICATION
• Subluxation (partial dislocation)
• Mild to moderate medial / lateral
Instabilities of the knee
ECONOMY HINGED KNEE
CHARACTERISTICS
• Encased Hinge for
greater comfort in use
• Condyle pads for knee
joint stabilization
• Adjustable pad over the
patella
INDICATION
• Mild medial / lateral
instabilities of the knee
CHARACTERISTICS
• Simple, easy to use
• Sewn in tubular inferior
buttress for mild
stabilization of the patella
INDICATION
• Mild Stabilization of patella
• Patellar tendonitis
• Chondromalacia
PATELLA
STABILIZER
LATERAL STABILIZER CHARACTERISTICS
• Light, easy to use, comfortable
CHARACTERISTICS
• Hypoallergenic, reduced foam
• Easy to use
• Flexion-extension control
• breathable • Post-Op. full mobilization for
• Hypoallergenic material prevention of muscle atrophy
• Strong tubular lateral INDICATION
buttress for lateral • Post-Op: - Ligament injury
stabilization + straps - Patellar and tendon problem
INDICATION - Fracture
• Patellar subluxation and - Total Knee Arthroplasty
dislocation ECONOMY POST-OP LITE
 Heel Wedges
• Principal purpose of braces and wedges is to
reduce pain, assist function, and possibly
prevent disease progression  changes or
alterations of biomechanical force loads
• Wedges are thought to assist patients with
medial compartment osteoarthritis by
mechanically decreasing the varus torque.
• Cochrane Review 2004:
• Limited evidence to support that a
lateral heel wedge decreases
concurrent NSAID utilization.
 Tilt your head to the right,
Exercises for RA bringing your ear close to
the shoulder. You may use
your hand to pull your head
farther into the stretch.
Please stretch within your
comfort zone—don't push
your joints too far, especially
if you're experiencing
inflammation in the joint
you're stretching (this
suggestion applies for all
stretches in this slideshow).
Hold 20 seconds.
Bring your head back to the
center, and then tilt it to the
left, again holding 20
seconds.
Repeat 3-5 times on each
side.
Rotate your chin towards your right
Stand with your feet about shoulder- Keeping your right leg straight,
shoulder.
width apart. bend your left leg and gently rotate
Hold 20 seconds.
Clasp your hands together above your it over your right leg.
You may use your hand to push your
head. Hold 30 seconds.
head farther into the stretch.
Lean to the left. Switch legs (rotate your right leg
Bring your head back to the center,
Hold 30 seconds. over your left), and repeat 3-5
and then rotate it to the left, again
Switch to the right, and repeat 3-5 times on each side.
holding 20 seconds.
times on each side.
Repeat 3-5 times on each side.
Find a free wall and stand about a foot to
18 inches away from it.
With your hands on the wall at shoulder
height, slowly bring your face closer to the
wall. Make sure your hips and shoulders
move in as one—don’t just lean in from
your shoulders. Push back up to where you
started. Repeat 8-12 times.
Work up to doing 2 sets of 8-12 push-ups.
Sitting down, keep your right leg straight and bend
your left leg over it (you don’t have to cross your
left leg over your right, but it’s an option).
Tighten your right thigh muscle.
Hold 6-10 seconds.
Repeat 5 times with your right leg, then switch to
tightening your left thigh muscle.
Try to work up to 10 repetitions on each leg.
 Holding a weight in each hand,
Clasp your hands in front of you at start with your arms stretched out Slowly bring your arms together,
chest height. to the sides. You can start with very keeping them extended.
Push your hands together as hard light weights—and then slowly Repeat 8-12 times.
as you can. build up and you build strength. Try to work up to 2-3 sets.
Hold 5 seconds, then rest for 5-10 See the next slide.
seconds.
Repeat 5 times.
Try to work up to holding for 10-
15 seconds.