Ilmu Kedokteran Fisik

dan Rehabilitasi - 4

dr. Nur Ahlina Damayanti, SpKFR, CPS

Geriatri

2
Soal

Statements below are physiological changes in geriatric, except..

a. Decreased muscle strength
b. Increased response to stimuli
c. Reduction in hormone production
d. Increased accumulation of fat
e. Impaired balance

3
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

5
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 multipel dalam •Massa otot

fisiologi dan anatomi yg diinduksi oleh •Kekuatan
inaktifitas fisik dan kondisi ini dapat dibalik •Fungsi kardiovaskular
melalui aktifitas fisik •Total blood volume
 Imobilisasi menggambarkan sindroma •Heart volume
degenerasi fisiologik → menurunnya aktivitas •Toleransi orthostatik
dan deconditioning •Toleransi latihan
 Imobilisasi/tirah baring lama: keadaan tidak •Kepadatan mineral tulang
bergerak/tirah baring selama 3 hari atau
lebih, dengan gerak anatomik tubuh
menghilang sebagai akibat perubahan
fisiologik
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

Complication of prolonged bed rest is/are..

a. Muscle weakness
b. Joint stiffness
c. Decubital ulcer
d. Osteoporosis
e. All correct

11
 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 above

12
Soal

To prevent orthostatic hypotension in patient with immobilization, the

following can be done...
a. Gradual mobilization
b. Vital signs every hour
c. Ankle pumping
d. ROM exercise
e. Breathing exercise

13
Narasi Soal

60-year-old male feels low back pain on the right side, radiating to the buttocks and
right leg. Pain worsens when standing for long periods of time, walking and
resolves when bending. No Loss of bladder or bowel control. Physical examination
shows tenderness in the right lumbosacral region dan posterior of right limb.
Hyperesthesia on the right leg. Radiological findings shows no discontinuity of
bone, and no protusion of disc.

14
Soal

What is the etiological diagnosis of the patient?

a. Traumatic brain injury
b. Spinal cord injury
c. Spondilitis tuberculosis
d. Canal Stenosis
e. Hernia nucleus pulposus

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LOW BACK PAIN
Anamnesis

 Lokasi
 Sifat
 Beratnya nyeri
 Waktu : onset, durasi, & frekuensi
 Faktor pemicu & pemberat
 Tanda & gejala terkait
Pemeriksaan Fisik
Pemeriksaan Fisik
20
21
Soal

Which of the statement below is FALSE regarding vertebral disc?

A. Protusion happens posterolaterally

B. Consists of nucleus pulposus and annulus fribrosus
C. Annulus fibrosus in the posterior is thicker
D. All correct

22
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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LOW BACK PAIN
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

26
 Risk Factors of Fall

Intrinsic Extrinsic
Advanced age Lack of stair handrails

Previous falls Poor stair design

Muscle weakness Lack of bathroom grab bars

Gait & balance problems Dim lighting or glare

Poor vision Obstacles & tripping hazards

Postural hypotension Slippery or uneven surfaces

Chronic conditions including arthritis, stroke, Psychoactive medications

incontinence, diabetes, Parkinson’s, dementia
Improper use of assistive device
Fear of falling

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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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30
KARDIORESPIRASI

31
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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33
Soal

Aerobic exercise is a mode of exercise that:

A. Uses anaerobic metabolisme

B. Changes glucose molecule → 2 ATP + piruvic acid/ lactate acid
C. Metabolisme happens outside mitokondria
D. None of the above

34
 Glikolisis
(Phase I)

METABOLISME
ENERGI SAAT
LATIHAN
Glikolisis
(Phase II)

Siklus Kreb’s

Transport Elektron
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

Soal

Branch of right coronary artery DOES NOT supply blood to which of the
following area
a. Lateral wall of left ventricle
b. Right Atrium
c. Right Ventricle
d. Inferior wall of left ventricle

37
 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
39
Soal

That must be evaluated during exercise in patient with heart condition

is/are..
a. Patient complaint
b. Heart rate
c. Respiratory rate
d. A and B correct
e. All correct

40
Soal

Unmodifiable risk patient with coronary heart disease is

A. Cholesterol
B. Hypertention

C. Diabetes mellitus

D. Age

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42
Soal

Exercise testing to evaluate functional capacity of patient with heart

failure is
a. 6-minute walking test
b. Cooper test
c. Treadmill test
d. Spirometry
e. Breathing test

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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

44
Uji Latih: Exercise capacity can be assessed by the following tests
depending on the facilities available and the level of medical
support:

Maximal Test Submaximal Test

• Laboratory: Cardiopulmonary Laboratory: submaximal treadmill
exercise test (CPET) test
• Field: Incremental shuttle walk test Field: Six minute walking 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.
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 koroner

menurun secara mendadak
setelah oklusi thrombus pada
plak aterosklerotik yang
sudah ada 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

Cardiac rehabilitation can be initiated in below conditions, except..

a. post myocardial infarct

b. post coronary artery bypass graft
c. chronic heart congestive
d. severe arrythmia

53
Soal

Male, 60 years old, post cardiac insufficiency also has osteoarthritis at

right knee. What exercise that can be prescribed as a maintenance
exercise for this patient ?
a. running
b. walking
c. jogging
d. static cycling

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 Respirasi

Semua proses yang menyebabkan pergerakan pasif O2 dari

atmosfer ke jaringan untuk menunjang metabolism sel,
serta pergerakan pasif CO2 selanjutnya yang merupakan
produk sisa metabolism dari jaringan ke atmosfer
Muscles
Pengukuran pada Pernapasan

 Pengukuran volume pernapasan

 →Spirometri ( gold standar untuk
diagnosis dan monitor PPOK dan
Asma, screening awal untuk deteksi
PPOK 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

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 FVC dengan FEV1 normal atau menurun
d. FVC normal dan FEV1 meningkat
e. Penurunan FEV1%

66
Soal

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 coughing
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Indications

Prevent Accumulations of secretions Remove Accumulated Secretions

Mucus production and viscosity Patients with acute or chronic
↑ lung disease
Prolonged bed rest Patients who are generally very
weak or elderly
Patients with general
anaesthesia with painful Patients with artificial airways
incisions that restrict deep
breathing
Patients on ventilator

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Thank You!

70

NADH