ASESMEN DAN DIAGNOSIS FISIOTERAPI Oleh Sugijanto Disampaikan pd

ASESMEN DAN DIAGNOSIS FISIOTERAPI Oleh: Sugijanto Disampaikan pd kuliah PROSES FISIOTERAPI

KEPMENKES 1363 Fisioterapi adalah bentuk pelayanan kesehatan yang ditujukan kepada individu dan atau kelompok untuk mengembangkan, memelihara dan memulihkan gerak dan fungsi tubuh sepanjang daur kehidupan dengan menggunakan penanganan secara manual, peningkatan gerak, peralatan (fisik, elektroterapeutis dan mekanis), pelatihan fungsi, komunikasi.

KEPMENKES 1363 Pasal 12 (1)Fisioterapis dalam melaksanakan praktik fisioterapi berwenang untuk melakukan ; a. Asesmen fisioterapi yang meliputi pemeriksaan dan evaluasi b. Diagnosa fisioterapi c. Perencanaan fisioterapi d. Intervensi fisioterapi e. Evaluasi/re-evaluasi/re-asesmen.

(2) Fisioterapis dalam melaksanakan kewenangan sebagaimana dimaksud pada ayat (1) berkewajiban untuk : a. Menghormati hak pasien; b. Merujuk kembali kasus yang tidak dapat ditangani atau belum selesai ditangani, sesuai sistem rujukan yang berlaku; c. Menyimpan rahasia sesuai dengan peraturan perundang-undangan yang berlaku; d. Meminta persetujuan tindakan yang akan dilakukan; e. Memberikan informasi dalam lingkup asuhan fisioterapi; f. Melakukan pencatatan dengan baik.

Sistem asuhan Himpunan yg t a beberapa komponen yg saling berinteraksi utk mencapai suatu tujuan. Dlm sistem minimal ada komponen input, proses, dan out put input proses Umpan balik output

Sistem Asuhan Fisioterapi input proses Pasien PT is Peralatan Metode Kode etik SOP dll Assesment Diagnosis Planning Intervensi Re. Evaluasi output Kesembuhan klien PT is Pandai Modif Peralatan Pengembangan metode dll standard praktik fisioterapi outcome Kepuasan -pasien -PT is -Manajemen -Share Holder

PROSES FISIOTERAPI ASESSMENT DIAGNOSE PLANNING INTERVENTION REEVALUATION COORDINATION, COMMUNICATION, DOCUMENTATION STANDAR PRAKTEK FISIOTERAPI

Asesmen (pengkajian) termasuk pemeriksaan pd perorangan/kelompok, nyata/berpotensi terjadi kelemahan, keterbatasan fungsi, ketidakmampuan atau kondisi kesehatan lain dgn cara pengambilan data riwayat sakit (history taking), skreening, tes khusus, pengukuran dan evaluasi dr hasil pemeriksaan melalui analisis dan sintesis dlm sebuah proses pertimbangan klinis.

Pemeriksaan (pengambilan data) HISTORY TAKING • Anamnesis • Pengambilan data relevan Screening (Observasi = inspeksi) Screening (pemeriksaan fungsi fisik) Quick test Tes Gerak aktif, gerak pasif, isometrik. Pengukuran subyektif obyektif: mis nyeri dgn VAS/VRS, Pengukuran Mobilitas sendi/ ROM, Manual Muscle Test Karakteristik antropometri Pengukuran postur Keseimbangan/Balance scale Aktifitas sehari-hari/IADL Index Barthel dll Tes khusus • Palpasi • Joint play movement, tes provokasi, kinerja otot, • Tes stabilisasi sendi. • Muscle strength test, length test. • Tes sensasi • Balance test, coordination test. • Strength Duration Curve • dll

Algorithm in assessment and intervension

Cervical and Shoulder Examination Algorithm Sugijanto, 2011

Shoulder Examination and Intervention Algorithm (Joe Godges, 2004) Sugijanto, 2011

Associated Upper Quarter Impairment Examination Algorithm (Joe Godges, 2004) Sugijanto, 2011

PAIN FROM TISSUE ORIGIN Wound healing process Inflammation Nosisensoric sensitization SPECIFIC TISSUE Ischemic Hypoxia Inflammation necrosis Contracture Fatique Sugijanto, 2011

PAIN FROM JOINT SURFACE Kompresi prmk tulang JOINT SURFACE Penglupasn rawan sendi Inflamasi tlg subchondrale Tumbuh osteophyte Lepasan fragmentasi Nyeri kompresi sendi Penguncian grk sendi Nyeri bl gerak ROM tertentu Sugijanto, 2011

PAIN FROM CAPSEL Instability Sprain/ rupture Inflamation Nyeri diam Contracture Capsel Immuno reaction Immobilzation Effusion Adhesion Nyeri ssd aktifitas Nyeri regang Acidosis Nyeri & hydrops Inter collagen space Nyeri regang Sugijanto, 2011

PAIN FROM MUSCLE Weakness Strain/ rupture Inflammation MUSCLE Immobilsation Adhesion Atrophy ? ! Nyeri diam Muscle spasm Nyeri kontraksi Tightness/ Contracture Nyeri regang Myofascial contracture Nyeri regang Sugijanto, 2011

PAIN FROM PERIPHERAL NERVE Entrapment Anoxia Paresthesia intermittent Inflamation Neuropathic pain Fibrosis NERVE Inflamation Systemic Paresthesia menetap Neuropathic pain Paresthesia menetap Sugijanto, 2011

EVIDENCE BASE PRAKTIS Penggunaan hasil penelitian secara bertingkat untuk proses assessment dan intervension

Sugijanto, 2011

Screening questionair Sugijanto, 2011

Red flag for thoracic spine

Red flag Sugijanto, 2011

L B P MEDICAL SCREENING QUESTIONAIR 1 Have you recently had a major trauma, such as a vehicle accident or a fall from a height? 2 Have you ever had a medical practitioner tell you that you have osteoporosis? 3 Do you have a history of cancer? 4 Does your pain ease when you rest in a comfortable position? 5 Have you recently had a fever? 6 Have you recently lost weight even though you have not been attempting to eat less or exercise more? 7 Have you recently taken antibiotics or other medicines for an infection? 8 Are you currently taking steroids or have you been on prolonged steroid therapy? 9 Have you been diagnosed with an immunosuppressive disorder? 10 Have you noticed a recent onset of difficulty with retaining your urine? 11 Have you noticed a recent need to urinate more frequently? 12 Have you noticed a recent onset of numbness in the area of your bottom where you would sit on a bicycle seat? 13 Have you recently noticed your legs becoming weak while walking or climbing stairs? Sugijanto, UEU 2011 2010 No

HISTORY TAKING (Anamnesis) Keluhan utama, beberapa contoh: ◦ Sensasi/Nyeri? Jenis, distribusi, dugaan penyebab, provokasi & peringanan. ◦ Mobilitas sendi? Pembatasan, kelemahan. ◦ Kinerja otot? Kelemahan, tegang, pemicu, pengurang ◦ Gangguan ambulasi? Berjalan, penggunaan alat, dugaan penyebab, dll ◦ Keseimbangan? Jenis, momen gangguan ◦ Fungsi ADL? Jenis, dugaan penyebab, ◦ Sesak nafas? Jenis, pemicu, pengurang. ◦ Dll.

ANAMNESIS (lanjutan) Riwayat keluhan kini termasuk mulainya, perjalanan sakit, gangguan terhadap regio/organ/sistem lain. Riwayat sakit dahulu yg mungkin berpengaruh pd keluhan kini. Pengobatan dan pembedahan yg telah dijalani Riwayat status kesehatan famili yg relevan. Kegiatan pekerjaan dan sosial

HISTORY TAKING Juga data lain yg relevan: Diagnosis medik Riwayat medik yg berkaitan Status sistem, organ lain yg relevan Status fungsional dan tingkat aktifitas

Screening (pengambilan data dr Observasi = inspeksi) Dinamik: ◦ Gait analisis, fungsional dasar, ADL, dll Statik: Prinsip umum inspeksi statik: ◦ Status kesadaran dan status psikologis umum ◦ Analisis total, quadrant, lokal. ◦ Kondisi kulit, posture, posisi sendi dan penyimpangan, status otot, bentuk, konsistensi,

Screening (dr pemeriksaan fungsi fisik) Pemeriksaan fungsi gerak dasar muskuloskeletal: ◦ Quick test gerak sendi ◦ Gerak aktif, gerak pasif, isometrik. Pemeriksaan fungsi dasar kardiovaskuler-pulmonal: ◦ Telaah sistemik Vital sign ◦ Pengembangan dada-abdomen, ventilasi paru, kapasitas paru,

Screening (pemeriksaan fungsi lanjutan) Pemeriksaan fungsi dasar neuromuskular: ◦ Pola jalan, keseimbangan dan lokomotor. ◦ Tes sensorik integrasi, nyeri, fungsi motorik, refleks, keseimbangan, koordinasi, perkembangan motorik. Pemeriksaan integument fungsi dasar ◦ Tes sensasi ◦ Pemeriksaan ketebalan kulit, tonus kulit, konsistensi

Tes khusus Palpasi Joint play movement, tes provokasi, kinerja otot, Tes stabilisasi sendi. Muscle strength test, length test. Tes sensasi Balance test, coordination test. Strength Duration Curve Tes ventilasi, kapasitas paru Tes tonus integument Tes kedalaman kerusakan kulit

PENGUKURAN subyektif obyektif: mis nyeri dgn VAS/VRS, Pengukuran Mobilitas sendi/ ROM, Manual Muscle Test Karakteristik antropometri Pengukuran postur Keseimbangan/Balance scale Aktifitas sehari-hari/IADL Pengukuran

EVALUASI Evaluation of the results of the examination through analysis and synthesis within a process of clinical reasoning. Pemeriksaan Evaluasi Pengumpulan • Analisis Data - data • Sintesis Clinical reasoning

Proses evaluasi analisis sintesis Fragment Assessment Diagnose Anamnesis Inspeksi Pemeriksaan Tes khusus & P’ukuran Muskulo skeletal Keluhan utama, Riwa peny. Diagno dan riwa medik Stat fungs dan tingkat aktifitas Dinamik, Statik Analisis total, kuadran, lokal. Pem. fungsi gerak dasar Tes cepat, gerak aktif, pasif dan isometrik Palpasi, JPM, Provokasi, pengukuran 2 ¬Jaringan /organ ¬Patologi ¬Gg gerak Neuro muskular Pengobatan status kes famili Pekerjaansosial Tes sensasi, motorik, keseimbang, koordinasi, Perkembang an motorik Motoric function & sensoric test ¬Sistem ¬Patologi ¬Gg gerak Pengukuran 2

Proses evaluasi analisis sintesis (lanjutan) Fragmentasi Kadio vaskuler pulmonal Integumen Assessment Diagnose Anamnesis Pemeriksaan Tes khusus & Pengukuran Keluhan utama, Riwayat peny. Diagnosis dan riwayat medik Status fungsional dan tingkat aktifitas Pengobatan status kes famili Pekerjaan-sosial Vital sign, Pengembangan dada-abdomen, ventilasi paru, kapasitas paru Tes ventilasi, Sistem kapasitas Patologi paru Gg gerak Gas arteri Pengukuran 2 Tes sensasi, konsitensi kulit, turgor, Tonus kulit ¬Sistem Kedalaman ¬Patologi gang. kulit. ¬Gg gerak Pengukuran 2

Diagnosis Merupakan pernyataan, label, Menggambarkan multi dimensi pasien/klien Dari tingkat basis (sel) > tertinggi fungsi Umumnya : ‘menyangkut kondisi fungsional tingkat jaringan, organ, sistem khususnya sistem gerak dan individu‘

Diagnosis Menggambarkan keadaan pasien menuntun menentukan prognosis menuntun rencana intervensi (diagn kerja) ◦ Mengindikasikan disfungsi ◦ direct intervension

Shoulder Pain ICD-9 -CM code: 726. 19 Subacromial bursitis ICF codes: Activities and Participation Domain codes: ◦ d 4452 Reaching (Using the hands and arms to extend outwards and touch and ◦ ◦ ◦ ◦ grasp something, such as when reaching across a table or desk for a book. ) d 4300 Lifting (Raising up an object in order to move it from a lower to a higher level, such as when lifting a glass from the table. ) d 4305 Putting down objects (Using hands, arms or other parts of the body to place an object down on a surface or place, such as when lowering a container of water to the ground. ) d 4451 Pushing (Using fingers, hands and arms to move something from oneself, or to move it from place to place, such as when pushing an animal away. ) d 4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book. ) d 4300 Throwing (Using fingers, hands and arms to lift something and propel it with some force through the air, such as when tossing a ball. ) d 4550 Crawling (Moving the whole body in a prone position from one place to another on hands, or hands and arms, and knees. ) d 4551 Climbing (Moving the whole body upwards or downwards, over surfaces of objects, such as climbing steps, rocks, ladders of stairs, curbs or other objects. ) Body Structure code: s 7201 Joints of shoulder region Functions code: b 28016 Pain in joints Sugijanto, 2011

Isi diagnose fisioterapi Minimal berisi : ◦ Pernyataan masalah pasien, misal : Gangguan mobilitas sendi, fungsi motor, kinerja otot, dan ROM, gait, locomotion, balance, sensory integration, ventilasi, respirasi/gas exchange, aerobic capacity/indurance ◦ Hubungan dgn jaringan/organ/sistem terkait, misal : connective tissue, ligament, otot, tulang, sendi, Central nervus system, peripheral nerve, vaskuler, respirasi, ◦ Disebabkan oleh patologi, misal: artrosis, inflamasi lokal, kerusakan spinal, fraktur, Arthroplasti sendi

ISI DIAGNOSIS Gangguan gerak & fungsi (function ICF) Pada ‘body structure’ (Anatomic) Oleh patologi tertentu (ICD)

Diagnosa Musculoskeletal (1) 1. Prediksi gangguan system muskulo skeletal 2. Gangguan Sikap 3. Gangguan performans otot 4. Gangguan mobilitas sendi, motor function, kinerja otot, dan ROM yg disebabkan oleh connective tissue. 5. Gangguan mobilitas sendi, motor function, kinerja otot, dan ROM yg disebabkan olehinflamasi lokal.

Diagnosa Musculoskeletal (2) 6. Gangguan mobilitas sendi, motor function, kinerja otot, dan ROM yg disebabkan kerusakan spinal. 7. Gangguan mobilitas sendi, motor function, kinerja otot, dan ROM yg disebabkan fraktur. 8. Gangguan mobilitas sendi, motor function, kinerja otot, dan ROM yg disebabkan Arthroplasti sendi. 9. Gangguan mobilitas sendi, motor function, kinerja otot, dan ROM yg disebabkan bedah tulang atau jaringan lunak. 10. Gangguan mobilitas sendi, motor function, kinerja otot, ROM, gait, locomotion, balance yg disebabkan amputasi

Diagnosa Neuromuskular (1) 1. Prediksi gangguan kinerja system neuromuskuler 2. Gangguan Perkembangan Neuromotor 3. Gangguan motor function dan sensory integration yg disebabkan Non progressive disorder CNS – congenital atau pada bayi dan masa anak. 4. Gangguan motor function dan sensory integration yg disebabkan Non progressive disorder CNS – pada usia dewasa 5. Gangguan motor function dan sensory integration yg disebabkan progressive disorder CNS

Diagnosa Neuromuskular (2) 5. Gangguan Peripheral nerve integrity dan motor function yg disebabkan Peripheral Nerve Injury. 6. Gangguan fungsi motorik dan sensory integration yg disebabkan Acute /Chronic Polyneuropathies. 8. Gangguan fungsi motorik dan Peripheral nerve integration yg disebabkan Non progressive disorder Spinal Cord. 9. Gangguan kesadaran , ROM, Motor Control yg disebabkan Coma, Near coma, atau status vegetative.

Diagnosa Cardiovascular /Pulmonary (1) 1. Prediksi gangguan kinerja system cardiovascularpulmonary 2. Gangguan kapasitas aerobik/ketahanan yg disebabkan deconditioning syndrome 3. Ganguan ventilasi, respirasi/gas exchange, aerobic capacity/indurance yg disebabkan Airways clearance dysfunction. 4. Gangguan kapasitas aerobik/ketahanan yg disebabkan Cardiovascular Pump Dysfuntion or failure

Diagnosa Cardiovascular /Pulmonary (2) 5. Ganguan ventilasi, respirasi/gas exchange, aerobic capacity/indurance yg disebabkan Ventilatory Pump Dysfunction or Failure. 6. Ganguan ventilasi, respirasi/gas exchange, aerobic capacity/indurance yg disebabkan Respiratory Failure. 7. Ganguan ventilasi, respirasi/gas exchange, aerobic capacity/indurance yg disebabkan Respiratory Failure pada neonatus 8. Ganguan sirkulasi darah, anthropometric dimensions disebabkan Lymphatetic System disorders.

Diagnose Integumentary (1) 1. Prediksi gangguan kinerja system integument 2. Gangguan integumenary integrity yg disebabkan Superficial skin involvement 3. Gangguan integumenary integrity yg disebabkan partial thickness skin involvement 4. Gangguan integumenary integrity yg disebabkan Full Thickness skin involvement 5. Gangguan integumenary integrity yg disebabkan Skin Involvement extended Into Facia, Muscle, or Bone and scar formation.

Prognose Ketetapan perkembangan optimal yg mungkin dicapai dgn intervensi dlm periode waktu. Sebagai hasil analisis dan sintesis terhadap hasil history taking dan data gathering. Digunakan utk penetapan target hasil.

Perencanaan terapi

Contoh penetapan program: Hub. Gangguan gerak & fungsi - jaringan/sistem – patologi dg alat & metoda Inflamasi lokal Kontraktur Capsuleligament SWD, joint stabilisation SWD, Joint mobilisation Tendomuskular US, transverse friction US, stretching Saraf perifer Rest Mobilisasi saraf Saraf pusat Paru / respirasi Fasilitasi proprioceptor -- entrapment Obstruksi -- -- Manipulasi/ traksi -- -- Rest, breath exc Mobilisasi dada -- -Inhalasi, PD, pursed breath

Contoh kasus Capsuloligame ntair Inflamasi lokal Aktualitas rendah ROM terbatas, firm, JPM nyeri/terbatas/ firm SWD Sub thermal, lat. Mobilisasistabilisasi Aktualitas tinggi ROM terbatas, springy, JPM nyeri/terbatas/ springy PRICE, SWD non thermal, isometric exc, Kontraktur immobilisasi ROM terbatas, firm, JPM nyeri/terbatas/ firm SWD thermal, joint mobilisat traksitranslas, ROM terbatas, springy, JPM nyeri/ terbatas/ springy SWD sub thermal, joint mobilisat traksi-