Escolar Documentos
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CLINICAL REASIONING
2014
Disusun Oleh :
Nama
NIM
: 021211002
FISIOTERAPI 2012
SEKOLAH TINGGI ILMU KESEHATAN BINAWAN
Jl. Kalibata raya no 25-30 Jakarta Timur
Telp. 021.8088.1129, 8088.0882 ;Fax.021.8088.0883
Kasus
Joan is a 45-year old office worker who re-presents to you with persistent lower back
pain.
She initially presented 3 weeks ago with acute onset severe pain after lifting a heavy
box for which you recommended paracetamol and an NSAID. Her pain has improved
but not resolved.
Joans lower back pain is aching in nature and diffuse, it radiates into her left
buttock. Sitting for long periods and housework exacerbate her pain. Joan is worried
that her back pain will get worse if she does too
much. She is currently taking paracetamol 1 g three times a day and diclofenac 50 mg
twice daily for pain, and fluoxetine 20 mg daily for depression. Joan is otherwise well
and has no drug allergies.
On examination she has diffuse tenderness of her lower back, no spinal deformity,
straight leg raise is normal and no neurological signs. BP 142/88 mmHg, PR 79 and
height 170 cm, weight 65 kg. Recent full blood count, liver and renal function tests were
unremarkable.
Reasons
Kekuatan otot menurun
dikarenakan jumlah
serabut otot menurun setelah
usia 25 tahun. Serta
dikarenakan adanya
keregangan otot atau postur
tubuh yang tidak tepat , serta
aktivitas sehari-hari yang
1.
2.
Disc
3.
Tulang
Mild Moderate
Severe
severe
terjadinya
trauma
punggung
sehingga
menimbulkan
nyeri.
Kekakuan otot cenderung dapat sembuh dengan sendirinya dalam jangka waktu
tertentu (beberapa hari sampai minggu). Namun pada kasus-kasus yang berat
memerlukan pertolongan medis agar tidak mengakibatkan gangguan yang lebih
lanjut (Idyan, 2008).
Keywords : low back pain, pain mechanism, acute, diagnostic
Strategy : GoogleScholar
5. Is the nociceptive component predominantly imflammatory or mechanical? List the
factors that support and negate your decision.
Whole body vibrations meningkatkan produksi enzim degradasi matriks dan enzim
proteolitik, berperan pada metabolisme cakram intervertebral menyebabkan
gangguan dan kerusakan. Juga, frekuensi getaran disebabkan kondisi jalan serta
rigiditas suspensi menyebabkan kelelahan (fatigue) pada otot-otot punggung,
menimbulkan rasa nyeri. Penelitian juga menyatakan hubungan antara whole body
vibration dengan dan nyeri punggung bawah, dengan peningkatan resiko terjadinya
gangguan jaringan spinal. (Thamrin, dkk. 2006)
Keyword : Low back pain, body mechanical, vertebra, factors
Strategy : Google Scholar
to the condition
Having unhelpful believes about pain and work instance
Becoming preoccupied with health, over- anxious, distressed and low in mood
Fear of movement and of re-injury
Uncertainty about what the future holds
Changes in behavior or recurring behaviors
Expecting other people or intervention to solve the problems and serial visits to
various practioners for help with no improvement (Accident Compensation
PAUL
Keywords : Low Back Pain, acute phase, assessment and measurement, diagnosis
Strategy : Google scholar
12. What the relationship will there be between pain and resistance?
P>R
R>P
P=R
Explain
Nyeri yang ada pada low back pain akan meningkat jika diberikan resistance, baik
dalam pemeriksaan, intervensi dan juga aktivitas sehari-hari, maka dari itu
pemeriksaan dan treatment serta rekomendasi aktivitas harus diberikan dengan
hati-hati agar tidak menambah tingkat keparahan. Evidence shows that
psychosocial factors are also significantly associated with the transition from acute
to chronic low back pain. (D. Hoy, P. Brooks, F. Blyth, R. Buchbinder, 2010)
Keywords : Low back pain, Epidemiology, Incidence, Prevalence, Remission,
Recurrence, Duration
Strategy : GoogleScholar
13. Is neurological examination necessary? why?
Perlu. Karena untuk mengetahui serta memastikan apakah ada gangguan neurologi
seperti rasa nyeri, hilang sensasi rasa ataupun manifestasi dari cedera yang di alami
(Guideline for the Evidence-Informed Primary Care Management of Low Back Pain
Low, 2011).
Keywords : low back pain, patient, physical therapy, diagnosis
14. Strategy : Google Scholar What must you test on day 1??
Postur
Evaluasi gait
Pemeriksaan gerak ( aktif dan pasif)
Pemeriksaan gerak resisted isometric
Pemeriksaan derajat nyeri
Pemeriksaan LGS
Pemeriksaan ketahanan otot
Pemeriksaan kekuatan otot
Test untuk ganggguan neurologis
Pemeriksaan fungsional
15. What should you test after day 1??
Postur
Evaluasi gait
Pemeriksaan derajat nyeri
Pemeriksaan LGS
Pemeriksaan ketahanan otot
16. From the S/E, what are you O/E finding likely to be??
Hasil dari pemeriksaan subjective menunjukkan
pemeriksaan obejctive.
-
Subjective
Pain
Posture
Limitation movement
Limitation functional
Muscle strength
kesamaan
dengan
hasil
Physical
Pain
Posture
Limitation movement
Limitation functional
Muscle-strength
(Bart W. Koes, Maurits van Tulder, Chung-Wei Christine Lin, Luciana G. Macedo,
Pasien mengalami low back pain karena kebiasaan postur yang salah saat
mengangkat barang dan beban yang berlebihan yang menyebabkan ada penekanan
berlebihan pada tulang belakang
1. Name all the possible structures which could be a source of the symptoms:
Symptomatic Area
Left lumbal
Left buttock
Muscle
Ligament
Bone
Gluteal
Hip
Knee
4. Behaviour of symptoms
a. Is the condition severe? Explain why.
Dalam kasus ini pasien bisa saja tergolong dalam keadaan parah, karena
pasien merasakan nyeri yang hebat setelah mengangkat beban yang
berat, serta nyeri semakin memburuk saat terlalu lama duduk ataupun
saat melakukan pekerjaan rumah.
b. Is the condition irritable? Explain why.
Dalam kasus ini, tidak terdapat adanya iritabilitas pada pasien, karena
pasien hanya mengeluhkan adanya nyeri yang disebabkan oleh spasme
otot dan juga tidak disebutkan adanya infeksi bakteri Tuberculosis.
c. Are there any precautions or contraindications?
Beberapa tindakan yang bisa dilakukan untuk menangani adanya nyeri
dan menghilangkan spasme dengan melakukan stretching exercise serta
latihan untuk menjaga postural control.
5. How is the severity, irritability or nature of the condition going to affect your physical
examination and treatment?
Faktor resiko low back pain meliputi usia, jenis kelamin, berat badan, etnis,
merokok, pekerjaan, factor psikis, paparan getaran, angkat beban yang berat yang
berulang-ulang, membungkuk, serta duduk lama.
Dari faktor di atas terapis dapat menilai dan menentukan tingkat keparahan
pasien serta dapat menentukan intervensi apa yang akan di lakukan selanjutnya
(Bimariotejo, Low Back Pain, 2009)
Keywords : low back pain, risk factors, physical therapy, diagnosis
Strategy : GoogleScholar
7. What subjective findings indicate likely physical findings?
Subjective
Pain
Limitation Functional
Limitation movement
Muscle Strength
Physical
Pain
Limitation movement
Limitation Functional
Muscle Strength
Functioning, Disability, and Health from the Orthopaedic Section of the American
Physical Therapy Association,2012)
Keywords : Low back pain, Clinical practice guidelines, Treatment, Function
Strategy : Google Scholar
8. What other factors need to be examined as reasons why the structure has become
symptomatic?
Beberapa faktor yang perlu diketahui oleh terapis antara lain apakah pasien
pernah mengalami trauma, riwayat kelainan kongenital atau adanya tumor
(Bimariotejo, Low Back Pain, 2009)
Keywords : Patient, Low back pain, risk factors, diagnosis, physical therapy
Strategy: Googlescholar
Adanya gangguan aktivitas karena nyeri menjalar dari lumbal bagian kiri hingga
ke bagian buttock dikarenakan adanya gangguan otot dan soft tissue pada daerah
lumbal yang disebabkan oleh acute low back pain.
Acute low back pain ditandai dengan rasa nyeri yang menyerang secara tiba-
tiba dan rentang waktunya hanya sebentar, antara beberapa hari sampai beberapa
minggu. Rasa nyeri ini dapat hilang atau sembuh. Acute low back pain dapat
disebabkan karena luka traumatik seperti kecelakaan mobil atau terjatuh, rasa nyeri
dapat hilang sesaat kemudian. Kejadian tersebut selain dapat merusak jaringan,
juga dapat melukai otot, ligamen dan tendon. Pada kecelakaan yang lebih serius,
fraktur tulang pada daerah lumbal dan spinal dapat masih sembuh. Sampai saat ini
penatalaksanan awal nyeri pinggang akut terfokus pada istirahat dan pemakaian
analgesic (Bimariotejo, Low Back Pain, 2009)
Keywords : Acute, low back pain, physical therapy, classification
Strategy : Googlescholar
2. What is your main hypothesis now with regard to the primary disorder and the
dominant pain mechanism?
Hipotesis sementara adalah adanya gangguan gerak yang disebabkan oleh nyeri
pada Low Back Pain.
3. Is there anything about your physical exam that would indicate caution in your
management?
Ada. Nyeri yang ada pada low back pain akan meningkat jika diberikan
resistance, baik dalam pemeriksaan, intervensi dan juga aktivitas sehari-hari, maka
dari itu pemeriksaan dan treatment serta rekomendasi aktivitas harus diberikan
dengan hati-hati agar tidak menambah tingkat keparahan. Evidence shows that
psychosocial factors are also significantly associated with the transition from acute
to chronic low back pain. (D. Hoy, P. Brooks, F. Blyth, R. Buchbinder, 2010)
Keywords : Low back pain, Epidemiology, Incidence, Prevalence, Remission,
Recurrence, Duration
Strategy : GoogleScholar
b. Memberikan exercise
c. Memberikan edukasi dan home program
d. Evaluasi tindakan
Functioning, Disability, and Health from the Orthopaedic Section of the American
Physical Therapy Association, 2012)
Keywords : low back pain, physical therapy, management intervention, education
Strategy : GoogleScholar
Immediate improvement was demonstrated after the exercise, with 0/10 lumbar
and leg pain in standing, no pain with lumbar extension AROM, decreased pain with
left side-bending AROM, and no pain with right single-leg stance. Extension created
right lum-bar pain at end-range, and right L5S1 accessory motion was still painful
and hypomobile. RMQ score was 0/24 (before 5/24). LoBACS scores were 91%,
100%, and 100% for the function, self-regulatory, and exercise subscales,
respectively. FABQ scores were 5/42 (before 18/42) for the work subscale and 4/24
(before 9/24) for the physical activity subscale. Re-examination demonstrated
normal lumbar AROM, normal and pain-free accessory motion testing, and a
negative slump test. The patient was discharged from physical therapy with all goals
met. (Sean D Rundell, Todd E Davenport, Tracey Wagner, 2009).
Keyword : Classification, Diagnosis, Discriminant validity,
Examination,
For a single acute episode with non-specific low back pain, the prognosis is very
god. Around 90% are considerably better with or without treatment within a few
weeks 2. Literature has, however, shown that after one year 33% have intermittent or
persisting pain of at least moderate intensity and that one out of five are still
considerably limited functionally. A study from Denmark has shown that 45% of the
patients still have back pain after one year. Croft found that only 25% have become
completely free of symptoms after one year and Cherkin has shown that 71% are
content with the condition of their back one year after the start of the acute period.
(Even Lrum, Reidar Dullerud, Gitl Kirkesola, Anne Marit Mengshoel, ystein P.
Nygaard, Jan Sture Skouen, Lars-Christian Stig, Erik Werner, 2002).
Key words: low-back pain , prognosis , acute pain , chronic pain .
Strategy : GoogleScholar
The main goals of the treatment plan are to return the patient to a full (or
desirable) level of activity and participation and to prevent recurrences and the
development of chronic complaints (National practice guidelines for physical therapy
in patients with low back pain, 2003)
Keywords : Physical therapy, goals treatment, low back pain, intervention
Strategy : Google scholar
9. Would you expect the patient to have residual signs and symptoms at the end of the
course of treatment?
Terapis tidak mengharapkan adanya gejala sisa pada pasien, diharapkan pasien
dapat sembuh total dan aktifitas fungsional dapat kembali normal.