lapkas ii_medical rehabilitation in patient with lumbal hnp_frans_revisi_final

8/9/2019 Lapkas II_Medical Rehabilitation in Patient With Lumbal HNP_Frans_Revisi_Final

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Chapter I

INTRODUCTION

Disc herniation is fundamentally a release of the nuclear material from the

confinement of the enveloping annulus fibrosus capsule. Herniation of the nuclear material

may result from excessive forces, repeated stresses, but any combination of the above may be

involved. The term herniation, or rupture, is more explainable and understandable in a

mechanical sense than the term slipped. Bulging of the disc is also an accepted term. 1

Herniated discs are common source of back pain.2 o! back pain "B#$ is a common

musculoskeletal disorder causing huge humanitarian and economical costs "%ndersson,

1&&&$. 't is often classified, according to duration of pain, as acute "short term$, sub(acute

"intermediate$ and chronic "long term$ and is typically referred to as being specific or non(

specific "%nderson, 1&&&) *erskey and Bogduk, 1&&+$.

Herniated nucleus pulposus most commonly happens at - +- years of age. % higher

prevalence occurs for the lumbar region at the +(/ or /(01 discs follo!ed by the /(.

%pproximately 3 of these in4uries !ill resolve !ith conservative care in month to 1 year.+

#ain and other symptoms from a herniated disc can vary !idely from one person to

the next. omplaints range from local pain to radiating pain. 5ne of the most common set of

symptoms associated !ith a herniated disc is sciatica.20ciatica is generally understood to

mean referred pain or hyperaesthesia(paresthesia do!n the course of the involved nerve root.

The patient may describe this discomfort as 6burning7, 6aching7, 6sharp7, 6dull7, or 6tender7.

The sensation may be locali8ed by the patient as being across the lo! back, into the buttocks,

along the posterior(lateral thigh, along the calf, or even into the ankle or toes. 1

The purpose of the management of lo! back pain are reduce pain, increase trunk and

pelvic muscles strength, increase lumbar stability, reduce lumbar muscle spasm./ The

management of lo! back pain comprises a range of different intervention strategies including

surgery, drug therapy, and non(medical interventions. The ob4ective of the present study is to

determine the effectiveness of physical and rehabilitation interventions "i.e. exercise therapy,

transcutaneus electrical nerve stimulation "T9:0$, education, massage, traction, lumbar

support, and heat;cold therapy$ for lo! back pain.

Chapter II

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CASE REPORT

I. Identity

:ame < *r. 'T

=ender ; %ge < *ale ; years old

%ddress < *alalayang '', *anado

>eligion < hristian

5ccupational < ?niversity(level instructor

*edical >ecord < 1++1+

9xamination date < *arch 2-, 2-1

II. Anamnes (History)

>eferred from :eurology Department #rof. dr. >. D. @andou *anado !ith umbal

spondylosis and act of ousting at (+.

hief complainange of *otion.

*otoric status

o!er extremity

>ight eft

*ovement normal normal*uscle tone normal normal

#hysiologic reflex normal normal

#athologic reflex negative negative

*iotome

>ight eft

2 / /

/ /

+ / /

/ / /

01 / /

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igure /. *anual muscle test for lo!er extremity.

Dermatome

>ight eft1 2 2

2 2 2

2 2

+ 2 2

/ 2 2

01 2 2

igure . 0ensibility test for lo!er extremity.

#rovocation test

>ight eft

Ealsava #ositive

aseAue :egative #ositive

0> -- /--

Braggard :egative #ositive

0icard :egative #ositive

ontra aseAue :egative #ositive

#atrick :egative :egative

@ontra #atrick :egative :egative

:0T :egative :egative

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unctional *easurement'< Bulging "H:#$ on level (+, +(/, and

/(01.

Dia-nosis

( linical diagnosis < Hernia :ucleus #ulposus

Hypertension stage '

( 9tiological diagnosis < *echanical subacute

( Topic diagnosis < Bulging (+, +(/, and /(01

( unctional diagnosis < Body functions < sleep function sometimes disturbed by pain,

exercise tolerance function limitation for bending for!ard activity.

Body structures < structure of trunk "it seems lordotic lumbal

straighten$, abdomen area have a potbellied.

%ctivities and participation < changing basic body potition "pain !hen

getting(up from lying position$, lifting and carrying ob4ect "canMt lift a heavily

ob4ect for example !ater gallon$, toileting "felt pain !hen straining during bo!el

movement$, dressing "felt pain !hen !earing trousers or pants$, felt pain if !ant

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!earing shoes, !ork as a ?niversity(level instructor and + times in a !eek to

go to !orkplace.

9nvironment factors < products and technology for employment

"using a laptop$, using stairs in !orkplace, professional "!ork as a ?niversity(

level instructor$, !ork place is far from home "*anado(Tondano$, in house 4ust

living !ith !ife and a grandchild, health services using %0@90 "health

insurance$.

#ersonal factors < years old, education 0trata 1 "01$, man.

%dvis< onsult to 'nternal Department.

onsult to :utrision Department.

Proems

( #ain on lo! back.

( imitation trunk range of motion.

( imitation in activity due to disability "dressing$.

( %bnormal mobility.

( Disturbance in vocational.

( Corried about the illness.

( Hypertension stage '.

( 5ver!eight.

$ana-ement2

*edikementosa< "from :eurology department$

( *eloxicam 1/ mg 2x1

( ?ltracet x1

( *yonal 2x1

( @almeco 1x1

>ehabilitation #rogramsehabilitation Department.

#lan< cek routine haematology, blood sugar, 2 hour postprandial, ureum, creatinin, uric acid,

lipid profile, urinalysis.

9=, Thorax x(ray.

*arch 2, 2-1

9=< normal

$arch 56 5789

0< #ain on lo! back

5< Blood pressure< 1-;- mmHg

E%0 I

0pasm on paravertebral muscle at level 1(/.

olding skin test positif on level 1(/.

#ain on pressure to vertebra lamina on level 1(.

0chober test< ,/ cm

>ight eft

Ealsava #ositive

aseAu

e

:egativ

e

#ositive

0> -- //-

Bragard :egativ

e

#ositive

0icard :egativ

e

#ositive

ontra

aseAu

e

:egativ

e

#ositive

#atrick :egativ

e

:egativ

e

@ontra

#atrick

:egativ

e

:egativ

e

:0T :egativ :egativ

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e e

*odified B# disability Auestionnaire< 2+L.

aboratoryesume :ormal

eukosit F/-- +.--- 1-.--- ;mm

9rytrosit /.1 +.2/ /.+- x 1-;mm

Hemoglobin 1/.2 12.- 1.- g;d

Hematocrit +2. F.- +F.- x 1-;mm

Trombosit 2// 1/- +/- x 1-;mm

Blood sugar 12 F- 12/ mg;d

2 hours post prandial 1++ 11- 1+- mg;d

reatine -.& -. 1.1 mg;d

?reum 2 2- +- mg;d

?ric acid .F 2 F mg;d

0=5T /+ - mg;d0=#T - - + mg;d

Total cholesterol 22 1- 2-- mg;d

HD /+ - +- mg;d

D 1+& - 1/- mg;d

Triglyseride 11F - 1&- mg;d

Hb%1 ,+ +,/ , L

%< H:#

Hypertension stage '

#ange of motion, including flexion, extension,

and rotation, should also be assessed. :eurologic examination should include assessment

of muscle strength and tone, assessment of tendon reflexes, and sensory examination. %

straight(leg raise test should be performed in patients !ith evidence of sciatica or

radicular pain. The straight(leg raise test is specifically aimed at detecting lumbar nerve

root irritation. % positive straight(leg raise sign is identified !hen sciatica is reproduced

bet!een - - degrees of leg elevation.

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igure &. 0traight(leg raise test.

>adicular pain arises from nerve root compression or irritation. 0choberMs test can be used

to measure the degree of impairment of range of motion. This test is performed by

marking the lumbar spine at - cm and at 1/ cm) more specifically, a mark is made 1- cm

above 01 and another / cm belo!. The patient is then asked to flex as far for!ard as

possible, and the degree to !hich the marks separate is noted. The points normally

separate at least / cm.12

igure 1-.'llustration of 0choberMs test.

rom physical examination for this patient found lordotic lumbal straighten, spasm on

paravertebral muscle at level 1(/, folding skin test positif on level 1(/, pain on

pressure to vertebra lamina on level 1(. 0chober test< ,/ cm, it means trunk

flexibility decreased because there are spasm on muscle at lo! back. #rovocation test

positive for valsava test, for left leg< aseAue test, 0>< /-L, ontra laseAue, it means

the possibility for H:#. 'n gait analysis, there is no antalgic gait. 'n motoric "muscle

strength and tone$ and sensoric examination "protopatic and proprioseptic$ !as normal.

or reflexes in lo!er leg, in this case, knee reflex and %chilles reflex are normal.

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:AS (:is"a Anao- Scae)< measure variation in back pain. The intensity of pain

recorded using a visual analoAue scale ranging from no pain to maximum pain.

>osenberg :, et al "2--+$ suggest that evaluation of patients according to E%0 of pain is

an accurate measurement. #atient !as asked the point !here they rated his pain.1'n this

case E%0 !as used for pain measurement. 9valuation for pain every time patient control.

igure 11. Eisual analog scale.

3"nctiona meas"rement using modified 5s!estry lo! back pain disability

Auestionnaire "5D' I 5s!estry Disability 'ndex$. 5D' !as originally described in 1&-.

The Auestionnaire consists of 1- items addressing different aspects of function. 9ach item

is scored from - to /, !ith higher values representing greater disability.1&'f all 1- section

are completed the score is calculated as follo!s)

9xample< 1 "total scored$

/- "total possible score$ x 1-- I 2L

'f one section is missed or not applicable the score is calculated)

1 "total scored$

+/ "total possible score$ x 1-- I /./L

'nterpretation os scores


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crippled< interpretation is reAuired.

1L ( 1--L< These patients are either bed(bound or exaggerating their

symptoms.

'n this case report the version of the 5D' !as used modified. *odified 5D' !as similar

to the modified 5D' used by Hudson(ook et al, !ho replaced the sex life section !ith a

Auestion related to fluctuations in pain intensity. Hudson(ook et al reported levels of

test(retest reliability and internal consistency for the modified version similar to those of

the original 5D'. % section regarding employment and home(making ability !as

subtitued for the section related to sex life because the sex life item is freAuently found to

be left blank. 'n this case report functional measurement "modified 5D'$ !as taken

everytime patient come for control schedule.Diagnosed !as made from anamneses, physical examination and additional

examination "*agnetic >esonance 'maging$, are hernia nucleus pulposus and

hypertension stage ', so for this patient have komorbid disease. There are some problem

for this patient) #ain on lo! back, imitation in activity due to disability "dressing, !hen

get up from lying potition$, %bnormal mobility "feel doesnMt comfort after !alking for

about 1-- m$, Disturbance in vocational "have past some steps in !ork place, sometimes

have stand !hen gived materi in classroom$, !orried about the illness, Hypertension

stage ', over!eight. or hypertension ' made a consult to 'nternal Department, and for

over!eight ' made consult to :utrision Department.

The purpose of the management of lo! back pain are reduce pain, increase trunk and

pelvic muscles strength, increase lumbar stability, reduce lumbar muscle spasm./ #hysical

fitness and cognitive behavioural therapy may have the most to offer in terms of

treatment. Drug therapy offers temporary relief, especially for acute back pain, but it is

rarely of material benefit in people !ith chronic back pain. #aracetamol and non(steroidal

anti(inflammatory drugs bring the pain to tolerable level, but they probably should not be

taken for long periods of time "the self(medication direction usually restrict use to 12

days$. *oist heat and "sometimes$ cold cabinets, may be useful. ure is the aim, but it

may be difficult to achieve. %bility to live !ith the pain !ith minimal restrictions

imposed by the pain is a more realistic goal. or those purposes, understanding the person

and constellation !ithin !hich the pain occurs is an important first step from !hich to

derive others. 9xplanation and education) physical conditioning, maintenance of activities

!henever possible) appropriate physical and mental relaxation) mood improvement and

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improvements in self(image that lead to greater confidence and social functioning and to

socioeconomic enhancement) and avoidance of relapses are all at least as important mere

prescription(!riting.1-

igure 1. Health are =uideline< %dult acute and 0ubacute B#.1

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Basic on some problems in medical rehabilitation, the patient are gived program in

physiotherapy, psycologic, occupational therapy, orthotic prostetic, social medicine. or

medication 4ust continued from :eurology department.

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%t physiotherapyhave gived program infrared on lo! back, massage on lo! back,

and *cken8ie exercise.

In%rared. 0uperficial heat modalities convey heat by conduction or convection. 0uperficial

heat elevates the temperature of tissues and provides the greatest effect at -./ cm or less from

the surface of the skin. 0uperficial heat modalities as infrared heat lamps. 1+ Therapeutic

effects of local administration of heat, both shallo! and deep, occurred by the presence or

production of heat transfer. 'n general, the physiological reaction that can be accepted as the

basis for the application of heat therapy is that the heat !ill increase viscoelastic collagen

tissue and reduce 4oint stiffness. Heat also reduces pain by increasing the pain threshold nerve

fibers. %nother effect is to improve muscle spasms, increase blood flo!, helping the

resolution of inflammatory infiltrates, edema and exudate. 0uperficial heat therapy produces

the highest heat on the surface of the body, but its penetration into the tissue 4ust a fe!

millimeters. Before therapy is important for remember contraindication heat therapy.22There

is moderate evidence that heat !rap therapy reduces pain and disability for patients !ith back

pain that lasts for less than three months "%ustralasian ochrane entre, *onash 'nstitute of

Health 0ervices >esearch, *onash ?niversity %ustralia, 2--/$. The addition of exercise to

heat !rap therapy appears to provide additional benefit. Heat treatments include infrared heat

lamps.1+'n aplication distance from lamp to skin surface are - F- cm " lamp F/- 1---

C$, +/ /- cm "for smaller lamp$. Duration time is 2- minutes. Therapy !ill stop if patient

feel hot on skin surface " - slightly hot$ " +1- hot$.1/or this patient !as gived

infrared on lo! back, !ith lamp distance to skin surface for about +- +/ cm, and duration

time 2- minute. 5bservation during therapy for control if the heat is comfort for patient.

'nfrared therapy !as given three times per !eek for this patient.

igure 1+. 0uperficial heating !ith infrared.

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$c;en


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*c@en8ie exercises !ere applied for this patient but not all exercise can be done because

patient said feel doesnMt comfort on lo! back !hen continue to step so in this case patient

only do step 1 and 2 and step /. This exercise !as continued at home and be done t!ice a day

except step /. 9xercise in hospital be done after infrared application and massage.

igure 1/. *c@en8ie exercise.

$assa-e. *assage is mechanic and systematic stimulation for body soft tissue through

giving pressure and stretch !ith rhythmic for therapeutic goal.1/'t can do by using hand or

!ith mechanical tools. 9ffects that arise in the administration of massage can be grouped into

t!o< that is reflektoris effects and mechanical effects are physiological. 9ffects from

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reflektoris include< a sense of comfort, relaxation of muscles, reduces mental tension and

soothe "sedation$. Chile the mechanical effects such as< improving blood flo! and lymph,

intramuscular movements that stretch the attachment and mobili8e liAuid deposits.

'ndications massage applications are< soft tissue in4ury !ith pain, stiffness, spasms and

muscle tension. Chile contraindications include infection, malignancy process, diseases of

the skin. The techniAues of massage can include0?D dr 0oetomo ; *edical aculty

?:%'> 0urabaya< 1&&2< p.1(F.

23.>ochman . *odalitas Terapi isik dan #enatalaksanaan :yeri. 'n< Hamid T, #utra

H, 0etiad4i 0, editor. %spek isiatrik :yeri. *edical >ehabilitation ?nit >0?D dr

0oetomo ; *edical aculty ?:%'> 0urabaya< 1&&2< p. 21(++.
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