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MULTIMODAL PHYSIOTHERAPY

DOSIMETRI ELECTROPHYSICAL AGENT (EPA’S)


EVIDENCE – BASED PRACTICE PHYSIOTHERAPY

Irfan
PERATURAN MENTERI KESEHATAH NO. 80 TAHUN 2013
TENTANG PENYELENGGARAAN PEKERJAAN DAN PRAKTIK
FISIOTERAPIS

– Fisioterapi adalah bentuk pelayanan kesehatan


yang ditujukan kepada individu dan/atau
kelompok untuk mengembangkan, memelihara
dan memulihkan gerak dan fungsi tubuh
sepanjang rentang kehidupan dengan
menggunakan penanganan secara manual,
peningkatan gerak, peralatan (fisik,
elektroterapeutis dan mekanis) pelatihan fungsi,
komunikasi.
PERATURAN MENTERI KESEHATAH NO. 80 TAHUN 2013 TENTANG
PENYELENGGARAAN PEKERJAAN DAN PRAKTIK FISIOTERAPIS

• Pasal 6, ayat 1 menyatakan :


“Fisioterapis dapat menjalankan praktik pelayanan Fisioterapi secara
mandiri atau bekerja di Fasilitas Pelayanan Kesehatan”.
• pasal 16
(1). Dalam menjalankan Praktik, Fisioterapis memiliki kewenangan untuk
melakukan pelayanan fisioterapi meliputi:
– a. asesmen fisioterapi yang meliputi pemeriksaan dan evaluasi;
– b. diagnosis fisioterapi;
– c. perencanaan intervensi fisioterapi;
– d. intervensi fisioterapi; dan
– e. evaluasi/re-evaluasi/re-assessmen/revisi.
(2) Dalam melakukan pelayanan sebagaimana dimaksud
pada ayat (1), fisioterapis dapat menerima pasien
langsung atau berdasarkan rujukan dari tenaga
kesehatan lainnya.
ROLE OF PHYSICAL THERAPISTS IN
HEALTH CARE
• Diagnose and manage movement dysfunction and
enhance physical and functional abilities.
• Restore, maintain, and promote optimal
– physical function,
– wellness and fitness, and
– quality of life as it relates to movement and
health.
• Prevent the onset, symptoms, and progression of
impairments, functional limitations, and disabilities
that may result from diseases, disorders, conditions,
or injuries.
Alur Pelayanan Pasien Rawat Jalan
Alur Pelayanan Pasien Inap
CORE VALUES OF PHYSICAL THERAPISTS
Critical Elements of Professionalism for Physical Therapists

Accountability

Altruism

Compassion/Caring

Excellence

Integrity

Professional Duty

Social Responsibility
HIGH JOB SATISFACTION
• CNNMoney.com gave physical
therapists a grade of “A” for
“Personal Satisfaction” as a quality
of life indicator in 2012.

• Forbes ranked physical therapists


as one of "The Ten Happiest Jobs,"
in 2011.

• Physical therapists have one of the


highest job-satisfaction levels.
• 78% "very satisfied" with their chosen
career.
• 2007 National Opinion Research
Center report.
JOB OUTLOOK
PT Employment Expected to Grow by 39% through 2020
– US Bureau of Labor Statistics, 2013
– 198,600 - Current Employment
– 276,000 - Projected Employment by 2020
Best Jobs in America
– U.S. News & World Report: 2013, 2012 and 2009

Fastest Growing Jobs


– CNNMoney.com: 2012, 2010

Highest Growth Expected in Rural Areas and Geriatrics


BENEFITS OF A PHYSICAL THERAPIST
CAREER
• Make a Difference
• Be a Movement
Expert
• Enjoy Job Security
• Love Your Job
• Choose Your
Location
• Be an
Entrepreneur
SPECIALTY CERTIFICATION
Physical therapists can specialize in the following areas!

• Cardiovascular and • Orthopaedics


Pulmonary • Pediatrics
• Clinical • Sports Physical
Electrophysiology Therapy
• Geriatrics • Women's Health
• Neurology

Physical therapists specialize to develop a greater depth of


knowledge and skills related to a particular area of practice.
Specialty certification is voluntary. Physical therapists are not
required to be certified in order to practice in a specific area.
GRADE POINT AVERAGE (GPA)
• Minimum GPA
– DPT programs often have minimum GPA requirements.
– Applicants who only meet the minimum GPA may not be
competitive.

• Average GPA for Accepted PTCAS Applicants in 2013


– Average GPAs of accepted applicants are often much
higher.
– Overall Undergraduate GPA = 3.54
– Combined Science and Math GPA = 3.40
– Core PT Prerequisite GPA = 3.50

• See also the PTCAS Applicant Data Report


– http://www.ptcas.org/About/
Source: 2012-13 PTCAS Applicant D
PENDAHULUAN
DEFINITION OF EPA BY ISEAPT
• EPA is defined as the use of electrophysical and biophysical
energies for the purposes of evaluation, treatment and
prevention of impairments, activity limitations, and
participation restrictions.

Electrophysical Agent adalah penggunaan energi elektrofisika dan biofisika


dengan tujuan evaluasi, intervensi/tindakan dan pencegahan pada gangguan
(impairments), keterbatasan aktivitas (activity limitations) dan hambatan
partisipasi (participation restriction).
EVALUATION-TREATMENT
• Evaluation procedures involving EPA include (but are
not limited to) ultrasound imaging and electro-
neurophysiological testing in order to assist with
physical therapy diagnosis, guide treatment procedures
and to evaluate treatment outcomes.
• Treatment procedures involving EPA include (but are
not limited to) the use of electromagnetic, acoustic and
mechanical energies to produce biophysical effects at
the cellular, tissue, organic and whole body levels in
order to achieve physiological and clinical effects which
serves to maintain and optimize health.
ISEAPT, 2014
The Process of PT Management
Treatment

Prognosis &
Treatment
Plan

Diagnosis

Evaluation

Examination
Physiotherapist Services
PRINSIP DASAR
PRINSIP DASAR

Dr. Goh Ah-cheng


Tim Watson, 2014
BASIC MODEL
ELECTROTHERAPY
Superficial Heat Conversive Heat
Reasoning Process
-Hotpack -Ultrasound
-Paraffin Bath -Microwave
Biophysical Change -Infra Red -Shortwave

Cryotherapy Electrotherapy
-Ice Pack / Cold Pack -DC Stimulators
Physiological Effect
-Ice Bath -AC Stimlators
-Ice Massage -PC Stimulators

Clinical Effect
Phototherapy Mechanotherapy
-Ultraviolet -Traction
-LASERs -CPM Divice
PERBANDINGAN ABSORBSI ENERGY
(Physiological effect)

Sparrow et al, 2005


PULSE RATIO
TREATMENT INTENSITY
Non Thermal Effect
Half Value Depth

Jika kedalaman target jaringan kurang dari 0,5 cm, maka tabel tidak dapat
dijadikan acuan
CONTOH kasus 1
• Aplikasi US therapy pada cedera akut pergelangan kaki.
• Asumsi : Setelah pemeriksaan di tetapkan lokasi cedera
ligamen anterior Tallo-fibular, maka dapat diputuskan
dosimetri untuk penggunaan US therapy sebagai
berikut :
– Cedera Superfisial  Frekuensi 3 MHz
– Cedera besifat akut  Intensitas 0,2 W/𝐶𝑚2
– Tidak dibutuhkan peningkatan dosis oleh kehilangan
energy permukaan karena kedalaman < 0,5 cm
– Cedera akut maka pulsed rasio  1:4
– Luas cedera sama dengan luas treatment head.
Total time = (1 minute) x (number of times the treatment head
fits over the lesion) x (the pulse ratio) which in this instance

• Prinsip kerja dosimetri


– Total waktu = 1 menit x luas cedera dengan
tranduser x pulsed rasio. Pulsed ratio
1: 1  2
– Pada contoh kasus diatas 1:2  3
• (1) x (1) x (5) = 5 Menit 1:3  4
1:4  5
1:9  10

KEPUTUSAN KLINIS DOSIS US Therapy :

F : 3 MHz , I : 0,2 W/𝐶𝑚2 , P : (1:4) , T : 5 Menit


CONTOH kasus 2
• Cedera Sub akut Ligamen lateral elbow dan
Superior radioulnar.
• Asumsi Hasil pemeriksaan, setelah pemeriksaan
ditetapkan dosimetri.
– Lesi superfisial  3 MHz
– Sub akut  0,4 W/𝐶𝑚2
– Tidak dibutuhkan peningkatan dosis oleh kehilangan
energy (kedalaman < 0,5 cm)
– Sub akut maka pulsed rasio : (1:2)
– Luas area diasumsikan 2 x treatment head
Working on the principles of 1 minutes worth of
ultrasound per head area, the total time taken to
treat the lession will be (1 minute) x (number of
time the treatment head fits over the lesion) x (the
pulse ratio) which in this instance

TOTAL TIME = (1) X (2) X (3) = 6 MENIT

KEPUTUSAN KLINIS DOSIS US Therapy :

3 MHz ; 0,4 W/𝐂𝐦𝟐 ; Pulsed 1 : 2 ; 6 menit


Contoh Kasus 3
• Kondisi cedera anterior capsule pada shoulder
• Asumsi hasil pemeriksaan didapatkan lesi pada
anterior capsule of glenohumeral Joint.
• Asumsi Lokasi cedera 3 cm dibawah kulit
• Sifat cedera kronis  Internsitas 0,5 W/𝐶𝑚2
• Memerlukan peningkatan dosis oleh kehilangan
energy oleh kedalaman target  Intensitas
0,88W/𝐶𝑚2
• Kronik  Pulsed Ratio = 1: 1
• Estimasi luas area 2 x Treatment head
• Working on the principles of 1 minutes worth of
ultrasound per head area, the total time taken to
treat the lession will be (1 minute) x (number of time
the treatment head fits over the lesion) x (the pulse
ratio) which in this instance
Total Time = (1) x (2) x (2) = 4 Menit

DOSIS TREATMENT =
1MHz ; 0,88W/Cm2 ; PULSED 1:1 ; 4 Menit
EVIDENCE-BASED PRACTICE
PHYSIOTHERAPY
LOW INTENSITY PULSED ULTRASOUND
(LIPUS)
Biophysical Change

Superficial Heat Conversive Heat


-Hotpack -Ultrasound
-Paraffin Bath -Microwave
-Infra Red -Shortwave

When thermal energy applied to human tissue, they are absorbed by various
tissue with the production of heat

The main biophysical change is increased temperature at the cellular, tissue and
organic level.
In Vivo vs In Vitro
Physiological Effect

Superficial Heat Conversive Heat


-Hotpack -Ultrasound
-Paraffin Bath -Microwave
-Infra Red -Shortwave

The physiological effect of heat application depend on increase the temperature


of the target tissue to a therapeutic level of 41 oC to 45 oC.

The temperature is reached about 8 to 10 minute

In respon to heat stimuluss, the body product physiologic response that may be
therapeutic

Within 30 minutes, the body reach thermal equilibrium, and further heating is
not benefical.
Pulsed Shortwave Therapy
Superficial Heat Physiological Effect Conversive Heat
-Hotpack -Ultrasound
-Paraffin Bath -Microwave
-Infra Red -Shortwave

Muscle Relaxation via


Increase Metabolism
Muscle spindles and GTO
Linear increase in
Increase Pespiration
Oxygen tension
Increase Cappilary Increase tissue
Pressure Permeability extensibility
Local Vasodilatation with Sedation of sensory
hyperaemia nerve
Superficial Heat Clinical Effect Conversive Heat
-Hotpack -Ultrasound
-Paraffin Bath -Microwave
-Infra Red -Shortwave
Dosimetri Model
Superficial Heat Conversive Heat
-Hotpack -Ultrasound
-Paraffin Bath -Microwave
-Infra Red -Shortwave

Dosimetri Model Reasoning Process

How to get the energy to the desired Biophysical Change


target tissue

How much energy needed to produce Physiological Effect


the desired physiological effect in
normal tissue

How much energy needed to produce Clinical Effect


the desired physiological effect in
pathological tissue
SWD - MWD
SUGGESTED TREATMENT DOSES
Pulsed Shortwave Therapy
• The general guide below is based on both clinical and research evidence
wherever possible.
• Acute conditions
– Mean power of less than 3 Watts.
– More acute the presentation the lower the delivered mean power (i.e.
3 Watts is max for this group).
– Using narrower (shorter duration) pulses and a higher the repetition
rate may be beneficial.
– Time : 10 minutes is probably sufficient
• Sub Acute Conditions
– Mean power of between 2 and 5 Watts
– As the condition becomes less acute, use wider (longer duration)
pulses
– Time : 10 - 15 mins
SUGGESTED TREATMENT DOSES
Pulsed Shortwave Therapy
• Chronic Conditions
– Mean power of more than 5 Watts is usually required in
order to achieve a reasonable tissue response. [Be careful
with the thermal component as research has shown that at
mean powers of about 12 Watts or more, most people can
feel some heating effect. If you want to avoid heating, you
MUST keep the mean power lower than this. To be safe,
better to keep the mean power below 5 Watts at the
present time].
– Pulses of longer duration are probably of benefit if there is
a choice.
– Time : 15 – 20 mins. There is no clear evidence of treating
for longer than 20 minutes, though this is not 'wrong' per
se.
HotPack
HotPack
HotPack
HotPack
HotPack
SHOCKWAVE THERAPY
Shockwave – Clinical Application
A range of clinical applicationtrials and literature is
included in the reference list at the end of this material.
Treatment Dose Issues
• In addition to the appied energy (mJ/𝑚𝑚2 )- in
therapywe are using the LOW (up to 0,08 mj/𝑚𝑚2 )
and possibly the MEDIUM (up to 0,28 mJ/𝑚𝑚2 ) energy
levels, the other significant factors are.
• a) number of shocks and
• b) number of treatment session repetitions
Shock Number
• Shock number usually between 1000 and 1500,
though some authorities suggest up to 2000.
• Some research has tried as few as 100 and also
500
• 500 more effective than 100
• 1000-1500 have been used in the clinical trials
with the best (most significant) outcomes
• Anecdotally, 1000-2000 shock per session
appears to be the most commonly applied range
Number of Treatment Sessions
• Some evidence for a singel session BUT only for High level
teratment – Using local anasthesia – not physiotherapy
• Most clinical research has used between 3 – 5 session at
low energy levels (typical therapy application), suggested
up to 7 may be needed in the more recalcitrant lessions.
• There have been no RCT trials yet to determine the
maximally effective therapy session number (or interval)
• Typically 3-5 session appears to be effective for the
majority of patients, spaced such as to let the tissue
‘reaction’ at least partly subside from the first session
before the next treatment is delivered. Optimal treatment
spacing has yet to be identified in the published research
evidence.
TERIMAKASIH