Biofeedback Training for Partial

Weight Bearing in Patients

After Total Hip Arthroplasty
Arch Phys Med Rehabil Vol. 90, August 2009

Dibacakan : dr Martha Kurnia

Disupervisi : dr I. Lukitra W, SpRM

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 PENDAHULUAN
• Partial Weight Bearing : amputasi, fraktur, THA
• THA (Total Hip Arthroplasty) :
- batasi weight bearing (WB)
- jumlah max WB ditentukan SpOT
- tujuan: kurangi iritasi mekanik  prothesa
longgar  membahayakan fase penyembuhan
• Cara ukur PWB: injak timbangan
- Sering, beban melebihi yang diresepkan
- Tidak merefleksikan beban dinamik
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 …pendahuluan
• Prosedur lain :
- training gunakan timbangan + audio feedback
 tidak efektif menurunkan gaya reaksi
- instruksi via video + terminal augmented verbal
feedback  berpengaruh pada pembelajaran
motor
- didactic-designed video instructions + terminal
augmented verbal feedback  membantu
mengurangi deviasi beban dari yang diresepkan

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 …metode
• Inklusi :
- px ambulans dg coxarthrosis  THA
- usia ≤ 70 thn
- tidak ada DM, neuropati perifer (dg tuning fork)
• Eksklusi :
- MMSE < 24
- Riwayat RA
- Defek kongenital & deformitas kaki :
charcot, prominent caput metatarsal, pes cavus, clawing,
hallux valgus, hallux rigidus
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 …metode
• Sampel : 11 px (9 pria, 2 wanita)
Usia rata2 : 56.1±9 thn (44 – 69 thn)
BB rata2 : 79.5±10.3kg (64-94kg)
TB rata2: 1.73±0.07m (1.60-1.85m)

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 PERIODE LATIHAN
• Goal : menjaga PWB sesuai resep
disupervisi trainer + PEDAR system
• Tempat tenang
• Dimulai pada hari px sudah boleh berdiri

 PEDAR system :
 in sole adaptif
 99 sensor
 Ukur distribusi tekn dinamik
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 …metode
1st day
• Saat px dapat berdiri dengan tegak dan tidak
berpegangan tempat tidur (1-2 hari post op)
• Ukur weight bearing yang dibolehkan dengan
timbangan (alasan keamanan)  threshold 20 kg
• Px jalan di parallel bar
- disupervisi PT
- menggunakan PEDAR system
- feedback information form
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9
 …metode
2nd day
• Jalan dg crutch disupervisi PT
• Prosedur jalan sesuai urutan sebanyak 10 langkah
diikuti : subyektif performance (estimasi)
feedback obyektif (PEDAR system)
• Tujuan : penilaian performance oleh px sendiri sesuai kriteria
& PEDAR
• Hasil : cukup efisien untuk pembelajaran sensorimotorik
• Px dianggap telah belajar stlh 3 siklus gait awal & mencapai
70% dari total langkah

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 OBSERVASI
• 4 Retensi Tes :
rekaman 3 siklus gait tanpa feedback
1. Akuisisi tes (langsung setelah latihan)
2. Retensi awal (30 menit)
3. Sehari setelah latihan
4. Dua hari setelah latihan

• Ukur puncak median plantar pressure (tiap siklus) :

- dalam batas toleransi ± 50 N  nil pressure error
- luar batas toleransi (lbh tinggi/lbh rendah) perbedaan
absolut pressure error
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 HASIL STUDI
• Ada perbedaan signifikan pressure error :
awal = 42.5±22.5N
P < 0.001
akhir = 3.7±11.4N
• Tak ada perbedaan pada px saat awal periode
latihan dgn perbedaan tes retensi
(30’, 1 hr, 2 hr)
• Vertikal ground reaction 
perbedaan awal & akhir training
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13
 DISKUSI
Pada grup kecil post THA, diobservasi :
• Lower pressure error
• Vertikal ground reaction force (VGRF)
Awal latihan (baseline)
Akhir latihan dg biofeedback
Px mampu menerapkan PWB yang diresepkan dlm
waktu singkat 
- Biofeedback bantu pembelajaran PWB
- Retensi ~ waktu : terbatas
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 …diskusi
• Hasil konsisten dg studi sebelumnya
• Vasarhelyi et al : komparasi px dg fraktur pada
ekstremitas bawah vs px sehat  baik px
sehat maupun px fraktur dpt melakukan PWB
sesuai resep
• Tveit & Karrholm : 15 px post THR diresepkan
reduksi weight bearing (30% BB)  tidak dpt
diikuti; 1/3 tdk sadar ketidakmampuan
mengikuti instruksi
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 …diskusi
• White & Lifeso : Efisiensi dari real-time dynamic
visual biofeedback foot-ground reaction force 
mengurangi beban asimetris ekstremitas post THA
• Femery et al : audiovisual biofeedback pada px
sehat 
audio : warning system pada tekn plantar yg
berbahaya
visual : derajat tekanan
subyek modifikasi pola gait sbg respon
biofeedback
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 …diskusi
• Hasil terbaru :
• 8 subyek sehat  dites dg treadmill + sensor
tekn plantar
• Subyek menggunakan audio+visual sinyal utk
beban berlebih, kurang, keliru
• Hasil: 5 dari 8  modifikasi pola gait
- 5% reduksi tekn plantar
( pada 2 studi : tak ada data utk retensi lama)
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 Keterbatasan studi
• Latihan dimulai sesaat setelah operasi (1-2 hari post op)
• Pada periode tertentu masih dipengaruhi G.A, spt
kelemahan stlh operasi besar
• Usai THA  px segera mobilisasi  mulai rehabilitasi
jalan secepat mungkin
• Terbatasnya jumlah sesi latihan
• Perhatian px terpecah pada 2 sumber feedback
(concurrent & intrinsic)  menurunnya kemampuan
retensi intrinsic trial
• Jumlah & distribusi praktek ( 2sesi pada 2 hari berbeda)
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 KONKLUSI
• Hasil mengkonfirmasi adanya kesulitan
menjaga PWB pada px post op lower extremity
• Meski, regimen sudah dikontrol individual dg
feedback  ada keterbatasan pencapaian
beban PWB sesuai resep dokter bedah
• Studi ini hanya 1 sesi latihan  perlu studi
tambahan dengan 2 bahkan lebih sesi latihan

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Terima Kasih

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 Total Hip Arthroplasty
• Beberapa Indikasi :
Arthritis, AS, Tumor, DJD, Fraktur/dislokasi,
Osteomyelitis, Osteotomi, dsb
• Kontraindikasi
Absolut : infeksi aktif pada join, infeksi sistemik/sepsis,
neuropatik sendi, malignancy yg mempengaruhi
fiksasi prothesa tidak kuat
Relatif : infeksi lokal, insufisiensi/absen otot abduktor,
defisit neurologis progresif, destruksi tulang progresif

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 Goal Rehabilitasi Post THA
• Jaga terjadinya dislokasi implan
• Menambah kekuatan fungsional
• Menguatkan otot hip & knee
• Cegah efek immobilisasi lama
• Melatih transfer & ambulasi independen dg
alat
• Mendapat full ROM tanpa nyeri

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 Prosedur Rehabilitasi THA
• Pre- Op
- Precaution of hip dislocation
- Transfer instruction : in & out bed
Chair : avoid deep chair, avoid crossing
legs, look at the ceiling, scoot to the
edge of chair then rise
- Ambulation : use assistive device (walker)
- Exercise : demonstrate day 1 exc
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 Rehabilitasi Post THA
• Post – Op
– Out of bed 2x/day (1-2 hari post op)
– Mulai ambulasi dg alat 2x/day (assistance
therapist)
Cemented : WBAT with walker at least 6 weeks,
cane at contralateral (4 – 6 months)
Cementless : TDWB with walker (6-8 weeks)

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 Latihan
• Isometric Exercise
SLR : tighten knee & lift leg off bed, keeping the
knee straight, flex the opposite knee
Quadriceps sets : tighten quariceps by pushing knee
down & hold for a count of 4
Gluteal sets : Squeeze buttocks together & hold for
a count of 4
Ankle pumps : pump ankle down & up repeatedly
Isometric abduction with self-resistance while lying
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• Stretching Exercise
• Bathroom Rehabilitation
• Assistive Devices
• Transfers
• Transfers to home

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Patient Instructions (Posterior Surgical Approach)

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 Mini Mental State Examination
1. Orientasi
2. Registrasi
3. Atensi
4. Recall
5. Language
6. Construction

Total nilai 30
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 PEDAR SYSTEM
• The Pedar Mobile system is a
portable insole pressure device
with matrix insoles (thickness,
2mm). Each insole contains 99
capacitive sensors.
• An electronic device with an
accelerometer was made to
automatically start and stop the
Pedar system so that data were
recorded only when the patient
was standing or walking.
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• THE TERM BIOFEEDBACK is derived from control system
technology and from biologic studies of self-regulatory
mechanisms that make human functioning possible
• This method requires that external feedback (usually
visual and/or acoustic) be brought to the patient by
electronic equipment to detect, amplify, and reveal
instantaneously internal biologic processes and functions,
of which he/she is are unaware
• The biofeedback method is particularly indicated in
situations in which the intrinsic and extrinsic sources of
information are absent or insufficient or, more generally,
when a self-regulating system is disturbed. The most
frequently used procedure is electromyographic feedback

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 Visual & Auditory Feedback
• In stroke patients, the biofeedback methods
• that feature visual feedback16,17 or acoustic
signals18-20 can
• be used for balance training or regulation of
perturbed stance.

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• Partial weight bearing at a specific target load
was not achieved by patients with a THA when
given verbal instructions. Especially when using
a low target load and when walking at home
with no supervision of a physical therapist
patients loaded the operated leg higher and
more frequently above the target load.
• Other training methods (eg, biofeedback) have
to be evaluated to use as training tools for
partial weight bearing at specific target loads.

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 Analisa Gait saat heel off

• Knee
Kinematik :Knee extended 178⁰, Move to 40⁰ flexion
Kinetik : The resultant force has moved  acts to extend the joint.
Peak activity of plantar flexor occurs the instant that resultant force
shifts anterior to the knee joint. (external)
Extension moment acting on the knee joint (internal)

• Hip
kinematik : as the heel leave the ground : 10⁰ - 15⁰ hyperextension
kinetik : Immediately before double support :
magnitude of extension moment at hip supporting extremity 140 ft.-lb

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