Case Presentation I

Kepada Yth.

Tuesday, 19 April 2016

dr. I Nyoman Murdhana, SpKFR-K

CASE PRESENTATION
PHYSICAL MEDICINE AND REHABILITATION MANAGEMENT OF PATIENT
WITH OSTEOSARCOMA OF RIGHT PROXIMAL TIBIA ENNEKING III POST
STANDARD TRANSFEMORAL AMPUTATION OF RIGHT LEG WITH
PULMONARY METASTASES

Presented by:
dr. Setia Wati Astri Arifin
Examiner:
dr. I Nyoman Murdhana, SpKFR-K

Presented in The Course of Taking Residency Training

Physical Medicine and Rehabilitation Program
Medical Faculty Univerity of Indonesia
Jakarta
2016

CONTENT

CONTENT.................................................................................................................................i
CHAPTER 1 LITERATURE REVIEW................................................................................1
1.1. OSTEOSARCOMA .....................................................................................................1
1.2. ABOVE KNEE (TRANSFEMORAL) AMPUTATION ...........................................5
1.3. REHABILITATION IN TRANSFEMORAL AMPUTATION ................................6
CHAPTER 2 CASE REPORT..............................................................................................12
2.1. IDENTITY...................................................................................................................12
2.2. ANAMNESIS...............................................................................................................12
2.3. PHYSICAL EXAMINATION....................................................................................15
2.4. SUPPORTIVE EXAMINATION...............................................................................23
2.5. RESUME......................................................................................................................26
2.6. DIAGNOSIS................................................................................................................27
2.7. GOALS.........................................................................................................................28
2.8. REHABILITATION PROGRAM.............................................................................29
2.9. PROGNOSIS...............................................................................................................31
CHAPTER 3 CASE ANALYSIS...........................................................................................32
REFERENCE.........................................................................................................................33
APPENDICES .......................................................................................................................36

CHAPTER 1
LITERATURE REVIEW
1.1. OSTEOSARCOMA
1.1.1. Definition
The term osteosarcoma was first used in the early 1800s by Alexis Boyer, the
imperial family surgeon for Napoleon.(1) Osteosarcoma is defined as a malignant
mesenchymal tumor in which the cancerous cells produce bone matrix.
Osteosarcomas are classified as primary and secondary. Primary are further sub-typed
as intramedullary/central and surface osteosarcomas as per World Shealth
Organization classification.(2)
1.1.2. Epidemiology
Osteosarcoma is the most common primary bone tumor.(3) The incidence is
0.2-.0.3/100.000/year, higher in adolescents (0.8-1.1/100.000/year at age 15-19),
where it accounts for >10% of all solid cancers. Adults are less affected with a second
peak incidence between 50 and 70 years. This later incidence is usually associated
with secondary osteosarcoma that could arise in Pagets disease, bone infarcts and
fibrous dysplasia. The male-female ratio is 1.4:1.(4)
1.1.3. Clinical Manifestation
The tumours usually arise in the metaphyseal region of the long bones of the
extremities, uncommonly occur in the diaphysis (9%).(2,4) The most common
anatomic sites of osteosarcoma at initial presentation are the long bones of the lower
limbs. Fifty percent of osteosarcomas are located around the knee, in the distal femur,
proximal tibia, or proximal fibula. Approximately 10% of tumors occur in the mid or
proximal femur, and 9% occur in the proximal humerus.(5,6)
The most common presentation is site specific pain. This is generally
worsened by physical exertion. Approximately 20% complain of night pain.(7) Night
pain gradually develops and becomes a hallmark of skeletal involvement. Physical
examination demonstrates a firm, soft mass fixed to the underlying bone with
tenderness. No effusion in the adjacent joint, and motion is normal. Incidence of
pathologic fracture is less than 1%. Systemic symptoms are rare.(8)
1

Image 1. The most common anatomic sites of osteosarcoma.(1)

Of patients with osteosarcoma, 10% to 20% have metastatic disease at initial
presentation. The most common site of metastasis is the lungs. Isolated pulmonary
metastases are present in 61% of patients with metastatic disease at presentation.
Isolated metastases to bone are present in 16% of patients, and 14% have both
pulmonary and bone metastases. Seven percent of patients have metastases to other
rare sites plus bone and/or pulmonary metastases, and 2% of patients have isolated
metastases to rare sites. Rare sites of metastasis in patients with primary metastatic
disease, as opposed to metastatic disease in patients with recurrent disease, are lymph
nodes, central nervous system, liver, adrenal gland, and soft tissues.(7)
1.1.4. Diagnosis
Radiologic evaluation in osteosarcoma informs the initial diagnostic
impression, aids in the determination of the best approach for biopsy, facilitates
surgical resection, and identifies sites of metastatic disease, if present. The
recommended imaging studies for osteosarcoma at the time of diagnosis are plain
radiography and magnetic resonance imaging (MRI) of the primary tumor site to
evaluate the extent of local disease, a bone scan to screen for bony metastases, and a
CT scan of the chest to determine whether pulmonary metastases are present.(9)
Radiographs of the primary tumor usually show a large, destructive, mixed
lytic and blastic mass that has permeative margins. The tumor frequently breaks
2

through the cortex and lifts the periosteum resulting in reactive periosteal bone
formation. The triangular shadow between the cortex and raised ends of periosteum is
known radiographically as Codman triangle and is characteristic but not diagnostic of
this tumor.(2)
CT should only be used in the case of a diagnostic problem or doubt, to
visualize more clearly calcification, periosteal bone formation, cortical destruction or
soft tissue involvement. When the diagnosis of malignancy cannot be excluded with
certainty on radiographs, the next imaging step is MRI of the whole bone with
adjacent joints, which is the best modality for local staging.(4) CT and MRI of bone
lesions have been used to investigate the extension of tumors and the involvement of
surrounding structures such as vessels, nerves, and soft tissues.(10)
Biopsy is a key diagnostic method for an osteosarcoma.(5) Some laboratory
tests are useful in the follow up and may also be of prognostic value, such as alkaline
phosphatase (AP) and lactate dehydrogenase (LDH).(4)
1.1.5. Staging
There are basically two systems used for staging OS. Ennekings
classification(11) was published in 1980 and contributed significantly to the research
of osteosarcomas. His system is simple to use and considers the histological grade of
tumour, the local extent and the presence of metastases.

Table 1. The Ennekings Classification of Osteosarcoma.(11)

1.1.6. Therapy
The standard treatment of patients with osteosarcoma consists of combination
of chemotherapy and surgery. Radiotherapy can be also applied in the treatment
program along with surgical resection.(9)
The primary goal of surgical management is to limit the local extent of the
disease and to prevent metastases. The secondary goal is to restore function. Limb
3

salvage can only be considered if there is no progression locally or distally and if

blood vessels and nerves are free from tumour. Amputation still remains an important
surgical modality attaining excellent local control.(9)
Indications for amputation are:

The very young, where leg length discrepancy will be a problem.

Involvement of neuro-vascular bundle.

Tumour progression on neo-adjuvant chemotherapy.

Local recurence or minimal tumour necrosis after neo-adjuvant chemotherapy in

limb salvage therapy.(9)
In addition to aggressive multiagent chemotherapy and surgical management

of the primary tumor, surgical resection of pulmonary nodules or metastatic bones

appears to have significantly increased survival of patients or results in a prolonged
disease-free interval.(12)
Radiotherapy can be administered before the initial biopsy in order to reduce
the viability of the cancerous cells that can be disseminated into the bloodstream by
the biopsy. Preoperative irradiation, in combination with neoadjuvant multiagent
chemotherapy, has been given in an attempt to reduce tumor viability before surgery,
increase the rate of limb salvage surgery and reduce the risk of local recurrence.(13)
Whether postoperative irradiation is useful when inadequate surgical margins are
present is controversial.
Chemotherapy may have benefit to improve limb salvage and led to higsher
survival rates. It has also been shown to reduce the number of pulmonary metastases
or to delay their appearance which facilitates surgical removal. Used drugs are
cyclophosphamide, vincristine, melphalan, Adriamycin (doxorubicin), methotrexate,
cisplatin, decarbazine, bleomycin, dactinomycin, actinomycin, and leucovorin rescue.
(10)
1.1.7. Survival Rate
The prognosis of patients without detectable metastases has improved
substantially, with 5-year survival rates reaching 60% to 70% with aggressive
chemotherapy and limb salvaging surgery. Unfortunately, the outcome for patients
with overt metastases or recurrent disease is still poor (approximately 10-20% 5-year
survival rate).(14,15) Patients with lung involvement have 3-year postpulmonary
metastases survival (PLMS) of 30%. (16)
4

The most important prognosticator is the presence of metastasis at

presentation. The second prognosticator is the response of tumour to neo-adjuvant
chemotherapy.(17,18) A good necrotic response usually predicts a long-term survival
in up to 90% of patients. Recent literature(19) suggests that tumour size is a good
indicator of histological response to neo-adjuvant chemotherapy, and therefore a good
pre-workup prognosticator.
1.2. ABOVE KNEE (TRANSFEMORAL) AMPUTATION
In terms of level of amputation, Dillingham et al. reported that lower limb
amputation accounted for 97% of all amputations between 1988 and 1996 with the
following distributions: 31.5% toes, 10.5% midfoot, 0.8% ankle disarticulation,
27.6% transtibial, 0.4% knee disarticulation, 25.8% transfemoral, and 0.4% hip
disarticulation. Survival rates after amputation vary based on a variety of factors.
Those who have amputations from trauma tend to have good long-term survival, but
those who have amputations because of a vascular etiology face sobering survival
statistics. More proximal levels of amputation have also been associated with
decreased survival rates. (20,21,22)
Amputation through the femur is chosen when there has been significant
trauma to the proximal tibia and knee, when there is a tumor in the proximal tibia or
distal femoral condyles that cannot be replaced by allograft or a total joint, when there
is infection or failure to heal following transtibial amputation, following failed
revascularization of the lower leg, and at times for intractable infection following total
knee arthroplasty.(22)
Considering not only vascular status, but also muscle attachment and
biomechanics of the residual limb in gait, is important when deciding on the precise
length of the residual femur. For those needing transfemoral surgeries, function and
prosthetic control improves as length of residual femur increases. Preservation or
reattachment of the adductor muscles provides sufficient power for stabilization of the
residual limb in adduction in stance so that the abductors can work to keep the pelvis
level during prosthetic gait. The surgeon may opt to use equal anteroposterior flaps,
equal mediolateral flaps, or a long flap from any one limb surface that will be
approximated to the opposite limb surface at closure. (22)
The two components of residual limb length are the actual length of the
residual tibia or residual femur and the total length of the limb including soft tissue.
5

Measurements are taken from an easily identified bony landmark to the palpated end
of the long bone, the incision line, or the end of soft tissue. In the transfemoral limb
the starting place for measurement can be the ischial tuberosity or the greater
trochanter.(22)

Table 2. Descriptive classification schema for residual limb lengths.(22)

Residual limb volume is typically assessed by serial circumferential girth
measurements with a tape measure. For those with transfemoral amputation,
measurement begins at either the ischial tuberosity or thegreater trochanter and is also
repeated at equally spaced points to the end of the residual limb. The interval between
measurements should be clearly documented (i.e., every 5 cm or every inch) for
consistency and reliability in future measurement.(22)
1.3.

REHABILITATION

IN

ABOVE

KNEE

(TRANSFEMORAL)

AMPUTATION
The primary surgical goal of a transfemoral amputation is to stabilize the
femur while retaining maximal femur length. During this procedure the adductor
magnus is pulled over the end of the femur, with myodesis (suturing muscle to bone)
to the lateral femur. Myoplasty (suturing of muscle to muscle) of the quadriceps and
the hamstrings is recommended. This procedure provides optimal adductor magnus
function and padding of the distal femur. (21,22)
1.3.1 Clinical Features and Examination
1.3.1.1. Symptoms
The postoperative or post-traumatic sequela of an amputation is that the
patient is missing all or part of a limb. In addition, there may be associated symptoms,
such as phantom limb sensation, phantom pain, stump pain, and pain from the surgery
6

itself. Phantom limb sensation is the perception that the extremity is still present and
occasionally distorted in position. Phantom limb sensation typically fades away
within the first year after amputation. Phantom limb pain is differentiated as a painful
perception within the absent body part. Pain at the surgical site, including incisional
discomfort, is common and should resolve within a few weeks of surgery. Residual
limb pain is perceived in the residual limb in the region of the amputation. The
incidence of residual limb pain has been reported between 10% and 25%; it may be
diffuse or focal and is commonly associated with neuroma, which is palpable around
the amputation site. (21)
1.3.1.2. Physical Examination
Wound healing, range of motion, muscle strength, and incisional integrity
must be evaluated in the residual limb. Visualization of the contralateral foot is a
mandatory component of the examination. Upper extremity strength should be
assessed to determine capability for use of assistive devices. Circumferential
measurements of the residual limb are taken as soon as the dressing allows, then
regularly throughout the postsurgical period. Measurements over the length of the
residual limb are made at regular intervals. Circumferential measurements of throughknee residual limb are started at the ischial tuberosity or the greater trochanter,
whicshever is more palpable, and taken every 8 to 10 cm. Length is measured from
the ischial tuberosity or the greater trochanter to the end of the bone. If there is
considerable excess tissue distal to the end of the bone, then length measurements are
taken to both the end of the bone and the incision line. For accuracy of repeat
measurements, exact landmarks are carefully noted. If the ischial tuberosity is used,
hip joint position is noted as well. Other information gathered about the residual limb
includes its shape (conical, bulbous, redundant tissue), skin condition, sensation, and
joint proprioception.(22,23)
1.3.2 Pre-operative Phase:
It involves medical and physical assessment, patient education, functional
prognosis, discussion about phantom limb pain, realistic short and long term goals.
Optimal rehabilitation care of the amputee begins, if feasible, prior to the amputation.
If possible, patient should be placed in a cardiopulmonary conditioning program.
(20,22)
7

1.3.3 Post-operative Phase:

This phase begins immediately post-operatively and continues until the patient
is discharged from the acute care hospital. Goals at this stage are pain control,
optimization of range of motion (ROM) and strength of both lower and upper
extremity musculature, promotion of wound shealing, phantom limb pain/sensation
management, functional mobility training, equipment prescription, and continued
patient education and emotional support.
Time to fitting of prosthesis is usually 6-8 weeks or longer, once stump has
matured. In the meantime, gait training is initiated without a prosthesis. Functional
mobility training for individuals undergoing lower extremity amputation may be
initiated post-op day 1, as appropriate given the patients medical status, and
progressed based on patient tolerance. Early post-operative mobilization will reduce
the risk of patients developing orthostatic hypotension.
For patients who received above knee amputation (AKA) or transfemoral
amputation, the following activity guidelines have been reported: (21,24,26)
-

Post-op Day 1: Bed mobility, therapeutic exercises

Post-op Day 2: Sitting edge of bed and transfer training. Out of bed (OOB) no
more than 2 hours BID.

Post-op Day 3: Ambulate as tolerated with assistive device

Post-op Day 4 to discharge: Continue ambulation BID and OOB to chair BID.
Progress distance of ambulation to patients tolerance. Encourage exercises
when in bed or sitting in chair.

1.3.4 Pre-Prosthetic Phase:

This phase involves residual limb shaping, stump shrinking, skin care,
increasing ROM and muscle strength, cardiovascular training, progressive functional
mobility training without a prosthesis, restoring locus of control of the patient, and
patient education and preparation for prosthetic use. During initial recovery it is
important to restore the individuals locus of control. Generally 6-8 weeks or longer
post-operatively with soft dressings, or 3-6 weeks with use of an immediate postoperative prosthesis. (20,22,24)
Once stitches out and wound almost healed stump bandaging can be started.
As a guideline, 15 cm width bandage is used for the AKA. Bandages should be reapplied at least 4x a day, or more often if bandage loosens or is too tight. Ideally, with
8

effective control of edema and compression, the transfemoral limb typically matures
into a more conical shape, with distal circumference significantly less than proximal
circumference. A smaller distal circumference is desirable so that shear forces on soft
tissue will be minimal when the prosthesis is donned and used. (20,22)

Figure 2. The application of an effective Ace wrap to a transfemoral limb also strives
to create a distal-to-proximal pressure gradient using a modified figure-of-eight
pattern.(22)
1.3.5 Prosthetic Prescription/Fabrication Phase:
It Involves team consensus on prosthetic prescription to satisfy the needs,
desires and abilities of the patient. Criteria for fitting of LE prosthesis are wound must
have healed, edema must have resolved, the stump should be conically shaped and
stump maturation should be achieved.(20,23,25)
1.3.6 Prosthetic Training Phase:
Prosthetic management and training are aim to increase wearing time and
functional use of the prosthesis. Ambulation activities with a lower extremity
prosthesis often begin during weeks 10-11 after amputation. The more proximal the
amputation, the more energy is demanded from the cardiovascular and pulmonary
9

systems for prosthetic gait. Before starting the prosthetic training, there are several
considerations which should be taken into account:(21,24)
a. Stump condition:
- Wound is closed and sufficiently healed to safely begin weight bearing in a
total contact cast
- Skin integrity is adequate for weight bearing and there are no abrasions/skin
tears on weight bearing surfaces or location of straps - Stump shape is appropriate for
prosthetic use, that is, the distal end should be narrower than the proximal end Patient is able to tolerate sufficient pressure on stump to begin weight bearing - Pain
is reasonably under control
b. Mobility levels before the amputation:
If the client could not walk before the amputation, it is unlikely they will be
able to walk with a prosthesis. The exception shere is wshen they could not walk due
to pain / deformity in the limb that has since been amputated.
c. Range of Motion (ROM) considerations (in the intact and amputated limbs):
- Patient has sufficient ROM in residual limb to allow upright standing with
prosthesis. BKA <20 knee flex contracture, AKA <10 hip flexion contracture.
- Intact limb has sufficient ROM of dorsiflexion, knee extension, and hip
extension, to allow upright standing to commence prosthetic training
d. Strengths and fitness
- Patient has sufficient strength (power and endurance) on intact side to begin
prosthetic training, that is, patient is able to stand up with minimal assistance
- Patient has sufficient strength in residual limb to begin prosthetic training
MMT >4/5 extensors
- Patient has adequate cardiovascular fitness to allow sufficient practice with
prosthesis to see improvement in performance e. Cognitive function: ability of patient
to learn and understand complicated tasks such as gait retraining and safety in using
prosthesis f. Social situation: availability of a supportive home environment to
encourage prosthetic training g. Attitude and motivation: compliance of patient to the
exercise program
1.3.7. Prosthetic Prescription
1. Socket:
There are two standard socket designs for transfemoral prostheses: the
10

quadrilateral design and the ischial containment design.

2. Suspension:
There are various methods for suspending a prosthesis, including suction,
liners, and belts.
3. Prosthetic Knees:
Knee units can be organized into five classes: outside hinges, single axis,
polycentric, weight-activated stance, and locking.
4. Shanks:
Whether it is exoskeleton or endoskeleton.
5. Foot-Ankle Assemblies:
The feet have been divided into four categories: SACH feet, single-axis feet,
multiaxial feet, and dynamic response feet.(20)
1.3.8 Ambulation
Typically the cost of ambulation is measured in oxygen consumption. With
respect to rate of oxygen consumption, individuals with an amputation typically walk
slower to keep their rate of oxygen consumption comparable to that of shealthy
controls. Individuals with or without amputation tend to selfselect a comfortable
walking speed that provides a comparable rate of oxygen consumption. While the rate
of oxygen consumption tends to be similar across individuals, those with amputation
incur a larger oxygen cost per distance than a nonamputee walking at the same speed.
Individuals with vascular amputations have higsher oxygen consumption per
distance than those with traumatic amputations.(21,22) Unilateral traumatic transtibial
amputees use approximately 25% more energy to walk the same distance as
nonamputees. This increases to 68% for traumatic transfemoral amputees. Vascular
transtibial and transfemoral amputees use up to 40% and 100% more energy,
respectively. The metabolic demand in knee disarticulations varies based on patient
habitus but is somewshere between transtibial and transfemoral about 40%.(23,25)

11

CHAPTER 2
CASE REPORT
2.1. IDENTITY
Name

:N

Age

: 36 years old

Address

: Lebak, Rangkasbitung

Occupation

: Housewife

Education

: 3rd class Elementary School

Marital status

: Married with two childrens

Medical record

: 4113239

Date of examination : April 8th, 2016

2.2. ANAMNESIS
History was taken on April 8, 2016 from autoanamnesis, patients cousin,
patients husband and from patients medical record.
2.2.1. Chief complaint
Post transfemoral amputation of right leg 1 weeks ago.
2.2.2. History of the Present Illness
Patient underwent surgical transfemoral amputation of the left limb on March
30, 2016 at RSCM. She was referred from Orthopedic Department for rehabilitation
program after amputation.
About 10 years ago (2006), there was a small lump in the back side of behind
her right knee. The lump had clear border with firm consistency, immobile, painful
and tender on palpation and was getting bigger progressively. Patient still did her
usual

activities,

no

complaint

about

any

leg

weakness,

numbness/burn

sensation/radicular pain, swelling/varises in any leg. She had normal appetite, no

nausea/vomit, no weight loss.
At 2009, the lump size approximately was average of a chicken egg (diameter
5-6 cm). The patient went to RSUD Rangkasbitung and got her first operation to
remove the lump. After the first operation, the lump was completely gone. Not for a
12

long time, the lump recurred in the same location (behind the right knee). The
characteristic of the lump was same with previous operated lump, had clear border
with firm consistency, immobile, painful and tender on palpation and was getting
bigger progressively.
At 2012, the lump size was 7-8 cm in diameter. The patient went to RSUD
Cengkareng and got her second operation to remove the lump. Just like after the first
operation, after the second operation the lump recurred below the back of the right
knee. The lump was firm consistency, lobulated, immobile, painful and tender on
palpation and was getting bigger progressively. Patient still did her usual activities, no
complaint about any leg weakness, numbness/burn sensation/radicular pain, in any
leg. She had normal appetite, no nausea/vomit, no weight loss, no shortness of breath.
Since early 2015, the lump was become more bigger, painful and more tender
on palpation, and there were nighttime pain. Sometimes she also felt difficult to fell
asleep because of the nighttime pain. The patient start to loss sher appetite and had
sleep disturbance. She started lost her weight, from 45 kg become 40 kg in 1 year. But
the patient still did her usual activities as a housewife. Although there was a mass in
her leg, patient still did her usual household activities and used wooden cane to help
her ambulate.
In November 2015, patient went to RSUD Rangkasbitung and referred to
RSCM. The family brought the patient to RSCM (Orthopaedic Polyclinic), and got
informed that the tumor was malignant and need to be removed with amputation as
soon as possible. Her body weigt was 42 kg.
On March 30, 2016 patient got an above knee amputation in RSCM. After the
amputation, she ambulated using wheel chair for long distance and bilateral crutches
for transfer and short distance ambulation. She can transfer by herself from lying
down to sitting and from sitting to standing with arm support. The patient still felt
pain on the operation wound on the stump, and sometimes still felt that her amputated
right leg was still there with pain and itchy sensation. Sometimes she felt mild
shortness of breath, no coughing, no wheezing. After amputation her body weight is
32 kg.
On April 8, 2016, patient was referred to Medical Rehabilitation Polyclinic to
get rehabilitative management post-amputation. The patient came using wheel chair
accompanied by her elder sister.

13

Patient is not able to stand with one leg without hand support for more than 10
seconds. Mobilization was helped by using bilateral crutcshes for near distance, but
for far distance she usually use wheelchair helped by her husband or her sister. She
can do most of the activities of daily living by herself, such as eating, drinking,
bathing, toilet, and dressing independently. She only get supervised when go the the
bathroom and on stairs.
2.2.3. History of Past Medical Condition
No history of hypertension, diabetes mellitus, heart disease, and cancer.
2.2.4. History of Family Illness
No history of hypertension, diabetes mellitus, heart disease, and cancer.
2.2.5. History of Psychosocial and Vocational
The patient is married with two children. She lives in her hometown in
Rangkasbitung in a house with her husband and children. Her husband worked as a
driver, his salary is not consistent with an average Rp. 1.000.000/month.
From November 2015, she temporarily stayed at Rumah Singgah RSCM
with her husband and her elder sister. Her room size is 3 x 5 m 2, shared with other 3
female patients. The room has good ventilation and the sunshine can get inside
through 4 windows and 1 terrace door. Room lighting is adequate and the electricity is
from PLN. Independent ambulation using wheelchair inside the room is possible. The
patient move around the room using bilateral cructhes. The common bathroom is
outside the room, 2 meters from her room and used together with other patients. There
are 2 rooms for bathing and 1 room with a squating toilet. The water is from water
tower. For the access to her room, there is a smooth pathway that is easily accesable
and is wide enough for a wheelchair. However the patient use bilateral crutches to
ambulate around Rumah Singgah and only using wheelchair if she went to RSCM.
Medical expenses using BPJS. She is a moslem. No history of smoking and
alcohol consuming.
2.2.6. Psychiatric History
The patient can accept her condition. She wants to recover and be able to
ambulate independently again and have a prosthesis to help her ambulate and for
14

cosmesis reason. Patient wants to return to her activity as housewife. There were no
history of suicidal or other psychological problem.
2.2.7. Medication, Allergies, and Diet
She had no history of drug abuse or allergy
2.2.8. Activities of Daily Living, Daily Habits, and Avocational
The patient had no history of smoking or drinking alcohol
ADL prior to surgery : independent
ADL after surgery : partial dependent
Time
04.30 05.00
07.00 08.00
08.00 09.00
09.00 11.00

Activity
Wake up, praying
Take a shower
Having breakfast
Sitting, chat with her roommates and neighbor,

Mets
1.5
1.5
1.5
2.0

learning using bilateral crutches and moving around

11.00 12.00
12.00 13.00
13.00 17.00

the guest house

Having lunch
Praying chat with her roommates and neighbor
Take a nap, chat with her roommates and neighbor,

1.5
1.5
2.0

learning using bilateral crutches and moving around

17.00 19.00
19.00 21.00
20.00 21.00
21.00 04.30

the guest house

Praying, chat with her roommates and neighbor
Having dinner
Chat with sher neighbour
Sleeping

1.5
1.5
1.0
0.9

2.3. PHYSICAL EXAMINATION

Physical examination was conducted on April 8, 2016.
General Physical Examination
Sign
Consciousness
Vital sign

Communication

Physical Finding
Compos mentis
BP
: 112/79 mmHg
Pulse : 93x/minute
RR
: 22x/minute
Temp. : 36,40C
SpO2 : 97-98%
Verbal

15

Impression
Normal
Normal
Normal
Normal
Normal
Normal
Normal

MMSE

25

Nutritional Status

Body weight : 32 kg
Malnutrition
Body height : 150 cm
BMI
: 14.2 (Underweigth)
Ideal body weight = (body height-100)

Gait Pattern
Balance

Normal

10%
(150-100) -10% = 45 kg
Above knee amputation:
Ideal BW (13%) = 39,15 kg
Using bilateral crutches: swing-through
gait pattern
Static sitting balance is good
Shifting weight bearing on sitting is good
Dynamic sitting balance is good
Static standing balance inadequate

Sitting

balance:

normal
Standing balance
impaired

General Physical Findings

System
Integument

Head

Neck

Physical Findings
Impression
Skin: brown-colored, no rash, no dry skin, no Normal
hyperpigmentation, normal temperature
Hair: no hair loss
Normal
Nail: no yellowish, no sign of anemic/cyanotic
Normal
No mass/tumor, no haematoma, no edema, no
Normal
lesion/trauma sign
No deformity, no mass, tracshea in the midline,
symmetrical, no enlargement of lymph nodes, Normal
carotid pulsation normal
Conjunctiva anemic, no sclera icteric, pupil

Eyes

Nose

isochors 3 mm /3 mm, direct light reflexes

positive/positive,

indirect

light

reflexes

Anemia

positive/positive
No septum deviation, no nasal discharge, no

Ear

Normal
conchae hypertrophy
No edema, no tenderness, no lesion sign
Normal
Lips: symmetrical, tongue in the middle, no mass,

Mouth

TMJ joint > 3 fingers, palatum arch normal, tonsil

T1-T1, no hyperemic, pharynx not hyperemic,

Chest

Normal

arch of pharynx symmetrical, uvula no deviation

Heart :
Normal
Percussion:
- Upper border on the 2nd intercostals space II
16

along the left midclavicular line

- Right border on the 4th ICS along the midsternal
line
- Left border on the 5th ICS space along the left
midclavicular line
Auscultation:
S1-S2 normal, no murmur, no gallop
Lungs :
Inspection : symmetrical movement

during

inspiration and expiration, suprasternal retraction

Palpation : stem fremitus symmetrical,

Limited chest
intercostalis space symmetrical, chest expansion:
expansion
Axillaris proc. Xyphoideus inf. Thoracal : 3 4
4 cm
Percussion : sonor on both lungs
Auscultation : vesicular, no ronchi, no wsheezing
Flexible on palpation, liver/spleen : not palpable,
Abdomen

no mass, no tenderness, bowel sound positive Normal

normal
Vertebral alignment straight, shoulder

Back

and scapulae symmetrical, no muscle

spasm, no tenderness, no hump, no

Normal

skin erusion/decubitus
Functional Examination
Mobility:

Lying down to side lying independent

Lying down to sit independent
Shifting on sitting independent
Sit to stand independent
Stand to walk (using bilateral crutches) independent

Activities of Daily Living: Barthel Index = 18 (mildly dependent) (Appendix 3)

Neuromuscular Examination
Level of consciousness: compos mentis (Glasgow Coma Scale E4 M6 V5 = 15)
CN I: Olfactory
Patient can recognize all scent given
Impression: normal

17

CN II: Opticus
Visual acuity test (gross examination) with visus 6/6 for both eyes. Visual field test
(confrontation test) was within normal limits.
Impression: normal with visus 6/6
CN III, IV, VI: Oculomotor, Trochlear, Abducens
Eye position when resting

: centre / centre

Eye movement followed a guided target to all direction : normal/normal

Direct light reflex

: positive/positive

Indirect light reflex

: positive/positive

No ptosis present
Impression: normal
CN V: Trigeminal
Afferent: discrimination in sharp and dull stimuli, could recognize light touch on
three brancshes (ophthalmic, maxillary, mandible)
Efferent: could open and close jaw against resistance. Jaw movement to the right
and left are normal.
Corneal reflex positive on the eyes
Impression: normal
CN VII: Facialis
Inspection: symmetrical face, symmetrical nasolabial fissure, symmetrical labial
angle.
- Afferent : test from 2/3 anterior tongue normal
- Efferent :
o Raising eyebrows

: symmetrical

o Frowning

: symmetrical

o Closing eyes

: symmetrical

o Smiling

: symmetrical

o Puffing up csheeks

: closed, no leak occurred

Impression: normal
18

CN VIII: Vestibulocochlear
- Auditory test: patient could shear rubbing fingers placed at distance from both ear.
Impression: normal
CN IX, X: Glossopharyngeal, Vagus
- Symmetric arch of pharynx and uvula
- Gag reflex: positive
- Taste on 1/3 posterior tongue: normal
- No dysphonic and hoarness
Impression: normal
CN XI: Accessory
- Patient could push her face against resistance to right and left (m.
sternocleidomastoideus)
- Shrugging of shoulder test (m. upper trapezius) normal
Impression: normal
CN XII: Hypoglossal
- Inspection: tongue in the midline
- Normal tongue movement
- Tongue protrusion: no deviation
- No dysarthria
Impression: normal
Musculosceletal Examination
General posture
-

Sitting position:
Symmetrical shoulder, normal vertebral alignment, both arms in neutral position
with above knee amputation of right leg.

Standing position (with hands holding tables):

-

Anterior:
Head is in the midline, shoulder is symmetrical, symmetrical body-arm
distance, above knee amputation of right leg, no varus or valgus of left leg.
19

Lateral:
Forward head, straight cervical, no kyphotic thoracal, no hyperlordotic lumbal,
no genu recurvatum, above knee amputation of right leg.
Posterior:
Head is in the midline, symmetrical shoulder, symmetrical body-arm distance,
normal vertebrae alignment, no hump, no pelvic obliquity, above knee
amputation of right leg.

Cervical
Look

: straight cervical, no mass, no sign of inflammation, normotrophy

Feel

: spasme and mild tenderness on bilateral paracervical and upper trapezius

muscles

Move

: mild pain on movement, ROM is full, MMT 5 (for ROM and MMT
details, see table below)

Upper Extremities
Look

: No deformity, no mass, no sign of inflammation, normotrophy

Feel

: no tenderness and normotonus on upper extremities

Move

: no pain on movement, ROM is full/full, MMT 5/5 (for ROM and MMT
details, see table below)

Sensory : Light touch

: normal

Pinprick

: normal

Proprioceptive

: normal

Reflexes: Physiologic
Pathologic
Hand prehension

: ++/++/++ (biceps/triceps/brachioradialis)
: -/- (Hoffman Tromner)
: Gross grasp : adequate/adequate

Palmar preshension:
Tripod grip

: adequate/adequate

Pinch grip

: adequate/adequate

Plate grip

: adequate/adequate

Cylindrical grasp : adequate/adequate

Spherical grasp : adequate/adequate
Coordination test
Index finger index finger

: good/good

Index finger nose

: good/good
20

Index finger nose index finger

: good/good

Pronation supination

: good/good

ROM
Movement
Cervical
Flexion
Extension
Lateral Bending
Rotation
Shoulder
Flexion
Extension
Adduction
Abduction
Internal Rotation
External Rotation
Elbow
Flexion
Extension
Lower Arm
Supination
Pronation
Wrist
Flexion
Extension
Ulnar Deviation
Radial Deviation
Thumb
Abduction
Adduction
MCP Flexion
IP Flexion
MCP Extension
IP Extension
Other Fingers
Abduction
Adduction
MCP Flexion
PIP Flexion
DIP Flexion
MCP Extension
IP Extension

Left

MMT
Movement

Right

Left

0-45
0-30
0-45
0-60

0-45
0-60

Flexion
Extension
Lateral Bending
Rotation

5
5
5
5

5
5

0-180
0-60
0-45
0-180
0-80
0-90

0-180
0-60
0-45
0-180
0-80
0-90

Flexion
Extension
Adduction
Adduction
Internal Rotation
External Rotation

5
5
5
5
5
5

5
5
5
5
5
5

0-150 0-150
150-0 150-0

Flexion
Extension

5
5

5
5

0-90
0-90

0-90
0-90

Supination
Pronation

5
5

5
5

0-80
0-70
0-30
0-20

0-80
0-70
0-30
0-20

Flexion
Extension
Ulnar Deviation
Radial Deviation

5
5
5
5

5
5
5
5

0-70
70-0
0-50
0-90
0-20
0-20

0-70
70-0
0-50
0-90
0-20
0-20

Abduction
Adduction
MCP Flexion
IP Flexion
MCP Extension
IP Extension

5
5
5
5
5
5

5
5
5
5
5
5

0-20
20-0
0-90
0-100
0-90
0-30
0-10

0-20
20-0
0-90
0-100
0-90
0-30
0-10

Abduction
Adduction
MCP Flexion
PIP Flexion
DIP Flexion
MCP Extension
IP Extension

5
5
5
5
5
5
5

5
5
5
5
5
5
5

Right

Lower Extremities
Look:
21

- Hip
Right : no deformity, no inflammation sign, normotrophy
Left
-

: no deformity, no inflammation sign, normotrophy

Thigh
Right : above knee amputation of right leg, cylindrical shape, flabby,
edema, operation wound closed with the sterile gauze.
Left

- Knee

Right : amputated
Left

- Leg

: normotrophy, no deformity
: normotrophy, no deformity

Right : amputated
Left

: normotrophy, no deformity

Feel:
- Thigh

Right : Hypotonus, no tenderness, no spasm

Amputee length :
From greater trochanter to muscle end 19 cm
From greater trochanter to bone end 17 cm ( 50%
standard length of above knee amputation)
Femur length (from greater trochanter to bone end): 17 cm
Stump circumference:
10 cm below greater trochanter: 46 cm
15 cm below greater trochanter: 44 cm
Stump pain positive
Phantom sensation positive
Phantom pain positive
Left

: No tenderness, normotonus, no spasm

True leg length 76 cm
Apparent leg length 84 cm

Femur length (from greater trochanter to lateral epicondyle): 35 cm

Thigh circumference:
10 cm below greater trochanter: 42 cm
15 cm below greater trochanter: 38 cm
Right : amputated

Knee
Left

- Leg

: no tenderness, no crepitation, no effusion

Right : amputated
22

Left
- Pulse:

: normotonus, no tenderness, no spasm

A. femoralis

+/+

regular, good

A. poplitea

NT/+

regular, good

A. dorsalis pedis

NT/+

regular, good

Move:
-

No pain on movement

Range of Motion and Manual Muscle Test: (see table below)

Thomas test : negative/negative

Sensory : Light touch

: normal

Pinprick

: normal

Proprioceptive

: normal

Reflexes : Physiologic

Patella

: (NT/++)

Achilles

: (NT/++)

Pathologic

: Babinsky (NT/-)

ROM
Movement
Hip
Flexion

Right

Left

MMT
Movement

0-100

0-120

Flexion

Extension

0-20

0-20

Extension

Adduction
Abduction
Internal Rotation
External Rotation
Knee
Flexion
Extension
Ankle
Plantarflexion
Dorsiflexion
Inversion
Eversion
Great Toe
MTP Flexion
IP Flexion
MTP Extension
IP Extension

30-0
0-45
NT
NT

30-0
0-45
0-35
0-45

NT
NT

Right

Left
5

Adduction
Abduction
Internal Rotation
External Rotation

4
(impression)
4
(impression)
4
4
NT
NT

0-135
135-0

Flexion
Extension

NT
NT

5
5

NT
NT
NT
NT

0-50
0-20
0-20
0-10

Plantarflexion
Dorsiflexion
Inversion
Eversion

NT
NT
NT
NT

5
5
5
5

NT
NT
NT
NT

0-30
0-70
0-70
30-0

MTP Flexion
IP Flexion
MTP Extension
IP Extension

NT
NT
NT
NT

5
5
5
5

23

5
5
5
5
5

2. 4. SUPPORTIVE EXAMINATION
(April 11, 2016)
Mini Mental State Examination
23 (Normal for level education)
Hamilton Rating Scale for Depression
3 (Normal)
Activity of Daily Living (Barthel 18/20 (Mildly dependent)
Index)
Karnofsky Performance Status Scale 90 (Able to carry on normal activity;
Definitions Rating
Fatigue Severity Scale
Berg Balance Scale

minor signs or symptoms of disease)

10 (not fatigue)
17 (high fall risk)

Rontgen Cruris Dextra AP & Lateral (March 15, 2016):

Kesimpulan:
Massa jaringan lunak region genu hingga pertengahan cruris kanan disertai multipel
lesi litik permeative dengan zona transisi luas di epimetadiafisis proksimal tibia kanan
dengan penipisan dan destruksi korteks serta reaksi periosteal tipe maligna (su burst
dan lamellar) DD/ soft tissue tumor maligna
Rontgen Genu Dextra AP & Lateral (March 15, 2016):
Kesimpulan:
Massa jaringan lunak region genu hingga pertengahan kruris kanan disertai multipel
lesi litik permeative dengan zona transisi luas di epimetadiafisis proksimal tibia kanan
dengan penipisan dan destruksi korteks serta reaksi periosteal DD/ soft tissue tumor
maligna
Penyempitan celah sendi femorotibial disertai dislokasi os fibula kanan ke lateral
Rontgen Thorax PA (March 15, 2016):
Kesimpulan:
Multipel nodul sebagian berkalsifikasi di lapangan tengah paru kanan, lapangan atas
dan bawah paru kiri, DD/ metastasis.
Tidak tampak kelainan radiologis pada jantung.
MRI Cruris Kanan dengan Kontras IV Gadodiamide (Marc 16, 2016):
Kesimpulan:
Tumor primer tulang sugestif maligna dengan keterlibatan m. gastrocnemius medial
dan lateral, m. soleus, serta kutis dan subkutis kanan proksimal
24

CT Scan Thorax (March 23, 2016):

Kesimpulan:
Nodul paru multipel (sebagian berkalsifikasi) disertai limfadenopati subkarina, sesuai
lesi metastasis.
Laboratory
Hb
Ht
Eritrocyte
MCH
MCV
MCHC
Thrombocyte

15/03/16
12.1
36.0
4.30
83.7
28.1
33.6
339

30/03/16
10.2
30.9
3.57
86.6
28.6
33.0
398

Leukocyte

10.91

19.61

LED
PT

40

Patient
Control
APTT
Patient
Control

10.9
10.8

10.8
10.7

SGOT
SGPT
Albumin
Natrium
Kalium
Chlorida
Calsium
(Ca)
Darah
Calsium (Ca++)
Ion
Magnesium
Fosfat Inorganik
(P)
Kreatinin darah
Ureum darah
GDS
eGFR
42.6

15/03/16
48
30
3.99
144
4.52
103.0
-

30/03/16
139
3.82
103.6
8.8

1.22

1.85
4.0

0.60
22
95
117.6
39.1

74
-

2.5. RESUME
A 36 years old female patient referred to Medical Rehabilitation Polyclinic
from Orthopaedic Polyclinic to get rehabilitation program after amputation 1 weeks
after having above knee amputation of right leg. The patient was amputated because
of osteosarcoma of the right proximal tibia Enneking III with pulmonary metastases.
From the anamnesis, there still were phantom sensation, phantom pain and
stump pain, mild shortness of breath. Patient had good mental status (MMSE was 23).
From functional examination he had partial dependent in mobility (Bartel index was
19). Patient is able to carry on normal activity, minor signs or symptoms disease
(Karnofsky Performance 90). Patient symptomatic but completely ambulatory (Status
Scale Definitions Rating ECOG Score 1). Patient is not fatique (Fatique Severity
Scale 10). From cranial nerve examination he has no cranial nerve paralysis. Hamilton

25

Depression Scale score is normal. Patient has already accepted her condition and
hopes she could still do her previous activities as a housewife.
From the physical examination, there were malnutrition (BMI was 14.2),
anemic conjungtiva, limited chest expansion. Further examination of the
musculoskeletal system found bilateral paracervical and upper trapezius muscles
spasm. In the lower extremity found above knee amputation of the right leg,
cylindrical shape, no contracture, the stump was still immature with edema and
flabby. The stump length was standard length of above knee amputation (50% of the
femur length). X-Ray and CT Scan Thorax showed the presence of pulmonary
metastases.
2.6. DIAGNOSIS
Medical diagnosis:
-

Osteosarcoma of right proximal tibia Enneking III post standard transfemoral

amputation of the right leg with pulmonary metastases

Normocythic normochromic anemia

Malnutrition

Rehabilitation diagnosis:
-

Palliative care in osteosarcoma of right proximal tibia Enneking III post

standard transfemoral amputation of the right leg with pulmonary metastases

Malnutrition

Stump immaturity

Phantom pain and sensation

High risk of fall

Mildly dependent ADL in toileting and going up with stairs

Limited chest expansion

Bilateral paracervical and upper trapezius muscles spasm

Diagnosis of functional (based on ICF):

Body functions
b.440: respiratory functions
b.280: sensation of pain
b.430: haematological system functions
26

Body structures
s.750: structure of lower extremity
s.430: structure of respiratory system
Activities and Participation
General tasks and Demands
d230:carrying out daily routine
Mobility
d.435:moving objects with lower extremity
d.450:walking
d460:moving around in different locations
d470:using transportation
Self Care
d570:looking after ones health
Domestic Life
d620:acquisition of goods and services
d630:preparing meals
d640:doing housework
d649:household task
d660:assisting others
Community, social and civic life
d910:community life
d920:recreation and leisure
d.870: economic self-sufficiency
2. 7. GOALS
Short term goals:
-

Patients and families understand the condition of the patients disease and
maintaining quality of life
27

Improve Hb > 10 g/dL

Adequate nutrition

Management of the stump

Management of phantom sensation and pain

Prevention of falls

Maintain strength of upper and lower extremity

Improve skill using bilateral crutches

Increase chest expansion

Long term goals:

-

Independent in activity of daily living with bilateral crutcshes/good prosthesis

Adaptation to amputation

Prevented skin damage

Maintain strength of upper and lower extremity

Maintain endurance

Maintain quality of life

2. 8. REHABILITATION PROGRAM
NO
1

PROBLEMS
Palliative care

TARGET
in Patients

PROGRAMS
and Education

osteosarcoma of right families understand

proximal
Enneking

tibia the condition of the

III

with patients

pulmonary
metastases,

and

disease

About the condition and the treatment

of the patient

maintaining

Problems that can arise in a patient at

home like pain or fatigue, how to solve the

post quality of life

problems in the home and when to seek

standard transfemoral

medical help to hospital

amputation of right

leg

Encourage the patient and family

religious spiritual activities together

Collaborate

with

Psychiatry

for

supportive psychotherapy
Education:

Stump care

Wash the stump daily with warm water

and mild soap

28

Rinsing the stump well and towel

drying

Clean the skin folds with an applicator

or cotton swab

Any wound/bruise have to be observed

Examine the stump with a mirror

Prevent trauma on Education:
the stump

Keep the skin moisturized

Do not ambulate by crawling or

dragging the stump

Ambulation with bilateral crutcshes

Prevent contracture Education:

of hip joint

- Preferred lying in prone position

- Prevent sitting for a long period of time
- Lie prone for 15 minutes, 3 times a day
- AROM exercise of right hip

Malnutrition

Normal

body Education:

weight

with

adequate nutrition

- Maintain an adequate and balanced diet

- Iron

containing

food

and

iron

supplementation
- Collaboration

with

Clinical

Nutrition

Department for evaluation and weight

3

Normocytic

management
Improving Hb >10 Education:

Normochromic

g/dL

- Maintain an adequate and balanced diet

Anemia

- Iron

containing

food

and

iron

supplementation
- Collaboration

with

Clinical

Nutrition

Department for evaluation and nutrition

management
4

Stump immaturity

Stump mature, no - Bandaging regularly with figure of 8

flabby

method
- Quadriceps setting exercise (QSE): hold 5
29

seconds, 10 repetitions, 3x/day

- Hamstring setting exercise (HSE): hold 5
5

Phantom

pain

seconds, 10 repetitions, 3x/day

and No phantom pain Education :

sensation

and

no

phantom

sensation
6

High risk of falls

Prevention of falls

Mild dependency in Independent

massaging and tapping of residual limb

Mirror therapy
Education:
-

Information about risk of falls

Ambulate

with

bilateral

crutcshes

safely
ADL Education:

ADL in toileting and in 30toileting and

going up with stairs

Do the desensitization techniques:

Recommendation

ambulate

with

going up with stairs

bilateral crutches for short distance and

by using bilateral

wheelchair for long distance for ADL

crutches/

good

prosthesis

Modify the squatting toilet into sitting

toilet

Install hand rail in the bathroom

Physiotherapist :
-

Gait training using bilateal crutcshes

Strengthening exercise of upper and

lower limb
Strengthening upper extremity muscle
(shoulder depressor, biceps, triceps) 10

rep, hold 6, 1 set, 5 times a day

Strengthening lower extremity muscle
(quadriceps,

hamstring,

gluteus

maximus ) 10 rep, hold 6, 1 set, 5

-

times a day
Endurance exercise : arm ergocycle,
QSE isotonic exercise

Limited
expansion

chest Increase

chest

expansion

Chest expansion exercise and deep

breathing: 10 repetitions, twice a day

Collaboration with

Cardiopulmonary

Rehabilitation Division for evaluation and

management of cardiorespiration function
30

Bilateral paracervical No

bilateral

and upper trapezius paracervical

muscles spasm

upper

and

trapezius

muscles spasm

: malam

Ad functionam

: dubia ad bonam

Ad sanationam

: malam

Gentle massage

Gentle stretching bilateral paracervical

and uppertrapezius muscle : 10 repetitions,
5 times a day

2. 9. PROGNOSIS
Ad vitam

31

CHAPTER 3
CASE ANALYSIS

Osteosarcoma
Lung
Metastasis
Above Knee Amputation of Right Leg

Anemia

Phantom pain,
phantom
sensation, stump
pain

Mildly dependent
ADL

High Risk of fall

Ambulation with
bilateral crutcshes/
prosthesis

Malnutrition

Energy
expenditure

Decreased Quality
of Life

Limited activity

32

Limited Chest
Expansion

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of Care: Lower Extremity Amputation. 2011.

34

25. Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med

Assoc. 2001 Jan;91(1):1322.
26 DeVita VT, Lawrence TS, Rosenberg SA. DeVita, Hellman, and Rosenbergs
Cancer: Principles & Practice of Oncology. Lippincott Williams & Wilkins; 2008.
1748 p.

35

Appendix 1. Mini Mental State Examination

Domain Tested (Test)
Orientation

Score

Year, month, day, date, time

(5)/5

Country, town, district, hospital, ward

(5)/5

Registration
-

Examiner names 3 objects (e.g.: apple, table, coin)

Patient asked to repeat 3 names score 1 for each correct

(3)/3

answer
Attention and Calculation
-

Subtract 7 from 100, then repeat from result, etc. stop

after 5

100, 93, 86, 79, 72, 65

(Alternative: spell WORLD backwards: D L R O W)

(2)/5

Recall
-

Ask for 3 objects learnt earlier

(1)/3

Language
-

Name a pencil and watch

(2)/2

Repeat No, ifs, ands, or buts

(2)/2

Give a three-stage command. Score one for each stage

(1)/1

(e.g.: Place your index finger of right hand on your nose,

(3)/3

and then on your left ear!)

-

Ask the patient to read and obey a written command on a

piece of paper stating: Close your eyes

(0)/1

Ask patient to write a sentence. Score if it is sensible and

has a subject and a verb.

(0)/1

Copying (Visospatial Ability)

-

Ask patient to copy a pair of intersecting pentagons

(1)/1
SCORE: (25)/30

Appendix 2. Hamilton Rating Scale For Depression

36

1. DEPRESSED MOOD (Sadness, hopeless, helpless, worthless)

0=Absent
1=These feeling states indicated only on questioning
2=These feeling states spontaneously reported verbally
3=Communicates feeling states non-verballyi.e., through facial expression, posture,
voice, and tendency to weep
4=Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal
and non-verbal communication
2. FEELINGS OF GUILT
0=Absent
1=Self reproach, feels she has let people down
2=Ideas of guilt or rumination over past errors or sinful deeds
3=Present illness is a punishment. Delusions of guilt
4=Shears accusatory or denunciatory voices and/or experiences threatening visual
hallucinations
3. SUICIDE
0=Absent
1=Feels life is not worth living
2=Wisshes she were dead or any thoughts of possible death to self
3=Suicidal ideas or gesture
4=Attempts at suicide (any serious attempt rates 4)
4. INSOMNIA EARLY
0=No difficulty falling asleep
1=Complains of occasional difficulty falling asleepi.e., more than 1/2 hour
2=Complains of nightly difficulty falling asleep
5. INSOMNIA MIDDLE
0=No difficulty
1=Patient complains of being restless and disturbed during the night
2=Waking during the nightany getting out of bed rates 2 (except for purposes of
voiding)
6.INSOMNIA LATE
0=No difficulty
1=Waking in early hours of the morning but goes back to sleep
2=Unable to fall asleep again if she gets out of bed
7.WORK AND ACTIVITIES
0=No difficulty
1=Thoughts and feelings of incapacity, fatigue or weakness related to activities;
work or hobbies
37

2=Loss of interest in activity; hobbies or workeither directly reported by patient, or

indirect in listlessness, indecision and vacillation (feels she has to push self to work or
activities)
3=Decrease in actual time spent in activities or decrease in productivity
4=Stopped working because of present illness
8.RETARDATION:PSYCHOMOTOR (Slowness of thought and speech; impaired
ability to concentrate; decreased motor activity)
0=Normal speech and thought
3=Interview difficult
1=Slight retardation at interview
4=Complete stupor
2=Obvious retardation at interview
9.AGITATION
0=None
1=Fidgetiness
2=Playing with hands, hair, etc.
3=Moving about, cant sit still
4=Hand wringing, nail biting, hair-pulling, biting of lips
10.ANXIETY (PSYCHOLOGICAL)
0=No difficulty
1=Subjective tension and irritability
2=Worrying about minor matters
3=Appreshensive attitude apparent in face or speech
4=Fears expressed without questioning
11.ANXIETY SOMATIC: Physiological concomitants of anxiety, (i.e., effects of
autonomic overactivity , butterflies, indigestion, stomach cramps, belching,
diarrshea, palpitations, hyperventilation, paresthesia, sweating, flushing, tremor,
sheadacshe, urinary frequency).
Avoid asking about possible medication side effects (i.e., dry mouth, constipation)
0=Absent
3=Severe
1=Mild
4= Incapacitating
2=Moderate
12. SOMATIC SYMPTOMS (GASTROINTESTINAL)
0=None
1=Loss of appetite but eating without encouragement from others. Food intake about
normal
2=Difficulty eating without urging from others. Marked reduction of appetite and
food intake
13.SOMATIC SYMPTOMS GENERAL
0=None
38

1=Heaviness in limbs, back or head. Backacshes, sheadacshe, muscle aches. Loss of

energy and fatigability
2=Any clear-cut symptom rates 2
14.GENITAL SYMPTOMS (Symptoms such as: loss of libido; impaired sexual
performance; menstrual disturbances)
0=Absent
1=Mild
2=Severe
15.HYPOCHONDRIASIS
0=Not present
shelp, etc.
1=Self-absorption (bodily)
2=Preoccupation with shealth

3=Frequent complaints, requests for

4=Hypochondriacal delusions

16. LOSS OF WEIGHT

A.When rating by history:
0=No weight loss
1=Probably weight loss associated with present illness
2=Definite (according to patient) weight loss
3=Not assessed
17.INSIGHT
0=Acknowledges being depressed and ill
1=Acknowledges illness but attributes cause to bad food, climate, overwork, virus,
needfor rest, etc.
2=Denies being ill at all
18.DIURNAL VARIATION
A.Note whether symptoms are worse in morning or evening. If NO diurnal variation,
mark none 0=No variation, 1=Worse in A.M., 2=Worse in P.M.
0=None
1=Mild
2=Severe
19.DEPERSONALIZATION AND DEREALIZATION (Such as: Feelings of
unreality; Nihilistic ideas)
0=Absent
3=Severe
1=Mild
4=Incapacitating
2=Moderate
20.PARANOID SYMPTOMS
0=None
1=Suspicious

2=Ideas of reference
3=Delusions of reference and persecution

21.OBSESSIONAL AND COMPULSIVE SYMPTOMS

0=Absent
1=Mild
39

2=Severe

Total Score = 3
0 - 7 = Normal
8 - 13 = Mild Depression
14-18 = Moderate Depression
19 - 22 = Severe Depression
> 23 = Very Severe Depression
Appendix 3. Formulir Barthel Index
NO FUNGSI

SKOR KETERANGAN

Mengontrol BAB

1
2
2

Mengontrol BAK

0
1
2

Inkontinen/tidak
teratur
(perlu enema)
Kadang-kadang inkontinen
(1x/mgg)
Kontinen teratur

Inkontinen
atau
pakai
kateter dan tak terkontrol
Kadang-kadang inkontinen
(max 1x/24 jam)
Kontinen (untuk lebih dari 7
hari)

Membersihkan diri 0
Melap
1
muka,menyisir
rambut,menyikat
gigi

Butuh orang lain

Mandiri

Penggunaan toilet 0
Pergi ke dan dari
WC
(melepas, 1
memakai celana,
menyeka,
menyiram)
2

Tergantung
pertolongan
orang lain
Perlu pertolongan pada
beberapa aktivitas tetapi
dapat mengerjakan sendiri
beberapa aktivitas lain
Mandiri

Makan

Tidak mampu
Perlu
seseorang
memotong makanan
Mandiri

0
1
2

Before 8/4/2016
sick

Berpindah tempat 0
dari tidur ke duduk 1
2

untuk

Tidak mampu
Perlu bantuan untuk duduk
(2 orang)
Bantuan minimal (1 orang)
40

3
7

Tidak mampu
Bisa berjalan dengan kursi
roda
Berjalan dengan bantuan 1
orang/walker
Mandiri

Tergantung orang lain

Sebagian dibantu (misal:
mengancingkan baju)
Mandiri

0
1
2

Tidak mampu
Butuh pertolongan
Mandiri

0
1

Tergantung orang lain

Mandiri

Mobilisasi/berjalan 0
1
2
3

10

Berpakaian

Naik turun tangga

Mandi

0
1

Mandiri

TOTAL NILAI
Keterangan: Skor BI (Nilai ADL):

20

20

18

: Mandiri

1219 : Ketergantungan ringan

911 : Ketergantungan sedang
5 8 : Ketergantungan berat
Appendix 4. Eastern Cooperative Oncology Group (Ecog) Score / Zubrod Score

Appendix 5. Karnofsky Performance Status Scale Definitions Rating

Able to carry on normal activity and to

100 Normal no complaints; no evidence of

41

disease.
work; no special care needed.

Unable to work; able to live at home and

care for most personal needs; varying
amount of assistance needed.

Unable to care for self; requires equivalent

of institutional or hospital care; disease may
be progressing rapidly.

90

Able to carry on normal activity;

minor signs or symptoms of disease.

80

Normal activity with effort; some signs

or symptoms of disease.

70

Cares for self; unable to carry on

normal activity or to do active work.

60

Requires occasional assistance, but is

able to care for most of his personal
needs.

50

Requires considerable assistance and

frequent medical care.

40

Disabled; requires special care and

assistance.

30

Severely disabled; hospital admission

is indicated although death not
imminent.

20

Very sick; hospital admission

necessary; active supportive treatment
necessary.

10

Moribund; fatal processes progressing

rapidly.

Dead

Appendix 6. Fatigue Severity Scale

Appendix 7. Berg Balance Test

42

10

1. SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand for support.
( ) 4 able to stand without using hands and stabilize independently
( ) 3 able to stand independently using hands
( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or stabilize
0
( ) 0 needs moderate or maximal assist to stand

2. STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding on.
0
( ) 4 able to stand safely for 2 minutes
1
( ) 3 able to stand 2 minutes with supervision
2
( ) 2 able to stand 30 seconds unsupported
3
( ) 1 needs several tries to stand 30 seconds unsupported
4
( ) 0 unable to stand 30 seconds unsupported
5
If a subject is able to stand 2 minutes unsupported, score full points for sitting
unsupported. Proceed to item #4.

3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON

FLOOR OR ON A STOOL
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
6
( ) 4 able to sit safely and securely for 2 minutes
7
( ) 3 able to sit 2 minutes under supervision
8
( ) 2 able to able to sit 30 seconds
9
( ) 1 able to sit 10 seconds
10 ( ) 0 unable to sit without support 10 seconds
11
4. STANDING TO SITTING
INSTRUCTIONS: Please sit down.
12
( ) 4 sits safely with minimal use of hands
13
( ) 3 controls descent by using hands
14
( ) 2 uses back of legs against chair to control descent
15
( ) 1 sits independently but has uncontrolled descent
16
( ) 0 needs assist to sit

5. TRANSFERS
INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer
one way toward a seat with armrests and one way toward a seat without
armrests. You may use two chairs (one with and one without armrests) or a bed
and a chair.
17
( ) 4 able to transfer safely with minor use of hands
18
( ) 3 able to transfer safely definite need of hands
19
( ) 2 able to transfer with verbal cuing and/or supervision
20
( ) 1 needs one person to assist
21
( ) 0 needs two people to assist or supervise to be safe
6. STANDING UNSUPPORTED WITH EYES CLOSED
INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
22
( ) 4 able to stand 10 seconds safely
23
( ) 3 able to stand 10 seconds with supervision
43

24
25
26

( ) 2 able to stand 3 seconds

( ) 1 unable to keep eyes closed 3 seconds but stays safely
( ) 0 needs help to keep from falling

7. STANDING UNSUPPORTED WITH FEET TOGETHER

INSTRUCTIONS: Place your feet together and stand without holding on.
27
( ) 4 able to place feet together independently and stand 1 minute safely
28
( ) 3 able to place feet together independently and stand 1 minute with
supervision
29
( ) 2 able to place feet together independently but unable to hold for 30
seconds
30
( ) 1 needs help to attain position but able to stand 15 seconds feet together
31
( ) 0 needs help to attain position and unable to hold for 15 second

8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE

STANDING
INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach
forward as far as you can. (Examiner places a ruler at the end of fingertips
when arm is at 90 degrees. Fingers should not touch the ruler while reaching
forward. The recorded measure is the distance forward that the fingers reach
while the subject is in the most forward lean position. When possible, ask
subject to use both arms when reaching to avoid rotation of the trunk.)
32
( ) 4 can reach forward confidently 25 cm (10 inches)
33
( ) 3 can reach forward 12 cm (5 inches)
34
( ) 2 can reach forward 5 cm (2 inches)
35
( ) 1 reaches forward but needs supervision
36
( ) 0 loses balance while trying/requires external support

9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION

INSTRUCTIONS: Pick up the shoe/slipper, which is in front of your feet.
0 ( ) 4 able to pick up slipper safely and easily
1 ( ) 3 able to pick up slipper but needs supervision
2 ( ) 2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and
keeps balance independently
3 ( ) 1 unable to pick up and needs supervision while trying
4 ( ) 0 unable to try/needs assist to keep from losing balance or falling

10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS

WHILE STANDING
INSTRUCTIONS: Turn to look directly behind you over toward the left
shoulder. Repeat to the right. (Examiner may pick an object to look at directly
behind the subject to encourage a better twist turn.)
5
( ) 4 looks behind from both sides and weight shifts well
6
( ) 3 looks behind one side only other side shows less weight shift
7
( ) 2 turns sideways only but maintains balance
8
( ) 1 needs supervision when turning
9
( ) 0 needs assist to keep from losing balance or falling
11. TURN 360 DEGREES

44

INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a

full circle in the other direction.

( ) 4 able to turn 360 degrees safely in 4 seconds or less

( ) 3 able to turn 360 degrees safely one side only 4 seconds or less

( ) 2 able to turn 360 degrees safely but slowly

( ) 1 needs close supervision or verbal cuing

( ) 0 needs assistance while turning

12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING
UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until
each foot has touched the step/stool four times.

( ) 4 able to stand independently and safely and complete 8 steps in 20

seconds

( ) 3 able to stand independently and complete 8 steps in > 20 seconds

( ) 2 able to complete 4 steps without aid with supervisionable to

complete > 2 steps

( ) 1 needs minimal assist

( ) 0 needs assistance to keep from falling/unable to try

13. STANDING UNSUPPORTED ONE FOOT IN FRONT

INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly
in front of the other. If you feel that you cannot place your foot directly in
front, try to step far enough ahead that the heel of your forward foot is ahead
of the toes of the other foot. (To score 3 points, the length of the step should
exceed the length of the other foot and the width of the stance should
approximate the subjects normal stride width.)

( ) 4 able to place foot tandem independently and hold 30 seconds

( ) 3 able to place foot ahead independently and hold 30 seconds

( ) 2 able to take small step independently and hold 30 seconds

( ) 1 needs help to step but can hold 15 seconds

( ) 0 loses balance while stepping or standing

14. STANDING ON ONE LEG

INSTRUCTIONS: Stand on one leg as long as you can without holding on.

( ) 4 able to lift leg independently and hold > 10 seconds

( ) 3 able to lift leg independently and hold 5-10 seconds

( ) 2 able to lift leg independently and hold 3 seconds

( ) 1 tries to lift leg unable to hold 3 seconds but remains standing

independently

( ) 0 unable to try of needs assist to prevent fall

Total Score = 17 (high fall risk)
Interpretation:

0-20 = high fall risk

21-40 = medium fall risk
41-56 = low fall risk

45