Cerebral Palsy

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Cerebral Palsy
Cerebral
Palsy
Soeroyo Machfudz & MTS Darmawan
PENDAHULUAN
• Penyebab gangguan otak besar adalah
adanya injuri pada brain sebelum atau
selama persalinan atau pada awal
kehidupan
• Ini sering menyebabkan gangguan yang
menetap pada anak
PENDAHULUAN
• Penyebabnya adalah adanya kerusakan
pusat kontrol motorik pada
pengembangan otak dan ini dapat
terjadi :
- during pregnancy (about 75 %)
- during childbirth (about 5 %) or
- after birth (about 15 %) up to
about age 3 years
PENDAHULUAN
• Non-progressive disorder, artinya
kerusakan otak tidak berdampak buruk,
tetapi gangguan secondary orthopedic
sering terjadi…….
– Contoh onset of arthritis and osteoporosis
dapat terjadi lebih awal pada orang dewasa
dengan CP.
PENDAHULUAN
• Tidak diketahui pengobatan penderita CP
yang memuaskan.
• Medical intervention terbatas dalam
treatment and prevention pada kejadian
komplikasi dari efek CP.
Definition
• Group dari kondisi khronis yang akan
berdampak pada body movement and
muscle coordination.
• Ini disebabkan karena kerusakan satu
atau lebih dari specific areas didalam
otak, usually occurring during fetal
development; before, during, or shortly
after birth; or during infancy
Definisi
• Jadi kelainan ini masalahnya bukan kelainan
pada otot dan sarafnya
• Pada dasarnya kecacatan dan kerusakan
perkembangan motor areas akan menganggu
fungsi otak sehingga kemampuan otak tidak
adequat dalam mengontrol gerakan dan postur
tubuh.
• Prevention : dengan ANC yang baik bisa
menduga dan mengurangi kondisi oksiginasi janin
kurang adekuat.
• Pencegahan terjadinya CP pada beberapa bayi
dengan cara resusitasi yang baik.
• Kejadian CP di Amerika Serikat menurun tajam sd
50%. Hal ini disebabkan karena dokter mengikuti
training khusus tentang resusitasi neonatal
Insidensi
• 1-2 dari 1000 bayi
• 10 x lebih sering ditemukan prematur
• Bagian otak yang mengendalikan pergerakan
otot pada bayi tersebut sangat rentan terhadap
cedera.
Klasifikasi dari CP
1.Spastic CP
2.Dyskinetic/Athethoid CP
3.Ataxic
4.The Mixed/dystonic
Classification of CP
1. Spastic CP ~ Muscle Stiffness
• Most common
• May involve 1 or both sides of the body.
• Clinical hallmarks include hypertonicity with
poor control of posture, balance, and
coordinated movement, and impairment of
fine and gross motor skills.
Classification of CP
1. Spastic CP ~ Muscle Stiffness
• Active attempts at motion ↑ the abnormal
postures & lead to overflow of movement to
other parts of the body.
• Common types of spastic CP include:
– Hemiparesis
– Quadriparesis (tetraparesis)
– Diplegia is when similar body parts are
affected, such as both arms.
Table 1. Topographical Distribution of Cerebral Palsy
Topographical
Descriptor
Area affected
Monoplegia
One limb involved
Hemiplegia
Involvement of one side of the
body
Diplegia
Lower extremities more involved
than
the upper extremities
Triplegia
Three extremities involved
Quadriplegia or
tetraplegia
All four extremities involved
Classification of CP
2. Dyskinetic / Athethoid CP
~ Uncontrolled Movements
involves abnormal involuntary movements that
disappear during sleep & ↑ with stress.
• Major manifestations
• Movements may become
Classification of CP
2. Dyskinetic / Athethoid CP
~ Uncontrolled Movements
• Major manifestations :
– Athetosis (wormlike movement),
– Dyskinetic movement of mouth
– Drooling
– Dysarthria.
Classification of CP
2. Dyskinetic/Athethoid CP
~ Uncontrolled Movements
• Movements may become
– choreoid (irregular, jerky) and
– dystonic (disordered muscle tone),
especially when stressed and during the
choreoid adolescent years.
choreoid
dystonic
Classification of CP
3. Ataxic CP ~ poor balanced
Manifested by
– Wide-based gait,
– rapid repetitive movements performed poorly
– disintegration of movements of the upper
extremities when the child reaches for objects.
Classification of CP
4. The Mixed / dystonic CP
• Combination of spastic & athetoid CP.
Etiology
• Common results from existing prenatal brain
abnormalities.
• Prematurity : the single most important
determinant of CP.
• Other prenatal or perinatal risk factors :
– Asphyxia, ischemia, perinatal trauma,
– Congenital & perinatal infections, and
perinatal metabolic problems such as
• hyperbilirubinemia and
• hypoglycemia.
PENYEBAB CP
• Infeksi, trauma dan tumor dapat
menyebabkan CP pada bayi usia dini.
• Beberapa kasus (sekitar 24%) dari CP tidak
bisa diterangkan lebih lanjut.
Pathophysiology
• Disabilities usually result from injury to the
cerebellum, the basal ganglia or the motor
cortex.
• It is difficult to establish the precise location of
neurologic lesions because there is no typical
pathologic picture.
Pathophysiology
• In some cases, the brain has
– gross malformations; in others,
– vascular occlusion, atrophy, loss of neurons
– degeneration may be evident.
Pathophysiology
• CP is nonprogressive but may become more
apparent as the child grows older.
Clinical Manifestations
Most common :
• Delayed gross motor development
– delay in all motor accomplishments;
– delay becomes more profound as the child grows)
Clinical Manifestations
• Additional manifestations include:
1. Abnormal motor performance
– e.g. early dominant hand preference, abnormal
and asymmetrical crawl,
– poor sucking, feeding problems or
– persistent tongue thrust (melet)
2. Alterations of muscle tone
(e.g. increased or decrease resistance to passive
movements, child feels stiff when handling or
dressing, difficulty in diapering or opisthotonos)
Clinical Manifestations
• Additional manifestations include:
3. Abnormal postures
(e.g. scissoring legs or persistent infantile
posturing)
Clinical Manifestations
• Additional manifestations include:
4. Reflex abnormalities
(e.g. persistent primitive reflexes, such as
tonic neck of hyperreflexia)
Clinical Manifestations
• Disabilities associated with CP include
– mental retardation, seizures,
– attention deficit disorder and
– sensory impairment.
Clinical Manifestations
• Severe cases : at birth
• Mild and moderate : 1-2 years old.
• Failure to achieve milestones may be the
first sign.
Diagnosis
• Prenatal, birth and postnatal history
• Neurologic examination
• Assessment of muscle tone, behavior and
abilities
• Other disorders, such as metabolic disorders,
degenerative disorders and early slow-growing
brain tumors are ruled out.
What can be done?
• The damaged parts of the brain cannot be
repaired, but often the child can learn to use
the undamaged parts to do what she wants to
do.
• It is important for parents to know more or
less what to expect:
What can be done?
• The child with cerebral palsy will become an
adult with CP.
• Searching for cures will only bring
disappointment.
• Instead, help the child become an adult who
can live with her disability and be as
independent as possible.
Treatment
Should address the following:
•
•
•
•
•
spasticity, dystonia,
muscle stiffness,
contracture, joint deformity,
muscle weakness, and
other aspects of abnormal motor control.
Therapy
• STRETCHING
• STRENGTHENING
• POSITIONING
STRETCHING
• CP tend to have ↑ muscle tone leading to
generally tight muscles.
• → keep the child limber so they can perform
everyday tasks.
• The arms and legs must be moved in ways
that produce a slow, steady pull on the
muscles to keep them loose.
STRENGTHENING:
• Therapists will work specific muscle groups to
enable them to support the body better and ↑
function.
• A new technique : aquatic work.
• Water can help resist or assist in the
performance of an exercise and also works on
lengthening and stretching muscles by the
mere force of gravity and suspension.
POSITIONING
• Braces, abduction pillows, knee immobilizers
wheelchair inserts, sitting recommendations, and
handling techniques are all ways of positioning a
patient.
• Such techniques require the body to be placed in a
specific position to attain long stretches and can help
eliminate unwanted tone due to hyperactive muscles.
• This is potentially the most important aspect of
therapy because it enables the body to do tasks it is
being asked to perform. The ultimate goal of therapy
is to make the patient more independent.
MATUR NUWUN