Anamnesis

Identitas: nama, usia, pekerjaan, jenis kelamin, dominance hand, menikah/tidak

Keluhan utama: yang dikeluhkan pasien saat ini dan durasi waktu

RPS:

 Penjabaran keluhan utama bila PAIN (SOCRATES: Site Onset Characteristic Radiation
Associated symptoms/impact on ADL/QOL/job Time course Exacerbated/relieving
factors Severity/VAS)
 Penjabaran keluhan utama bila kelemahan: identifikasi jenis strokenya dengan
menanyakan saat serangan sedang apa, makin bertambah berat/gradual atau
mendadak berat, kelemahan tangan atau kaki, keluhan penyerta (TIK), history
previous stroke, Tekanan darah saat itu, sejak kapan, sempet flacid, mulai muncuul
gerakan pada tangan berapa lama setelah serangan
 Fungsi lain yang terganggu : memory deficits, visual, hearing and smelling
disturbance, difficulty of swallowing, comunication, bowel and bladder, numbness
 Analisis functional : independent, kemampuan transfer, walking, rehabilitation
history, current medication
 Patient’s Hope

RPD

Previous history of stroke (how many, type, when, functional), hypertension, dislipidemia,
prior heart disease, diabetes mellitus terkontrol / tidak dengan obat, tensi dan lab
terakhir

RPK

Idem RPD

R sosioekonomi

Family and home : jumlah anak, Caregiver, home situation (door, floor, toilet), pembiayaan

Lifestyle : history of alcohol and smoking Brinkman index : batang/hari x lama merokok
(tahun). Nilai 0-199 ringan; 200-599 : sedang; > 600 : berat. Hobby and leisure

Work : last job, job analysis

Physical examination

Vital sign and counsiousness

Communication : fluently, compreshension, repetition, naming

Kognitif  MMSE (disturbance of orientation, attention and calculation, registration,
naming, recall, language)

Barthel indeks :

Grooming, bathing : 1

BAB, BAK, toileting, dressing,stairs : 2

Transfer, mobility : 3

St. Generalis : jantung, paru, chest expansi

Cranial nerve

I Penciuman
II Visus, lapang pandang
III,IV,VI : huruf H
III : direct & indirect reflex, levator palpebra
IV superior oblique, VI rectus lateral, lainnya III
V refleks kornea, jaw refleks
Motorik: masseter, temporalis, pterigoideus lateralis & medialis
Sensorik: oftalmic, maksilaris,mandibularis
VII sensorik 2/3 lidah depan, motorik: raising eyebrow (occipito frontalis),
frowning (corrugator supercilli), closing eye (orbicularis oculi), wrinkling of the
nose (procerus & nasalis), smiling (zygomaticus major), lip purse (orbicularis oris),
puffing cheeck (buccinator)
VIII pendengaran & vestibular
IX sensorik 1/3 belakang lidah, motorik arcus faring-uvula (uvula tertarik ke arah
sehat)
X gag reflex
XI SCM & trapezius
XII lidah (lick the wound)
Postur : buka baju
Anterior: synergic pattern, shoulder, body arm distance, pelvic obliguity
Lateral:hiperkifotic, hyperlordotic, genu recurvatum
Posterior: skoliosis
Flexibility trunk : finger to floor
Gait
Hemiplegic/hemiparetic gait
Head: deviasi ada/tidak
Arm: arm swing normal/tidak
Trunk : lateral movement
Hip: hip hiking
 Knee : extension/fleksi berkurang
Ankle: plantar fleksi
Foot : foot clearance

Determinants of gait
1. Pelvic tilt 5 derajat
2. Pelvic rotation 4 derajat
3. Lateral displacement of hip 2 inchi
4. Knee flexion in mid-stance 5 derajat
5. Knee foot mechanism:
- Early stance phase: foot dorsifleksi, knee fully extended
- Late stance phase: foot plantar fleksi, knee mulai fleksi

Balance

Neuromusculoskeletal

Upper extremity

L : deskripsi synergic pattern (shoulder adduksi, internal rotasi; elbow flexion, pronated
forearm, wrist flexion, thumb adduction & fingers flexion), trofi otot

F : indentasi, tenderness, tonus, tightness, sensibilitas (light touch, temperature, pain/pin

prick)

M : pain on movement, clonus, spasticity, ROM, MMT

Proprioceptive

Reflex physiologic : biceps, triceps, brachioradialis

Reflex pathologic : hoffman tromner

Reflex primitif bisa muncul misalnya rooting

Hand prehension :

Grasp: cylindrical, spherical, hook

Precision : lateral pinch, tip to tip, 3 jaw chuck

Coordination : finger to nose (yang dilihat intention tremor, dismetri)

disdiadokokinesia

Lower extremity
L : synergic pattern (hip adduksi, ekstensi, internal rotasi; knee ekstensi; plantar fleksi,
equinovarus), trofi, edema/tidak

F : tenderness, tonus, tightness, sensibilitas (light touch, temperature, pain/pin prick)

M : pain on movement, clonus, spasticity, ROM, MMT

Proprioceptive

Reflex physiologic : patella, achiles

Reflex pathologic : babinski, gordon, chaddock, oppenheim, gonda, schaeffer

Prognosis

Ad vitam:

Prognosis of stroke depends on: delisa

1. Cause of strokehemoragic (60%) worse than ischemic(80%)

2. Age: > 65 th worse than <65th
3. Severity of lesion

Mortality in 1 year: 25-40%

Ad Functionam:

Greatest general neurologic recovery occurs during the first 3 months after the stroke and
remain significantly up to 6 months. Slow recovery may continue up to 1 year, some
reported functional recovery up to 2 years.

UE prognosis:

Poor if there is complete arm paralysis at onset (delisa: only 11% gain good recovery
function) or no measurable grasp strength by 4 weeks.

If there is some motor recovery by 4 weeks: 70% will reach good or full recovery

If complete functional recovery occurs usually complete within 3 months of onset.

The degree of functional motor recovery in the arm is less than in the leg, stroke affecting
MCA territories much more frequent.

Mobility prognosis: braddom

75% independent in mobility skill

68% independent in selfcare/ADL

37% return to vocasional

Negative factors of return to work:

1. Low score on BI at time of discharge

2. Prolonged LOS
3. Afasia
4. Prior alcohol abuse

Strong predictor for poor outcome: braddom

1. Coma at onset
2. Persistent incontinence
3. Poor cognitive function
4. Severe hemiplegi
5. Lack of return of motor function at 1 month

Language prognosis:

Greatest language recovery is during the first 3 months, and meaningful improvement
maybe seen in 6-12 months after stroke.

Dysphagia prognosis:

Dysphagia

Bladder prognosis:

Many patients will recover bladder function within 1 month. 30% were still incontinent at 1
month. Improved to 15% at 6 months.

Ad Sanationam

The risk of another stroke in the 1st year 12%-25%

Treatment

Bila dibutuhkan hand splint: resting hand splint

Wrist ekstensi 20°

MCP fleksi 35-45°

IP ekstensi

Thumb abduksi dan IP ekstensi

BPI
Harus dapat menggambarkan diagram BPI beserta otot2 yang dipersyarafi

Lesi preganglionik sensorik normal krn lesinya diatas akar dorsalnya

Operasi steindler: immobilisasi segera stlh operasi-6 minggu, elbow fleksi 100°, PROM
elbow, wrist, finger langsung stlh operasi, AROM 3 minggu setelahnya, passive ekstensi
setelah 7 minggu

Intrinsic minus hand = claw hand caused by imbalance between strong extrinsic and
deficient intrinsic characterized by MCP hyperextension and PIP and DIP flexion. Causes by
ulnar nerve palsy (cubital tunnel syndrome and guyon syndrome), median nerve palsy
(volksman contracture and leprosy) and compartment of the hand.

Pathoanatomic components

1. Loss of intrinsic lead to loss of baseline MCP flexion and loss of IP extension.
2. Strong extrinsic EDC lead to unoppose extension of the MCP joint.
3. Strong FDP and FDS lead to unoppose flexion of PIP and DIP.

Provocative test if MCP joint are brought out of hyperextension, the flexion deformity of
the PIP and DIP will correct.

Intrinsic Plus hand caused by muscle imbalance between spastic intrinsic (interossei and
lumbrical) and weak extrinsic (FDS,FDP,EDC) characterized by MCP flexion and PIP and DIP
extension.

Etiology:

1. Trauma
2. RAMCP joint dislocation and ulnar deviation leads to spastis intrinsic
3. Neurologic patologies: TBI, CP, stroke, parkinson

Pathoanatomy

1. Spastic intrinsic lead to flexion MCP and extension pf IP

2. EDC weakness fail to provide balancing extension force to the MCP joint
3. FDS and FDP weakness fail to provide balancing flexion force to the PIP and DIP

Provocative test

Bunnell test: intrinsic tighness test to differentiate tightness between intrinsic and extrinsic
tightness.

When the MCP passively extended, the instrinsic muscle will be stretched, so the IP flexion
will be limited, but when the MCP is flexed the IP flexion will increase  positive bunnel test
In extrinsic muscle tightness, the IP flexion will not increase even when the MCP is flexed.

Positive when PIP flexion is less with MCP extension than with MCP flexion.

Cerebral Palsy

Definisi
A group permanent disorders of development of movement and posture causing activity
limitation attributed to non progressive disturbances in immature brain before 2 0r 3 year
old.

Risk factor:

Prenatal (conception –onset to birth): prematurity (<36 weeks), Low birth weight (<2500g),
infection (TORCH), bleeding in third semester.

Perinatal ( 28 weeks gestation- 7 days after birth): Prolonged and difficult labor, Premature
rupture of membrane, presentation anomalies, vaginal bleeding.

Postnatal (0-2 years): infeksi/meningoencephalitis, head trauma, jaundice, seizures,

coagulopathy.

Klasifikasi CP: spastik, dyskinesia (dystonia and athetoid) and ataxia.

Prognosis berjalan:

1. According by bleck
a. Extensor thrust
b. ATNR
c. STNR
d. Neck righting
e. Moro reflek
f. Parachute
g. Foot placement

0: good prognosis

1: kemungkinan berjalan

2: bad prognosis

2. According epidemiologies
Hemiplegi: 15-18 months
Diplegia: 24 months
 3. According campous du-paz
Good prognosis Bad prognosis
Head and neck control 9mo 20mo
Sitting w/o support 24mo 48mo
Crawling 30mo 48mo

GMFCS (gross motor function classification system): based on the highest level of mobility
that a child 6-12 yo expected to achieve
Level 1: walking w/o restriction
Level 2: walking without ass device, limitation mobility in outdoor and community
Level 3: walking with ass device, limitation mobility in outdoor and community
Can sit on own or with limited external support and has some independence in standing
transfer
Level 4: self mobility limited, used transported mobility device or powered mobility device
Usually supported when sitting
Level 5: self mobility severely limited even with the used of powered mobility device

MACS (Manual ability classification system) : based on typically manual activity

performance in ADL, child 4-18 yo

Level 1: handling objects with easily and successfully

Level 2: handling most objects with easily but reduced speed and quality of achievement
Level 3: handling objects with difficulty, need help to prepare or modify activities
Level 4: Handling objects with difficulty, need assistance and assistive device/adaptive
equipment
Level 5: doesn’t handling objects

Hip subluxation & Dislocation

1. A the time you diagnose CP,
2. Age 12-24 months, review every 12 months
3. Scrutton&Baird : children with CP can’t walk 10 steps at 30 months oldMP >15%-->
konsul ortho
reevaluate every 6 months for :
- MP 25% krn risiko dislokasi >50%
- Limited hip abduction ROM
- children with CP can’t walk 10 steps at 30 months old
Penyebab :
- Lack of weight bearing
o Weight bearing  hip anterversion berkurang
- Muscle imbalance
o Spasticity of hip adductors & flexors, weakness of hip abductors & extensors
- Poor handling
Subluksasi MP 33-80 %, dislokasi MP >80%
Gambar perkins & hilgen reiner, a/bx100%
Efek subluksasi hip (ICF)
Body function & structure : degeneration of acetabular cartilage, pain, limited ROM
Activity & participation : function, hygiene, ability to be positioned
Treatment
1. Positioning
- Hip abduction : Lying 6 hours/day, begin after birth
Sitting 6 hours/day, begin 6 months
Standing 1 hours/day, begin 12 months
- Bracing for positioning : SWASH (standing, walking & sitting hip) orthosis
Positioning dilakukan kalau tidak bisa berjalan 10 steps usia 30 bulan, MP>15%
2. Tone management
- Botox
- Intrathecal baclofen
- Selective dorsal rhizotomy : CP usia 3-8thn, spastic diplegik, ambulatory
3. Surgery
- Soft tissue procedure : miotomy adduktor with/without iliopsoas atau obturator
osteotomi abduksi 30 derajat
- Bony procedure : femoral osteotomi, pelvic osteotomi (VDRO varus derotation
osteotomy)

SCOLIOSIS IN CEREBRAL PALSY

- Insidens > 20 %
- Bed ridden children insidens almost 100 %
- Ambulatory child almost rare
- Associated with GERD (sandifer syndrome)
- Mostly thoracic kifosis, thoraco lumbar kifosisstiff long C-curve
- Rate of progression during growth spurt 2-4 0 /month
- Structural /rigid deformity faster in Quadriplegic
- Progression continue after skeletal maturity 1.4-4 0 /year if curve >50 0 at the end of
growth spurt, and 0,8 0 /year if curve <50 0

Group of CP

1. Ambulatory hemiplegia similar with idiopathic scoliosis

2. More severely dependent wheel chair : thoracal/thoracolumbar C-curve, pelvic
obliquity cause by hip subluxation

Differs from idiopathic scoliosis:

1. Are more likely to progress (progress 1-2 degree starting at age 8-10 years)
2. Curve begins at earlier age
3. Curve is long, stiff C shape curve (left sided are not uncommon)
4. Curve has greater sagital plane deformity (kifotic or lordotic)
5. Associated with pelvic obliquity
6. Skeletal maturity is delayed in CP
7. Bracing is less effective

Etiology :

1. Trunkal imbalance
2. Muscle weakness
3. Pelvic Obliquity

Indication of bracing :

1. Non proressive curve < 50 0

2. Early stage in patients <10 yo
3. To delay surgery until older age

Goal Brace :

1. Stabilize spine
2. Level the pelvis
3. Facilitate relocation of hip one of pelvic obliquity corrected
4. Improve sitting balance, but doesn’t affect natural course of disease
5. Used to slow progression in skeletally immature patient

Indication surgery :

1. Curve 50-90 0 in ambulatory that is progressive that interfering with sitting

position
2. Patient >10 yo
3. Adequate hip ROM
4. Progression curve >100 or significant deterioration of child ability to function

Treatment :

1. Konservasi
a. Sitting adaptation using adjustable head support, shoulder harness and
strap, waist strap and fitted on wheelchair
b. Spinal Brace : TLSO molded to slow down progression, supported the
spine, reserve vertebra growth, whole body brace
2. Surgery

Cara periksa skoliosis pada anak CP : Posisi duduk, tengkurapkan & lihat dari depan
ada curvatura atau tidak

Komunikasi

Penilaian : anamnesis respons bila dipanggil, bila ingin sesuatu, arti tangisan
 Program : non verbal (gesture) bila ingin sesuatu ajarkan gesture, mis. bila ingin
BAK sentuh di supra pubik

Treatment Hypertonia :

1. Generelized tone : comprehensive therapy program, sitting system

2. Regional tone : rhizotomy , baclofen pump, multistage orthopedy surgery,
therapy
3. Focal tone : ROM, casting, splinting, injection therapy

NDT : normalizing movement pattern and inhibition abnormal reflex

AFO pada CP

Tujuan orthosis LE pada CP:

- Memperbaiki pola jalan ( ambu)

- Memperbaiki deformitas (non ambu)

1. Solid AFO (nonhinged AFO) sering digunakan pada non ambulatoir CP untuk
memperbaiki deformitas kaki. Ciri calf band lebih lebar dan lekukan ankle lebih lebar.
Terdiri dari:
a. Posterior leaf spring
Memberikan fleksibilitas ankle, memungkinkan dorsifleksi saat stance, tidak bisa
mengontrol varus dan valgus, indikasi untuk mild equinus spastik (MAS 1)
b. GRAFO
Mekanismenya mendorong tibia ke belakang, mencegah ankle dorsifleksi secara
pasif saat stance phase. Diindikasikan untuk crouch atau jump gait.
c. Antirecurvatum AFO
Mekanismenya 5° dorsifleksi, bagian belakang AFO mendorong tibia ke depan
dan vektor GRF bergeser kearah belakang lutut untuk menciptakan flexion
moment pada lutut

2. Hinged AFO
Dapat ditambahkan ditambahkan plantarfleksi stop atau dorsifleksi stop
KI pada anak yg tdk bisa dorsifleksi pasif, kontraktur fleksi lutut dan kelemahan
triceps surae.

Orthopedic shoes untuk koreksi hiperlaxity. Nancy hilton orthosis untuk

Swallowing problem
PF : lip seal, drooling, tonus bukal, gerakan rahang & lidah, tongue thrust, high palatum,
posisi leher

Cara periksa spastik orofaring

Pemeriksaan gold standard: FEES

Treatment:

1. Positioning: chin tuck, wheelchair head rest to control head position

2. Dietary changes: soft food, liquid
3. NGT or gastrostomy tube

Drooling diberikan stimulasi oromotor, injection into salivary glands effect hanya
berlangsung 24 minggu.

Amputee

Anamnesa

1. Sebab, kapan
2. Stump : luka, nyeri, bengkak
3. Aktivitas sekarang, ADL/kerja, deconditioning
4. Walking aid/prostesis
- Endurance : indoors, outdoor
- Nyeri
- Keluhan saat berjalan

Etiology

- Dis-vascular : DM, peripheral vascular disease 82%

- Trauma
- Malignancy : osteosarcoma
- Congenital

Geriatric amputation : DM, PVD

Triad foot ulcers :

1. Peripheral neuropathy
2. Claw foot deformity : metatarsal head, dorsal aspect of PIP, tip of distal phalang
3. Often only to minor trauma lead to infection

Key point diabetic foot exam:

 1. Evaluate sensation with monofilament (semmes weinstein)
2. Perform exam annually
3. Evaluate vascular status
4. Assess skin integrity
5. Evaluate foot deformity & limitation of ROM

5P acute arterial occlusion : pallor/pale, pain, pulselessness, paresthesia, paresis

ABI : TDS ankle a. dorsalis pedis/TDS brachial. Normal 0.9-1.2, >1.2 indicate non
compressible artery, <0.9 PAD

Toe brachial index utk menilai aliran posterior

Ukur dari medial tibial plateu

Phantom pain : pain in a surgically removed limb.

Stump pain : pain in a non surgically removed limb

Th/ TENS, trisiklik antidepresan, anti konvulsan, analgesik, chemical sympathectomy,

anesthetic block, vibrasi, tapping, massage, extensive use of prosthesis

Prosthesis pada penderita DM

Prosthesis diresepkan saat stump matur, evaluasi saat ada keluhan. Perhatikan defisit
sensorik.

Soft liner menggunakan silikon karena ada gg. Mikrovaskular

Harus fit, tidak boleh ada gerakan piston dan rotasi

Perhatikan endurans kardiorespirasi

Energy expenditure:

Syme: 15%

Traumatic below knee : 25%

Vascular below knee : 40%

Traumatic above knee : 68%

Vascular above knee : >100%

Hip disarticulation : 200%

BKA+BKA: 41%

BKA+AKA: 118%
AKA+AKA: >200%

PWB crutches: 18-36%

NWB crutches: 41-61%

Wheeling : Forward : biceps, tricpes, deltoid anterior, pectoralis major

Backward : deltoid posterior, trapezius

Check out prosthetic : alignment, posture, gait, turning-obstacle

Deviasi gait yg perlu diperhatikan: lateral trunk bending, hip hiking dan internal hip rotation,
circumduction, toe clearance, hyperextended knee, knee instability, inadequate dorsiflexi
control.

Kekuatan otot untuk berdiri cek hip ekstensor and abduktor, fleksi knee harus 90

Prosthetic BK sering nyeri daerah epicondylus, ingat daerah intolerant head of fibula, tibial
crest and tendon hamstring.

Lakukan visual inspeksi setelah dipake jalan, powder test (kalo longgar bedak ngga akan
menempel ke prosthesis), lipstick test menunjukkan pressure area

Tanya alignment prosthesis sama rifqi

SCI (Spinal Cord Injury)

Problem :

1. ISCoS
2. Autonomic dysreflexia
3. Spasticity
4. Neurogenic bladder/bowel
5. Pain
6. Sexuality
7. Ambulation/transfer
8. Wheelchair
9. Decubitus ulcer

ASIA Impairment Scale (AIS)

Sensory level : the most caudal of spinal segmen which sensory (LT and PP) is normal on
both side
Motor level : the lowest key muscle function that has grade at least 3 on both side and one
level above is 5 on both side

Neurological level : the most caudal spinal segmen which sensory and motor function is
normal on both side

Zone of partial preservation (ZPP) : the most caudal sensory and motor function that is
partially innervated below sensory and motor level in complete injury (AIS A)

Sensory examination, score:

- 0 = no sensation, or cannot differentiate between dull and sharp

- 1 = altered sensation, more or less
- 2 = normal sensation

MMT :

- Not testable : immobilization, severe pain, amputation, contracture >50% ROM

AIS :

- AIS A : Complete injury, no sensory or motor function is preserve in S4-5

- AIS B : Sensory Incomplete injury, sensory but not motor function is
preserve below the NL and include S4-5 and no motor function is preserve more
than 3 level below the motor level on either side of the body
- AIS C : motor incomplete, motor function is preserve below the NL and
more than half of key muscle below NL have MMT less than 3
- AIS D : motor incomplete, motor function is preserve below the NL and at
least half of key muscle below NL have MMT > 3
- AIS E : normal, history of SCI

Syndrome :

- Central cord syndrome : hyperextension cervical injury, without

fracture/dislocation, weakness UE greater than LE
- Anterior cord syndrome : decrease blood supply to 2/3 anterior of the spinal
cord, decrease pain, temperature, motoric below the level of injury, no
proprioceptive impairment
- Brown-Sequard syndrome: hemisection lesion, loss of motoric function at level
LMN type, loss of motoric function below level UMN type, loss propioceptive and
vibration at and below level lesion, sensory loss at the level of lesion and loss of
pain and temperature sensation at the level and contralateral, stab wound
- Cauda Equina syndrome: lumbosacral nerve root, LMN, ACR and BCR absent
- Conus Medullaris syndrome: (L1 and L2 area) mixed UMN and LMN, saddle
anesthesia, preserved ACR and BCR
Autonomic dysreflexia: above T6
Definition: symphatetic response that can be countered by the body caused by noxious
stimuli
Noxious stimuli  sympatic responsevasokonstriction of Splancnic bedoverloading of
blood vessel cause an increase of blood pressurestimulate the baroreseptor in
aortaparasymphatic response from the brainparasympatic effect above the level but
below the level is still vasoconstriction.

Treatment: sit up, longgarkan baju, remove abdominal binder, cek TD, find noxious stimuli,
dalam 2-5 menit jika symptom masih ada atau TD >150 mmHg berikan anti HT, jika symptom
masih ada dan TD <150 mmHg lakukan bowel/bladder evakuasi, jika symtom masih ada
diluar bladder dan bowel cari faktor2 lainnya.

Spasticity

One of UMN syndrome, hyperexcitability stretch reflex, velocity dependent

Komponen stretch reflex : muscle spindle, spinal cord, golgi tendon organ

- muscle spindle (intrafusal) terdiri dari nuclear chain (aferen II) & nuclear bag (aferen Ia).
Aferen Ia sensitif terhadap regangan cepat eksitasi aferen Ia kornu dorsalis medula
spinalis  bersinaps  alfa motor neuron  kontraksi otot agonis. Aferen Ia juga
bersinap dengan interneuron inhibitorik  inhibisi otot antagonis
- kontraksi otot menyebabkan golgi tendon organ terjepit eksitasi aferen Ib medula
spinalis relaksasi otot antagonis. Relaksasi otot antagonis juga dipengaruh oleh
supraspinal
- gamma motor neuron terletak di ujung muscle spindle untuk mempertahankan regangan
muscle spindle sehingga otot tetap berkontraksi bila diinginkan (input supraspinal)

spastisitas terjadi karena hilangnya kontrol supraspinal terhadap refleks regang

Treatment

1. Prevention stimulus nociceptif: bladder/bowel

2. Stretching /splinting/positioning
Splinting misal dgn AFO untuk mencegah plantar fleksi berlebihan, positioning
mengurangi risiko kontraktur dan memperbaiki derajat spastisitas. Postur yg hrs
dihindari leg scissoring, posisi windswept dan posisi fort leg. Sendi yg spastisitas dpt
dilakukan serial splinting diganti tiap 5-7 hari.
3. Oral medication
DZp 1x2,5 mg , baclofen 2x 5-10 mg stimulate inhibitor GABA, tizadine 2-4 mg,
clonidine dan dantrolene sodium
4. Botox/motor point blockinhibition release of ach
 5. Intrathecal baclofen
6. Surgery: neurosurgery atau orthopedic

Spastisitas ditangani bila menimbulkan masalah:

1. Nyeri
2. Hygiene/personal care
3. Fungsional

MAS

Neurogenic bladder

Neurogenic bowel

Sexuality
Men: Ejakulasi retrogard krn spastisitas dari sphincter

Pain

Wheelchair

Fraktur vertebra:

1/3 anterior: fr. Stabil

1/3 posterior: fr. Tdk stabil

Fraktur kompresi: >50% tidak stabil, <50% dibag. Medial dan displaced tidak stabil.

Activities C5 C6 C7 C8 T1
UE dressing Independent
Feeding Independent
LE dressing Independent
Grooming Independent
Transfer Independent
Bowel & Independent
bladder
Mucous Independent
clearance
Wheelchair Mostly Independent Independent independent
independent with coated except in
with power rims uneven
terrain
Ambulation T2-9 T10-L2 AFO, L3-S5
standing KAFO, community
 frame, tilting forearm ambulation,
table crutches, cane/crutches
household
ambulation

Scoliosis

Pertambahan 1°/tahun pikirkan brace/operasi

Treatment: exercise general (kardio endurance), exercise spesifik scoliosis, koreksi postur
dan brace

Lepra (MH)

Cardinal sign:

1. Macular anaesthesia
2. Thickening of peripheral nerve
3. Finding positive skin smear of acid fast bacillus /AFBsmear of skin external ear krn
suhunya 33°

Thickening 9 peripheral nerve:

1. N. Greater auricularis nerve, dibelakang telinga

2. N. Facialis m.orbicularis oculi akibatnya terjadi lagophthalmus dan juga syaraf
otonomnya terkena shg sekresi lacrimal gland << matanya kering mengakibatkan
keratitis exposure krn ulkus kornea
3. N. trigeminus reflek kornea
4. N. Medianus  precision grip, antara FCR dan PL
5. N. Ulnarisplacement grip, medial siku
6. Cutaneus N. Radialis pure sensorik, teraba di dorsal wrist sisi radialis
7. N. Common peroneal, teraba di head fibula menyebabkan foot drop
8. N. Tibialis Posterior, di bag belakang malleolus medialis otot intrinsik kaki
menyebabkan claw toe
9. N. Suralispure sensorik, 10 cm diatas malleolus lateralis

Tipe basil:

Pauci basillertidak terlalu menular, basil terlokalisasi di area syaraf perifer, deformitas >>

Multibasiller sangat menular, imunitas rendah

Medication: triple drugDapson, lamprene dan Rifampisin diminum 6 bulan

Disabilitas:
  Basil lepra mengeluarkan toxin: Reaksi I : Reversal Reactionneuritis diberikan
KS 6 bulan

Reaksi II: Eritema nodosum Leprosumkemerahan

dan sangat menular

Imbalance flexor dan ekstensor ekstrinsik yang menyebabkan terjadinya hiperekstensi MCP
dan fleksi PIP dan DIP dan penyeimbangnya adalah intrinsik muscle

Anamnesis:

Keluhan Utama: tidak dapat meluruskan tangan dan kakinya nyeret (can’t lift up his foot)

RPS: sejak kapan, apakah ada nyeri, joint stiffness, swelling, wound, numbness, dry skin, gg
penglihatan, fungsional/ADL (eating, dressing, grooming, toileting), pekerjaan (writing,
lifting or carrying), saat berjalan (dragging), riw. Pengobatan

RPD: DM

PEMERIKSAAN FISik

Kesadaran, vital sign, status nutrisi (IMT)

Cari makula anestesia di punggung bawah

Regio Facialis:

L : facies leonina : madarosis, saddle nose; makula hipopigmentasi; lagoftalmus; tanda-tanda

keratitis

F : nerve thickening, sensibility trigeminal nerve

M : MMT orbicularis oculi

corneal reflex, jaw reflex

Regio UE:

L : makula, dryness, mutilasi, tanda2 inflamasi, atrofi, deformitas

F : nerve thickening, sensibility,

M : ROM, MMT n. ulnaris (abd & flexor dig minimi), n. medianus (abd pollicis brevis), n.
radialis (ekstensor wrist)

Special test:
Froment sign : sign of adduktor pollicis weakness caused by ulnar nerve palsy, Adduktor
pollicis : n. ulnaris, Fleksor pollicis brevis : n. medianus + n. ulnaris  menjepit kertas dg
fleksi thumb.

Regio LE:

L: macula, ulcus plantaris, deformitas (claw toe, drop foot)

F: Nerve thickening, sensoris

M: ROM, MMT dorsifleksi, plantar fleksi

Refleks fisiologis refleks patologis proprioception

Gait: steppage gait

Sensorik

Tangan

1. Thenar eminance
2. Pulp of thumb
3. Pulp of index finger
4. Pulp of little finger
5. Palmar/dorsal

Kaki

1. Pad of big toe

2. Ball of the foot (medial)
3. Ball of the foot (lateral)
4. Instep
5. Centre of the heel

Impairment:

Facial disfigurement

Nerve damage

Eye damage

Personality disorder

Secondary impairment:

Ulcer

Shortening of finger and toe

Contracture

Bone destruction

Disabilitas:

Manual dexterity

Personal care

Mobility

Communication?

Behaviour

Handicap:

Unemployment

Economic dependent

Physical dependent

social integration

Treatment

- Untuk mencegah kebutaan: kedip pasif dibantu tangan

- Mata kering: dikasih air mata buatan/ air matang
- SOS : save our soles/skin: soaking, oiling and scrapping (digosok dengan batu
apung/sikat gigi)
- OT : sensory stimulation using green bean, corn, rice
meningkatkan ROM & kekuatan otot intrinsik (latihan meremas lilin malam)
- OP : knuckle bender is a dynamic MCP flexion mobilization orthoses (claw hand), AFO
plantarfleksi 90 stop (drop foot)
- Jangan lupakan masalah pekerjaan (hindari ngangkat berat), masalah psikososial (konsul
psikolog)

Down Syndrome (Trisomi 21)

IQ :

- 20-25 : sangat berat

- 25-40 : berat (mampu rawat)

-40-54 : sedang (mampu latih)

-55-70 : ringan (mampu didik)

Halls ten sign in newborns:

1. Poor moro reflex

2. Hypotonia
3. Flat facial profile
4. Upward slenting palpebra fissures
5. Morphologically simple, small round ears
6. Redundant loose neck skin
7. Single palmar crease
8. Hyperextensible large joints
9. Pelvis radiograph morphologically abnormal
10. Hypoplasia of fifth finger middle phalanx

GDD

global delay development diartikan sebagai keterlambatan pada lebih dari satu sektor
perkembangan, sehingga mengakibatkan penurunan pada kualitas hidup.

DMD

Ciri-ciri:

1. The first 5 years of life

2. X-linked resesif  manifestasi pada laki (perempuan carrier) , sama seperti Becker
3. Mekanisme : defisiensi dystropin (protein di plasma membran)  mengganggu
membran sitoskeleton  kegagalan regenerasi serabut otot & replacement dengan
jar. Fibrotik
4. Kelemahan proksimal lebih dahulu
a. Di dahului pelvic girdle, baru shoulder girdle
b. DF<<PF, evertion<<invertion, knee ext<<knee flex, hip ext<<hip flex, hip
abd<<hip add
5. Meryon’s slip sign  anak tergelincir dari pegangan pemeriksa saat anak diangkat di
bawah lengan  kelemahan stabilisasi scapula
Reaching test  kelemahan UE
6. Rapid Progression
7. Penyakit penyerta :
a. Peny. Paru restriktif  chest exp
 b. Skoliosis
c. Abnormal jantung
d. IQ < 75 ( krn dystrophin juga ditemukan di otak)
8. Penunjang
a. CK meningkat (300-400x dari Normal)
b. EMG : fibrilasi dan positive sharp wave saat istrhat
Motor unit : durasi pendek, amplitudo rendah, polifasik
c. Biopsi otot : gambaran jar. Fibrosis dengan serabut sirkuler
9. Prinsip Rehab :
a. Mempertahankan status ambulasi yang lebih baik selama mungkin
b. Mencegah komplikasi

Identitas

Keluhan utama : sulit bangkit dari duduk

RPS :

- KU sejak kapan ? Bangkit dengan menopang pada kedua tangan

- Kelemahan kaki/tangan sejak kapan ? Proksimal lebih berat

- LE  Pola jalan : (rocking , side to side, waddling gait, tip toe, wide base) , jatuh tanpa
sebab,

episodic weakness, fatigue or decrease endurance, muscle cramps

- UE  Felt weakness since?

- Large calves, lumbar lordosis

- Aktifitas : jalan, lompat, lari, naik tangga  bisa? Cepat lelah?

Fine motor

-Feeding & repiratory difficulties, speech problem , nutrisi

- Sering keram

- Bila tidak bisa jalan , apakah perlu bantuan

RPD :

- Delay in motor milestones

- Floppy baby
- Pre, peri,post Natal
- Lahir spontan, aterm, BB, lgsg nangis
RPK:

Riw. Psikososek :

- Caregiver ??
- Pekerjaan ortu
- Lingk. Rumah
- Pembiayaan kesehatan

PF :

Pasien tidur di matras

- Vital sign , BB, TB

- Status generalis : jantung, paru ( inspeksi  otot bantu pernapasan, chest ekspansi),
komunikasispeech, feeding swallowing difficulties
- Status Muskuloskeletal :
UE : L = Atrofi, pseudohipertrofi, deformitas
F = Ukur pseudohipertrofi di deltoid ( diameter muscle belly) dx&sin, sensory deficit
+/-?
M=ROM : anak angkat tangan
MMT: proksimal lebih lemah
RF, RP ?
LE : L = Atrofi gluteus maksimal, pseudohipertrofi, deformitas
F = ukur pseudohipertrofi calves muscle ( diameter below MTP) dx&sin, sensory
deficit +/-?
M=ROM
MMT: proksimal lebih lemah, hip fleksi/ekstensi
RF, RP ?

Pasien diminta duduk  lihat cara pasien duduk

1. Sitting balance
2. N. Fascialis  Gerakan TMJ, otot-otot pengunyah dan wajah
3. Thorax expansi
4. Fungsi2 :
a. Bicara : ajak ngomong  artikulasi, pergerakan rahang endurance
b. Swallowing : drooling, tonus otot2 wajah
c. Komunikasi : reseptif dan ekspresif

Special test : Meryon slip test, reaching test

Pasien diminta berdiri  lihat cara berdiri :

- Gower Sign ? Trendelenberg?

- Postur : asimetri?atrofi? hiperlordosis lumbal? skoliosis
- Gait: independent/dependent ambulation, waddling gait,walk on toes, gluteus medius
lurch, wide base(ukur lebarnya)

Pem. Penunjang :

- CK (> 10.000) DD/ Becker 20-80% dari Normal

- EMG : myopathies
- Muscle biopsy
- IQ?

Medical D/ : Duchene’s muscular dystrophy (early stage)

Functional D/:

Impairment : muscular dystrophy

Disability : stair, hopping, jumping, walking, running

Handicap : playing with friend, sport school

Masalah :

- Nutrisi
- Fungsi kardiorespirasi
- 4 domain  ADL
- Sekolah, play  sosial

Goal :

1. Meningkatkan atau mempertahankan status gizi anak  diet TKTP

2. Mempertahankan kekuatan otot  lat. Penguatan otot
3. Meningkatkan ketahanan kardiorespirasi (lat. Aerobik)  berenang , sepeda
4. ADL mandiri
5. Sekolah dan bermain
6. Mencegah komplikasi : kontraktur, skoliosis, fungsi respirasi

Edukasi ortu : u/ bantuan ADL, tetap sekolah & bermain

List of problems

1. Medical problem : DMD early stage

2. Rehab problem (versi UNAIR)  disusun berdasarkan priority
a. Ambulation : waddling gait, frequent falll
b. ADL : difficulty in toileting, squatting
c. Communication
d. Psychological :
e. Sosec : health insurance
f. Vocational : playing , sport school
g. Others : weakness, fatigue