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CEREBRAL

PALSY
Rizky Rafiqoh Afdin-G1A217097
Annisa Puja Ikrima-G1A217098

Dosen Pembimbing:
dr. Juli Hartati, Sp.KFR

KEPANITERAAN KLINIK SENIOR


BAGIAN REHABILITASI MEDIK RSUD RADEN MATTAHER
JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS JAMBI
2019
Cerebral Palsy

01Penyebab paling umum timbulnya cacat fisik seumur hidup


di sebagian besar negara

02Mempengaruhi sekitar 1 dari 500 neonatus, dengan


prevalensi 17 juta orang di seluruh dunia

Manifestasi klinis cerebral palsy sangat bervariasi pada


03kelainan gerakan,kemampuan dan keterbatasan fungsional
dan bagian tubuh yang terkena.

04There is currently no cure, but progress is being made in


both the prevention and the amelioration of the brain injury

Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s Hospital. 2016.
Definisi Cerebral Palsy

Cerebral Palsy

Cerebral palsy (CP) adalah gangguan yang memengaruhi kemampuan seseorang


untuk bergerak dan mempertahankan keseimbangan dan postur. CP adalah
kecacatan motorik yang paling umum di masa kecil. Kelainan gerak dan postur akibat
lesi otak yang immature.

Source: Centers for Disease Control and Prevention- Cerebral Palsy


EPIDEMIOLOGI

Cerebral palsy adalah kecacatan motorik yang


paling umum terjadi pada anak-anak

Australia dan Eropa, secara historis prevalensi


cerebral palsy mulai dari 1,5 hingga 2,5 per 1.000
kelahiran hidup
Studi terbaru di Amerika Serikat, Taiwan dan Mesir telah
menemukan tingkat prevalensi di atas 3 per 1.000
kelahiran hidup pada orang usia 4-48 tahun.

Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s Hospital. 2016.
KEMAMPUAN MOTORIK KASAR
The Gross Motor Function Classification System (GMFCS)
Sistem Klasifikasi Fungsional Motorik Kasar (GMFCS) Oleh CanChild di Kanada

GMFCS level I GMFCS level II GMFCS level III


 Anak-anak  Menaiki tangga sambil
berjalan di  Berjalan menggunakan
rumah, sekolah, di luar memegang ke pengaman.
 Kesulitan berjalan jarak perangkat mobilitas genggam.
rumah.
 Bisa menaiki tangga tanpa jauh tidak seimbang pada  Menggunakan mobilitas roda
pengaman. permukaanyang tidak saat bepergian jarak jauh dan
 Berlari dan melompat, tetapi rata.
dapat mendorong diri sendiri
 Memiliki kemampuan
kecepatan, keseimbangan
minimal untuk berlari dan untuk jarak yang lebih
dan koordinasi terbatas
melompat. pendek.
Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s Hospital. 2016.
KEMAMPUAN MOTORIK KASAR

Sistem Klasifikasi Fungsional Motorik Kasar (GMFCS) Oleh CanChild di Kanada

GMFCS level IV GMFCS level V


 Menggunakan metode mobilitas yang  Anak-anak diangkut dengan kursi
memerlukan bantuan fisik.
 Mereka dapat berjalan jarak dekat di roda manual di semua pengaturan.
rumah dengan bantuan fisik atau  Anak-anak terbatas dalam
menggunakan mobilitas bertenaga atau
alat bantu tubuh ketika diposisikan. kemampuan mereka untuk
 Di sekolah, di luar rumah dan di
mempertahankan postur
komunitas anak-anak diangkut dengan
kursi roda manual atau menggunakan antigravitasi kepala dan badan dan
mobilitas bertenaga. mengendalikan gerakan kaki dan
lengan Hospital. 2016.
Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s
Types of cerebral palsy Based on Topographical description in
cerebral palsy: unilateral and bilateral cerebral palsy

Based on affected region:


•Monoplegia : affects one limb,
usually an arm
•Hemiplegia : affects one side of the
body including arm, leg, and trunk
•Diplegia : affects either both the legs
or both the arms
•Quadriplegia : affects all four limbs,
and trunk muscle

Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s Hospital. 2016.
Types of cerebral palsy Based on Clinical Presentation

Spastic cerebral Dyskinetic


palsy Cerebral Palsy
01
02
includes athetoid, choreoathetoid, and
dystonic cerebral palsies
 have problems controlling the
 Spastic CP affects about 80% of people with CP movement of their hands, arms, feet,
 Increased muscle tone and legs, making it difficult to sit and
 Their muscles are stiff and can be awkward walk
 The movements are uncontrollable
and can be slow and writhing or rapid
and jerky
 Sometimes the face and tongue are
affected and the person has a hard
time sucking, swallowing, and
talking.
 A person with dyskinetic CP has
muscle tone that can change
Types of cerebral palsy Based on Clinical Presentation

Ataxic Cerebral Mixed


Palsy 03 Cerebral Palsy
04
 People with ataxic CP have  Some people have symptoms of more
problems with balance and than one type of CP.
coordination  The most common type of mixed CP
 Unsteady when they walk is spastic-dyskinetic CP.
 They might have a hard time with
quick movements or movements
that need a lot of control, like
writing. 
 They might have a hard time
controlling their hands or arms
when they reach for something.
TIPE MOTORIK

Source: Worldcpday. org


Classification based on muscle tone

Hypertonic cerebral palsy

Hypertonic atau hypertonia mengacu pada tonus


otot yang abnormal tinggi, yang menciptakan
kekakuan dan rigiditas otot. Cerebral palsy
spastik ditandai dengan hipertonus.

Hypotonic cerebral palsy


Hipotonik atau hipotonia mengacu pada
tonus otot rendah yang abnormal. Gejala
hipotonia termasuk kelemahan. Bentuk
cerebral palsy non-spastik (ataksik,
diskinetik, dan cerebral palsy athetoid)
ditandai oleh hipotonia.
Risks of CP During Pregnancy Risks of CP During Birth

 Bacterial and viral infections  Loss of oxygen to the infant brain


 Maternal blood clotting  Breech birth (baby being delivered feet or
 German measles (rubella) rear end first)
 Maternal bleeding in later weeks of pregnancy  Premature birth (a child is born before start
 Exposure to toxins (mercury from raw fish, of 37th week of pregnancy)
undercooked/raw meat, cat feces)  Low birth weight (less than 5 pounds, 7.5
 Maternal thyroid problems ounces)
 Incompatible blood type between mother and  Inability of placenta to provide nutrients and
fetus oxygen
 Maternal seizures  The use of vacuum extractors of forceps

Source: cerebralpalsyguide.com
Risks Of CP After Birth

 Severe jaundice
 Infections
 Vascular problems shortly after
birth
 Lack of oxygen (asphyxiation)
 Head trauma

Source: cerebralpalsyguide.com
Screening and Diagnosis of Cerebral Palsy

Developmental Developmental Developmental and Medical


Monitoring Screening Evaluations
WHO:     Parents, grandparents, other WHO:     Healthcare provider, early childhood WHO:     Developmental pediatrician, child
caregivers teacher, or other trained provider psychologist, or other trained provider
WHAT:   Look for developmental WHAT:   Look for developmental milestones WHAT:   Identify and diagnose
milestones WHEN:   At 9, 18, and 24 or 30 months, or developmental delays and conditions
WHEN:   From birth to 5 years whenever there is a concern WHEN:   Whenever there is a concern
WHY:      To help you WHY:      To find out WHY:      To find out
•celebrate your child’s development •if your child needs more help with development, •if your child needs specific treatment
•talk about your child’s progress with because it is not always obvious to doctors, •if your child qualifies for early intervention
doctors and childcare providers childcare providers, or parents HOW:     With a detailed examination,
•learn what to expect next •if a developmental evaluation is recommended formal assessment tools, observation, and
•identify any concerns early HOW:     With a formal, validated screening tool checklists from parents and other caregivers,
HOW:     With easy cdc milestones often in combination, depending on the area
of concern

Source: Centers for Disease Control and Prevention- Cerebral Palsy


CDC’s Developmental Milestones
DENVER
Structural changes observed in muscle of children with
cerebral palsy compared with typically developing children

Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s Hospital. 2016.
Movement disorders in cerebral palsy

Source: Graham H Kerr, et all. Cerebral Palsy. Orthopaedic Department, The Royal Children’s Hospital. 2016.
LANGKAH-LANGKAH MENEGAKKAN DIAGNOSIS CEREBRAL PALSY
DIAGNOSIS

 Tanda awal Cerebral palsy biasanya tampak pada usia < 3


tahun, dan orang tua sering mencurigai ketika kemampuan
perkembangan motorik tidak normal.

 Untuk menetapkan diagnosis Cerebral palsy diperlukan


beberapa kali pemeriksaan, harus dipastikan bahwa proses
gangguan otak tersebut tidak progresif
DIAGNOSIS
 Kriteria Levine dapat digunakan dalam membuat diagnosis Cerebral
palsy usia > 1 tahun:
 Kelainan pola gerak dan postur
 Kelainan pola gerak oral
 Strabismus
 Kelainan tonus otot
 Kelainan evolusi reaksi postural dan tahap perkembangan
 Kelainan refleks tendon, refleks primitif, dan refleks plantar

 Diagnosis Cerebral palsy ditegakkan jika minimum terdapat 4


abnormalitas dari 6 kriteria di atas. Bila hanya memenuhi satu kriteria
belum dapat dikatakan CP, namun dikatakan kecurigaan CP.
PEMERIKSAAN FISIK NEUROLOGIS

A Status Mental

B Penglihatan dan Pendengaran

C Kekuatan otot dan kontrol motorik

D Refleksdan Tonus Otot dan Gerakan Involunter


Pemeriksaan Muskuloskeletal

Penilaian tulang
Range Of Motion belakang

01 02

Pelvic Obliquity &


Penilaian Hip,
Perbedaaan Panjang
Tungkai 04 03 lutut dan kaki
Pemeriksaan Fungsional

3
Mobilitas

1
2

Duduk Keseimbangan
Manual Ability Classification System (MACS) Communication Function Classification System (CFCS)

•MACS Level I: Children handle objects with ease. •CFCS Level I: The person can effectively send and
•MACS Level II: Children largely handle objects receive communicative information with unfamiliar
successfully, but with compromised speed or and familiar partners.
quality. •CFCS Level II: The person effectively, but slowly,
•MACS Level III: Children experience difficulty sends and receives communication information with
handling objects and often require help. both unfamiliar and familiar partners. 
•MACS Level IV: Children can handle certain •CFCS Level III: The person is usually able to
objects (with difficulty), but require extensive help effectively send and receive communication
from others. information with familiar partners, but may struggle to
•MACS Level V: Children have extremely limited communicate with unfamiliar partners.
ability to perform manual activities. •CFCS Level IV: The person inconsistently sends and
receives communication information with familiar
partners, and rarely can communicate with unfamiliar
partners.
•CFCS Level V: The person rarely communicates
effectively, even with familiar people.
PEMERIKSAAN PENUNJANG

Radiologis
Ultrasonography (USG) kranial
Computed Tomography (CT) Otak
Magnetic Resonance Imaging (MRI) Kranial
Electroencephalography (EEG)
Diagnosa Banding
PENATALAKSANAAN
CEREBRAL PALSY

Physical therapy and rehabilitation


•Occupational therapy. This type of
therapy helps a child learn to do everyday
activities such as dressing and going to
school.
•Recreational therapy. Participating in
art programs, cultural activities, and
sports can help improve a child’s physical
and intellectual skills.
•Speech and language therapy. A speech
therapist can help a child learn to speak
more clearly, help with swallowing
problems, and teach new ways to
communicate, such as by using sign
language or a special communication
device.
Orthotic devices
Pemberian bracing pada penderita
Cerebral palsy bertujuan untuk
mengurangi beban aksial, menjaga
stabilitas, memperbaiki postur tubuh,
pencegahan dan koreksi deformitas serta
memposisikan anggota gerak dalam posisi
yang lebih fungsional.
AFO untuk mencegah plantarfleksi
meningkatkan stabilitas saat berdiri dan
berjalan, menempatkan kaki pada posisi
yang tepat dan menjaga clearance saat fase
swing sehingga mengurangi penggunaan
energi dan meningkatkan panjang langkah
dan kecepatan berjalan
Assistive devices and technologies

These include special computer-based


communication machines, Velcro-
fastened shoes, or crutches, which can
help make daily life easier.
Vojta

Bobaths
Pengelolaan Medis
 Medikasi untuk mengurangi spastisitas
digunakan pada anak-anak,
 Baclofen (Lioresal) dan Dantrolen
(Dantrium)
 Penilaian kembali spastisitas pada anak
CP yang sedang tumbuh setiap 6 bulan
sekali
 >> botox
SURGERY
Preventing CP

Before Pregnancy

Be as healthy as possible before pregnancy, Vaksinasi

During Pregnancy

Pelajari cara memiliki kehamilan yang sehat, ANC, cuci tangan,


Hubungi dokter jika sakit, demam, atau memiliki tanda-tanda
infeksi lain selama kehamilan
After the Baby is
Born
Pelajari cara menjaga bayi tetap sehat dan aman setelah lahir, harus
diperiksa untuk penyakit kuning di rumah sakit dan lagi dalam waktu 48
jam setelah meninggalkan rumah sakit, divaksinasi, cegah cedera
PROGNOSIS
Jumlah orang dewasa dengan cerebral palsy meningkat
karena meningkatnya kelangsungan hidup bayi berat lahir
rendah dan peningkatan umur populasi. Mobilitas orang
dewasa dan kemampuan untuk melakukan aktivitas
kehidupan sehari-hari harus dipantau secara rutin seiring
bertambahnya usia pasien.
THANK YOU