Cerebral Palsy

Rehabilitation: How to
Optimized
LUH KARUNIA WAHYUNI
Anak Palsi Serebral
Palsi Serebral
Gangguan kontrol postur & gerakan
• Hilangnya kontrol otot selektif
• Ketergantungan pada pola refleks primitif
• Tonus otot abnormal
• Ketidakseimbangan kerja antara otot
agonis & antagonis
Lesi pada otak yang • Reaksi ekuilibrium dan proteksi yang tidak
imatur optimal
Non-progresif
Ensefalopati statik
PS Anak PS Dewasa
Cerebral Palsy …..

Non-progressive lesion -- but the results or impairments do change

Primary impairments : immediately and directly a result of the lesion
Secondary impairments : develop in systems or organs over time because the
effects of primary impairments -- can progressively influence movement
Pola Gerakan Atipikal pada Palsi
Serebral
•paresis
•ko-aktivasi otot yang rendah
•tonus otot abnormal (spastisitas atau
hipotonus atau fluktuatif)
•gerakan didominansi oleh refleks primitif,
atau gerak involunter
Distribusi Gangguan Gerak pada PS
Hemiplegia 35,6 %

Diplegia 33,7 %
Spastic
Quadriplegia 7,9 %

All spastic 77,2 %

Dyskinetic (dystonia/athetoid) 12,5 %

Ataxia 8,9 %

All non- spastic 22,8 %

Gangguan Kontrol Postur & Gerak
Fungsi
Fungsi Fungsi
Fungsi oromotor
motorik motorik
respirasi dan
kasar halus
menelan

• Gangguan mobilisasi & ambulasi

• Gangguan biomekanik respirasi
• Kesulitan makan
• Gangguan fungsi komunikasi
• Gangguan aktivitas kehidupan sehari-hari
(regulasi diri, bermain, sosialisasi)
Sensory / Perceptual System
•Visual problem (myopia & retinal detachment, strabismus, refractive errors, visual
perceptual dysfunction)
•Difficulty with visual fixation, tracking, and saccadic movements
•Secondary impairments -- uses extension pattern -- eye extension – upward gaze
•Less of visual awareness of self in relationship to the environment
•Problems in the threshold for sensory feedback, sensory processing impairments -
-- proprioceptive, tactile, and vestibular functioning
Swallowing process
Saliva Control in Individuals
with Cerebral Palsy
Drooling -- the abnormal, unintentional spilling of saliva from the mouth onto the
lips, chin, neck, clothing, and environmental objects (Arvedson and Brodsky,
2002)
It is estimated that 10-16% individuals with CP demonstrate drooling
Drooling can cause many problems from socialization issue (loss of self esteem)
to health issue (irritation of infection of skin around the mouth, dehydration)
Causes of drooling relating to swallow difficulty, oral structure problem, medical/
dental status, postural control problem, nasal obstruction, intraoral sensory
awareness
•90% CP demonstrated variable degree of GER
•Drvaric DM, Roberts JM, Burke SW.
•Gastrooesophagea evaluation in tottaly involve CP
•patients. J Ped Orthoped 1987; 7(2): 187-190

•Postural abnormalities and/or

spasticity in abdominal muscles

Abdominal compressions

Increased intra-abdominal pressure

The Causative Factors of the Respiratory Problem in
Cerebral Palsy

•Recurrent aspiration  dysphagia and

GER
•Ineffective cough
•Restrictive lung disease
•Immobility  cognitive impairment
•Poor nasopharyngeal motor tone 
upper-airway obstruction and OSAS
Highlight ....

Neurological impairment .... Delayed development (postural control inadequate) ....... Recurrent
cough (aspiration) .... Undernutrition !!!!!

Clinical response must take account of the child’s

prognosis, level of understanding, QOL, and wishes
Hypotonic Cerebral Palsy

•Low tone, poor postural control

•Kypotic -- the expansion of the anterior
portion of the chest is limited
•Belly breathing pattern
•Ribcages – elevated and flattening
anterior-posteriorly

Inadequate force or holding stability to build enough

pressure to effectively clear mucous
Hypertonic Cerebral Palsy

•Too much stability

•Immobile ribcage during inspiration and
expiration
•Elevated ribcage with horizontallly
positioned ribs
•Depend on compensatory fixing to
maintain trunk posture
Language Development
in Individuals with Cerebral Palsy
Receptive and expressive language disorders -- because the lesion that cause CP
rarely focal -- associated conditions such as mental retardation and language
deficits are commonly reported
Difficulty in interacting, resulting from:
• Parents is not able to interpret the child’s signal
• Child reduce ability to imitate communication
• Lack of ability to explore and interact with the environment and object -- restrict development intent,
vocabulary, and concept development
Dysarthrias of CP
The most characteristic & frequently occurring speech disorder in CP (Hardy,
1983; Hodge & Wellman, 1999)
Definition (Darley, Aronson & Brown, 1975):
• “A group of speech disorders due to disturbances in muscular control of the speech mechanism resulting
from impairment of any basic motor processes involved in the execution of speech”

Secondary to abnormal muscle tone, coordination, strength, endurance of the

speech musculature
Affect range of motion, speed, force, timing & accuracy of movement (Duffy,
1995)
 Impact of
abnormal muscle Lack of variety of
Impact of gravity on a contractions on movements that
body that is poorly growth and children with cerebral
aligned and moves change of bones palsy make, including
abnormally weight bearing postures

The impairment in
bony structure in
cerebral palsy are
usually secondary

Musculoskeletal System
Cerebral Palsy ......
The newborn child with cerebral palsy
usually has no deformities or
musculoskeletal abnormalities at birth.
Scoliosis, dislocation of the hip , torsion
of long bones, joint instability ,
premature degenerative changes in
weight-bearing joints and fixed
contractures develop during the rapid
growth of childhood
Effects of Spasticity on Bones
•Scoliosis
•Foot deformities (planovalgus or
equinovarus)
•Bunions
•Knee , elbow, shoulder and wrist joint
contractures
•Torsional mal-alignment of the femur
and tibia
•Dislocated hips
Tujuan Rehabilitasi Medik Palsi Serebral
Pencapaian kemampuan anak yang optimal
◦ Berkomunikasi
◦ Mobilisasi dan ambulasi
◦ Melakukan aktifitas kehidupan sehari-hari
◦ Bermain
◦ Bersekolah

Mencegah atau mengatasi komplikasi sekunder

(persepsi-kognisi, aspirasi, GER, obstipasi, nyeri, muskuloskeletal)
Prognosis Fungsional
Diagnosis palsi serebral yang sama
belum tentu dengan prognosis
fungsional yang sama

Prognosis fungsi adalah prognosis

untuk komunikasi, makan, mobilisasi
ambulasi, bermain dan bersekolah
Tatalaksana Fungsional
Target goal yang dapat dicapai oleh anak (jangka pendek dan jangka
panjang)....optimal !!
Seluruh tim yang terlibat dalam tatalaksana memiliki persepsi yang sama (dokter,
psikolog, terapis, guru, orangtua dan keluarga)
KOMUNIKASI antar anggota tim....!!
Keterlibatan orangtua
CP Management Priority

1st Decade Function

2nd Decade Appearance

3rd Decade &

Pain
subsequent
Graham , H.K, Selber P . Musculoskeletal aspects of cerebral palsy. J Bone Joint Surg
[Br] 2003;85-B:157-66
Tatalaksana Rehabilitasi Medik Pada Palsi
Serebral
Latihan peregangan otot Latihan aktivitas fungsional
Latihan penguatan Latihan bicara dan bahasa (mis.
augmentative & alternative
Hidroterapi, hipnoterapi communication)
Sensori integrasi Casting, Ortosis (AFO, KAFO), sepatu,
Terapi neurodevelopmental alat bantu fungsional
Modalitas (Electrical Stimulation / ES, Terapi medikamentosa (injeksi toksin
Ultrasound / US) botulinum A, antispastisitas per oral)

Peresepan yang jelas

indikasi, jenis, durasi, intensitas, integrasi terapi
Latihan Peregangan Otot
Tujuan  mencegah komplikasi kontraktur

Kontraktur  mengganggu kegiatan fungsional &

kebutuhan perawatan (berpakaian, mandi, toileting)

Latihan peregangan otot memperhatikan posisi, rentang

waktu & frekuensi latihan, cara melakukan latihan

Ortotik, bidai, casting

Latihan Penguatan Otot
Kelemahan otot merupakan kontributor utama defisit
fungsional pada palsi serebral

Latihan penguatan otot pada anak palsi serebral

selama 6-8 minggu secara potensial dapat
meningkatkan kekuatan otot
Sepatu & Ortosis
Peralatan Adaptif
• Meningkatkan kontrol
gerakan pada posisi telentang,
mobilisasi & ambulasi
• Meningkatkan fungsi
(misalnya perawatan diri)
Kesimpulan
Palsi serebral bukanlah kondisi yang progresif

Manifestasi palsi serebral dapat berubah dari waktu ke waktu

Pendekatan menyeluruh dari berbagai disiplin ilmu sangat penting, sehingga

tujuan dari penatalaksanaan palsi serebral dapat tercapai dengan optimal

Keterlibtan orangtua dan keluarga pada rangkaian tatalaksana sangat

penting
TERIMA KASIH!!