7.25 Cerebral Palsy 1

8/13/2019 7.25 Cerebral Palsy 1

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CEREBRAL PALSY

dr Jalila Zamzam,Sp.A

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Cerebral Palsy: Definition

Cerebral palsy is a static encephalopathy

Encephalopathy = Brain Injurythat is non-

progressivedisorder of posture and movement

Variable etiologies

Often associated with epilepsy, speech problems,

vision compromise, & cognitive dysfunction

Resulting from defect or lesion of the developingbrain

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Cerebral Palsy: Prevalence

2-4/1000; 7-10,000 new babies each yr

150 years ago described by Dr. Little anorthopedic surgeon and known as Littles

Disease During past 3 decades considerable advances

made in obstetric & neonatal care, butunfortunately there has been virtually no

change in incident of CP

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Cerebral Palsy:

Clinical Presentation

Remember that motor developmental

progression is from.

Head to Toe, (jari kaki)

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Cerebral Palsy: Classification

Various classifications of Cerebral Palsy

Physiologic

Topographic

Etiologic

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Cerebral Palsy: Physiologic

Athetoid

Ataxic

Rigid(kaku)-Spastic

Atonic

Mixed

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Cerebral Palsy: Topographic

Monoplegic

Paraplegic

Hemiplegic

Triplegic

Quadraplegic

Diplegic

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Cerebral Palsy: Etiologic

Prenatal (70%)Infection, anoxia, toxic, vascular, Rh disease,genetic, congenital malformation of brain

Natal (5-10%)Anoxia, traumatic delivery, metabolic

Post natalTrauma, infection, toxic

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The following maternal and prenatal risk

factors statistically correlate with CP:9

Long menstrual cycle (siklus mens pnjg)

Previous pregnancy loss (kehamilan sblmx)

Previous loss of newborn (kematian bayi sblmx)

Maternal mental retardation Maternal thyroid disorder, especially iodine

deficiency

Maternal seizure disorder (kejang pd ibu)

History of delivering a child weighing less than2000 g (sblmx BBLR)

History of delivering a child with a motor deficit,mental retardation, or a sensory deficit (sblmx

klhiran cacat)


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The following factors during pregnancy also

correlate statistically with CP:

Polyhydramnios

Treatment of the mother with thyroid hormone

Treatment of the mother with estrogen orprogesterone

Maternal seizure disorder Maternal severe proteinuria or high blood pressure

Maternal methyl mercury exposure (keracunanMercuri)

Congenital malformations in the fetus Male sex of fetus

Bleeding in third trimester (perdarahan)

Intrauterine growth retardation (IUGR)

Multiple gestation

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The following perinatal factors are

associated with an increased risk of CP:11

Prematurity

Chorioamnionitis

Nonvertex and face presentation of the fetus

Birth asphyxia


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The following postnatal factors may

contribute to CP:12

Infections (eg, meningitis, encephalitis)

Intracranial hemorrhage (eg, due to

prematurity, vascular malformations, or

trauma)

Periventricular leukomalacia (in premature

infants)

Hypoxia-ischemia (eg, from meconiumaspiration)

Persistent fetal circulation or persistent

pulmonary hypertension of the newborn


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Diagnosis Observation of slow motor development Abnormal muscle tone

Unusual posture (postur y tak sesuai)

Presence of persistent infantile reflexes

Ruling out of progressive hereditaryneurologic/metabolic disorder

Targeted lab tests, cerebral imaging (e.g. MRI),

ultrasound (brain lesions, abnormalities) Presence of associated disabilities: hearing &

vision impairment, seizures, perceptionproblems with touch or pain, cognitive

dysfunction


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Cerebral Palsy: Complications

Gastrointestinal and nutritional

Failure to thrive due to feeding and swallowing difficultiessecondary to poor oromotor control

Obesity, less frequently than failure to thrive

Gastroesophageal reflux and associated aspiration pneumonia

Constipation (diare)

Dental caries (karang)

Respiratory

Increased risk of aspiration pneumonia because of oromotor

dysfunction Chronic lung disease/bronchopulmonary dysplasia

Bronchiolitis/asthma

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Skin

Decubitus ulcers and sores

Orthopedic

Contractures Hip dislocation

Scoliosis

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Neurologic

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Epilepsy: Epilepsy occurs in 15-60% of childrenwith CP and is more common in patients withspastic quadriplegia or mental retardation.

Hearing loss: This occurs particularly in patientswho had acute bilirubin encephalopathy(kernicterus).

Vision: Visual acuity decreases in premature

infants because of retinopathy of prematurity withhypervascularization and possible retinaldetachment.

Visual-field abnormalities due to cortical injury

Strabismus


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Cognitive/psychological/behavioral

Mental retardation (30-50%)

Attention-deficit/hyperactivity disorder

Learning disabilities

Impact on academic performance and self-esteem

Increased prevalence of depression

Sensory integration difficulties Increased prevalence of progressive

development disorder or autism associatedwith concurrent diagnosis of CP

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Management No cure (tdk ada pengobatan)

Goals: increase functionality, improvecapabilities and sustain health in terms of

locomotion, cognitive development, socialinteraction and independence

Early, intensive, team-based management holistic approach(pendekatan), not just onesymptom (gejala)

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Treatment1. Global Strategies- Common neurodevelopmental Tx that aims to

provide immediate improvement in dynamic range ofmotion

-Conductive education: Emphasizes an integratedmodel of education & rehabilitation

2. Physical Therapy-muscle strengthening, fitness programs

3. Medications-Botulinum toxin (Botox):produces a protein that blocksthe release of acetylcholine/relaxes muscles (can alsoreduce drooling when injected into salivary glands)


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Treatment cont.)3. Medications

-Baclofen (Lioresal): can provide pain and spasm relief,improved sleep, ease of care; however, manycomplications (e.g. headache, vomiting(muntah),seizures)

4. Surgical Treatments

-Selective dorsal rhizotomy: selective cutting of dorsalrootlets from spinal cord segments; intended tominimize/eliminate spasticity; some complications

-Hip reconstruction/repair (due to muscle imbalance,incidence of hip dislocation in children with CP as highas 59%)

5. External Aids (Orthoses)


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Cerebral Palsy

What is

substantially

disablingCerebral Palsy?

Mobility

Communication

Learning

Self Care

Self Direction

Independent Living

Economic Sufficiency


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Dr.Jalila Zamzam,SpA

7.25 Cerebral Palsy 1

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