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Transcript of Pp. Paraplegia.def
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PARAPLEGIA
Vanda I.C. SumilatAnsharSyukur
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PENGERTIANSuatu gangguan fungsi motorik dan/atau sensorik pada ekstremitas bawah (www.wikipedia.org)
Kelumpuhan sebagian atau komplit pada ekstremitas bawah dan trunk akibat cedera medulla spinalis segmen thoraco-lumbo-sacral (Setiawan, 2006)
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Complete
•Hilangnya fungsi sensorik&motorik hingga segmen sacral yang terbawah
Incomplete
•Hilangnya sebagian fungsi sensorik&motorik di bawah level cedera termasuk hingga segmen cervical terbawah
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Medulla Spinalis
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MEDULLA SPINALIS
Bagian dari CNS, terletak 2/3 bagian atas canalis vertebralis
Panjangnya pada pria sekitar 45 cm, wanita 42-43 cm
Berbentuk Silindris -- segmen upper cervical & thoracalBerbentuk Oval --- segmen lower cervical & lumbal
Berawal dari dasar otak (atlas/V.C1), berakhir setinggi L1-L2 (conus medullaris), ke bawah melanjutkan diri sebagai fillum terminale.
Di bawah Conus medullaris terbentuk anyaman akar saraf (saraf tepi) menyerupai ekor kuda (cauda equina)
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Lanjutan …..
Diameter sepanjang medulla spinalis tidak sama , tapi mempunyai 2 bagian yang membesar pada regio cervical dan lumbosacral
Pembesaran pada regio cervical terjadi pada daerah yang berkaitan dengan asal dari nervus spinal C5 – T1, yang menginervasi extremitas atas.
Pembesaran pada regio lumbosacral terjadi pada daerah yang berkaitan dengan asal dari nervus spinal L1 – S3, yang menginervasi extremitas bawah
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Medulla Spinalis
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Medulla Spinalis
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Potongan Medulla Spinalis
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Potongan Medulla Spinalis
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Imaging of Spinal Cord
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SEGMEN MEDULLA SPINALIS
CervicalThora
calLumba
lSacral
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Segmen Medulla Spinalis
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• 8 Pasang Akar saraf
• 12 Pasang Akar Saraf
• 5 Pasang Akar Saraf
• 5 Pasang Akar Saraf, 1 Pasang Coccigeal
Cervical
Thoracal
LumbalSacral
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Segmen Medulla Spinalis
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Meningen
• Kuat berupa jaringan fibrous
Duramater
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M
E
N
I
N
G
E
N
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Dengan adanya selaput tersebut, maka terbentuk
ruangan – ruangan
Epidural, antara duramater dan dinding canalis vertebralis, berisi anyaman vena dan jaringan ikat lepas
Subdural, antara duramater dan arachnoid, berisi cairan limfe
Sub arachnoid, antara arachnoid dan piamater, tempat mengalirnya cairan otak spinal (liquor cerebro spinal/ cerebrospinal fluid/CSF)
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Cerebro Spinal Fluid (CSF)
Bersirkulasi dalam ruang sub arachnoid
Diproduksi oleh sistem ventrikel otak
Fungsinya :- Protein- Metabolisme
Constituent
Normal Value
Na+ 148mM
K+ 2.9 mM
Cl- 125 mM
HCO-3 22.9mM
Glukose 50-75mg/dl
pH 7.3
Protein 15 – 45 mg/dl
Albumin 80%
Globulin 6% - 10%
Limfosit 0-6/mm3
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CROSS – SECTIONAL TOPOGRAPHY
Bagian central membentuk huruf H (Gray Matter) dan dikelilingi oleh White Matter
2 bagian medulla spinalis dipisahkan oleh septum medianus (dorsal/posterior) dan fissura medianus (ventral/anterior) Sulcus dorsolateral (posterior) adalah pintu masuk akar saraf posterior (sensorik) dan sulcus ventrolateral (anterolateral) adalah pintu keluar akar saraf ventral (motorik)
3 area white matter : funikulus posterior, funikulus lateralis, funikulus anterior
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CROSS SECTIONAL SPINAL CORD
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Gambar Penampang Melintang
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GRAY MATTER / SUBSTANSIA GRISEA (ABU - ABU)
Cornu Anterior (anterior horn cell/ AHC) Berisi akar saraf motorik.
Cornu IntermediolateralTerbatas pada regio thoracal dan upper lumbal.
Cornu Posterior (posterior horn cell/ PHC)
Berisi akar saraf sensorik Canalis Centralis
Terletak di tengah substansia abu-abu, membagi medulla spinalis menjadi 2 daerah commisura grisea anterior & Posterior
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WHITE MATTTER / SUBSTANSIA ALBA (PUTIH)
Berisi serabut-serabut sensorik, motorik dan otonom
Terdiri dari tiga area funikulus, yaitu- anterior (berisi fasikulus
descending/motorik)- lateral (berisi fasikulus decsending &
ascending)- posterior (berisi fasikulus
ascending/sensorik)
Tiap funikulus terdiri dari satu atau lebih traktus atau funikulus
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Tractus Ascending (sisi kiri) & Descending (sisi kanan)
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Warna Biru = Tractus Ascending (sensory)
Warna Merah = Tractus descending (motorik)
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Warna Biru = Tractus Ascending (sensory)
Warna Merah = Tractus descending (motorik)
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SPINAL CORD ASCENDING TRACT
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SPINAL CORD DESCENDING TRACT
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MICROSKOPIC ANATOMYMedulla Spinalis berbeda pada setiap
level/regioWhite Matter
Cervical >
Beberapa tractus tidak ada pada level tertentu
Gray Matter Berbeda pada tiap level
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Microscopic Anatomy
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DERMATOM
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Supplay Darah Medulla Spinalis
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INSIDEN SPINAL CORD INJURY
Di USA Setiap tahun 7800-10.000 orang
65% pasien usia 16-30
tahun
Akibat celaka (44%),
sport injury (18%),
tikaman (24%)
Lansia (deg.
disorder)
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ETIOLOGI Traumatik
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Traumatik
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LANJUTAN ……
- Disrafisme- Malformasi Arnold Chiari --- siringomielia
- Abses Epidural- Abses Tuberkulosis dan penyakit pott vertebra- Sifilis, HIV, Paraparesis spastik tropis
- Infark medulla spinalis- Malformasi arteriovenosa- Hematoma epidural yang menekan medulla
spinalis
Kongenital
Infeksi
Vaskular
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LANJUTAN ……
- Sklerosis multipel- Mielitis transversa pasca infeksi virus- Spondilitis dengan kompresi medulla
spinalis
- Metastasis vertebra- Tumor ekstrinsik benigna –
neurofibroma- meningioma- Tumor medulla spinalis intrinsik –
ependimoma- glioma - metastasis
Inflamasi
Neoplasma
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LANJUTAN ……
- Kompresi akibat penyakit Paget - Degenerasi campuran subakut
- Penyakit neuron motorik- Spondilosis dengan kompresi medulla
spinalis
- Paraplegi Spastik Herediter
Metabolik
Degeneratif
Herediter
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Meningioma Spinalis
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AREA YANG SERING CEDERA
C1-
C2
T10-L2
C4-C7
Th4 – Th10
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LANJUTAN …..
Mekanisme Cedera
Penyebab Level
HyperFlexion Kecelakaan Lalu Lintas
C5 – C6
Hyperextension Kecelakaan di rumah
Cervical
Kompresi Menyelam C5-C6
Jatuh Dari Ketnggian
T12-L1
Rotasi Kecelakaan Lalu Lintas
T12-L1
Penetrasi Luka tusuk, tembak
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INJURY LOCATION CAUSED PARAPLEGIA
Thoracal
Lumbal
Sacral
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PATOGENESIS
Medulla Spinalis dan radiks dapat rusak melalui 4 mekanisme :
1. Kompresi oleh tulang, ligamentum, herniasi diskus intervertebralis, dan hematom.
2. Regangan jaringan berlebihan (biasanya pada hiperfleksi)
3. Edema medulla spinalis setelah trauma menyebabkan gangguan aliran darah kapiler dan vena
4. Gangguan sirkulasi akibat kompresi tulang atau sistem arteri spinalis anterior dan posterior.
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MIKROSKOPIK PATOGENESIS TRAUMA:
Hemorrhage central gray matter dan pia arachnoid nekrosis & Edema white matter gangguan mikrosirkulasi medulla
Penurunan perfusi vaskuler
Tension oksigen berkurang
Fibrosis dan cavitation
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MANIFESTASI LESI
Spinal shock (Sesaat setelah trauma)Hilangnya reflex spinal di bawah level injury, Muscle Flaccid, hilangnya sensasi, kontrol bladder dan bowel, seksual , dan hilangnya termoregulasi, hypotensi.
Ini dapat terjadi selama beberapa hari – 6 minggu bahkan 3 bulan.
Heightened Reflex Activity (Peningkatan Aktivitas Refleks )
Setelah beberapa minggu, respon refleks terhadap rangsang mulai timbul, mulai dari lemah dan makin menguat ---- spastik
Muncul Refleks Babinsky, tripple fleksi (gerak menghindar dari rangsang dengan mengadakan flexi ankle, knee dan hip joint)
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LANJUTAN …… Komosio Medulla Spinalis
Fungsi medulla hilang sementara akibat trauma tanpa disertai fraktur dan dislokasi.
Dalam beberapa menit/jam hingga hari dapat sembuh sempurna tanpa gejala sisa.
Bila lebih dari 48 jam mengarah pada kerusakan lebih.
Kontusio Medulla SpinalisTerdapat perdarahan, edema,
perubahan neuron, dan reaksi peradangan.
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LANJUTAN ….
Lacerasio Medulla SpinalisTerjadi kerusakan berat akibat diskontinuitas
medulla spinalis.
PerdarahanPerdarahan epidural, subdural maupun
hematomieli.
Hilangnya fungsi medulla spinalis di bawah lesi.
Kompresi Medulla SpinalisNyeri radikuler dan paralisis flaksid setinggi lesi
akibat kompresi pada radiks saraf tepi.
Gangguan sensorik sesuai dermatom
Inkontinensia alvi dan impotensi
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Paraplegi yang disebabkan oleh trauma memiliki cedera lain yang menyertai :
- Fraktur tulang panjang- Cedera organ abdominalis- Trauma kepala- Trauma dada dan fraktur
costae.
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Injury Spinal Cord diklasifikasikan sesuai level, derajat (complete atau incomplete), dan mekanisme injury
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Klasifikasi SCI
Pertama kali dikemukakan oleh Stokes Manville sebelum PD II
Dipopulerkan oleh Frankel tahun 1970an
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ASIA IMPAIRMENT SCALE
No motor or sensory function is preserved in the sacral segments S4 – S5
Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4 – S5
Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3
Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more
Motor and sensory function are normal
A = Complete
B = Incomplete
C = Incomplete
D = Incomplete
E = Normal
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TANDA & GEJALA
Gangguan
Motorik Sensorik
Kontrol Vasomotor
Kontrol Bladder&Bo
wel
Seksual Psikologi
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Efek Cedera Medulla Spinalis Pada Setiap Level
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EFEK INJURY TERHADAP KEMAMPUAN FUNGSIONAL
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KOMPLIKASI Skin Breakdown (Dekubitus ulcers /
pressure sores) Osteoporosis dan Fractures Heterotropic Ossification Tractus Urinarius Infection Autonomic Dysreflexia Deep Vein Thrombosis (DVT) Cardiovaskular Disease Respiratory Dysfunction and Infection Neuropathic
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DIAGNOSIS Myelography
Physical Examinati
on
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PROGNOSIS Sebuah penelitian prospektif selama 27
tahun menunjukkan bahwa rata-rata harapan hidup pasien cedera medula spinalis lebih rendah dibanding populasi normal.
Penurunan rata-rata lama harapan hidup sesuai dengan beratnya cedera. Penyebab kematian utama adalah komplikasi disabilitas neurologik yaitu : pneumonia, emboli paru, septikemia, dan gagal ginjal.
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TERAPI MEDIS Penyelamatan nyawa pada masa akut Operasi (a.l fixation surgery) Pengosongan Bladder dan Bowel Pengaturan Nutrisi Pencegahan DVT Perubahan Posisi untuk menjaga integritas
kulit
KONSERVATIF Reposisi dan stabilisasi fraktur Postural reduction ( 6 – 12 minggu) Penggunaan Brace (orthose) dan Plaster (gips)
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FISIOTERAPI FASE AKUTAssesment
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PENATALAKSANAAN FISIOTERAPI FASE AKUT Menjaga Fungsi Respirasi
Breathing exercise, strenthening, stretching, chest PT.
Perubahan Posisi Pencegahan pressure sores, kontraktur, inhibisi spastisitas
ROM exercise & penguluran dan penguatan bagian yang sehat
Orientasi pada posisi vertikal sedini mungkin setelah cedera stabil
Perhatian terhadap gerak yang boleh & tidak boleh. Support mental
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REHABILITASI
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No Problem FT Modalitas Terpilih
Metode/Tekhnik
Dosis
1 Penurunan rasa percaya diri
Komunikasi Terapeutik
Tanya Jawab, Mendengarkan, Motivasi, Visualisasi
F = 3x sehariI = Penderita
fokusM= Kontak
langsungT = 5 menit
2. Respiratory Problem
Breathing Exercise,Aktivitas fungsional meniup
Abdominal & Diafragma breathing, coughing, Huffing,
F = 3x sehariI = 6 x
pengulangan dan deep inspirasi
T = 5 menit
3. Peningkatan Tonus (Spastisitas)
Exercise Inhibision technique, fascilitation technique,
F = 3x sehariI = 2x
pengulangan
M= Kelompok Otot
T = 10 menit
PROGRAM FISIOTERAPI PADA REHABILITASI
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No Problem FT Modalitas Terpilih
Metode/Tekhnik
Dosis
4. Kontraktur Perubahan Posisi supine/sidelying/ pronelying/sitting/standing
F = 6x sehariI = 2 jam/posisiM= Fasilitasi
dari bagian yg sehat
T = 2 jam/ posisi
Mobilitas di bed Perubahan posisi
Stretching Penguluran F = 2x sehariI = 3x
pengulangan + Full ROM
M= Kelompok otot
T = 6 det./kel.otot
5. Pressure Sores Perubahan Posisi supine/sidelying/ pronelying/sitting/standing
F = 6x sehariI = 2 jam/posisiM= Padding
PositionT = 2
jam/posisi
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No.
Problem FT Modalitas Terpilih
Metode/Tekhnik
Dosis
6. Penurunan Kekuatan & Ketahanan otot
Exercise Strenthening exercise, PNF
F = 3x sehariI = 2x
pengulangan+ tahanan minimal-moderate
T= 2-3 menit/posisi
7. Penurunan Ketidakstabilan
Stabilizing Exercise
Sitting and Standing Stability
F = 3x sehariI = 2x
pengulangan/posisi
M= Sitting, standing
T= 2-3 menit/posisi
8. Gangguan Fungsi Tungkai
Functional Skill Exercise
Transfer, wheelchair skill, standing in paralel bars, walking with crutches, climbing stairs
Disesuaikan
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No Problem FT Modalitas Terpilih
Metode/Tekhnik Dosis
9 Penurunan Tonus (Flaccidity)
Aproximasi F = 3x sehariI = 6-10 gerakan/sendiT = 30 s/sendi
Muscle Belly Fascilitation
F = 3x sehariI = 6-10 gerakan/muscle bellyM= prime mover muscleT = 3-5 menit
Passive Exercise
Relax Passive Exercise
F = 3x sehariI = 3x/gerakanT = 15 – 30s/gerakan
Strenthening Assisted Active, Free Active
F = 3x sehariI = 3x/geraknT = 5 menit
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No Problem FT Modalitas Terpilih
Metode/Tekhnik
Dosis
10 Bladder Problem
Bladder Training F = 3x sehariI = T =
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n
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FUNCTIONAL SKILL EXERCISE Sitting transfer with legs down Transfer from wheelchair to floor and reverse Wheelchair skill Putting on Brace Standing up in paralel bars Balancing in standing at the paralel bars Walking in paralel bars Walking with forearm crutches Climbing stairs Climbing curbs Standing up from wheelchair using forearm
crutches Falling and returning to standing with crutches
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PROGRESSION OF PHYSICAL TREATMENT
At Paralel Bars
Sitting
Supine
4-point kneel
Prone
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Paraplegic Transfer, Assisted
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Paraplegic Transfer, Independent
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Paraplegic Transfer, Independent
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Paraplegic Transfer to Elevated Toilet Seat, Independent
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KAFO And Paraplegic Balance
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Padding Position
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EVALUASI Apakah dapat
mencapai tujuan Fisioterapi
Variasi
Modifikasi
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DokumentasiPencatatan semua
proses Fisioterapi
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DAFTAR PUSTAKAAnonim, 2009; Paraplegia; retrieved February, 25, 2009
from http://en.wikipedia.org/wiki/paraplegiaAnonim, 2009; Paraplegia; retrieved February 25, 2009
from http://www.spinal-injury.net/paraplegia.htmAnonim., 2001; Spinal Cord Injury Info Sheet; Retrieved
February 25, 2009 from http://www.spinalcord.uab.eduAfifi, Adel K., Bergman, Ronald A., 2005; Functional
Neuroanatomy; second edition, New York, Lange Medical Books/McGraw-Hill, page 45 – 62
Bradley, Walter G, et al., 2003; Pocket Companion to Neurology in Clinical Practice; fouth edition, Philadephia, Butterworth-Heinemann, page 131 – 139
Copstead, Lee-Ellen C., Banasik, Jacquelyn L., 2005; Pathophysiology; third edition, USA, Elsevier Saunders, page 1142 – 1144
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Drake, Richard L., Vogl, Wayne., Mitchell, Adam W.M., 2005; Gray’s Anatomy for Students; Philadelphia, Elsevier Churchill Livingstone, page 62 – 69
Ginsberg., 2005; Neurologi; edisi delapan, Erlangga; Jakarta, hal. 134 – 141
Harsono., 2007; Kapita Selekta Neurologi; edisi kedua, Gadjah Mada University Press, Yogyakarta, hal. 319-327
Huether, Sue E., McCance, Kathryn L., 2004; Understanding Pathophysiology; third edition, Philadelphia, Mosby, page 396 – 401
Kisner, Carolyn., Colby, Lynn Allen., 1990; Theraputic Exercise Foundation and Techniques; third edition, F.A Davis Company, Philadelphia, page 665 - 666
Mardjono, Mahar., Sidharta, Priguna., 2008; Neurologi Klinis Dasar; Jakarta, PT. Dian Rakyat, hal. 35 – 37
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May, Laura., Loomis, Joan., 1991; Physiotherapy in Neurological Dysfunction, page 203 - 219
Payton, Otto D., 1989; Manual of Physical Therapy; Churchill Livingstone, New York, page 74 -75, 120-168
Pinzon, Rizaldi., 2007; Mielopati Servikal Traumatika; Diakses tanggal 25/2/2009 dari http://www.kalbe.co.id
Porth, Carol Mattson., Gaspard, Kathryn J., 2004; Essentials of Pathophysiology; Philadelphia, Lippincott Willims & Wilkins, page 716 – 723
Setiawan., 2006; Cedera Medulla Spinalis; Poltekes, Surakarta
Victor, Maurice., Ropper, Allan H., 2001; Principles of Neurology; seventh edition, USA, McGraw Hill Companies, page 1293 – 1299
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TERIMA KASIH
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SCHEMATIC PATHWAY
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LANJUTAN …..
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Arcus Reflex
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LANJUTAN ……
Efek vertebral injury dapat berupa :Fraktur
Fraktur dislokas
i
Fraktur Kompresi
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SINDROM SPESIFIK MEDULLA SPINALIS
Hemisection (Brown-Sequard Syndrome)
Anterior Horn&Lateral Corticospinal Trac. Syndrome (Motor Neuron Disease)
Central Canal Lesion (Syringomyelia)
Anterior Spinal Artery Syndrome
Conus Medullaris & Cauda Equina Syndrome
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Struktur Lesi Medulla Spinalis
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Thoracic injuries Injuries at the thoracic level and below result in
paraplegia. The hands, arms, head, and breathing are usually not affected.- T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury. - T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good.
Lumbar and Sacral injuries The effect of injuries to the lumbar or sacral region of
the spinal canal are decreased control of the legs and hips, urinary system, and anus.
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BRACE CERVICAL2. Soft Collar and
Brace (posterior appliance)
Orthosis (Halo)
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BRACE THORACO LUMBARThoraco Cervical Brace
Taylor Orthose
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MOTOR AND SENSORY EVALUATION
Wajar bila terdapat perbedaan antara level motorik terendah dan level sensorik terendah.
Cedera Complete - Tidak ditemukan fungsi motorik maupun sensorik di area S4 dan S5 atau area anal.
Cedera Incomplete - Bila ada fungsi motorik atau sensorik pada S4 dan S5, menurut Skala Asia Impairment.
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MODIFIED ASWORTH SCALE (MAS)
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Derajat I Derajat II
Derajat III Derajat IV
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FISIOTERAPI PADA REHABILITASI Assesment Penguluran Penguatan dan Ketahanan Mobilitas di bed dan mat activities Mendidik keseimbangan Mengurangi tekanan /pressure sores Menjaga respirasi Transfer Ketrampilan berkursi roda Hidroterapi Latihan jalan Edukasi pasien dan keluarga Support mental
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nm
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LATIHAN PENGUATAN UNTUK TANGAN
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POSISI DARI TIDUR TERLENTANG KE POSISI DUDUK DENGAN MIRING KE KIRI
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DARI POSISI TIDUR KE POSISI DUDUK DENGAN BANTUAN KEDUA TANGAN
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KURSI RODA UNTUK PENDERITA PARAPLAGIA
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Bangku yang dimodifikasi untuk BAB
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KURSI RODA DENGAN MODIFIKASI
MEJA MAKAN
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TURUN TANGGA DGN KURSI RODA
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LATIHAN PINDAH TEMPAT DGN MENGGUNAKAN PAPAN
SELUNCUR
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LATIHAN PINDAH TEMPAT TANPA MENGGUNAKAN
PAPAN SELUNCUR
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LATIHAN PINDAH TEMPAT DARI KURSI RODA KE LANTAI