Makalah Cva | Balance (Ability) | Physical Therapy

MAKALAH Jurnal Penyakit CVA (Cerebro Vasculer Accident)

Disusun Oleh : Avisensia Selvi Y. V Binti Eka Desitasari Bondhan Ajar Megantoro Budi Setyono Cecep Bayu Kuncoro Christa Yohanita Tahu Cicik Sylvia suseno Cindy Pramudita Daniel Pradana Putra Denny Eka Dergantara Deny Ayoga agustian Devi Arista Febriana Devi Megaratna Dia Ayu Titis sari Dicky Pratama Yudha

(200901016) (200901018) (200901019) (200901020) (200901021) (200901022) (200901023) (200901024) (200901025) (200901027) (200901028) (200901029) (200901030) (200901031) (200901032)

PROGRAM STUDI S1 ILMU KEPERAWATAN STIKES KARYA HUSADA PARE KEDIRI 2010/2011

KATA PENGANTAR

Syukur Alhamdulillah penulis panjatkan kehadirat Tuhan Yang Maha Esa, karena dengan rahmat-Nyalah penyusun bisa menyelesaikan Makalah Asuhan Keperawatan pada masalah Muskuloskeletal tepat pada waktunya. Dalam penyusunan Makalah ini, penulis mengambil judul yaitu, “Makalah Jurnal penyakit CVA” yang di dalamnya membahas tentang jurnal terapi pada penyakit CVA. Makalah ini dibuat untuk memenuhi tugas kuliah Sistem Neurologi. Dalam penyusunan makalah ini, penulis banyak mendapatkan bimbingan dan dorongan dari berbagai pihak, untuk itu penulis mengucapkan terima kasih kepada: 1. Semua dosen yang ikut membimbing dalam penyusunan makalah ini. 2. Keluarga, terutama Bapak, Ibu, serta Kakak yang selalu memberikan dorongan sehingga Makalah ini dapat selesai tepat pada waktunya. 3. Teman-teman serta semua pihak yang tidak bisa di sebutkan satu per satu,yang telah memberikan bantuan, saran, dan nasihat sehingga Makalah Asuhan Keperawatan ini dapat penulis selesaikan. Kami menyadari ada banyak kekurangan dalam penyusunan Makalah ini. Dalam kesempatan ini, penyusun menghaturkan maaf yang sebesar-besarnya, dan mengharapkan kritik ataupun saran yang sifatnya membangun agar penulisan Makalah yang berikutnya dapat lebih sempurna.

Pare, April 2011

Penulis

JURNAL

Walking Impediments and Gait Inefficiencies in the CVA Patient Deanna Fish, MS, CPO Cheryl S. Kosta, PT ABSTRACT The use of motor activity parameters for patients results in arbitrary values of acceptance for measuring balance, alignment, range of motion, walking, and other functional activities. Statistical analysis of each measure results in an averaged value, and the synthesis of all averaged measures creates the ethereal and elusive "normal model." This model is useful in providing general direction and goal setting strategies; however, clinicians must recognize acceptable limits of combined measures for providing the most effective structural and functional outcomes. This article considers the functional and dysfunctional components of gait in patients who have had a cerebrovascular accident. Often, these two types of patterns (i.e., functional and dysfunctional) are interdependent and difficult to differentiate. As a result, each patient must be evaluated and treated individually to maintain the integrity of the structural components and produce the maximum level of functional independence. Key Words: cerebrovascular accident, gait inefficiencies, ambulation, rehabilitation Introduction Mobility and functional independence are two important concepts addressed during the rehabilitation process. Mobility is defined as the quality of being able to move about in one's environment, while independence refers to the ability to self-govern or self-determine the course of one's activities. These two goals are unique for each person in need of rehabilitation treatment procedures. The goals do not necessarily imply freedom from dependence on others, but instead are aligned with each patient's abilities, needs, and interests, and access to the effective tools necessary to secure these goals. Ambulation is an especially critical movement pattern, as it relates to one's ability to transport oneself in the environment, both on a small (i.e., household) and large (i.e., community) scale. Patients who have had a cerebrovascular accident (CVA) present with disruptions to many physiologic systems, and as a result, the mechanical stability provided by the lower limbs becomes precarious. Compensatory movement strategies are developed to promote weighttransfer abilities and limited movement patterns. The short-term acquisition of these compensatory strategies often allows for early weight bearing and transfer ability. However, long-term ambulatory ability is dependent upon the stability of the system, energy costs associated with walking, potential development of musculotendinous contractures and ligamentous laxities, and the degree of neurologic function or return. In general, a patient's

ability to return to pretrauma levels of ambulation is often greatly diminished with the development of joint deformities and muscular weaknesses. Bipedal Ambulation Upright bipedal ambulation is accomplished activity that is unique to the human model. Plantigrade (or flat foot) alignment of the lower extremities provides both a means of support to the proximal top-heavy trunk segment and propulsion of the entire mass through space. Walking is a complex interaction of the neurologic, musculoskeletal, cardiopulmonary, and numerous other systems that requires minimal conscious thought for most people. In the CVA population, involvement of one or more of the integrated physiological systems can result in movement dysfunction that alters or completely impedes walking ability. Rehabilitation programs are designed to restore and maintain a person's functional level within normal limits through the application of specific treatment protocols. Establishing self-care abilities, effective support and stability, preventing or correcting deformities, and substituting for functional components of ambulation are a few of the primary rehabilitation goals. Impediments to Energy Efficient Gait The normal sequence of required for walking involves the initiation of the command in the central nervous system. The command then travels throughout the peripheral nervous system to the muscles. Contraction of muscles creates the generation of forces (moments) across the joints in specific timing sequences to produce segment deviations and displacements. This displacement results in movement, and the body must now balance the generation of such internal forces with the external forces of the environment (i.e., gravity, ground reaction, terrain). Disruption of this sequence at any point along the pathway can result in serious impedance to walking. Several significant factors contribute to increased energy costs for patients with CVA (Table 1 ). Involvement of one or more of these factors may result in the inability to control the functional and efficient manipulation of body segments through space, and therefore excessive displacement of the center of mass (COM) occurs. It might be suggested that the more systems involved (i.e., neurologic, motor control, musculoskeletal, ligamentous, cardiopulmonary) the greater the movement difficulties. Still, even minor disturbances to the intricate balance of the physiological systems can result in devastating consequences. Patients with such involvement battle increased energy costs and fatigue, suggested by decreased walking velocity and increased ambulatory heart rate.1 Rehabilitation Treatment Programs Indications for rehabilitation treatment programs include the need to improve self-care and mobility skills. After a CVA, patients benefit from participation in effective treatment programs aimed at improving balance, walking ability, independence, and overall quality of life. Additional medical concerns involve the prevention of osteoporosis, pressure sores, spasticity, muscular atrophy, cardiovascular deconditioning, circulatory dysfunction, and contractures.25 Decreased cognitive abilities often interfere with the development or retraining of motor programs. The prescription criteria and individual design of each rehabilitation treatment program is best developed by an interdisciplinary team approach. Cerebrovascular Accident

In a CVA, lesions to one side of the brain result in hemiplegia, characterized by uncoordinated movements and lack of control of the contralateral side of the body. The severity of the lesion will determine the degree of motor and cognitive involvement. Frequently, neurologic involvement produces hypertonicity of the muscles of the arm and leg, which disrupts balancing mechanisms, proprioceptive feedback, voluntary motor control, and ambulatory abilities. Patients with such accidents commonly present with lower extremity extensor synergy with equinovarus positioning of the foot and ankle complex, sustained plantarflexion of the ankle, sustained knee and hip extension, and pelvis retraction on the involved side. Notable gait deviations include weight transfer on the lateral of the foot, knee hyperextension, limitations to functional hip flexion, and sustained pelvic retraction (rotation about a vertical axis). As a result, this asymmetric gait pattern will produce decreased velocity, decreased support time on the involved limb, decreased step length on the involved limb, decreased cadence, decreased weight transfer through the limb, and increased energy costs.1,6-9 Lehmann et al.9reported a reduction in walking speed, cadence, and step length when comparing a small group of able-bodied and hemiparetic subjects. As noted previously, a decrease in walking speed will tend to increase energy costs associated with the ambulatory pattern. Presumably, this can be attributed to an increase in heart rate of deconditioned individuals with sedentary lifestyles or those patients recovering from trauma. Predictors of poor functional outcome after stroke have been noted to be advanced age, absence of early neuromuscular return, continued episodes of stroke, and additional neurologic or orthopedic disabilities.10 Once rehabilitation is introduced, the patient must still contend with neurologic, muscular, and skeletal involvements. These instabilities can be minimized with the use of a well-designed orthosis to allow the patient to acquire a more normal and energy-efficient gait pattern.11 Identification of Initial Insult CVAs appear with sudden onset due to acute vascular lesions of the brain. These lesions may be produced by hemorrhage, embolism, thrombosis, or rupture of an aneurysm, which results in hemiplegia or hemiparesis. The physical presentation is loss of voluntary control of one half of the body (either right or left side) with both upper and lower extremity involvement. The neurologic damage accompanying this condition is often permanent, and patients are also left with residual effects to their musculoskeletal, somatosensory, psychological, and cardiopulmonary subsystems. Identification of Neuroanatomic Pathology The size and location of the cerebral lesion will determine the systems affected. The extent of the damage to the brain tissues directly influences the neurologic involvement of the patient and often predicts the degree of functional recovery expected for each individual patient. It becomes necessary for the clinician to have a detailed understanding of the particular deficit so that effective treatments may be developed. For example, the motor cortex is located in the frontal lobe, and lesions to this area result in disrupted motor plans and motor programming. Lesions to the parietal lobe have a great effect on the somatosensory system and the sensory processing abilities of the individual. While the function of these two areas is interrelated to produce appropriate movement strategies, the specific deficits require varied treatment approaches to maximize the restoration of functional abilities and outcomes. Effects of Impairments and Pathological Changes

Direct Effects Shumway-Cook and Woollacott12 note the direct effects of the cerebrovascular accident to be evidenced in numerous physiologic systems. Disorders of the sensory system result in peripheral neuropathy, poor proprioception, perceptual difficulties, and attention deficits. Motor disruptions may present as motor loss, decreased motor strength, or significant increases or decreases to muscle tone. Cognitive dysfunctions compound movement difficulties as many of the basic motor programming and planning capabilities are lost or "buried" with varying degrees of motor apraxia. These patients often lack the ability to generate new motor plans and/or lack the ability to correctly run existing motor programs. General movement qualities are noted to be decreased endurance, increased energy costs, paralysis, incoordination, and possibly spasticity. Rehabilitation is often focused on "uncovering" or "rediscovering" some of the preexisting motor pathways and developing alternative pathways necessary for safe ambulation. The direct effects of CVA are listed in. Indirect Effects Many of the indirect effects of the initial impairments and pathological changes have been discussed. Musculoskeletal complications include damage to soft-tissue structures secondary to the application of altered ground reaction forces, musculotendinous contractures, deviated skeletal joint angulation, and possibly, pain. Psychologically, many patients suffer from fatigue and depression, along with decreased motivation when their functional recoveries are slow or absent. Social deprivation can occur when CVA patients are returned home before they or their spouses are ready. The required navigation of stairs and ramps will often force a patient to stay within the home, rarely venturing out for fear of falling. The deconditioning associated with bed rest immediately after the stroke and then compounded by decreased ambulation abilities becomes cyclical in nature. Additional medical complications associated with advanced age and inactivity can also dramatically affect the potential rehabilitation of this patient population.

Composite Effects The composite effects of CVA include both the direct and indirect effects of the original central nervous system lesion.13 This results in a varied presentation of decreased postural control, increased or decreased upper and lower extremity muscle tone, vestibular involvements, visual impairments, and somatosensory and proprioception dysfunctions. In particular, the composite effects on locomotor abilities in a commonly noted hemiplegic gait pattern will be outlined. In the hemiplegic gait, initial loading of the limb occurs with a flat-footed or toe-heel contact secondary to motor deficits and an extensor synergy that produces a concentric contraction of the gastrocnemius-soleus complex. This serves to disrupt the forward momentum of the body as a whole, and a drastic decrease in velocity can often be observed. This particular profile presents with a (moderately) supinated foot and ankle alignment that will be exacerbated by the residual muscle imbalance. Forward trunk lean, pelvic retraction, and trunk rotation (about a vertical axis) toward the involved side often accompanies this phase of the gait as the patient attempts to align the proximal mass anterior to the knee joint and reduce the potential for anterior knee buckling. Weak quadriceps and/or gastrocnemius-soleus muscles create excessive knee instability, and postural compensations also appear in the form of increased hip external rotation and pelvic retraction. These postural adjustments serve to align the knee axis externally to the line of

progression and decrease step length, respectively. Hip abduction, occurring secondary to the extensor synergy, aids in reestablishing an effective anterior-lateral forefoot lever at the distal base of support. All of these functional compensations promote increased stability, yet also contribute to increased energy costs Stance-phase movement is also characterized by a disruption to forward momentum as the knee progresses posteriorly into hyperextension. Observational gait assessment reveals the thigh and distal limb segment proceeding posteriorly while the trunk segment is attempting to advance anteriorly. These two opposing forces increase the energy required to advance the body mass forward, and also create significant stresses to the soft tissues at the posterior-lateral knee joint. Pelvic retraction, sustained hip external rotation, and forward trunk lean are still evidenced. Initiation of the swing phase is difficult, because a hyperextended hip alignment during terminal stance is never obtained. Sustained pelvic retraction and anterior trunk lean prevents prestretch to the hip flexors; as a result, the hip-joint receptors do not receive the proper signal to decrease extensor-muscle activity and initiate flexor-muscle patterning. As a result, lateral trunk deviation is often required to unload the limb toward the contralateral side, which adds to increased energy costs. Swing-phase compensations often include a circumductory motion to achieve ground clearance as the foot remains plantarflexed and the limb is functionally longer. While all of these abnormal alignments and motions produce a somewhat functional gait pattern, the resulting energy costs often deter a patient from pursuing many ambulation activities due to fatigue.

Disability Functional disability can be viewed as the social, mental, physical, and emotional disruptions to the patient's life after this type of acquired trauma. Mounting medical bills, limited social support mechanisms, physical limitations, and cognitive involvements leave many patients unable to acquire the necessary skills to perform self-care and mobility tasks without the intense attention of a rehabilitation team. Early and sustained treatment programs can maximize patients' functional outcomes and the possibility to return to their own homes or environments. Long-term monitoring of each patient's status can identify and intercept potential complications, such as contracture formation, balance disturbances, and motor memory loss from inactivity, before they progress to devastating consequences.

Conclusion The physical and psychological benefits to upright bipedal ambulation in the CVA population are well documented. Psychological factors for patients of all ages include greater satisfaction with life and increased interaction with their environment. Medical benefits include improved maintenance of cardiorespiratory and vascular systems, and prevention of osteoporosis, pressure sores, and contractures have been noted. Indications for rehabilitation programs include pain, disrupted balance problems, abnormal anatomic alignment, motor deficits, and energy conservation considerations. The treatment program should emphasize a multisystem approach and address all possible components of gait disturbances: for example, neurologic, musculoskeletal, cardiopulmonary, visual, and vestibular. Greater reduction in energy costs can be evidenced in patients when motor deficits, segmental deviations, and overall body symmetry has been properly incorporated into a new and effective

ambulatory pattern. The continued development of more advanced multisystem and early intervention rehabilitation programs will enhance the clinical evaluation procedures and treatment recommendations for CVA patients afflicted with movement disorders.

References: 1. Dettman MA, Under MT, Sepic SB. Relationships among walking performance, postural stability, and functional assessments of the hemiplegic patient. Am J Phys Med. 1987;66:7790. 2. Heckmatt JZ, Dubowitz V, Hyde SA, Florence I, Gabain AC, Thompson N. Prolongation of walking in Duchenne muscular dystrophy with lightweight orthoses: review of 57 cases. Dev Med Child Neurol. 1985;27:149-54. 3. Granata C, Cornelio F, Bonfiglioli S, Mattutini P, Merlini L. Promotion of ambulation of patients with spinal muscular atrophy by early fitting of knee-ankle-foot orthoses. Dev Med Child Neurol. 1987;29:221-224. 4. Lough LK, Nielsen DH. Ambulation of children with myelomeningocele: Parapodium versus parapodium with ORLAU swivel modification. Dev Med Child Neurol. 1986;28:489-497. 5. Waters RL, Perry J, Conaty P, Lunsford B, O'Meara P. The energy costs of walking with arthritis of the hip and knee. Clin Orthop Rel Res. 1987;214:278-284. 6. von Schroeder HP, Coutts RD, Lyden PD, Billings E, Nickel VL. Gait parameters following stroke: a practical assessment. J Rehabil Res Dev. 1995;32:25-31. 7. Harburn KL, Hill KM, Kramer JF, Noh S, Vandervoort AA, Teasell R. Clinical applicability and test-retest reliability of an external perturbation test of balance of stroke patients. Arch Phys Med Rehabil. 1995;76:317-323. 8. Gray CS, French JM, Bates D, Cartlidge NEF, James OFW, Venables G. Motor recovery following acute stroke. Age Ageing. 1990;19:179-184. 9. Lehmann JF, Condon SM, Price R, de Lateur BJ. Gait abnormalities in hemiplegia: their correction by ankle-foot orthoses. Arch Phys Med Rehabil. 1987;68:763-771. 10. Adunsky A, Hershkowitz M, Rabbi R, Asher-Sivron L, Ohry A. Functional recovery in young stroke patients. Arch Phys Med Rehabil. 1992;73:859-862. 11. Lehmann JF, Condon SM, Price R, de Lateur BJ, Smith C. Ankle foot orthoses: effect on gait abnormalities in tibial nerve paralysis. Arch Phys Med Rehabil. 1985;66:212-218. 12. Shumway-Cook A, Woollacott M. Motor Control: Theory and Practical Applications. Baltimore, Maryland: Williams & Wilkins; 1995. 13. Schenkman M, Butler RB. A model for multisystem evaluation, interpretation, and treatment of individuals with neurologic dysfunction. Phys Ther. 1989;69:538-547.

ANALISA DAN KOMENTAR

Pengertian CVA/Stroke (Penyakit Serebrovaskuler) adalah kematian jaringan otak (infark serebral) yang terjadi karena berkurangnya aliran darah dan oksigen ke otak. Stroke bisa berupa iskemik maupun perdarahan (hemoragik).

Penyebab Penyebab utamanya dari stroke diurutkan dari yag paling penting adalah arterosklerosis (trombosis) embolisme, hipertensi yang menimbulkan pendarahan srebral dan ruptur aneurisme sekular. Gejala-gejala Sebagian besar kasus terjadi secara mendadak, Gejala sangat cepat dan menyebabkan kerusakan otak dalam beberapa menit (completed stroke). Bipedal Ambulasi o Berjalan adalah interaksi kompleks dari syaraf, tulang dan otot, kardiopulmonal dan beberapa sistem lain yang memerlukan kesadarn pada semua orang. o Komunitas CVA/Stoke menyebabkan kegagalan berjalan/kelumpuhan sebagian/seluruh kemampuan berjalan. Pragram Rehabilitasi  Program rehabilitasi didesain untuk mengembalikn dan menjaga cara berjalan yang normal, membangun kemampuan mandiri, support yang efektif dan pencegahan deformitas dan juga meminimalisir penggunaan alat-alat bantu berjalan.  Urutan cara berjalan yang normal dimulai dari SSP, lalu perintah itu berjalan melewati saraf perifer menuju ke otot. Kontraksi otot menimbulkan gerak, dan tubuh harus menyeimbangkan kondisi dalam dan luar tubuh. Contoh grafitasi dan reaksi tanah.  Gangguan dalam system tersebut mengakibatkan kegaagalan berjalan secara serius. Beberapa factor yang menyebabkan kegagaln tersebut adalah kegagalan system saraf, system motorik, musculoskeletal, ligament, dan kardiopulmona.

Program terapi Rehabilitasi  Syarat untuk terapi meliputi : kemampuan gerak dan kemandirian diri.  Rehabilitasi intensif bisa membantu penderita untuk belajar mengatasi kelumpuhan/kecacatan karena kelainan fungsi sebagian jaringan otak. Bagian otak lainnya kadang bisa menggantikan fungsi yang sebelumnya dijalankan oleh bagian otak yang mengalami kerusakan. Rehabilitasi segera dimulai setelah tekanan darah, denyut nadi dan pernafasan penderita stabil. Dilakukan latihan untuk mempertahankan kekuatan otot, mencegah kontraksi otot dan luka karena penekanan (akibat berbaring terlalu lama) dan latihan berjalan serta berbicara.  Setelah serangan CVA pasien di rehabilasi secara efektif dengan tujuan keseimmbangan meningkatakana kemampuan berjalan, kemandirian dan kualitas hidup meningkat dengan keseluruhan.  Program tambhan terapi meliputi pencegahan osteoporosis, atropi muscular, kelemahan cardiovaskuler, disfiungsi pernafasan .

Kecelakaan Cerebrovaskuler Di CVA luka di sisi tepi otak mengakibatkan hemiplegia, gejalanya seperti gerakan yang tidak terkoordinasi dan kelemahan tubuh bagian samping. Sebagian luka yang lain mengakibatkan penurunan kemampuan motorik dan kognitif. Contoh kerusakan kemampuan kognitif seperti kerusakan mekanisme kesimbangan, dan kelumpuhan. Sedangkan kerusakan motorik contohnya sulit memposisikan kaki dan lutut, kesulitan untuk meluruskan sendi. Maka dari itu kemampuan motorik menurun, kemampuan berjalan dan aktivitas juga menurun karena memerlukan banyak energy untuk melakukan hal tersebut.

Kesimpulan Terapi yang di bererikan pada penderita CVA di atas untuk meningkatkan factor psikologis pada pasien dari kesemuanya, meliputi kepuasn pada diri , meningkatkan PD dalam lingkungan. Pengobatan tersebut bertujuan untuk menjaga system respiratori dan cardiovaskuler,serta pencegahan osteoporosis. Indikasi untuk program rehabilitasi meliputi rasa sakit, gangguan keseimbangan, bentuk tubuh yang tidak normal, defisiensi motoris dan penggunaan energi yang bijak. Program rehabilitasi harusnya meliputi berbagai system yang memungkinkan terjadinya penyebab gangguan cara berjalan. Contoh sistem saraf, jantung, otot, dan visual. Pengobatan yang berkelanjutn pada berbagi system dan penanganan cepat serta tepat akan meminimalisir resiko cedera dalam bergerak.

Komentar Kita setuju dengan isi jurnal tersebut, karena dalam jurnal tersebut memberikan teknik terapi dalam menjaga respirasi dan cardiovaskuler pada pasien CVA yang sangat signifikan dan dapat melatih pasien dalam melakukan mobilisasi secara mandiri serta dapat meningkatkan percaya diri pasien tanpa memperbesar resiko cidera dan komplikasi lebih lanjut.