it is very difficult to manage cerebral palsy because we cant repair brain damage but we can give good quality of independent life by combination good rehabilitation tool which include advance therapeutic technique, botulinum toxin early age child and SEMLOSSS surgical concept in others. Our aim of management is to take these person to their highest capability and decrease their physical limitation as much as possible. This ppt have brief review about latest concept in mx of cerebral aplsy

1. Holistic concept in treatment of
children & adult affected with
Cerebral Palsy
Dr Jitendra Kumar Jain
Consultant Pediatric Orthopedic Surgeon
Secretary , Samvedna “trust for children with special need”
Chairman, Trishla Foundation
Allahabad, UP
www.samvednatrust.com, www.trishlaortho.com
Fb: samvednatrust.cerebralpalsy, jitendra.jain.35513800
You tube: jjain999
Email: samvedna9453039213@gmail.com

2. Cerebral Palsy ?
It is not a disease
It is group of Neuro-motor disorder which
comprises of motor dysfunction, disturbance of
sensation, perception, cognition, communication ,
behavior, epilepsy, hearing, speech & immunity
etc.
It is a life long condition that affect individual &
his immediate surrounding

3. Etiopatholgy ?
Non-progressive disturbances in the
developing fetal or infant brain upto 3 year of
postnatal period.
Severity of Lesion may range from sectoral
defect to global affection of brain
The brain injury is static; it is not progressive.
However, the dysfunctions or disabilities
associated with cerebral palsy can be static,
progressive or regressive.

4. • Spectrum of presentation range from clumsiness
in gait to severe disability.
Cont.

5. Cont.
It can
present in a
Variety
of manner

6. No cure for cerebral palsy as Brain
damage can not be repaired.
Our aim of management is to rehabilitate the
child to their maximum ability & diminish their
disability & impairment by all means
Goal is to allow the individual live with
least impact of disability
Any cure ?

7. What you will do in this case ?

8. What the parents & family want
from us !

9. Cont.
• Even small degrees of improvement
makes a great difference. Getting a
child to walk, be it in crutches, in
braces or with a walker, is much
better than having him in a
wheelchair.

10. Prognosis
 With Early intervention more than 8o% children
can be given fully acceptable life in society
 Quality of life & survival in CP child with
Ambulatory capability with or without walking
aid is roughly equal to normal population
 More than 70% children with mild to moderate
affection have nearly normal IQ
 Can be active, productive members of their
communities.
 Can have jobs, live independently, marry, have
children & retire

11. These children can also excel in all
the activity given to them !

12. Standard Treatment protocol ?
• Developmental Physiotherapy along with
judicious use of light wt polypropylene brace
& walking aid is the mainstay of treatment.
• NDT, SI, TRP, MRP, CIMT, Context therapy,
Strength training, Mirror therapy, FES,
Hydrotherapy, Horse riding etc are few
example of therapeutic technique
• Task oriented (context therapy )
+ child oriented therapy
• Training in Activity of Daily Living

13. Halt in progress ?
• Still most of the spastic children stop
showing progress after getting certain
milestone at some age in his early life even
after good physiotherapy & rehabilitation

14. Why it is so ?
• Contracture and bony deformities are going to
occurs in most of the children with hypertonic
cerebral palsy (Cosgrove & Graham, 1994).
• Without intervention detrimental changes
in gait & function can occur over time
span as short as 1.5 years.

15. What they need ?
• Interventional modality to prevent / slow
the progression / treat the negative
consequences
• Continuation of good therapeutic
modality & ADL
• Judicious use of day / night
polypropylene bracing & walking aid
• Control of weight

16. Quality of ideal intervention modality
• Selective spasticity control without any
negative impact on already weakened muscle
& Postural control
• Early rehabilitation
• Short & painless hospitalization
• Avoid repeated intervention
• Can prevent future progression of deformity

17. Intervention modality ?
Intervention modality for early age (2-6 year age)
• Botulinum toxin
Intervention modality after age 6
• Orthopedic surgery-

18. Older concept: Orthopedic surgery
• Multistage surgery
• Repeated surgical intervention i.e.. birthday
syndrome
• Child had always left out with deformity despite
repeated surgery
• Risk of deformity spread to adjacent joints
(dislocation) and to the skeleton (bony torsion) during
the ‘waiting-time’ for surgery
• Selective control of spasticity was not possible
• Recurrence / overcorrection
• Some times ambulatory children become non-
ambulatory

19. Cont.

20. Why orthopedic surgery is given
discredit?
• Orthopedic surgery in cerebral palsy
is largely discredited because of
inappropriate case selection, wrong
operation, traditional concept and
wrong decision.

21. Advancement in orthopedic surgery
Orthopedic Selective Spasticity Control Surgery (OSSCS)
Tendon transfer
Lever arm restoration
Early surgical intervention
Single Event Multilevel Corrective Surgery
(SEMLS)
Single Event Multi Level surgery by OSSCS concept
with some modification
(SEMLOSSS)

22. Basic concept of OSSCS
A: Antigravity monoarticular muscles support the body to be upright.
B: Multi-articular muscles co-exist in the human body.
C: When the multi-articular muscles are lengthened or sectioned selectively,
then hypertonicity of these muscles are reduced. the mono-articular
muscles are preserved and facilitated.
D. With this concept of Selective Spasticity control we can achieve good
balance of muscle tone in whole body
Concept By
Takashi Matsua
Japan

23. Tendon transfer
• Rarely required but very useful in certain problem like weak
wrist extension, foot varus & delayed knee flexion in swing
phase
• Only in spastic cerebral palsy
• Partial / complete tendon transfer
• Very much helpful in replacing function of weakened
muscle
• Use in hand (FCU to ECRB) / foot (Tibialis Ant half tendon
/ Tibialis posterior) / knee problem (Rectus Femoris)

24. Lever arm restoration
• Lever arm dysfunction- Disruption in the
muscle joint complex due to an ineffective
lever arm moment despite normal muscle force
results in functional weakness & decrease
power generation eq. hip dislocation, increase
hip anteversion, bony torsion, planovalgus feet
• Lever arm restoration by Corrective/
Derotational Osteotomy

25. Ideal age ?
• The development of walking skill is completed by the
age of five to six years (J Bone Joint Surg Am.
1980;62:336-353. DH Sutherland et al)
• So surgery can be performed after achieving walking
skill (> 6 year)
• Neither too early nor too late
• 6-9 year is ideal age
• Can be done at any age when
1. Progression has stopped with all therapeutic
modalities
2. Child has already developed permanent sequel like
fixed contracture, bony torsion, joint dislocation or at
risk

26. SEMLS
• Sectoral or global
damage of brain
• Whole extremity
• > 30 muscle are involved
in single step of gait
• Best result if all
abnormalities are detected
before surgery &
corrected in single setting
surgery (Izumi K, et all.
Dev Med & Child Neuro
2004, 46: 540–547)

27. SEMLOSSS
• Every spastic muscle, contracture, bony & joint deformity
managed in single anesthesia setting (SEMLS)
• Surgical technique based on concept of orthopedic
selective spasticity control surgery (OSSCS) with
some modification
• Myofascial release of multiarticular spastic muscle
• Sparing of short monoarticular antigravity muscle
• Aponurotic & myofascial release more frequently
lesser tendon lengthening
• Tendon transfer along with lever arm restoration if
needed

28. Cont.
• Surgical planning is based on repeated evaluation
preoperatively by video gait analysis, detail
musculoskeletal evaluation and reconfirmation
during anesthesia
• Usually perform under regional block like spinal/
epidural/ brachial anesthesia
• Mini incision technique with aesthetic scar
• Plaster for only 10-12 days
• Shorter & pain less hospital stay (2 day )
• Early start of therapy (2 week)

29. Cont.

30. Benefit of SEMLOSSS
• All spasticity, contracture, muscle imbalance & bony
deformity corrected in single setting anesthesia
• No loss of antigravity activity
• Improve the appearance, speed & efficiency of gait by
simultaneously realignment of the lower extremity, patho
mechanics of the hip, knee and ankle in single stage
• Drastic decrease in recurrence & subsequent surgery
• Decrease psychological trauma to parents & children
• It enhance the recovery, speedup, decrease time frame,
easy therapy & better cooperation from child & parents

31. My experience
• 12 year of experience
• 120 camps in more than 12 state
• Total number of CP affected children & adult -
15000
• SEMLOSSS in 320 (age group-6yr to 32 yr)
• Botulinum toxin in 280
• Therapy at center based at Allahabad – 2000
• Others mx at home and other center
• More than 500 children are attending normal
school

32. Cont.
• Traditional SEMLS from beginning & change to
SEMLOSSS in year 2008
• Early surgical intervention (6.5 to 9 year) – excellent
recovery without any recurrence of deformity or
increase in disability with aging (6 year follow-up ) &
early recovery (3-4 month )
• Late surgical intervention is also effective in elder age
but took longer time to recover (9mth to 1 year ) with
some residual deformity
• We took SEMLOSSS not as a surgical tool but as a part
of total rehabilitation
• This technique has shown us a new path in these
children

33. Glimpse of few children mx by
SEMLOSSS

34. Post operative protocol
• Plaster splint for short duration (10-14 day)
• Intensive phase (early & middle phase) & maintenance
therapy (late phase)
• Rehab Start with early phase of relaxation exercises
comprise of Myofascial massage to relieve pain &
spasm, slow & gentle joint mobilization (2-4 week)
• Middle phase comprise of Strength training exercise,
FES, Gait training ( after 4 week of surgery )
• Proper braces & walking aid

35. Cont.
• Late phase – training in ADL & higher
function after achievement of good muscle
power & balance
• Slow increase in intensity of therapeutic
exercise
• Intensive therapy time-- Early age surgical
intervention (3-6 mth) & late age surgical
intervention (6-12 mth)
• Maintenance phase-- Home based therapy in
higher function & ADL till the maturity .

36. Message
• SEMLOSSS is not only surgery but it is Good
rehabilitation tool
• Not to be lost resort
• Permanent correction of deformity, good balance of
muscle tone with rare possibility of deformity recurrence
• Successful rehab surgery give all round acceleration of
other function like learning, personality development ,
behavior along with motor function recovery.
• Now advance orthopedic surgical intervention is being
considered an important incident in total management of
patient with spastic cerebral palsy.