Holistic concept in treatment of children & adult affected with

Cerebral Palsy Dr Jitendra Kumar Jain

Consultant Pediatric Orthopedic SurgeonSecretary , Samvedna “trust for children with special need”

Chairman, Trishla Foundation Allahabad, UP

www.samvednatrust.com, www.trishlaortho.comFb: samvednatrust.cerebralpalsy, jitendra.jain.35513800

You tube: jjain999Email: samvedna9453039213@gmail.com

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

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 brainThe brain injury is static; it is not progressive.

However, the dysfunctions or disabilities associated with cerebral palsy can be static,

progressive or regressive.

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

Cont.

Cont.

It can present in a Variety of manner

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 ?

What you will do in this case ?

What the parents & family want from us !

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.

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

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

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

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

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.

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

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

Intervention modality ?

Intervention modality for early age (2-6 year age)

• Botulinum toxin

Intervention modality after age 6

• Orthopedic surgery-

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

Cont.

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.

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)

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

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)

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

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

modalities2. Child has already developed permanent sequel like

fixed contracture, bony torsion, joint dislocation or at risk

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)

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

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)

Cont.

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

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

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

Glimpse of few children mx by SEMLOSSS

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

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 .

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.