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: [email protected]
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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”
• 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