Read all latest development in management of cerebral palsy on samvedna trust blogs In last 10 year , lots of new development has taken place in the cerebral palsy management . Earlier it was thought that once child is diagnosed as a case of cerebral palsy , he will be disable for whole life. but with new advancement whole scenario of  cerebral palsy has changed . This new development has occur both in therapy as well as intervention modality. in therapy  multimodal approach by the use of nuro-developmental therapy, Sensory integration , Context therapy, tone reducing posture , strength training exercises along with the use of electrical stimulation give rise to excellent  chance of recovery in all age group. But as ages advances  this modality also stop working in spastic & mixed cerebral palsy and child start deteriorate. Earlier thought was that Result of surgery in cerebral palsy is unpredictable, some feel better and some worse following surgery. Now with advance technique and well planned surgery, child always became better.

New Advancement in Intervention Modality—

Botulinum Toxin

Single Event Multi Level Surgery

Early Surgical Intervention

Liver Arm Restoration

Tendon Transfer

Orthopedic Selective Spasticity Control Surgery (OSSCS)


Botulinum Toxin – Botulinum toxin is a powerful toxin which has been misused for biological warfare in the past. Its effect last for only 3 to 4 month but the duration of response of can be prolonged to up to some extent by use of serial cast, day night splint & good physiotherapy Mechanism of action: It acts pre-synoptically by blocking the release of the neuro-transmitter acetyl-choline at the NM junction. It does not kill neurons but causes temporary and ultimate reversible blocked of cholinergic transmission.

Role of Botulinum Toxin – Effective in only Spastic Cerebral Palsy and it Facilitate better Physiotherapy & nursing care. Agonist Muscles can be strengthen in better way and This toxin exerts its effect beyond the injection site in the form of relief of sustained abnormal posture.

Side Effects of Botulinum Toxin – Very-2 rare. Transient weakness, Swelling, bruising and calf pain, Skin rashes, Flue like syndrome. Asthenia, Urinary Incontinence.

Problem – Due to short term effect it was being used repeatedly every six month but most of our children families are not able to afford this costly treatment. So we have stop using it repeatedly and now we are using only in certain children of 2-4 year age group with sever plasticity with the purpose to facilitate better physiotherapy and to post pone OSSCS till age of 6 year

Single Event Multilevel Surgery (SEMLS) – Cerebral palsy is caused by sectoral or global brain damage so depending upon extent of lesion, whole of the affected limb is involved and on the other hand a single gait pattern require coordination of more than 30 muscles, so to correct gait pathology it is mandatory to balance each of the affected muscles. Child can get best result if all abnormalities are detected before surgery & corrected in single setting surgery followed by well structured therapy programme.

 Early Surgical Intervention– Development of walking skill is completed by the age of five years, so 6-10 year age is ideal for surgery but it can be done at any age group. Surgery should not be delayed to long, otherwise progressive deformity and co- spasticity of muscles will lead to de-compensated changes in joint & bone. Child can develop lots of non-reversible problem with late surgical intervention like over lengthening of tendon (Tendo Achilles, Patellar tendon), development of non correctable deformity like genu recurvatum, crouch gait, bony torsion, joint dislocation, mid foot break & development of plano-valgus feet and early degenerative changes in joints, some time permanent neglect of hand function. Surgery should also be not done too early unless otherwise the child develops some joint pathology like joint dislocation & bony torsion. Surgery at properly selected age group shortens the period of therapy & with early surgical intervention child can have early schooling, early & fast rehabilitation and better extracurricular activity .

 Liver Arm Restoration – Lever arm dysfunction can lead to functional weakness of muscles & gait problem. Simultaneous correction of this problem can have positive impact on gait correction. It has been seen that SEMLS by OSSCS concept in early we can prevent lever arm problem in elder age group. Only sever lever arm dysfunction require surgical correction usually in elder age children .Lever arm restoration is being done by corrective osteotomy. In cerebral palsy lever arm problem involve hip, foot as increase in hip ante version, plano-valgus feet. both problem can be managed by bony surgery.

Orthopedic Selective Spasticity Control Surgery – Orthopedic Selective Spasticity Control Surgery (OSSCS) — OSSCS is an orthopedic procedure, designed to control or reduces all kinds of hypertonicity such as spasticity & rigidity in cerebral palsy.This concept is given by Dr Takashi Matsua from Japan .It has brought a new concept of cerebral palsy management.

Basic Concept of OSSCS – Muscles of the vertebrate body are divide into two groups according to spanning number of joints. Their functional nature differs according to their biarticular / mono-articular representation. These muscles are distributed side by side in body. Long multi-articular muscle has more propensity of spasticity & more responsible for abnormal hypertonic posture, on the other hand short mono articular muscles have more antigravity and voluntary activity & provide stability to body during antigravity posture. Selective lengthening of multi-articular muscles & preservation of mono-articular muscles (Selective Spasticity control) at all affected body parts in single setting surgery (SEMLS) lead to good balance of muscle tone in whole body. Selective spasticity control may allow many patients with CP to use motor control more effectively and functionally. With simultaneous release of spastic multi articular agonist & antagonistic muscle in each joint of the body, the abnormal postural reflexes can be relieved along with better facilitation of  reciprocal and alternate movements. This concept of surgical interval give excellent response if surgery is being carried out between 6- 10 year age; although it can be done at any age group after that.




Complete section of tendon (no consideration of muscle behavior)

Selective lengthening of biarticular muscle and sparing of mono articular muscle

Tendon transfer

Not done

Not able to balance muscle power of antagonist

Possible with this procedure

Some time patient deteriorate

No deterioration

Usually delayed & done at the age of 9-10 year Early intervention from 6 year onward to prevent Joint malfunctioning


Concept of SEMLOSSS is given by Dr J K Jain . SEMLOSSS is single event multi level surgery by OSSCS concept with lots of new modification done by Dr J K Jain with some deletion and addition of surgical technique (Lever arm restoration & tendon transfer) used in cerebral palsy . Results of SEMLOSSS is excellent if children have undergone surgical intervention at early age before onset of puberty (6-10 year) . as age progresses child start developing fix bony deformity and torsion then we add bony alignment Osteotomy along with basic OSSCS surgical concept. Tendon transfer are also being add up in certain patient with sever weakness or to balance muscle tone . All these correction are being done in single anesthesia setting. we are getting excellent results in properly selected elder children with cerebral palsy by the use of newer modification in existing surgical technique , innovative ideas and well planned post surgical therapy

Advantage of New Technique –Permanent correction of deformity can be achieved with this concept & recurrence is very –very rare so most of time child do not require second surgical intervention. Well performed surgery on properly selected patient give good result provided the rehabilitation after surgery is carefully managed. Gait pattern become much more normal with properly performed Single event multilevel surgery. Successful surgery give all round acceleration of other function like learning, speech, behavior along with motor function recovery. SEMLOSSS treat a wide range of problems in motor activities and activities of daily living and provide new path for functional improvement and for active life styles in most patients with cerebral palsy.

Remarkable result in all grade of cerebral palsy irrespective of their severity. Surgery should not be delayed to long, otherwise progressive deformity and co- spasticity of muscles will lead to de-compensated changes in joint and bone and makes gaits laborious, energy consuming and inefficient. Early surgery shortens the period of therapy even for years. Although it can be done at any age group with proper indication. In upper extremity it help to improve the ability to turn over, to crawl and to use crutch. It Can also be carried out in severely paralyzed to facilitate voluntary movement that are depressed by spasticity.

It help in acquiring in rolling, crawling, sitting, kneeling, standing and independent gait.  SEMLOSSS is quite a reliable and promising procedure for patients, parents, physiotherapists and occupational therapists and even for school teachers.Well performed surgery on properly selected patient give good result provided the treatment after surgery is carefully managed. Now surgery is being considered an important incident in cerebral palsy management in patient.