Frequently Asked Questions about SEMLARASS 

1. What is SEMLARASS?

Single Event Multi-level Lever Arm Restoration and Anti Spasticity Surgery (SEMLARASS) refers to a new and path breaking multi-level rehabilitative surgery to correct lever arm dysfunction and spasticity. SEMLARASS was conceptualised by Dr. Deepak Sharan at Bangalore, India in 2001.

2. Which patients benefit from SEMLARASS?

Patients suffering from cerebral palsy (spastic, dystonic or athetoid), head injuries and stroke may benefit.

3. What benefits can be obtained from SEMLARASS?

In case of ambulatory patients SEMLARASS helps in improving the gait (or walking patterns). In case non-ambulatory patients, SEMLARASS helps patients achieve mile stones like neck control, drooling, sitting balance, crawling, assisted standing and taking steps. In athetoid cerebral palsy it helps reduce the abnormal movements.

4. What types of surgeries are performed in SEMLARASS?

1. Soft tissue surgery: Orthopaedic Selective Spastcity Control Surgery (OSSCS) for spasticity reduction. The techniques used are Intramuscular Release and Controlled Sliding Tendon Lengthening. 
2. Osteotomies of the femur, tibia and calcaneum for the correction of lever arm dysfunction (bony deformities).

The surgeries are done through small incisions, the bones are stabilised by external fixators (rods and frames) that are removed after 6-10 weeks and joints fusions are avoided. Several new surgical techniques have been developed by Dr. Sharan.

5. What is the ideal age for SEMLARASS?

The ideal age is between 4 to 6 years, to avoid joint decompensation and over lengthening of  tendons  that happens due to continued usage of deformed joints. But earlier intervention is sometimes required for complications, e.g., hip subluxation or dislocation or severe contractures. The child develops a mature gait pattern by the age of 4 or 5 years and is better able to cooperate with a rigorous post-operative physiotherapy programme. SEMLARASS can also be performed in older children, adolescents and adults since it is the only effective way of correcting level arm dysfunction and preserving ambulation, but the results are less gratifying than in younger children. The surgery is followed by a supervised and intensive rehabilitation protocol developed by RECOUP’s experts.

6. What are the advantages of SEMLARASS?

• Avoids the psycho-social trauma of multiple hospital admissions and allows for an uninterrupted period of rehabilitation and education.
• Minimally invasive procedures that do not require large skin incisions and consequent risk of blood loss and infection
• Use of External Fixators that do not require a second operation for removal.
• Joint fusions (e.g., Grice Subtalar Arthrodesis) are not performed allowing for continued growth of the feet and avoiding degenerative arthritis in neighbouring joints.
• Simultaneous lever arm restoration is essential for spasticity and contracture correction as well as to reduce chances of   
  recurrence of deformities and repeat surgery at a later stage.
• Economical (see the cost below).
• SEMLARASS can be carried out on patients with severe paralysis, e.g., spastic quadriplegia, athetosis and dystonia. Voluntary movements depressed by severe spasticity can be facilitated after SEMLARASS.
  

7. What are the advantages of SEMLARASS over other conventional surgical procedures?

• No loss of antigravity activity (muscle weakness) since only spastic non-antigravity (multi joint) muscles are released. 
• No loss of sensation and stereognosis (sense of position).
• No increase in the occurrence of dislocations and deformities.
• Avoids most of the problems associated with Botulinum Toxin, Selective Dorsal Rhizotomy (SDR) and Intrathecal Baclofen Therapy (ITB). 

8. What is the duration of hospital admission?

The average duration of hospitalisation at the time of surgery is 4-7 days. After surgery, the child usually has plaster casts in both legs from hips to toes with knee kept straight. The average duration of immobilisation in plaster is 6-10 weeks. In the upper limbs the plaster slabs (half cast) are applied from upper arm to the fingers with the elbow kept bent at 90 degrees. The plaster is usually kept for 10-21 days.

9. When does the post-operative rehabilitation start?

The postoperative rehabilitation starts the day after the removal of plasters. Intensive therapy (4-6 treatment sessions per day) using Manual therapy, Body weight supported suspended treadmill training, Aquatic therapy, Hippotherapy, Virtual reality based therapy, EMG Biofeedback, Constraint Induced Movement Therapy, Tai Chi, etc. The intensive post-operative rehabilitation lasts for 3 -6 months and is available only at RECOUP Hospital in Bangalore. 

10. How does SEMLARASS help in improving motor functions of patients with CP?

Since the bones are severely deformed and twisted (lever arm dysfunction) because of persisting spasticity for years, the muscles cannot produce useful contraction because its line of pull is abnormal because of the bone deformity. Once the bone is "untwisted" the direction of pull of the muscles is improved. Also, spastic muscles are inherently very weak and cannot be effectively strengthened unless spasticity and lever arm dysfunction is reduced by SEMLARASS. After surgery, it is possible to improve the strength of the muscles using special rehabilitation techniques.
 

11. Is this surgery helpful for the upper limb?

OSSCS in the upper extremities help to improve the ability to turnover, to crawl and to use crutches. Basic motor functions as well as fine motor skills can be facilitated. The hand, elbow and shoulder in patients with spasticity or athetosis are candidates for surgery. Surgery may also be indicated for acquiring stability in sitting and standing and for decreasing drooling.

12. Is this surgery helpful for mentally retarded or mentally disturbed patients with CP?

Patient with IQ (Intelligent Quotient) below 70, emotionally disturbed or for those without sufficient motivation can be considered for SEMLARASS. By the control of excessive hypertonicity, emotional barrier can be removed and the motivation and the driving force of these patients can be facilitated. Important functional benefits facilitating better nursing care can be obtained. However, the overall results are sometimes inferior when compared to children with normal intelligence because of compliance issues with postoperative rehabilitation.

13. How do I know whether the patient will benefit from SEMLARASS?

An initial consultation and assessment with the Paediatric Physical Therapists and with Dr. Deepak Sharan at RECOUP Hospital will reveal whether the patient is a suitable candidate for SEMLARASS or not.

14. How much will the child improve after SEMLARASS?

It is not possible to quantify the amount of improvement expected after surgery in numerical or percent terms. This is because the eventual outcome depends on many factors that the surgical procedure cannot control, e.g., severity of CNS injury, age of the child, body weight, cognition, associated co-morbidities, motivation of patient, family support and quality of rehabilitation.

We inform the parents what they can expect of the procedure from a functional perspective, such as “Will the child still be able to stand? Will the child able to roll? Will the child sitting balance improve? Will the child’s walking ability improve?” for children in whom the surgery is expected to improve walking. Showing video tapes of similar children before and after SEMLARASS helps them to get a perception of what level of improvement is anticipated.