The orthopedic management of the stroke patient

The basic problem following a cerebrovascular accident is that the normal inhibitory regulating mechanism, the cerebral motor cortex, is damaged to a variable extent. This releases primitive peripheral reflex activities resulting in aberrant function of limbs and restricted motion in joints. The sensory cortex can equally be damaged and careful assessment of sensory appreciation in the stroke patient has to be made. The initial treatment of patients after a stroke consists of a variety of physiotherapy techniques, the rationale of which is to reduce the power of dominant aberrant reflex activities and build the strength in the antagonistic group of muscles. The potential for the efficacy of physiotherapy is somewhat restricted, but there is a place for appropriate bracing. A certain number of patients exist, however, for whom physiotherapy cannot achieve the desired results and for whom bracing is either ineffective or unacceptable. The only alternative for these patients is functional electrical stimulation or reducing the activity in the deforming muscles. This can either be done by direct inactivation of the motor nerve or by actually lengthening the muscle tendon unit to reduce the power of the muscle group. An alternative is to transfer tendons.