Cerebrovascular accidents

Abstract

CVA comprises a large number of clinical entities, depending on the site of infarction in the brain. Accurate evaluation of deficits in the patient's sensory and/or motor systems and the patient's intellectual status are paramount in establishing realistic rehabilitation goals. With respect to the motor system, two types of voluntary movement may occur. These include synergistic or pattern movement and selective movement. Spasticity in the affected lower extremity may result in a variety of lower-extremity deformities and contractures. Those most commonly encountered include hip flexion and adduction contracture, inadequate knee flexion and knee flexion contracture, and ankle equinus, varus, and equinovarus. Correct evaluation of deformities may be aided by the use of poly-EMG analysis and evaluation after nerve block or motor point blocks. In hemiplegic gait dysfunction, the basic requirements for functional ambulation include (1) ability to maintain standing balance; (2) voluntary hip flexion; (3) leg stability; and (4) ability to follow instructions and adequate motivation. Often a hemiplegic patient can be trained to ambulate if an adequate extensor synergy pattern develops, since mass extension can provide stability of the leg for weight bearing. Medical rehabilitative management of the CVA patient includes early mobilization, restorative exercises (including neuromuscular facilitation techniques), measures to prevent or correct contractures, the use of AFOs, and occasionally functional electrical stimulation. Orthopedic management of deformities in CVA is indicated where conservative measures fail. Surgical procedures seek to alter the forces causing shortening of the muscles and tendons. Hence, the most commonly performed surgical procedures include (1) tendon lengthening or release; (2) soft-tissue release; and (3) tendon transfer. Surgery for hip contractures is not common; however, occasional release of hip flexors is indicated when hip flexion contracture impedes ambulation or prone lying. Inadequate knee flexion, caused by dysphasic quadriceps contraction, can be corrected by release of the vastus medialis and rectus femoris muscles. Distal hamstring tendon release with or without knee joint capsule release is the surgical procedure of choice for severe knee flexion contractures. Surgical correction of an equinus deformity is by TAL, with or without neurectomy of tibial nerve branches to the gastrocsoleus muscles. Severe ankle varus may require a SPLATT procedure. Surgery for equinovarus includes the combined surgery for both equinus and varus (that is, TAL and SPLATT procedures). Toe curling is corrected by toe flexor releases.(ABSTRACT TRUNCATED AT 400 WORDS)