Procedures that are available to restore function after stroke include the selective peripheral neurotomy to reduce spasticity, tendon lengthening, tendon transfers, and even at times nerve transfers. When a patient presents to determine whether they are a candidate for surgery, there are several assessments that must be undertaken. First is we must determine whether or not the patient has full passive range of motion across the joints we're looking to recover. If a patient is limited by a fixed shorting that is a muscle and tendon group that has shortened and can no longer be straightened to its full length, a different procedure must be considered. The only way to achieve that full length then is often the lengthening of that tendon or the complete dividing of that tendon. If a patient can pass the we'd be moved through the entire full passive range of motion, we then try to determine the efficacy of cutting the nerve or lengthen the tendon to simply reduce spasticity. This can sometimes be determined by injecting local anesthetic at the site of the nerve or muscle to relax that muscle temporarily. It could also be determined by using botulinum toxin or botox into the muscle we're looking to relax. By doing so, we can model what the intervention will produce by causing relaxation temporarily of that muscle in seeing how this affects the overall functioning of the limb. Additionally, sometimes we can use EMG or nerve testing studies by placing needles into the muscles of interest in finding out whether these muscles are contributing to the attempted function or resisting the attempted function. If the muscles are resisting the attempted function, then we determined that these are muscles that should be downgraded or eliminated if the muscles are contributing to the intended function that we want to make sure that these move well in her unimpeded. In certain cases, we determine that there are muscles that have functioned and it can be controlled well by the patient, but they aren't achieving a useful movement. For example, turning the palm up and turning the palm down can sometimes be maintained that a patient after a stroke, but they don't have the ability to open and close the fingers. If we determined this to be the case, sometimes we can use these nerves in the nerve transfer so that the function now is moved to something that is much higher priority. That is a grasp and release of the hand. So the patient's function that was not useful now becomes a function that is useful. These procedures are all used together in concert to achieve the best function of a limb that we can accomplish.