So when a patient suffers hemiplegia the body can do some recovering on its own over time. The brain develops what’s called plasticity and it can find other pathways to accomplish some of the tasks that had accomplished formerly. And sometimes patient can recover the ability to grasp and release the hand to reach the mouth to walk better. But usually this plateaus or reaches a final function that still is far less than what they originally had. When this occurs, typically surgical procedures are available to get an additional degree of function. So a patient’s walking after Hemiplegia usually is stiff, spastic, he foot years use turned in, the toes are curled, and the typical answer for this as an AFO brace or an ankle foot orthosis. The patient’s foot of strapped into this to hold the ankle up or at a functional position and then the shoes put on over the top of the brace. This doesn’t correct the underlying problem in this means the patient will be relying on this brace for the rest of their lives. Sometimes function still exists in the muscles that should bring the foot up and bring the foot out and extend the toes, but they’re overpowered by the muscles that push the foot down, turn the foot in, and curl the toes. A simple procedure to correct. This is called the selective peripheral neurotomy. A patient who has this kind of tone should undergo a trial of botox or botulinum toxin. Botox can be injected into those muscles to push the foot down or turn the foot in and sometimes relieve some of that hyperactivity in those muscles to balance the function out. Oftentimes botox is not sufficient because these muscles are quite large muscles and a very large doses required. Instead of botox or even following botox, the procedure, the selective peripheral neurotin me can accomplish the same goals in as long lasting. In our practice. We often use botox to show the patient what we are trying to achieve with surgery. We will inject the muscles, provide a little bit of relaxation, and let them know that surgery would cause even more robust relaxation and be permanent. Once they decide that this is what they would like to have done, a surgical procedure what lasts a little over an hour is performed when this is the foot and walking off, and this is just behind the knee, we open, identify the nerve and the branches that are providing stimulus to the muscles that are overactive are trimmed back. We can usually cut these back by say two thirds or even four fifths, maintaining control of the muscle, but reducing that hyperactive tone substantially. When this is done, that foot will land flat on the floor once again, and many patients can graduate from that brace and walk independently.