Physical Medicine Rehab · Supplementary · from Physical Medicine Rehab

Case 2: Stroke Rehabilitation with Spasticity

Patient Presentation

Demographics: 62-year-old female retired schoolteacher

Chief Complaint: "My left arm is stiff and curled up, and I can't use it for anything"

History of Present Illness: This 62-year-old right-handed female retired schoolteacher is presenting to the outpatient PM&R spasticity clinic 3 months after a right middle cerebral artery (MCA) territory ischemic stroke. She was found by her husband with left-sided weakness, slurred speech, and left facial droop. She was brought to the emergency department within 90 minutes of symptom onset and received IV alteplase. Despite thrombolytic therapy, she retained significant left-sided hemiparesis.

She completed a 3-week inpatient rehabilitation program and was discharged home 2 months ago. Since discharge, she has continued outpatient physical and occupational therapy twice weekly. Her left lower extremity strength has improved to the point where she can ambulate with a single-point cane and an ankle-foot orthosis, though her gait is slow with circumduction. However, her left upper extremity has become progressively more spastic and functionally useless over the past 6 weeks.

Her left arm is now held in a flexed posture with the elbow flexed at 90 degrees, forearm pronated, wrist flexed, fingers clenched in a fist, and thumb adducted across the palm. She cannot actively extend her fingers or open her hand. She reports pain in the left shoulder (rated 6/10) and difficulty with hygiene in the left palm (maceration and odor from clenched fist). Her occupational therapist has noted plateau in progress and recommended botulinum toxin injections for spasticity management.

Past Medical History:

• Right MCA ischemic stroke (3 months ago)
• Atrial fibrillation (likely embolic source of stroke)
• Hypertension
• Hyperlipidemia
• Type 2 diabetes mellitus
• Obesity (BMI 32)
• Left hemiplegic shoulder pain
• Depression (post-stroke)

Medications:

• Apixaban 5 mg twice daily
• Metoprolol succinate 50 mg daily
• Lisinopril 20 mg daily
• Atorvastatin 80 mg daily
• Metformin 1000 mg twice daily
• Baclofen 20 mg three times daily
• Tizanidine 4 mg at bedtime
• Sertraline 100 mg daily
• Acetaminophen 1000 mg three times daily

Social History:

• Retired schoolteacher (30 years of elementary education)
• Lives with husband in a single-story home
• Former social drinker, no alcohol since stroke
• Non-smoker
• Previously independent in all ADLs, now requires moderate assistance for dressing and bathing
• Uses a single-point cane and AFO for ambulation
• Unable to drive

Family History:

• Father had stroke at age 68
• Mother had atrial fibrillation and heart failure
• Brother with hypertension and diabetes

Physical Examination

• Vital Signs: BP 138/82 mmHg, HR 72 bpm (irregular), RR 14/min, Temp 36.8°C, SpO2 97% on room air, BMI 32
• General: Pleasant, cooperative female ambulating with single-point cane in right hand and left AFO. Left arm held in flexed posture
• Neurologic — Motor:
• Right upper extremity: 5/5 throughout
• Left upper extremity: Shoulder flexion 3/5, shoulder abduction 3/5, elbow flexion 4/5 (spastic), elbow extension 2/5, wrist extension 1/5, finger extension 1/5, grip (spastic flexion) — unable to voluntarily release
• Right lower extremity: 5/5 throughout
• Left lower extremity: Hip flexion 4/5, knee extension 4/5, ankle dorsiflexion 3/5, ankle plantar flexion 4/5 (spastic)
• Spasticity (Modified Ashworth Scale):
• Left elbow flexors: 3 (considerable increase in tone, passive movement difficult)
• Left wrist flexors: 3
• Left finger flexors: 3
• Left forearm pronators: 2 (marked increase in tone through most of ROM)
• Left thumb adductors: 2
• Left ankle plantar flexors: 2
• Sensory: Diminished light touch and pin prick in left upper and lower extremities. Proprioception impaired in left hand and foot
• Left Shoulder: Reduced ROM (flexion 90°, abduction 80°). Positive Neer impingement sign. Subluxation of 2 fingerbreadths at the glenohumeral joint. Tender over the supraspinatus
• Skin: Maceration and early skin breakdown in left palm from clenched fist. Mild odor
• Functional Assessment: FIM score 92/126. Ambulates 150 feet with cane and AFO with supervision. Berg Balance Scale 32/56 (moderate fall risk). Left arm non-functional for ADLs

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Brain MRI (at stroke onset): Right MCA territory infarction involving the posterior limb of the internal capsule, corona radiata, and portions of the insular cortex and frontal operculum
• Left shoulder X-ray: Inferior subluxation of the glenohumeral joint, 2 cm. No fracture
• Left shoulder ultrasound: Supraspinatus tendinopathy with partial-thickness tear. No rotator cuff full-thickness tear. Moderate subacromial-subdeltoid bursitis
• EMG/NCS: No evidence of brachial plexopathy or peripheral nerve entrapment. Findings consistent with upper motor neuron pattern
• PHQ-9: Score 14 (moderate depression)
• Montreal Cognitive Assessment (MoCA): 22/30 (mild cognitive impairment, deficits in visuospatial and executive function)

Clinical Image

Diagram illustrating the Modified Ashworth Scale for spasticity grading, upper extremity spastic posturing pattern, and botulinum toxin injection sites for post-stroke upper limb spasticity. Source: Educational illustration.

Diagnosis

Post-Stroke Left Upper Extremity Spasticity (Modified Ashworth Scale 3) with Left Hemiplegic Shoulder Pain and Functional Limitation, 3 Months After Right MCA Ischemic Stroke

Key Diagnostic Criteria:

• Upper motor neuron pattern spasticity with velocity-dependent increase in muscle tone
• Modified Ashworth Scale 3 in elbow flexors, wrist flexors, and finger flexors
• Functionally limiting: unable to use left hand for ADLs, hygiene complications from clenched fist
• Hemiplegic shoulder pain with subluxation contributing to disability

Treatment Plan

1. Botulinum toxin injections (onabotulinumtoxinA): Under EMG or ultrasound guidance, inject the following muscles:

• Biceps brachii: 100 units (2 sites)
• Brachioradialis: 50 units (1 site)
• Flexor carpi radialis: 50 units (1 site)
• Flexor carpi ulnaris: 50 units (1 site)
• Flexor digitorum superficialis: 50 units (2 sites)
• Flexor digitorum profundus: 50 units (2 sites)
• Adductor pollicis: 20 units (1 site)
• Pronator teres: 50 units (1 site)
• Total: 420 units onabotulinumtoxinA

1. Post-injection rehabilitation (critical window): Intensive occupational therapy 3-5 times/week for 4-6 weeks following injection (onset of effect 3-7 days, peak effect 2-4 weeks). Stretching program, serial casting of the wrist if needed, task-specific training, constraint-induced movement therapy if candidate
2. Shoulder pain management: Subacromial corticosteroid injection for bursitis. Shoulder sling/support for subluxation management during ambulation. Gentle ROM exercises avoiding provocative positions. Electrical stimulation to supraspinatus and posterior deltoid
3. Oral medication adjustment: Wean baclofen gradually (generalized tone reduction may impair lower extremity function needed for ambulation). Continue tizanidine at bedtime for nighttime spasms
4. Splinting: Resting hand splint for nighttime use to maintain wrist and finger extension after botulinum toxin takes effect. Custom thermoplastic splint fabricated by occupational therapist
5. Follow-up: Reassess in 3-4 months for repeat botulinum toxin injections (effect wears off in 3-6 months). Consider intrathecal baclofen pump if spasticity becomes generalized and refractory. Long-term goals: improve hand hygiene, reduce pain, improve functional use if motor recovery permits

Key Learning Points

• Botulinum toxin is the first-line focal treatment for post-stroke spasticity; it selectively weakens overactive muscles without the sedation and generalized weakness caused by oral antispasticity medications
• The "therapeutic window" after botulinum toxin injection (weeks 2-8) is the critical period for intensive rehabilitation, as reduced spasticity allows more effective stretching, strengthening, and motor relearning
• Hemiplegic shoulder pain affects 30-70% of stroke patients and is multifactorial (subluxation, rotator cuff injury, spasticity, adhesive capsulitis, complex regional pain syndrome); a systematic evaluation is needed to identify treatable causes
• Oral antispasticity medications (baclofen, tizanidine, dantrolene) should be used cautiously in stroke patients, as generalized tone reduction may impair functional mobility — particularly standing and ambulation where some tone in the lower extremity may be beneficial
• The Modified Ashworth Scale (0-4) is the most widely used clinical tool for grading spasticity, though it has limitations in distinguishing neural (velocity-dependent) from non-neural (contracture) contributions to increased resistance

All cases for this lecture as Markdown