Barathi Sreenivasan1, MD, FRCPC, CSCN (EMG) Diplomate, Julian Spears2 , MD, SM, FRCSC, FACS, Chaya Plonka1, PT, Anne Hackland1, OT, Darinka Jokanovic1, RN, Rauni Somogyi1, SW, RSW.
 1. University of Toronto, Sunnybrook Hospital, Toronto, Canada 2. University of Toronto, St. Michael’s Hospital, Toronto, Canada

Background: 53 year old male presented with the unique combination of left posterior frontal CVA and right frontal meningioma resection attended outpatient rehabilitation. Patient developed increased tone in hip adductors, quadriceps, and gastrocsoleus, resulting in difficulty with passive stretch and Activities of Daily Living (ADL’s) including ambulation, transfers, dressing, bathing, and sleep. Examination showed focal spasticity with Modified Ashworth (MAS) in hip adductors and gastrocsoleus of grade 4 bilaterally and quadriceps grade 3 on the right and 2 on the left and bilateral ankle clonus. Passive inter-adductor distance was 575 mm.  Wong-Baker faces pain score was 6/10. 

 

Treatment: According to Canadian Stroke Best Practices Recommendations, patient underwent multidisciplinary rehabilitation. This included Occupational Therapy addressing ADL’s, transfers, stretching, and upper extremity positioning. Physiotherapy addressed gait, balance, lower extremity positioning and stretching. Nursing assisted physician with positioning during spasticity management focal injections and counselled patient. Physician treated patient initially with oral antispasticity agents, followed by focal botulinum toxin injections to bilateral hip adductors and gastrocsoleus. Quadriceps were not injected due to functional contribution of quadriceps tone to upright stance and transfers.  

 

Results:  Patient reported improvement in passive stretch and ADL’s including sleep, dressing, toileting, cleaning and transfers and ambulation distances. Physical examination showed improvement in MAS in hip adductors and gastrocsoleus, with elimination of ankle clonus. The Wong-Baker faces pain rating scale improved to 0/10. Passive inter-Adductor distance improved to 627 mm. 

 

Conclusion: Patients with unique double diagnoses of stroke and meningioma can benefit from collaborative multidisciplinary spasticity rehabilitation management. 
 

Keywords 
spasticity
stroke
multidisciplinary
rehabilitation
unique

FOCAL SPASTICITY MANAGEMENT USING COLLABORATIVE MULTIDISCIPLINARY REHABILITATION IN A CASE OF UNIQUE DUAL DIAGNOSIS WITH STROKE