STEP 2: Spasticity Live Course - April 25-26, 2025, in Rosemont, IL-Hemiplegic Stroke Leading to Upper Extremity Chemodenervation

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The document presents a detailed case-based discussion on managing spasticity in a 55-year-old man, Mr. R, who suffers from right spastic hemiplegia due to a left MCA infarction, a type of embolic stroke from an unknown source. The case, presented by Marilyn Pacheco, MD, from Edward Hines VA Jr. Hospital, outlines Mr. R's condition and the treatment strategy for managing his spasticity, particularly focusing on upper extremity chemodenervation.<br /><br />Mr. R has managed to maintain some independence, as he can walk unaided and regularly visits the gym, but he experiences spasticity in his right upper extremity, especially at his wrist and elbow. Examination shows normal left-sided upper and lower extremity strength, but modifications in posture and muscle tone are noted on the right side, indicating significant spastic responses, such as flexed elbows and wrists.<br /><br />The document discusses the Modified Ashworth Scale and the Tardieu Scale, both used to rate muscle tone and the quality and speed of muscle reactions. Mr. R's muscle tightness and tone were assessed to inform the management plan.<br /><br />The management approach is twofold: non-pharmacologic and pharmacologic. Non-pharmacologic interventions include aggressive stretching, ice/heat applications, vibration, electrical stimulation, and orthotic devices. Pharmaceutically, Mr. R has been tapered off baclofen and botulinum toxin injections are recommended for targeted muscles in the right upper limb, such as the pectoralis major, biceps brachii, and pronator teres. The discussion also touches on appropriate dosing guidelines for these treatments and optional neurolysis targets involving specific nerves.<br /><br />Comprehensive references are provided, including texts like "Spasticity Diagnosis and Management" and "Managing Muscle Overactivity Due to Upper Motor Neuron Syndrome," which support the management recommendations for spasticity in stroke patients.

Asset Subtitle

Marilyn S. Pacheco, MD

Keywords

spasticity

right spastic hemiplegia

MCA infarction

chemodenervation

Modified Ashworth Scale

Tardieu Scale

botulinum toxin injections

non-pharmacologic interventions

neurolysis

stroke management