Clinical Management of Upper Limb Spasticity

Case Report A 67-year-old right-handed male who had suffered an ischemic left basal ganglia stroke with right hemiparesis was evaluated for post-stroke rehabilitation therapies. He had undergone comprehensive inpatient rehabilitation six months earlier. When he was discharged home, he required supervision for upper and lower body dressing but was at a “modified independent” level for ambulation. However, during his three-month follow up visit, he demonstrated increased right upper-extremity spasticity. Specifically, he reported active right hand grasp but could not voluntarily open his fist to use previously acquired skills to complete self-care tasks. When he walked, he was embarrassed by the position of the right arm, which mimicked a boxer’s posture: right elbow flexed and fisted right hand held up to his mouth. On examination, Modified Ashworth scores in the right arm were 3/4 right shoulder, 3/4 right elbow, 1+/4 right wrist, and 2/4 right fingers. Manual muscle testing showed elbow flexors to be 3+/5, right wrist extensors 4/5, and right finger flexors 4/5, but right finger extensors 1/5. Left arm exam was within normal limits. During gait evaluation, the patient developed an exaggerated right elbow flexion posture to 90 degrees with the shoulder adducted and internally rotated and the fist in a clenched position. His standing balance was uneven and a mild left trunk lean was documented. The patient inquired if there were medications or therapies he could receive that would keep the right arm better positioned down at his side. He also wanted to use the right arm for daily tasks like opening a door handle or grasping a bottle. Lastly, he was embarrassed by how the arm appeared and was hoping that treatment would make his stroke less obvious to others. UPMC Rehab Grand Rounds