Case Study by Dr Tram Bui, Senior Rehabilitation Specialist and VMO at Royal Rehab
Background: Helen, aged 74, presented with a six-month history of progressive decline in her mobility and had frequent falls. She had a cerebrovascular accident (CVA) two years prior, which left her with residual left body paresis. Prior to this incident, Helen mobilised independently with a frame and lived with her husband, Ken.
History: As well as experiencing more frequent falls, Helen was experiencing painful spasms in her left upper limb, which interfered with her activities of daily living. Between the spasms and the falls, Helen’s mobility had become significantly reduced, and she relied on her husband Ken for physical assistance and transfers.
Examination: On presentation, Helen was tearful, with a stooped posture and slowed gait. On physical examination, she had increased tone in her upper arm, including the pectoralis major, biceps, pronator teres, flexor carpi radialis, flexor digitorum profundus, flexor digitorum superficialis and flexor carpi radialis muslces. Clinically, this has resulted in an adducted arm, fixed flexion of the elbow, pronated forearm and flexed fingers. In addition to her physical signs, a psychological assessment with the Geriatric Depression Scale indicated that Helen had mild depression.
Management: Helen has ongoing spasticity, occuring in up to 40% of patients after stroke, most commonly in the upper limbs. Because of Helen’s high falls risk, oral agents such as the skeletal muscle relaxant Baciofen are best avoided. Helen was referred for further review and management as an inpatient at Royal Rehab Private Hospital and was treated through a specialist mutidisciplinary program. Here she was recommended a program of stretching, positioning, splinting, and botulinum toxin injections to the left upper arm and chest wall. She received botulinum toxin injections to the identified spastic muscles followed by upper arm therapy and gait retraining.
Helen was also prescribed an SSRI, resulting in significant mood improvement over the next couple of months. Following discharge, physiotherapy was continued on an outpatient basis.
An aged care assessment of their home situation was organised through a My Aged Care referral, which enabled Helen and Ken to access a range of community support services.
Discussion: Spasticity can be disabling and occurs commonly following post stroke. It may be complicated by contractures resulting in further pain and disability, and can affect independence in activities such as hygiene, mobility and sleep. Disabling spasticity is best managed in a specialist multidisciplinary program, taking into consideration the patient’s life circumstances, expectations and support.
Depression is common after a CVA, with an estimated prevalence of 29% at 12 months post stroke. The major predictors are the level of disability, pre-stroke depression, cognitive impairment, stroke severity and anxiety. Physical and cognitive recovery from this depression has been shown to be enhanced with early pharmacological treatment and psychotherapy. The SSRI Fluoxetine also has some evidence of benefit in motor recovery post stroke.
Summary: Royal Rehab Private Hospital has mutidisciplinary geriatric and specialist neurological services to manage patients effectively following a stroke. Inpatient admission may be needed followed by a referral to a Day Rehabilitation program which will allow patients to attain the intensity of rehabilitation required to optimise physical and functional gains in the critical window period following a stroke.