Suzanne Wolfe, OT
Shepherd Pathways, Atlanta GA

Improved Left Upper Extremity Motor Return and Spasticity Management following CVA

History: Patient is a 32-year-old gentleman with a history of stroke and subsequent left hemiparesis. He has a complex past medical history including Crohn's disease, rheumatoid arthritis, viral cardiomyopathy, reactive airway disease and a dilated aortic root. His stroke occurred in 2010 with a large right middle cerebral artery infarct. Patient has a history of pacemaker/defibrillator placement for which he must wear a magnetic inhibitor during FES application. He ambulates without an assistive device using a left ankle-foot orthosis and is modified independent in his self-care.

Initial Upper Extremity Presentation:  Patient wears a left wrist/hand Dynasplint orthosis with an antispasticity hand piece which he wears nightly for 3-4 hours. His left upper extremity (LUE) functions within a flexor synergy pattern and as an infrequent stabilizer. He utilizes a home NMES unit daily for left upper extremity (LUE) re-education and performs therapeutic weight bearing including lying in prone while weight-bearing on his elbows for proprioceptive input. He has received Botox injections in the past to the following muscle sites with his last injections occurring on 11/15/13: Left flexor carpi ulnaris, flexor carpi radialis, flexor pollicis longus, flexor digitorum superficialis, and flexor digitorum profundus. LUE PROM is within normal limits. Despite home programming, Botox injections, and several outpatient OT admissions, he continues to present with hypertonicity and limited active movement in his LUE. Upon admission to outpatient OT on 8/17/15, his LUE strength was 2- to 2/5 in shoulder, 1/5 elbow flexion and extension, 1 to 1+ in wrist, 0/5 digit extension, and  3 to 3+ digit flexion. Left grip strength was 20 pounds upon admission. Left wrist and digits were a 2 on the Modified Ashworth scale (MAS) and elbow a 1+. He has good strength in his dominant right upper and lower extremity.

Treatment Progression: At the initiation of LUE cycling using the RT300, the patient presented with limited to no functional use of the LUE. He was seen for a total of 14 LUE cycling sessions using the RT300 from 8/17/15 to 10/12/15 at a frequency of 2x per week. Each cycling session was 25-30 minutes in duration. Electrode placement included the left biceps, triceps, anterior deltoid in addition to continuous stimulation for shoulder joint stability and sustained digit flexion. Following the 4th cycling session, the patient began reporting that his fingers and elbow felt more relaxed. He additionally demonstrated increased motor activation against gravity at the left anterior deltoid and pectoralis muscles. His parents reported that his arm swing appeared more natural during gait following the 10th cycling session. At his 13th cycling session, patient reported being able to tolerate his hand orthosis for a longer period of time during night.   

Final Upper Extremity Presentation: Patient has demonstrated increased LUE motor activation and power output during FES arm cycling, including the LUE asymmetry percentage being greater than the unaffected RUE during 10 of the 14 cycling sessions. Power output during the initial three sessions ranged between 1 and 7 Watts with nine of the eleven remaining sessions being above 8.5 Watts and as high as 26.9 Watts. During discharge evaluation of the LUE, the patient demonstrated improved manual muscle grades throughout and reduced spasticity in his left elbow, forearm, and digits since time of admission (now a 1 on the MAS). Patient presented with 1+ forearm supination upon discharge which was without trace contraction following his 7th cycling session. Following 14 cycling sessions, patient improved shoulder flexion to a 2/5 manual muscle grade, adduction to 3-, horizontal adduction to 3-, horizontal abduction to 2+, internal rotation to 3+, external rotation to 2, elbow flexion to 2-, elbow extension to 2+, and wrist flexion to 2. Left grip strength improved from 20 pounds upon admission to 25 pounds. Patient continued to report increased relaxation at his left digits, wrist, and elbow in regards to muscle tone and increased ability to move his left arm overall. Patient’s parents report increased ease when they assist with his home SROM program, stating that he is now able to initiate many movements and that his arm swing during gait continues to be more natural and relaxed.a

Assessment:  Patient made excellent progress in LUE motor return and spasticity management during an OT program at Shepherd Pathways outpatient ABI clinic which utilized the RT300 FES arm system.