Muscle Activation Patterns During Intensive Acute Inpatient Rehabilitation Therapy in a Patient with Dense Hemiplegia After Stroke – a Case Report

Case Diagnosis: Left middle cerebral artery thrombotic stroke with right sided hemiplegia

Case Description or Program Description: Muscle weakness is one of most common negative symptoms after stroke. Motor control impairments after stroke are not related to spasticity alone. In fact, they can also be due to muscle strength deficits secondary to loss of central neuronal connections, motor neurons and muscle fibers. Impairment in function and daily activity limitation are related to an inability to generate optimal muscle force after stroke. We present a case of a patient with right hemiplegia after a left middle cerebral artery stroke with a manual muscle test (MMT) score of 0/5 in both right upper and lower extremities.

Setting: Acute inpatient rehabilitation unit

Assessment/Results: Our patient participated in 20 sessions of intensive acute inpatient physical and occupational therapy. These sessions featured traditional training methods, body weight support training, neuromuscular electrical stimulation (at rest and during activity) and robotic exoskeleton assisted gait training.

After almost 3 weeks of therapy, our patient was able to activate forearm and wrist muscles only with electrical stimulation. No voluntary active muscle contraction was noted in the right upper extremity. However, she was able to generate voluntary active muscle contraction in the right lower extremity quadriceps.

Discussion (relevance): Patient showed overall improvement in function in terms of transfers and daily living activities related to improvement in standing balance, core strength and quadriceps activation. Strength training is imperative during early rehabilitation after stroke. It is challenging to treat a patient with dense hemiplegia (MMT 0/5) to achieve enough muscle force to be able to perform functional activities. Alternative neuromuscular therapy methods were used to achieve our therapy goals.

Conclusions: Our goal was to examine how intensive post-stroke therapy could change force generation as calculated by MMT. The amount each therapy technique contributed to the change in muscle activation patterns needs further investigation.