Optimizing Recovery: An Opportunity to Improve Access to Post-stroke Rehabilitation Care in Rural Settings

Abstract

Post-stroke spasticity (PSS) is a debilitating sequela that can lead to significant pain, severe functional decline, worse health outcomes, higher mortality rates, and increased healthcare costs. Botulinum toxin (BTX) injections are a widely recognized treatment modality to combat PSS. Not surprisingly, given that BTX administration requires a specialized provider and in-person visits, patients in rural communities are often unable to receive this vital intervention. We present the case of a 59-year-old male who suffered a left ischemic thalamic stroke resulting in severe PSS. He was initially taken to a large academic center for his stroke care, followed by a two-week inpatient rehabilitation stay, during which he made significant progress. Unfortunately, once discharged to his rural community, he was lost to follow-up. Over time, he developed painful upper and lower extremity spastic hemiparesis, which impaired his ability to ambulate, complete independent activities of daily living (ADLs), and led to severe depression. Fortunately, the patient's neighbor noted a significant decline in function and quality of life, prompting her to bring him to her Physical Medicine and Rehabilitation provider for possible intervention. Due to the kindness of his neighbor, the patient was able to reestablish care two hours away, allowing him to initiate BTX injections and address the unique challenges posed by his worsening spasticity. In response to the patient's rural residence, the authors developed a post-stroke telehealth follow-up protocol to ensure continuous virtual monitoring between in-person BTX injections. This case illustrates the potential of telemedicine to bridge the gap in care for patients residing in rural areas by leveraging the growing availability of internet access. We discuss the successful implementation of this telehealth follow-up protocol and propose it as a sustainable model for delivering essential care to underserved rural populations.

Keywords: botulinum toxin injections; post-stroke spasticity; rural health; stroke; telehealth.

Figure 1. Patient Follow-Up Timeline

MAS: Modified Ashworth Scale; BTX: Botulinum Toxin