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Post-stroke focal lower-limb spasticity — SCE Geriatric Medicine MCQ

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HardStroke & RehabilitationPost-stroke focal lower-limb spasticitySCE Geriatric Medicine

A 79-year-old man is reviewed 5 months after a right hemispheric ischaemic stroke. He walks with a quadripod but has painful involuntary flexion of the left toes during stance, which impairs foot placement and prevents tolerance of his ankle–foot orthosis. Examination confirms focal spasticity of the long toe flexors without fixed contracture or clinically significant spasticity elsewhere. There is no skin lesion, infection, urinary retention or constipation. The multidisciplinary team has agreed goals of reducing pain and improving orthosis tolerance. Eight weeks of stretching, orthosis and footwear adjustment, trigger management and a supervised trial of functional electrical stimulation have produced no meaningful benefit. What is the most appropriate next management step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Refer to a specialist spasticity service for goal-directed assessment and targeted treatment

Explanation lettering: D = shown as A · C = shown as B · E = shown as C · A = shown as D · B = shown as E

This is persistent focal lower-limb spasticity rather than generalised spasticity. Potential exacerbating triggers and fixed contracture have been excluded, functional goals have been defined, and appropriate conservative and electrotherapy measures have failed. The painful involvement of small toe-flexor muscles also makes treatment technically complex. NICE recommends referral to a specialist spasticity service when spasticity remains unresponsive, is treatment-intolerant or presents complex needs, including small-muscle injection or spasticity-related pain. Oral baclofen (A) is principally considered for generalised spasticity and may reduce useful tone, worsen gait or cause sedation. Botulinum toxin may ultimately be appropriate, but the NICE named-product and dose recommendation applies specifically to focal upper-limb spasticity; direct injection of painful small lower-limb muscles in a general clinic is therefore not the best next step (B). Intrathecal baclofen (D) is an invasive specialist intervention generally reserved for severe, widespread refractory spasticity, not isolated toe-flexor overactivity. Functional electrical stimulation is a reasonable trial for focal spasticity, but it has already produced no meaningful benefit; persisting with it would delay appropriate escalation (E). Specialist referral does not predetermine the intervention: it enables anatomical targeting, reassessment of biomechanics and selection of treatments such as image-guided focal injection within a goal-directed programme.

Reference: Stroke rehabilitation in adults: Recommendations (18 October 2023) — https://www.nice.org.uk/guidance/ng236/chapter/Recommendations Stroke rehabilitation in adults: Rationale and impact (18 October 2023) — https://www.nice.org.uk/guidance/ng236/chapter/Rationale-and-impact