Case Presentation: A 48-year-old female was referred to Neuromuscular Medicine (NMM) for left-sided spasticity. She has a past medical history of low back pain, opioid addiction, and constipation. The patient in early 2022 had a right cerebral artery (RCA) aneurysm and underwent surgical clipping. She experienced a right hemispheric ischemic stroke postoperatively, which caused left sided hemiparesis and hemisensory loss. This resulted in spasticity and wheelchair dependence. The patient has been compliant with her plan of care, receiving physical therapy (PT) and occupational therapy (OT). She has also had 2 Botox injections in her left arm since discharge from the hospital. Her symptoms have reached a plateau after 8 months of therapy, with significant remaining contractures and tactile sensibility loss in left upper and lower extremities at point of consultation. NMM employed a procedure that utilizes the fascial responses of purposeful touch called neurofascial release to restore the communication between the motor neurons of the central nervous system (CNS) and the muscles they innervate. In this procedure, one hand assesses and monitors the fascial strain pattern, while the other palpates over the fascia in the direction that causes the abnormal fascial tension to be softened. After two treatment sessions 4 weeks apart, in combination with standard therapy, the rigidity of the muscles caused by spasticity has been relieved significantly. Modified Ashworth Scale was 4 before our intervention and 2 afterwards. Sensation by light touch, proprioception, and vibration of the left arm has been restored to baseline and there has been some notable contracture reversal. The patient will continue her monthly treatment sessions with this technique.

Discussion: Approximately a quarter of stroke survivors present with spasticity 2 weeks after the cerebrovascular accident (CVA). Spasticity is a motor-sensory hybrid disorder manifesting as hyperactivation of the stretch reflexes and exaggeration of tendon jerks. Unresolved spasticity leads to involuntary contractures [1]. The inability of a muscle to reach its full range of motion imposes restrictions on adjacent tendons and soft tissues, leading to the arm being frozen in a painful position. Autonomic adrenergic fibers exist in fascia, therapeutic touch thus may induce pressure-sensitive fascial mechanoreceptor activity, followed by parasympathetic response, resulting in changes to local vasodilatation and tissue viscosity, lowering the tone of the smooth muscle cells within the fascia, loosening up contractures [2,3].

Conclusions: Neuro-fascial release activates the various connective tissue receptors that elicit neuromuscular reflexes, stimulating autonomic and viscoelastic alterations and rendering rapid tissue responses. Rehabilitation is critical in facilitating reversal of stroke-induced contractures, enhancing activity, reducing the burden on caregivers, and lessening the associated financial expenses. Stroke patients with spasticity often require long-term interventions but usually report limited rehabilitation modalities to be available. Novel rehabilitation frontiers will help close the gap of significant perceived unmet need in post-stroke medical and social services provision.

IMAGE 1: Figure 1: Somatosensory and motor homunculus of the brain.