514 - Use of Intramuscular Hyaluronidase as a Complementary Treatment to Botulinum Toxin Chemodenervation in Post-Stroke Spasticity Management: A Case Report

Case Diagnosis: 77-year-old female with history of right basal ganglia stroke with residual left hemiplegia and upper extremity spasticity managed with botulinum toxin chemodenervation with diminishing benefit after 2 years of treatment.

Case Description: The patient initiated chemodenervation of the left arm approximately 6 months after her stroke and continued with satisfactory results for approximately 2 years. At that point, she began to note decreased duration of effect to only 2 months, continued difficulties maintaining independence with dressing, and impaired balance attributed to reduced elbow extension. She was evaluated for complementary intramuscular hyaluronidase injections and elected to proceed. After 6 months of asynchronous chemodenervation and hyaluronidase treatments with ongoing Occupational Therapy, the patient has reported subjective improvement and achieved mild objective functional gains without any reported adverse effects. Assessments have demonstrated 10- and 30-degree improvements in active elbow flexion and extension, respectively, improved grip strength, and a shift from minimum assist to modified independence for upper body dressing.

Discussions:

The use of human recombinant hyaluronidase targeting muscle stiffness secondary to immobilization is an emerging concept in spasticity management. It has shown some benefit in limited literature and more research is warranted.  To our knowledge, this is the first report of complementary hyaluronidase use with ongoing chemodenervation, and suggests this intervention may be able to augment the clinical benefits of botulinum toxin.


Conclusions: While more research is needed to validate the use of hyaluronidase in treating muscle stiffness complicating spasticity management, there is some emerging evidence of its benefit. Consideration of complementary treatment with intramuscular hyaluronidase may allow for further functional improvement for patients like ours who have found limited or diminishing benefit from standard of care management. It would provide another targeted treatment option to limit the use of systemic agents for isolated limb symptoms as well as higher risk, more permanent procedural options.