Rachel Anderson, MD
Resident Physician
University of Kentucky
Lexington, Kentucky, United States
Nicholas C. Elwert, DO
Assistant Professor
University of Kentucky
Lexington, Kentucky, United States
A 61-year-old male with a history of right basal ganglia and cerebellar strokes with resultant left-sided spastic hemiplegia presented with a new left anterior pontine stroke and spastic tetraplegia. He was previously on dantrolene 100 mg three times daily and receiving chemodenervation for spasticity management. During his hospitalization, his dantrolene frequency was increased to four times daily. He was initiated on tizanidine 2 mg three times daily but unable to tolerate dosage/frequency increase due to somnolence. He was started on baclofen 5 mg three times daily for intractable hiccups. His baclofen dosage was gradually increased to 15 mg TID due to uncontrolled spasticity. After this increase, his Modified Barium Swallow (MBS) study showed worsening dysphagia, possibly due to decreased pharyngeal spasticity. Consequently, baclofen was reduced to 10 mg TID, which led to an improvement in swallowing function on repeat MBS.
Discussions:
This case highlights the complex interplay between spasticity management and swallowing function. The patient's dysphagia, which worsened with the increased baclofen, underscores the potential role of functional spasticity in maintaining adequate swallow mechanics. Baclofen reduces muscle spasticity, which in this case, appeared to negatively impact pharyngeal muscle tone. The subsequent improvement in swallowing following the reduction of baclofen suggests that the patient was relying on some level of spasticity for effective swallowing.
Conclusions:
The management of spasticity in stroke patients requires careful consideration of potential impacts on other functions, such as swallowing. In this case, the patient’s worsening dysphagia with increased baclofen dosage suggests that some degree of spasticity was beneficial for his swallowing mechanics. Reducing baclofen dosage led to improved dysphagia, indicating that functional spasticity played a role in this patient’s swallow. This case highlights the need for individualized treatment plans that consider both the benefits and potential side effects of spasticity medications, particularly in complex stroke patients.
