'ACCESS' has almost nothing to do with recovery! ARE YOU THAT BLITHERINGLY STUPID? 100% RECOVERY PROTOCOLS ARE NEEDED!
Optimizing Recovery: An Opportunity to Improve Access to Post-stroke Rehabilitation Care in Rural Settings
Published: June 13, 2025 DOI: 10.7759/cureus.85939 Peer-Reviewed Cite this article as: Murphy K, Jonik S, Rothka A J, et al. (June 13, 2025) Optimizing Recovery: An Opportunity to Improve Access to Post-stroke Rehabilitation Care in Rural Settings. Cureus 17(6): e85939. doi:10.7759/cureus.8593Abstract
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.(Botox does nothing to cure spasticity, so you're leaving this patient disabled!)
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.
Introduction
Stroke is the leading cause of long-term adult disability in the United States, affecting over 700,000 people annually [1]. Despite remarkable advances in research aimed at improving mortality outcomes, the comorbid complications from the initial neurologic insult - such as post-stroke spasticity (PSS) - continue to plague stroke survivors. According to the American Stroke Association, 25%-43% of stroke survivors experience PSS [2]. PSS commonly develops within the first three months post-stroke, with younger patients noted to be at higher risk [2]. When unchecked, uncontrolled spasticity can result in debilitating functional outcomes, severe pain, and impaired quality of life [3]. The scientific literature emphasizes early intervention, including botulinum toxin (BTX) injections, as paramount to minimizing the morbidity and mortality associated with PSS [4]. However, despite these advancements, translating research findings into real-world applications remains challenging - particularly for patients residing in rural areas. Existing disparities in rural healthcare access - such as provider shortages, limited access to specialists, and transportation barriers - exacerbate this gap, often leaving patients without timely or appropriate interventions. We hypothesize that vastly disproportionate access to standard medical care and resource availability, based on location of residence, is a major reason for this disconnect.
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