From Underuse to Recovery: Intensive Neurorehabilitation of Deforming Spastic Paresis in Resource-Contrasted Settings - A Unified Physiopathological Framework

Abstract

Background: Deforming spastic paresis following stroke remains one of the most disabling sequelae of upper motor neuron injury. The pathophysiological cascade - from neural lesion to spastic myopathy through progressive underuse -is well characterised but systematically under-treated, particularly in resource-limited settings where conventional physiotherapy remains sparse and low-intensity. The concept of therapeutic intensity, formalised through the formula I=(R×L×E)/T (repetitions × load × effort / time), provides a pharmacological-like framework for dosing neurorehabilitation. This paper presents a unified physiopathological model of underusedriven spastic paresis and its reversal through intensive, task-oriented physical therapy, illustrated by two clinical cases treated in contrasted resource environments.

Methods: Two male patients (58 and 52 years) with chronic post-stroke hemiparesis (14 and 22 months post-onset respectively) underwent a 12-week intensive neurorehabilitation protocol combining aggressive prolonged stretching, maximum-amplitude alternating movements, a guided self-rehabilitation contract (CAG), and - in the Cameroonian case -the Cogni-Famille task-shifting protocol engaging trained family members. Case 1 was treated at the private physiotherapy practice in Vitry-sur-Seine, France; Case 2 at the Regional Hospital of Bafoussam, Cameroon.

Results: Both patients demonstrated clinically significant functional recovery across all measured domains. The Modified Ashworth Scale (wrist flexors) decreased from 3/4 to 1+/4 (Case 1) and from 3/4 to 2/4 (Case 2) at 12 weeks. The E5E retraction index decreased from 0.62 to 0.31 and from 0.74 to 0.41, respectively. Walking perimeter increased from 300 m to 1,800 m (Case 1) and from 80 m to 1,200 m (Case 2). Therapeutic intensity, measured by I=(R×L×E)/T, increased 6-fold in Case 1 and 17-fold in Case 2 relative to prior conventional treatment. Both patients achieved their primary functional goals: partial return to professional activity (France)
and full return to farming (Cameroon).

Conclusion: Intensive neurorehabilitation - applied consistently, regardless of resource context -can reverse the underuse-driven pathological cascade and achieve functional recovery well beyond conventional expectations. The therapeutic intensity formula operationalises dosing in a replicable, measurable manner. The Low-Tech, High-Sense paradigm demonstrates that human expertise, not technological equipment, is the primary determinant of neuroplastic recovery in post-stroke spastic paresis.