Therapeutics
Caio M G Toledo, N/A, MD
Medical resident
IMREA HCFMUSP
São Paulo, Sao Paulo, Brazil
A 32-year old male patient sustained a severe TBI in 2009 after an assault. He developed right hemiparesis, and a 2014 brain CT scan revealed extensive lesions in the left cerebral hemisphere and bifrontal regions.
In February 2025, he sustained a second TBI in a high-speed motor vehicle accident with rollover. He presented with plegia of the left upper limb (LUL) and involuntary dystonic movements of the right upper limb (RUL).
In the physical examination, the RUL exhibited distal weakness with involuntary dystonic movements (elbow flexion, shoulder abduction and external rotation).
He underwent physical therapy, occupational therapy, psychotherapy via telehealth, music therapy, and isokinetic training. Between August and September 2024, he received weekly sessions of focal shockwave therapyapplied over the dorsum of the right hand with finger extension facilitation. Due to persistent dystonia, botulinum toxin type A injection was applied at the following muscles: deltoid, infraspinatus and biceps brachii.
Discussions: Post-traumatic dystonia is rare but can severely impair function and quality of life [2,3]. The present case illustrates the complex evolution of a patient with multiple TBIs, resulting in combined motor deficits, involuntary movements, and cognitive dysfunction. A multimodal rehabilitation program, including neuromodulation and botulinum toxin, was adopted to optimize motor outcomes. Evidence supports the efficacy of botulinum toxin in focal dystonia, reducing abnormal postures and improving function
Conclusions: This case highlights the chronic and multifaceted impact of recurrent TBI and the importance of an integrated multidisciplinary approach. Rehabilitation, neuromodulation, and botulinum toxin therapy were fundamental for managing post-traumatic dystonia and improving functional independence.
