A survey of the current practice of intramuscular Botulinum toxin injections for hemiplegic shoulder pain in the UK
Disability and Rehabilitation
Nov 10, 2017 – Volume 41 – Issue 6 Published by Informa UK Limited.
Richard J. Holmes[1] and Louise A. Connell[2]
  1. Physiotherapy Department, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
  2. School of Health Sciences, University of Central Lancashire, Preston, UK
A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity
Archives of Physical Medicine and Rehabilitation
Nov 01, 2018 – Volume 99 – Issue 11 Published by Elsevier BV.
Chris Boulias, Farooq Ismail, Chetan P. Phadke, Stephen Bagg, Isabelle Bureau, Stephane Charest, Robert Chen, Albert Cheng, Karen Ethans, Milo Fink, Heather Finlayson, Sivakumar Gulasingam, Meiqi Guo, Muriel Haziza, Hossein Hosseini, Omar Khan, Michael Lang, Timothy Lapp, Robert Leckey, Rodney Li Pi Shan, Nathania Liem, Alexander Lo, Mark Mason, Stephen McNeil, Sonja McVeigh, Thomas Miller, Patricia B. Mills, Pierre Naud, Colleen O’Connell, Marc Petitclerc, Julie Prevost, Rajiv Reebye, Denyse Richardson, Lalith Satkunam, Satyendra Sharma, Christine Short, Genevieve Sirois, Milan Unarket, Theodore Wein, Kathryn Wilkins, and Paul Winston
Cryoneurotomy as a Percutaneous Mini-invasive Therapy for the Treatment of the Spastic Limb: Case Presentation, Review of the Literature, and Proposed Approach for Use
Archives of Rehabilitation Research and Clinical Translation
Dec 01, 2019 – Volume 1 – Issue 3-4 Published by Elsevier BV.
Paul Winston, Patricia Branco Mills, Rajiv Reebye, and Daniel Vincent
Ischemic Monomelic Neuropathy: The Case for Reintroducing a Little-Known Term
Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques
May 04, 2020 – Volume 47 – Issue 5 Published by Cambridge University Press (CUP).
Paul Winston and Dannika Bakker

Ischemic monomelic neuropathy (IMN) is a little-known, painful axonal neuropathy, secondary to vascular occlusion or steal phenomenon. It typically occurs after vascular bypass, hemodialysis fistulization, or diabetic microvascular disease in the absence of significant clinical features of ischemia. There is limited literature to assist in the characterization and diagnosis of this condition. We describe three patients with IMN with no surgical or peripheral vascular disease history who exhibited spontaneous, persistent foot pain, edema numbness, and weakness with denervation on needle electromyogram in a distal lower leg peripheral nerve distribution. Occlusive disease was found in all patients on angiogram, requiring vascular bypass surgery.


Practical Guidance for Outpatient Spasticity Management During the Coronavirus (COVID-19) Pandemic: Canadian Spasticity COVID-19 Task Force
Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques
May 26, 2020 – Volume 47 – Issue 5 Published by Cambridge University Press (CUP).
Rajiv Reebye, Heather Finlayson, Curtis May, Lalith Satkunam, Theodore Wein, Thomas Miller, Chris Boulias, Colleen O’Connell, Anibal Bohorquez, Sean Dukelow, Karen Ethans, Farooq Ismail, Waill Khalil, Omar Khan, Philippe Lagnau, Stephen McNeil, Patricia Mills, Geneviève Sirois, and Paul Winston
Access to Focal Spasticity Care: A Cross Canada Survey of Physiatrists
Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques
Jun 04, 2020 – Volume 47 – Issue 6 Published by Cambridge University Press (CUP).
Kevin E. Liang, Pham Vivian Ngo, and Paul Winston

Successful management of focal spasticity requires access to botulinum toxin type A (BoNT-A) injections, physiotherapy, occupational therapy, and orthoses/bracing. To assess the quality of focal spasticity care across Canada, we sent a survey consisting of 22 questions to physiatrists involved in the management of outpatient spasticity. Thirty-four physiatrists from all 10 provinces responded to the survey. Wait time for BoNT-A treatment averaged 12.7 weeks from time of referral across Canada. More than 75% of patients faced barriers to obtaining physical therapy and orthoses. Access to best quality care for spasticity patients across Canada varies widely.


Use of the Posterior Lumbar Approach for Psoas Major Injection in Hip Flexor Spasticity
Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques
Jul 27, 2020 – Volume 48 – Issue 2 Published by Cambridge University Press (CUP).
Allen Duong, Satyendra Sharma, and Anne A.M. Agur

Hip flexor spasticity in patients with upper motor neuron syndrome of multiple etiologies has been managed with botulinum neurotoxin injections mainly targeting the “iliopsoas” muscle. A lumbar approach to target psoas major (PM) has been described; however, it has not been incorporated into clinical practice due to perceived risk of injury to surrounding structures. This study will investigate the feasibility and accuracy of ultrasound-guided (UG)-PM injection using a lumbar approach by assessing the intra/extramuscular injectate spread in cadaveric specimens.


In eight lightly embalmed specimens, toluidine blue dye/saline was injected into PM using a UG-posterior lumbar approach. The posterior abdominal wall was exposed, and dye spread and surrounding structures digitized and modeled in 3D. The area and vertebral level of dye spread, distance of dye to the inferior vena cava (IVC), and abdominal aorta (AA) and dye spread to adjacent organs were quantified.


The models enabled visualization of the dye spread in 3D. Mean area of dye spread was 24.4 ± 2.8 cm2; most commonly between L2 and L4 vertebral levels. Mean distance of the dye to AA was 3.2 ± 1.2 cm and to IVC was 1.8 ± 0.4 cm. Dye spread remained intramuscular in all but one specimen. No dye spread occurred to any adjacent organs.


The injection of PM using the UG-posterior lumbar approach was consistent and without spread to surrounding structures. This technique alone or in addition to the anterior approach is expected to have better clinical outcomes in the treatment of hip flexor spasticity. Further clinical studies are required.


COVID-19 pandemic. What should Physical and Rehabilitation Medicine specialists do? A clinician's perspective
European Journal of Physical and Rehabilitation Medicine
Sep 01, 2020 – Volume 56 – Issue 4 Published by Edizioni Minerva Medica.
Stefano Carda, Marco Invernizzi, Ganesh Bavikatte, Djamel Bensmaïl, Francesca Bianchi, Thierry Deltombe, Nathalie Draulans, Alberto Esquenazi, Gerard E. Francisco, Raphaël Gross, Luis J. Jacinto, Susana Moraleda Pérez, Michael W. O'''''Dell, Rajiv Reebye, Monica Verduzco-Gutierrez, Jörg Wissel, and Franco Molteni
Spasticity Outpatient Evaluation via Telemedicine
American Journal of Physical Medicine & Rehabilitation
Sep 15, 2020 – Volume 99 – Issue 12 Published by Ovid Technologies (Wolters Kluwer Health).
Monica Verduzco-Gutierrez, Natasha L. Romanoski, Allison N. Capizzi, Rajiv N. Reebye, Supun Kotteduwa Jayawarden, Nicholas C. Ketchum, and Michael O’Dell

The COVID-19 global pandemic has resulted in significant changes to delivery of care in the field of physiatry. Most prominently, in-person visits have fast tracked to virtual visits. As we are forced to quickly adopt this new technology for our doctor-patient interactions, many questions remain with regard to structuring telemedicine visits for optimal outcomes. Little has been written on virtual evaluations of patients with spasticity. The intent of this article was to provide a framework for conducting a virtual spasticity assessment via telemedicine. We will provide tips on how to conduct a person-centered virtual examination assessment and how to document goals related to the virtual assessment.


Cryoneurotomy to Reduce Spasticity and Improve Range of Motion in Spastic Flexed Elbow: A Visual Vignette
American Journal of Physical Medicine & Rehabilitation
Oct 26, 2020 – Volume 100 – Issue 5 Published by Ovid Technologies (Wolters Kluwer Health).
Jonathan Rubenstein, Alexandra W. Harvey, Daniel Vincent, and Paul Winston
The role of physical and rehabilitation medicine in the COVID-19 pandemic: The clinician's view
Annals of Physical and Rehabilitation Medicine
Nov 01, 2020 – Volume 63 – Issue 6 Published by Elsevier BV.
Stefano Carda, Marco Invernizzi, Ganesh Bavikatte, Djamel Bensmaïl, Francesca Bianchi, Thierry Deltombe, Nathalie Draulans, Alberto Esquenazi, Gerard E. Francisco, Raphaël Gross, Luis Jorge Jacinto, Susana Moraleda Pérez, Michael W. O’Dell, Rajiv Reebye, Monica Verduzco-Gutierrez, Jörg Wissel, and Franco Molteni
Reliability and Validity of the Modified Heckmatt Scale in Evaluating Muscle Changes With Ultrasound in Spasticity
Archives of Rehabilitation Research and Clinical Translation
Dec 01, 2020 – Volume 2 – Issue 4 Published by Elsevier BV.
Marisa C. Moreta, Alana Fleet, Rajiv Reebye, Gina McKernan, Michael Berger, Jordan Farag, and Michael C. Munin
Peri-operative Botulinum Neurotoxin injection to improve outcomes of surgeries on spastic limbs: A systematic review
Dec 01, 2020 – Volume 188 Published by Elsevier BV.
Sepehr Saeidiborojeni, Patricia Branco Mills, Rajiv Reebye, and Heather Finlayson
Perioperative Botulinum Toxin Injections to Enhance Surgical Outcomes in Patients With Spasticity: Preoperative, Intraoperative, and Postoperative Case Reports
Archives of Rehabilitation Research and Clinical Translation
Mar 01, 2021 – Volume 3 – Issue 1 Published by Elsevier BV.
Geoffrey Frost, Heather Finlayson, Sepehr Saeidiborojeni, Philippe Lagnau, and Rajiv Reebye
Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion
Mar 31, 2021 – Volume 13 – Issue 4 Published by MDPI AG.
Philippe Lagnau, Alto Lo, Ryan Sandarage, Katharine Alter, Alessandro Picelli, Jorg Wissel, Monica Verduzco-Gutierrez, Areerat Suputtitada, Michael C. Munin, Stefano Carda, Omar Khan, Serdar Koçer, and Rajiv Reebye

Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.


A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm
Frontiers in Neurology
May 28, 2021 – Volume 12 Published by Frontiers Media SA.
John W. Fitterer, Alessandro Picelli, and Paul Winston

Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway.

Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators.

Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.


Ultrasound With E-Stimulation Diagnostic Nerve Blocks for Targeted Muscle Selection in Spasticity
American Journal of Physical Medicine & Rehabilitation
Jul 14, 2021 – Volume 100 – Issue 11 Published by Ovid Technologies (Wolters Kluwer Health).
Paul Winston, Mahdis Hashemi, and Daniel Vincent
Surgical Approaches to Upper Limb Spasticity in Adult Patients: A Literature Review
Frontiers in Rehabilitation Sciences
Aug 31, 2021 – Volume 2 Published by Frontiers Media SA.
Mahdis Hashemi, Nadine Sturbois-Nachef, Marry Ann Keenan, and Paul Winston

Introduction:Spasticity is the main complication of many upper motor neuron disorders. Many studies describe neuro-orthopedic surgeries for the correction of joint and limb deformities due to spasticity, though less in the upper extremity. The bulk of care provided to patients with spasticity is provided by rehabilitation clinicians, however, few of the surgical outcomes have been summarized or appraised in the rehabilitation literature.

Objective:To review the literature for neuro-orthopedic surgical techniques in the upper limb and evaluate the level of evidence for their efficacy in adult patients with spasticity.

Method:Electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched for English, French as well as Farsi languages human studies from 1980 to July 2, 2020. After removing duplicated articles, 2,855 studies were screened and 80 were found to be included based on the criteria. The studies were then divided into two groups, with 40 in each trial and non-trial. The results of the 40 trial articles were summarized in three groups: shoulder, elbow and forearm, and wrist and finger, and each group was subdivided based on the types of intervention.

Results:The level of evidence was evaluated by Sackett's approach. There were no randomized control trial studies found. About, 4 studies for shoulder, 8 studies for elbow and forearm, 26 studies for wrist and finger (including 4 for the thumb in palm deformity), and 2 systematic reviews were found. Around, two out of 40 trial articles were published in the rehabilitation journals, one systematic review in Cochrane, and the remaining 38 were published in the surgical journals.

Conclusion:Most surgical procedures are complex, consisting of several techniques based on the problems and goals of the patient. This complexity interferes with the evaluation of every single procedure. Heterogenicity of the participants and the absence of clinical trial studies are other factors of not having a single conclusion. This review reveals that almost all the studies suggested good results after the surgery in carefully selected cases with goals of reducing spasticity and improvement in function, pain, hygiene, and appearance. A more unified approach and criteria are needed to facilitate a collaborative, evidence-based, patient referral, and surgical selection pathway.


Case Report: Perspective of a Caregiver on Functional Outcomes Following Bilateral Lateral Pectoral Nerve Cryoneurotomy to Treat Spasticity in a Pediatric Patient With Cerebral Palsy
Frontiers in Rehabilitation Sciences
Sep 06, 2021 – Volume 2 Published by Frontiers Media SA.
Jack Scobie and Paul Winston

Spasticity is common and difficult to manage complication of cerebral palsy that significantly affects the function and quality of life of patients. This case study reports a 15-year-old male with quadriplegic cerebral palsy, Gross Motor Function Classification System 5 (GMFCS 5), who presented with significant bilateral adducted and internally rotated shoulders as a component of generalized spasticity. Spasticity in the lower limb of the patient had been treated with botulinum toxin A (BoNT-A) injections; however, the shoulder region was spared due to concerns of toxin spread and aspiration risk. Following diagnostic nerve blocks, the patient underwent bilateral cryoneurotomies of the right and left lateral pectoral nerves (LPNs) lasting 3.5 min for each lesion. One month after the cryoneurotomies, the range of motion (ROM) had improved from 86° to 133° on the right and 90° to 139° on the left. Improvements in ROM were retained at 9 months post-procedure. At 8.5 months following the cryoneurotomies, the caregiver reported improvements in upper body dressing, upper body washing, transferring, and the ability of the patient to remain sitting in his wheelchair for extended periods. Cryoneurotomy may be an effective procedure for improving shoulder ROM and specific functional outcomes for caregivers of patients with spasticity arising from cerebral palsy.


Canadian Physicians' Use of Perioperative Botulinum Toxin Injections to Spastic Limbs: A Cross-sectional National Survey
Archives of Rehabilitation Research and Clinical Translation
Dec 01, 2021 – Volume 3 – Issue 4 Published by Elsevier BV.
Farris Kassam, Sepehr Saeidiborojeni, Heather Finlayson, Paul Winston, and Rajiv Reebye
Canadian Physicians’ Use of Intramuscular Botulinum Toxin Injections for Shoulder Spasticity: A National Cross-Sectional Survey
Jan 10, 2023 – Volume 15 – Issue 1 Published by MDPI AG.
Farris Kassam, Brendan Lim, Sadia Afroz, Ève Boissonnault, Rajiv Reebye, Heather Finlayson, and Paul Winston

Spasticity of the upper extremity can result in severe pain, along with many complications that can impair a patient’s activities of daily living. Failure to treat patients with spasticity of the upper limb can result in a decrease in the range of motion of joints and contracture development, leading to further restriction in daily activities. We aimed to investigate the practice patterns of Canadian physicians who utilize Botulinum toxin type-A (BoNT-A) injections in the management of shoulder spasticity. 50 Canadian Physical Medicine and Rehabilitation (PM&R) physicians completed a survey with an estimated completion rate of (36.23%). The demographics of the survey participants came from a variety of provinces, clinical settings, and patient populations. The most common muscle injected for shoulder adduction and internal rotation spasticity was the pectoralis major, this was followed by latissimus dorsi, pectoralis minor, subscapularis and teres major. Injection of BoNT-A for problematic post-stroke shoulder spasticity was common, with (81.48%) of participants responding that it was always or often used in their management of post-stroke spasticity (PSS). Dosing of BoNT-A demonstrated variability for the muscle injected as well as the type of toxin used. The goals of the patients, caregivers, and practitioners were used to help guide the management of these patients. As a result, the practice patterns of Canadian physicians who treat shoulder spasticity are varied, due to numerous patient factors. Future studies are needed to analyze optimal treatment patterns, and the development of algorithms to standardize care.


International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi
Archives of Physical Medicine and Rehabilitation
Mar 01, 2023 – Volume 104 – Issue 3 Published by Elsevier BV.
Marjorie Salga, Laure Gatin, Thierry Deltombe, Thierry Gustin, Stefano Carda, Philippe Marque, Paul Winston, Rajiv Reebye, Theodore Wein, Alberto Esquenazi, Mary-Ann Keenan, Franco Molteni, Paolo Zerbinati, Alessandro Picelli, Flavia Coroian, Bertrand Coulet, Nadine Sturbois-Nachef, Christian Fontaine, Alain Yelnik, Bernard Parratte, Prakash Henry, Srikant Venkatakrishnan, Philippe Rigoard, Romain David, Philippe Denormandie, Alexis Schnitzler, Etienne Allart, and François Genet
Spasticity Management Model for Low- and Middle-Income Countries Based on World Health Organization Rehabilitation Initiatives
American Journal of Physical Medicine & Rehabilitation
Nov 22, 2023 Published by Ovid Technologies (Wolters Kluwer Health).
Roger De la Cerna-Luna[2] and Rajiv Reebye[1]
  1. Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), World Rehabilitation Alliance
  2. Medicina Fisica y Rehabilitacion HNERM, World Rehabilitation Alliance
Does casting after botulinum toxin injection improve outcomes in adults with limb spasticity? A systematic review
Journal of Rehabilitation Medicine
Apr 13, 2024 Published by Medical Journals Sweden AB.
J Farag, R Reebye, C Ganzert, and P Mills
Effect of treating elbow flexor spasticity with botulinum toxin injection and adjunctive casting on hemiparetic gait parameters: A prospective case series
Journal of Rehabilitation Medicine
Apr 13, 2024 – Volume 52 – Issue 10 Published by Medical Journals Sweden AB.
S Jayawarden, R Sandarage, J Farag, C Ganzert, P Winston, P Mills, and R Reebye
A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: An international group consensus
Journal of Rehabilitation Medicine
Apr 13, 2024 – Volume 53 – Issue 1 Published by Medical Journals Sweden AB.
G Francisco, A Balbert, G Bavikatte, D Bensmail, S Carda, T Deltombe, N Draulans, S Escaldi, R Gross, J Jacinto, N Ketchum, F Molteni, S Perez, M O’Dell, R Reebye, P Säterö, M Verduzco-Gutierrez, H Walker, and J Wissel