The diagnostic nerve block with anaesthetics as a predictive tool before selective neurotomy in the treatment of focal spasticity
Professor Thierry Deltombe (Belgium)
Description:
My presentation will first describe the several type of spastic muscle overactivity : spasticity, spastic dystonia, spastic co-contraction, spastic motor overflow and spastic myopathy. An appropriate recognition of these different muscle overactivity type is of importance as the treatment will vary according to. I will present the diagnostic nerve block with anaesthetics and selective neurtomy procedure including the different sites of nerve treated; related indications and side effects. A littérature review with available scientific evidence will be presented. Last, the exact place of these 2 techniques in the interdisciplinary management of spastic muscle overactivity will be presented focusing on the exemple of the spastic foot.
Learning objectives:
- Describe the diagnostic nerve block with anaesthetics procedure
- Describe the selective neurotomy procedure
- Determine the appropriate candidate for nerve block and neurotomy
- Discuss the place of nerve block and neurotomy in an interdisciplinary approach
TENS as Adjunctive Therapy to Botulinum Toxin
Description:
This presentation will review the physiological basis for TENS use in spasticity management, followed by an overview of the best available evidence for this modality. We will then discuss a practical approach to TENS application in our patients..
Learning objectives:
- Describe the theoretical basis for TENS as a modality for spasticity management
- Be aware of the research on TENS for spasticity
- Have a practical approach to TENS use in your patients
Cryoneurotomy a new use of an old tool
Dr. Daniel Vincent
Description:
Many patients continue to live with disabling spasticity that negatively affects their health and quality of life. For these patients, traditional therapies such as bracing, medications, and botulinum toxin may not have achieved satisfactory outcomes. I will outline the role and techniques for diagnostic nerve blocks which are required to perform cryoneurotomy as an advanced procedure for the treatment of spasticity.
Learning objectives:
- What is the role of diagnostic conduction anesthetic blocks
- How are diagnostic conduction anesthetic blocks performed
- How is cryoneurotomy performed
- Review of cryoneurotomy treatments for spasticity
MEDICO-SURGICAL COLLABORATION : How We Interact & Practical Pearls from Around the Globe
Professor Areerat Suputtitada
Description:
Upper motor neuron lesion leads to a variety of both positive and negative phenomena, including muscle spasticity of agonists and weakness of antagonists. Patients with spasticity are at risk for development of a variety of deformities caused by these imbalances in muscle forces, leading to functional impairments, contracture, pain, and poor hygiene. The approach to the patients is by necessity multidisciplinary, because a variety of nonsurgical and surgical interventions are available. In evaluating each patient, must consider the severity and direction of any deformity, potential for improvement in function, the ability to alleviate pain, and potential for improvement in hygiene and cosmesis. Similar to the physiatry concept of botulinum toxin versus oral spasticity agent. Surgery can be local in the form of muscle releases, fusions, joint arthroplasty, and other procedures, or it can be more global and far reaching, such as nerve ablation or dorsal rhizotomy. Botulinum toxin injection and phenol or alcohol neurolysis are widely used for decreasing spasticity. Noninvasive neuromodulations as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tdcs) are promising for decreasing spasticity, neuropathic pain and facilitating motor recovery. Some particular cases we also do three dimensional gait and motion analysis before and after treatment, both advanced treatments as chemoneurolysis , noninvasive neuromodulations or surgical interventions. The physiatrists and neurologists, neurosurgeons and orthopedists collaboration in Thailand will be highlight.
Learning objectives:
- Know medico surgical collaboration in Thailand
- Know nonsurgical management using in Thailand
- Know surgical management using in Thailand
- Recognize the researches facilities in Thailand
- Recognize the management strategies and health care policies of government sections
- Know the Health care available and world standards in private sections
Role of Botulinum Toxin in the Peri-Operative Management of the Spastic Limb
Dr. Patricia Mills
Description:
The role of botulinum toxin as a peri-operative adjunct for limb spasticity surgical management will be discussed. Preliminary results of a systematic review will be presented, with presentation of a case study to illustrate the importance of considering the use of BoNT peri-operatively.
Learning objectives:
- Understand the rationale for use of BoNT peri-operatively in the spastic limb
- Know preliminary results of a systematic review on current evidence for use of peri-operative BoNT for limb spasticity
- Be able to provide a case based example of the importance of BoNT for improving surgical outcomes on spastic limbs
Management of the Spastic Non-Functional Hand
Dr. Rajiv Reebye
Description:
This session is focused on the non-functional spastic hand, a common presentation post UMN lesion. The important anatomical considerations of the spastic non-functional hand will be discussed. The importance of goal setting will also be discussed as well as the surgical management options for the spastic non-functional hand.
Learning objectives:
- To describe common patterns of UMN non-functional spastic hand
- To discuss the important anatomical considerations when treating the patient with a non-functional spastic hand
- To outline the importance of goal setting in the treatment of the non-functional hand
- To discuss surgical management options in the treatment of the non-functional spastic hand
Laser neurotomy and tenotomy
Professor Franco Molteni (Italy)
Description:
Introduction Neuro-orthopedic surgery is a standard approach in patients with hypertonicity and musculoskeletal alterations following lesions of the central nervous system [1]. In recent years, the use of laser technologies in surgical practice has gradually spread, The use of laser technology in the neuro-orthopedic field has not been yet reported in literature. Aim of the study is to verify the feasibility and the effectiveness of laser technology for minimally invasive surgical treatment of hypertonicity and musculoskeletal deformities in adult patients with Upper Motor Neuron Syndrome (UMNS).
Materials and methods Neurotomies and myotomies under ultrasound guidance and rhizotomies in radioscopy were performed from December 2017 to March 2019 on 52 patients with UMNS: 7 patients were treated on upper limbs, 41 patients on lower limbs, two patients on both upper and lower limbs; 1 patient on the dorsal roots and lower limbs, 1 patient on the dorsal roots. Clinical and instrumental analysis were conducted on patients undergoing surgery before, after 1 weeks and after 3 months surgical procedure.
Results An improvement in posture, balance, mobility, in articular range of motion (ROM) and a reduction in muscular hypertonicity both in upper and lower limbs were measured starting from the first evaluation after surgery and were also maintained at 3 months follow-up. A reduction of pain and need of analgesic therapies were observed when compared to conventional surgery; neither low-molecular-weight heparin nor antibiotics prophylaxis was needed. No major complications were reported.
Discussion The use of mini-invasive laser technique for selective neurotomies, rhizotomies and myotendineal lengthening turned out to be feasible, safe and effective in a selected population of patients with upper motor neuron syndrome for which there was indication of conventional neuro-orthopedic surgery. These preliminary results show that this approach could represent an effective alternative to conventional neuro-orthopedic surgery in a selected population of patients.
[1] Genet F, Denormandie P, Keenan MA. – Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques. – Ann Phys Rehabil Med. 2018 Oct 2. pii: S1877-0657(18)31450-7. doi: 10.1016/j.rehab.2018.09.004. [Epub ahead of print]
[2] Azadgoli B, Baker RY. Laser applications in surgery. Ann Transl Med. 2016 Dec;4(23):452. doi: 10.21037/atm.2016.11.51.
Learning objectives:
- Evaluate
- Compare
- Treat
- Choose
- Review
- Measure
Neuromodulation for Spasticity.
Professor Areerat Suputtitada (Thailand)
Description:
Spasticity is associated with various diseases of the nervous. Current advanced treatments such as botulinum toxin injections, alcohol or phenol neurolysis are sufficiently effective in a large number of patients. Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation ( TDCS ) can be considered as adjunctive treatment. According to the meta-analysis, the statistically significant effect of TMS in reducing spasticity was revealed only for lesions at the brain stem and spinal cord level. For spasticity decrement in hemispheric stroke, further research is required.. Interestingly, the evidences found that resting motor threshold (rMT) is a functional marker of the corticospinal pathway for predicting post-stroke upper limb function. However, two findings could not be clearly interpreted: (i) the fact that the rMT is an independent predictor of motor function as several confounding factors are well-established, and, (ii) whether the stroke location impacts this prediction. The current evidences found that navigated repetitive transcranial magnetic stimulation in a conventional rehabilitation program positively influenced motor and functional recovery in stroke patients but still need the large scale clinical trials. TDCS has no significant evidences in deceasing if spasticity but has the evidences of promoting the learning process via modulating cortical excitability by stimulating over the left M1 and DLPFC.
Evidence from functional magnetic resonance imaging (fMRI) studies reveals that M1 plays a significant role in motor learning. Anodal stimulation over the M1 was shown to improve implicit motor learning on a serial reaction time task as well as on an explicit motor learning task. While the improvement effect of anodal tDCS and decrease in performance due to cathodal tDCS was shown. Moreover, the evidences of TDCS for improving neuropathic pain , psychiatric problems including cognitive function in patients with neurological diseases are increasing , which may facilitate the spasticity decreasing as well.
Learning objectives:
- Know the neurophysiology of TMS and TDCS
- Know the evidences based medicine of TMS and TDCS in Spasticity
- Know how to apply TMS and TDCS .
- Know my own experiences in Clinical using of TMS and TDCS
- Know cost effectiveness of TMS and tDCS
- Know the combination of TMS and TDCS with other Neurorehab management.
ASSESSMENT AND TREATMENT.
Dr. Paul Winston (Canada)
Description:
Review of the common tools for assessing spasticity from the Modified Ashworth Scale to the Tardieu Scale. We will be using video demonstrations. A good introduction for clinicians new to spasticity care. Then the use of the Diagnostic Nerve Block DNB to enhance the assessment of determining if it is muscle resistance or spasticity or contracture that prevents in further gains in the range of motion and function. This session serves as a guide for how neuro-orthopedics and casting will be applied.
Learning objectives:
- Understand the MAS
- Learn to use the Tardieu Scale for clinical assessment and outcomes
- Interpret how the diagnostic nerve block can assist in treatment decisions.
CASTING/TAPING for Spasticity Management: Interactive Workshop
Dr. Stefano Carda (Switzerland),
Dr. Lise Leveille,
Dr. Rajiv Reebye,
Dr. Carl Ganzert (certified orthotist), Hodgson Orthopedic Group
Dr. Jordan Farag – Resident Physician, University of British Columbia
Reporting on a case series that is a component of the overall plan. – Dr. Carl Ganzert
Learning Objectives:
- Summarize rationale behind upper extremity case series
- Report results
- Interpret findings from the study
- Discuss next steps for academic inquiry
Description:
My component of the presentation will be to summarize a case series effort which has been conducted to identify the effects of a combined botulinum toxin and upper extremity
Serial casting for spasticity – Dr. Stefano Carda
Description:
Serial casting has been developed to treat spasticity, either alone or in conjunction with surgical and pharmacological treatments, from decades. Only recently many publications provided strong evidence of its importance in treating spasticity mainly in children with Cerebral Palsy, and also adult stroke survivors, when applied after neuromuscular blocks with botulinum toxin. The rationale of casting in spasticity is to provide a prolonged and effective stretching to the muscle(s), aimed to gain some length and inhibit spasticity. There is also some evidence that prolonged stretching could enhance botulinum toxin effect directly. Casting techniques in spasticity, moreover in adult patients, differs from classic casting techniques utilized in patients suffering from bone and joint traumatic injuries or in post-surgical immobilization. Some of the most important key-point needed to provide an effective and safe casting in patients with spasticity are summarized and showed.
Learning Objectives:
- Identify the (presumed) mechanisms of action of casting in spasticity
- Summarize the principal indications of casting in patients with spasticity
- Illustrate the practical modalities for the application of casting in patients with spasticity
Casting as an Adjunct to Botulinum Toxin for Spasticity – Dr. Jordan Farag– Resident Physician, University of British Columbia
Description:
This presentation will introduce casting as a therapeutic adjunct to botulinum toxin in the setting of limb spasticity. We will review current evidence for casting, with a focus on the various casting protocols described in the literature.
Learning Objectives:
- Explain the rationale and mechanism of action for casting in spasticity
- Discuss and apply the current literature for casting an an adjuct therapy post-Botulinum toxin
- Interpret findings from the study
- Discuss next steps for academic inquiry
Systems, Heaps and Emergent Properties
Professor Stephen Tredwell – Professor Emeritus Orthopaedics, University of British Columbia
Description:
In this introductory talk, I hope to be able to introduce the concept of a functional human system and the advantages this approach has over individual effort in producing outcomes that the individual members of the system could not do alone.
I will touch briefly on the impact of spasticity on growth and development and will illustrate with anecdotal sketches the values and drawbacks of current classifications and the essential role of followup.
Some mainstream treatment strategies for spasticity have arisen as emergent outputs of multi-discipline dialogue and collaboration, I will present two examples: the use of Botulinum toxin and advanced adaptive seating and positioning equipment
Learning Objectives:
- Distinguish between functional human systems and non connected groups of concerned individuals
- Question existing treatment pathways for patients with spasticity
- Appraise the value and limitations of classification systems
- Evaluate the value of comprehensive follow up
Nerve Blocks in Spasticity management
Professor Thierry Deltombe – Head of the Interdisciplinary Spasticity group, CHU UCL Namur site Godinne, B-5530 Yvoir, Belgium
Description:
My presentation will first describe the several types of spastic muscle overactivity: spasticity, spastic dystonia, spastic co-contraction, spastic motor overflow and spastic myopathy. Appropriate recognition of these different muscle overactivity type is of importance as the treatment will vary according to.
I will present the diagnostic nerve block with anesthetics and selective neurotomy procedure including the different sites of nerve treated; related indications and side effects. A littérature review with available scientific evidence will be presented. Last, the exact place of these 2 techniques in the interdisciplinary management of spastic muscle overactivity will be presented focusing on the example of the spastic foot.
Learning Objectives:
- Describe the diagnostic nerve block with anaesthetics procedure
- Describe the selective neurotomy procedure
- Determine the appropriate candidate for nerve block and neurotomy
- Discuss the place of nerve block and neurotomy in an interdisciplinary approach
How we manage upper limb spasticity. A collaborative approach.
Dr. Emily Krauss,
Daniel Vincent
Dr. Paul Winston. The Victoria Combined nerve and spasticity clinic.
Description:
Many patients continue to live with disabling spasticity that negatively affects their health and quality of life. For these patients, traditional therapies such as bracing, medications, and botulinum toxin may not have achieved satisfactory outcomes. Due to common complaints of pain, difficulty with limb positioning, and hygiene concerns there has been an increase in demand for novel adjunctive therapies that can improve patient outcomes. We present our retrospective case series review addresses the efficacy of using a selective diagnostic motor nerve block (DNB) to help predict patient outcomes and to guide the following appropriate novel therapeutic approaches: selective microfascicular surgery, tenotomy, and cryoneurotomy. A multidisciplinary team consisting of a physiatrist, hand surgeon, and an interventional anesthesiologist collaborated on patient assessment. Ultrasound (US)-guided e-stimulation DNB with 1% lidocaine was used as a screening tool to determine the most responsible muscle(s) for the spastic limb as well as whether there could be an increase in maximum active and passive range of motion in the spastic muscle group, or conversely whether fixed contractures existed. Outcomes were collected using the Tardieu Scale, Modified Ashworth Scale (MAS), and video comparisons. Patients were differentiated into one of four treatment streams: surgical microfascicular neurectomy, percutaneous cryoneurotomy, surgical tenotomy, or unlikely to benefit from further procedures.
Neurotomy – Surgical microfascicular neurectomy in the Upper Extremity for the treatment of Spasticity.
Dr. Emily Krauss (Canada)
Description:
Patients are assessed for surgery by a multidisciplinary team including a physiatrist and a hand surgeon. Ultrasound-guided nerve block of the musculocutaneous and median nerves is performed. In patients with improved hand and upper extremity position after nerve block, surgery is offered. In the operating room, the overlying muscle fascia is released and the respective main nerve trunks are exposed. Detailed understanding of the microfascicular anatomy and intraoperative nerve stimulation is used to identify motor nerve branches for neurectomy. In the musculocutaneous nerve, branches to brachialis muscle are identified. In the median nerve in the forearm, branches to flexor digitorum superficialis (FDS), and the anterior interosseus nerve are identified while protecting sensory fascicles. Identified motor nerve branches are divided, clipped, and transposed. Pectoral and ulnar nerve surgery to be discussed as well.
Learning objectives:
- Identify why peripheral nerve surgeons have a role in spasticity.
- Review the surgical anatomy.
- Identify the key branches to target for neurectomy.
Novel Interventions: CryoNeurotomy
Daniel Vincent , Dr. Paul Winston. Victoria. BC.
Description:
Novel therapies are needed to improve spasticity management outcomes with minimal risk to the individual. We propose the percutaneous cryoneurotomy of peripheral motor nerves as a treatment for spasticity. Alcohol and surgical neurotomy have been well represented the spasticity literature. Reports of percutaneous procedures remain scarce. Cryoneurotomy has decades of reported safe efficacy in the pain literature on sensory nerves over thousands of procedures. Its unique properties included the absence of neuroma formation and Wallerian degeneration while preserving the epineurium to allow for eventual regeneration. We present cyroneurotomy of the musculocutaneous nerve, radial nerve the tibial nerve. We have found that cryoneurotomy is a novel safe adjuvant treatment for the treatment of spasticity. Our initial results suggest patients can achieve significantly increased active and passive range of motion in the upper extremity and decreased clonus, and improved gait after tibial nerve cryoneurotomy.
Learning objectives:
- Learn to select appropriate patients.
- Review anatomy
- Review the technical considerations of cryoneurotomy