My name is Erin McGonigal, and I'm an assistant professor at the Medical College of Wisconsin. I will be presenting on special considerations regarding spasticity and its treatment. I do not have any relevant financial relationships to disclose. The learning objectives include being able to describe considerations to be taken into account when treating spasticity in specific populations, and listing the other various uses of botulinum toxins. The main consideration when treating the pediatric population, which consists primarily of children with cerebral palsy, is that dosing of all medications is weight-based. This includes dosing of botulinum toxins, and these limitations may contribute to a provider's recommendation to pursue intrathecal baclofen treatment. This population is also unique in that they will continue to grow and develop, so their treatment plan will need to change and adapt over time. Dosing will change, as may muscle selection. Treatment goals will be covered in a separate presentation, but vary widely depending on the child's cognitive abilities. Children also require additional considerations, as their increased tone will require decades of management. Choice of which toxin to use will be influenced by pediatric approvals. Some providers may also take into account the relative risk of antibody formation to the toxins with long-term use, which appears to vary by formation. The pediatric population is also more likely to require surgical intervention, such as tendon lengthenings, over their lifetime, and the timing of these also need to be considered. The number of patients with cerebral palsy living into adulthood has been increasing as care of these patients during childhood has improved. Thus what was for years viewed as a pediatric diagnosis is now being seen by adult providers. Because of the chronicity of their condition, adults with CP often have some degree of contracture in the affected muscles. These patients have often had prior surgeries, for which records may or may not be available. Some of these patients have received toxin injections for years, but for others, their spasticity may not have been recognized as treatable until recently. While outside of the scope of this lecture, ambulatory adults with CP are prone to musculoskeletal issues such as bursitis and arthritis from years of abnormal gait mechanics. There are also specific considerations to be taken when treating patients with spinal cord injuries. The dosing window for toxin injections in particular, or the range of the dose a patient will tolerate, can be either larger or smaller than with other patient populations. Much of this depends on the completeness of the patient's injury and their functional level and goals of injections. Patients with complete injuries have no use of the muscles involved, so there is less concern for causing weakness. Goals are usually passive, such as helping with wheelchair seating and hygiene. Patients with incomplete injuries, on the other hand, may actually use some of their spasticity to compensate for their weakness. Increased tone in the quadriceps, for instance, can help keep a patient's knee from buckling as they walk. Patients with multiple sclerosis are another unique population to treat. They are often younger and more active than stroke patients with more aggressive functional goals. The patterns of spasticity seen in MS are less predictable than with spasticity of other etiologies due to the heterogeneity of this disease based on location of the lesions. A thorough exam of all four limbs is imperative, even when only one side appears to be affected. These patients tend to be more sensitive to oral medication and toxin injections as well, though not always. Most importantly, these patients can be a moving target depending on the progression of their disease, particularly in the later stages. Thankfully, medications for preventing relapses have improved significantly in recent years, so the level of disability seen in patients diagnosed today is significantly less than those diagnosed years ago. Aside from the management of spasticity and dystonia, there is a long and growing list of other uses for botulinum toxins. Chronic migraine is one of the more widely recognized uses due to direct-to-consumer marketing. This protocol consists of 31 injections, which are standard and do not vary from patient to patient. Because of this, these injections are performed by mid-level providers in some clinics. Injections for blepharospasm and hemifacial spasm use very small doses of toxin and are usually performed by neurologists. Injections for overactive bladder are performed by urologists by accessing the bladder through the urethra. Techniques for these, including dose, dilution, and number of sites, can vary. Hyperhidrosis can be treated with botulinum toxins by intradermal injections in a grid-like pattern. While most often used in the axillary region, these injections can be effective anywhere there is excessive sweating. Sialeria can be treated with injections of botulinum toxins into the parotid and or submandibular glands. Strabismus was one of the earliest uses for botulinum toxins, though far less frequent than most other current uses. Spasmodic dysphonia can be treated by ENTs by injecting the vocal cords. While not a medical use, the use of toxin injections for aesthetics is also popular, and it's important to ask patients about this, as many will not volunteer this information unless specifically asked. When receiving botulinum toxin injections for multiple indications, it is recommended to receive these injections as close together as possible, ideally the same day. There is little data on mixing toxins or using different brands for different indications, so most providers will recommend sticking with one formulation in a specific patient. Which of the following populations may require additional considerations when treating? Cerebral palsy, multiple sclerosis, spinal cord injury, all of the above. Correct answer is D. There are multiple populations of patients who require special considerations when implementing a treatment plan. In summary, etiology of spasticity may influence presentation and management. There are now many other uses for botulinum toxins, and it's important to be aware of these and always ask patients which other injections they may be receiving.

spasticity

cerebral palsy

botulinum toxins

spinal cord injuries

multiple sclerosis