Hello, everyone. I'm going to talk a bit about issues in the aging patient with cerebral palsy. These are my disclosures, none of which are relevant to this discussion. Adult patients with cerebral palsy are a unique population that are caught in limbo. Historically, it's a pediatric condition, but at this point, nearly 90% of patients reach adult life. Estimates, which I personally believe are low, are that there are approximately half a million adults with CP in the U.S. In New York City, the adults now outnumber kids with about 8,000 kids and nearly 9,000 adults. The increased incidence and life expectancy that we see in the cerebral palsy population are due to a number of factors. Of course, there's improved obstetric, neonatal, and pediatric care with nutritional support and other and respirator support. Improved survival rates at earlier gestational ages have contributed to the increased incidence. And increasing rates of prematurity, there are also, as a part of that, increased rates of multiple births and increasing maternal age. The data from New York Presbyterian Hospital, my home institution, reveal a marked increase in patients in the adult and transition age from age 18 to 34, in our population, 169% in the decade between 2007 and 2017. And also, above 35, a very substantial increase. We saw an increase in pediatric population, too, but it was dwarfed by the adult population. The concept of a continuum is one which I want to emphasize today. The temporal spectrum is an important context for this discussion. Chronic diseases like cerebral palsy are not episodic. Rather, it's a continuum of care across all ages is what's needed. This is important not only for medical care, but for research. Having CP, of course, does not end at 18 or 20 or 25. The temporal spectrum is an important context in that there is a corollary that, like all people with chronic diseases, people with cerebral palsy deserve coherent, comprehensive, expert, continued care for the underlying chronic condition and all of their other health care conditions as well. This concept is borne out in other chronic diseases, which can serve as a model for CP. The Naomi Berry Diabetes Center at Columbia Presbyterian treats diabetes from birth to senescence. That in one facility, and patients do not have to move from one facility to another as they go through the various chronologic developmental states. Another continuum of disease is congenital heart disease. When children have complex reconstructive surgery as infants or children, they are not typical adults, and so specialized continuous care is needed to make sure that they have a coherent care program when they reach adult life. Cystic fibrosis is another example. They were early adapter of transition programs through the Cystic Fibrosis Foundation, and those programs allow for a seamless continuity of care into adult life. This concept of a continuum is really important and needs to be applied to cerebral palsy, which is a similar chronic condition, but what about cerebral palsy? There's the age distribution of hospitalized CP patients in the U.S. from between 1970 and 2007 exhibits the need for this transitional continued care starkly because the pediatric population has dropped significantly, and the adult population has increased from about a quarter to approaching half of patients. There is a continuation of all the childhood health issues, impairments in mobility and dexterity and spasticity, communication, and swallowing difficulties. There are the emergence of new issues, pain, early onset arthritis and osteoporosis, fractures, gastroesophageal reflux may become worse. There's progressive change in tone and bladder and bowel dysfunction that occur in adults. Majority of adults report chronic pain, and there are many studies that state this. There's one that we're looking at now from Schwartz et al. in 1999 reports that 59% of 160 CP patients were found with signs of osteoarthritis, and 27% of the ages between 15 and 25 years old were found with osteoarthritis as opposed to 4% in the general population. So what's needed to improve adult CP care? We need to deal with the diversity of the population. We need to meet comprehensive health care needs. We need to deal with the increasing incidence in life expectancy, and we need to understand for our patients that there is progression of the phenotype, if you will, with progression and with age. So our goal is multidisciplinary patient care that is supported by evidence-based research, clinical outcomes research, patient-based outcomes research, and health policy research. Here are a few examples of the adult CP problems. Cervical spinal stenosis has been seen over the last decade. Many others, including our own Joseph Tokoski, have pointed to the increased incidence of cervical spinal stenosis in CP. And this, even though it's been known, it's not disseminated. How long will it take for that kind of information to get to providers? This is an example of one of our patients who had symptoms not of neck pain, but of lower extremity and some upper extremity dysfunction that was attributed to CP. But when, because of our index of suspicion, did the workup, we discovered that there was an important spinal stenosis that needed to be treated and can be treated. Cervical spinal stenosis is the perfect argument for the paradigm of an expert adult CP care provider. The examination is complicated by preexisting neurological abnormalities, and it requires specific knowledge and a high index of suspicion. The outcomes are dramatically improved if treated properly. Tele-alta and instability, another really common problem in adults with CP. My example is a 24-year-old with right spastic hemiplegia and recurrent right patella subluxation and pain over a period of years. He experienced a significant decrease in the ability to ambulate and to climb stairs. And he went from a GMFCS2 to a GMFCS4. He had a significant patella alta, a grossly unstable patella, slight valgus deformity and intraarticular swelling. The patient was told by very competent orthopedic providers that there were no options to improve his pain and disability because of his CP, and so no treatment was entertained. And because of that lack of prevention, prophylaxis, surgical treatment and reconstruction were needed, and we did perform a right MPFL reconstruction with tibial tubercle osteotomy, and looking at his preoperative radiographs, and we did our surgery with placement of screws and stabilizing osteotomy, and his function returned to a GMFCS2. In hindsight, prevention measures for this patient would have been much more effective, if you will, and could have avoided this large surgical reconstructive treatment. But it also points out that there is care for adult patients, and that even when the golden time was missed, we can restore function and ameliorate the symptoms of musculoskeletal disease. Adult hip surveillance is another important concept in this continuity of orthopedic care. Hip subluxation or dislocations are associated in our patients with pain, gait abnormalities, and decreasing function and quality of life. Prevention is really the key. There's such a high number of adult patients who report hip pain. It's as high in some studies as 75%, and pain is probably pretty grossly underreported, especially for those with poor cognitive abilities. A survey of 123 GMFCS4s and 5s revealed 31% reporting moderate to severe, very severe pain in the preceding four weeks, and 7% reporting pain almost every day. Adoptions for the adult dislocated hip are very limited. The cause of hip pain is the degenerative joint disease, and so there's an importance of preventing that dislocation, and that's achieved through surveillance programs. Total hip arthroplasty can be done in our patients with CP quite successfully, and the survivorship of total hips in this day and age is good. However, we would—again, our goal would be to prevent the need for that surgery. But in a large series, 88% of patients with total hip replacements and cerebral palsy return to their pre-morbid GMFCS level. So adults with CP need hip surveillance. A multidisciplinary team approach is always critical, and standardized radiographic screening so that there can be early identification of problems and allow timely surgical intervention once displacement is identified as what is needed. So there are a number of barriers to adult health care for CP patients. There's a lack of awareness, and providers don't have the exposure and knowledge that is needed to really provide specialized care for these patients. The existing services are a problem for our patients. There's a lack of access to the services that do exist. And there's also a major cultural issue. Patients have a perception that their disease is permanent and there's nothing more can be done, and that perception is aided and abetted by us as the child, adolescent, young adult leaves the pediatric environment, they're often told that their treatment's finished and there really isn't anything more to be done and that they can look forward to decades of no surgery, no intervention, et cetera. And that's truly a dangerous assumption, and it leads to people avoiding care and not getting the care that they need. There's no standard of care. So there's been very, very little clinical research in adults with CP. So there are not even really validated assessment instruments for quality of life and treatment efficacy. And there definitely is no continuum of care for the adult with CP. But the ideal situation is a team approach that incorporates both pediatric and adult specialists to provide that optimum care. There is an example at our Weinberg Family Cerebral Palsy Center where we have adopted that philosophy of integrating the care of children and adults in the single institution and allowing the patient to stay and have a medical home with that center and not have to move on. So CP care today, although much improved, is disjointed and difficult for patients to navigate, particularly for adults. And what we really need is holistic care coordination, enlisting adult providers from other disciplines That has not been very difficult in the environment we have in New York City, where I'm able to enlist the interest, care, participation of care providers of all specialties to see our adult CP patients. And together, the adult and pediatric providers can make a difference in these adult patients with CP, fusing the expertise of the adult technical provider and the holistic view of the pediatric provider who understands the disease trajectory. Thank you very much. And I look forward to hearing some questions from you. Hello, everyone. My name is Hannah Azizi. I'm a pediatric physiatrist. I work at Columbia University in the city of New York. I will present chemo-neurolysis in adults with cerebral palsy, and it's mostly focused on quality of life in patients with CP. No disclosures. So overall, different studies have shown that adults with cerebral palsy, they are at higher risk for pain compared to other adults with no CP. And the main predictor for pain in adults with CP is age, the same as general population, but the incidence of pain in them is higher. And compared to children, it happens across all GMFCS levels. So in children, it's more associated with GMFCS5, while in adults with CP, they can have pain even with GMFCS1 to the lower level ones. And the pain locations, most common ones is low back pain, hip pain, and pain in legs. And some specific etiologies could be hip dislocation, osteoarthritis, fracture, or musculoskeletal conditions. So also, it has been shown that the same as in children, in adults, pain is associated with a lower quality of life and satisfaction. There's a recent study by Megan Flanagan, which is published in 2020. And this study, it's a cross-sectional study in adults with CP, and showed that pain was not associated with gross motor function classification system level, as I said before. And also pain increased with age. And in their study, self-reported spasm scores were associated with increased pain compared to modified Ashford scale and TARDO on clinical exam. So I will present several cases. All of them are my clinic patients. So the first one is a 38-year-old man with spastic diaplegic CP, GMFCS3. So when he came on his first visit, he has a history of back pain for eight years, multiple surgeries and failed spines, failed back syndrome. He was referred for intrathecal pain pump placement for severe pain. And his MRI showed a posterolateral fusion mass, and he was getting PT and massages. For his function, it's deteriorated over five years and went from like not using, now using wheelchair 85% of the time compared to 20% five years ago. And also he's using crutches 50% of the time. And he's taking multiple pain medications and muscle relaxants including fentanyl patch, tramadol and gabapentin. And even though taking pain medication on almost a standing level, he was in severe pain. So subjectively, he reported muscle tightness in legs, especially in his groin area. And he had spasms at night. Most of them they noticed they have spasms more at night than day. And the tightness in legs was making his hygiene care difficult for him. And as I said, pain was constant even though he was taking pain medication. And three to four in the morning and by the end of the day, it was seven to eight out of 10. And so the intensity was worse with activity. And he did not want to pursue intrathecal pump for pain at the time of his visit with me. On his exam, what was noticeable that he had severe tenderness and bulging of paraspinal muscles and severe spasticity in hip adductors and very limited hip abduction. And also to a lesser degree, he had spasticity and tightness in hip flexors and hamstrings. My assessment was that he had a non-radiating low back pain, the pain was not radiating to legs. Sorry, the pain was not radiating to legs. And also he had severe tenderness in paraspinal muscles and spasticity and spasms in lower extremities, which was affecting his quality of life. And then myofascial pain could worsen his low back pain. And he received botulinum toxin injection to hip flexors, adductors and paraspinal muscles and methocarbomol was discontinued and he was started on tezanidine. So, on his follow-up visit, he had improved, he reported improved range of motion in his hip area, adductors, which was, which made his ADLs and toileting easier for him. And he reported that the pain in the adductor area resolved by 96% or even more. And before he used to have pain every day, but now the pain was more when he was sitting for a long period of time. And he felt more stable when he was using his lobster crutches. And there was a significant decrease in low back pain, but the low back pain after that was only 20% less than before and he was taking tezanidine four times a day. So, on exam, the range of motion in hip flexors and adductors improved and my assessment was that considering the significant improvement in the pain and his quality of life, we repeat the injections for him. So, he receives injections every five to six months, which was delayed during COVID time, but overall it's every five to six months. And he methocarbomol was continued, completely discontinued and he's on tezanidine. And also he, there's no surgical plan for him at this time. And he has been referred for spinal injection by Ortho. The second patient, a 55 year old woman with spastic quad CP, GMFCS4. She had bilateral hip surgeries done around a year ago before her visit with me. And when I saw her, there was no concern in her follow-up visits and imaging. Sorry, I don't know why it goes to the next one. So, he's, she's using a power wheelchair for long distances and also has lobster and crutches at home, not receiving any therapy. Most of the adult patients, they don't receive any therapy at the time of their visit. And also oxybutynin and sertraline. Subjectively, she reported a sharp pulling pain in right more than left groin areas and to a lesser degree in proximal thighs and behind the knees for two months. She remembered the fall episode in bathroom before her symptoms started. And also she had muscle spasms and at night and right leg, reported that her right leg crosses over left leg and she had, and contracts at night. And on exam, I couldn't do any exam on her lower extremities actually, because of the severity of pain. And I was concerned about her hips, but they reported that recent x-ray for hip has been okay. And the surgeon was not worried about her hips. And so her hips were in flex position. Abduction was very limited and she had severe tone in quads. So legs were extended in wheelchair and also was more in quads than hamstrings. I couldn't in that time do any popliteal tests on her because of pain. And her ankles fused and plantigrade on right, equinus on left and for gait, she was completely dragging her feet on floor and feet were externally rotated. So I did a botulinum toxin injection for her just for pain relief. And so she received to hip AD doctors, ileo-sas and rectus femoris a low dose just to improve her positioning in wheelchair. I couldn't locate the site of pain on her first exam because every movement could cause her pain. And she was also referred to PT and wheelchair clinic. So on her follow-up visit, she reported that pain of spasms decreased more than 75%. And she mentioned that her legs do not cross anymore. And she's able to sleep on right side, turn to both sides. And she had started PT and walking and negotiating the stairs with her physical therapist. And on her exam, this time I was able to do some range of motion on lower extremities and just before I was not even able to touch her legs, but now I could do some even range of motion without having pain. And she was very happy about that. And so because my assessment was considering the significant subjective improvement and there was decreased pain and improved quality of life, she would benefit from repeated injections. And it's now more than two years. Again, every five, six months, she receives the injections and it lasts for her. So sometimes patients, when they come subjectively, they feel much better. Maybe on exam, the range does not change considerably, but subjectively they feel much better. So the third patient was a 60-year-old woman with CP spastic diplegia GMFCS4. She had worsening of her function and gait over seven years because of immobility and not doing any therapy or being active. And went from a GMFCS3 to 4. I was not receiving any therapy, the same as the other patient. And she was able to do transfers to toilet on her own, but needed assistance for shower. And she was taking pain medication, Baclofen, Naproxen and Tylenol. So she also was seen by ortho before coming to me. And because of hip pain, they did an X-ray which showed that she had dislocation with advanced secondary degenerative change. So also she reported that she had low back pain and left more than right hip pain, and she was not walking anymore. On her exam, she was completely in flexed position in wheelchair, hips, knees, so on. She had contracture in hip flexors, adductors and hamstrings. Hip abduction was less than neutral, so the legs were overriding each other almost. And hips and knees, they were in flexed position. And botulinum toxin injection was not for her for pain relief and for the muscle spasms, which were affecting her quality of life and also hygiene care. Injection was not to iliopsoas, adductors and hamstrings. So on her follow up visit, she reported that she's more comfortable using bathroom and doing her hygiene care. She didn't have muscle cramps anymore at night to wake her up at night. And she was more comfortable with bed mobility, just moving in bed. And she had a better sitting and standing posture and was able to move her legs with less pain. But she continues to have hip pain, the intensity decreased by almost 50%. And since then, she has not had any back pain since her first injection. So on exam, she was more comfortable and some improvement in her passive range of motion in hip abduction and extension and knee extension. And due to significant pain relief and also improved hygiene care, she continues to have botulinum toxin injection. And she has been scheduled for total hip replacement by Ortho. This patient was a 56-year-old woman with CP spastic lift hemiplegia, GMFCS2. She also has a history of seizure disorder. And again, was not receiving any therapy, no management for her tone. And she has vision impairment, but she's independent with ambulation and ADLs. And she also had pain in left knee, left shoulder. And recently, she had a left knee cortisone injection. So she came because she had persistent spasms and pain in left upper extremities. Due to vision impairment, she was not willing to use a cane. So she reported like she trips and that she didn't have stability when walking. And she was not able to walk. On exam, I noticed that she had more dystonia than spasticity. So she had repetitive continuous movement in left upper extremity and more distally within her wrist and shoulder and upper extremity was held in extension. So as you see, the modified Asher scale was in both agonist and antagonist muscles due to dystonia. So both elbow flexors and extensors, wrist flexors, and wrist was completely flexed and all are deviated. And the wrist extension was only to neutral. So she had a positive Thomas test due to hip flexor tightness and also the hamstrings were tight. And she did not have any knee flexion contracture. So she had the full knee extension. And ankle dorsiflexion was less than neutral and minus five with knee extension. Her gait on left overall was antalgic and circumduction and the queerness on the left and flat on the right. And she had a leg length discrepancy with callus on medial foot. She was using an AFO, which she had for several years and was not fitting well. So due to spasticity and dystonia in left upper extremity, which was causing her discomfort and pain, and also worsening of her gait over time and increased fall risk, I scheduled, I discussed botulinum toxin injection with her. So she received the injections to upper extremity muscles, agonist, antagonist, both groups, elbow flexors, extensors, pronator teres, wrist and finger flexors, and hip flexors and gastroc. She started OT and she was also casted for a new AFO as he left. So when she came back, she had 90% decrease in pain and in the dystonic movements in left upper extremity. So her left upper extremity was quiet, we called it quiet, no dystonic movements anymore. And she has reported better gait and tripping less than before. However, she was not very happy about the left upper extremity function, because before she was able to hold a grocery bag, somehow carry it on her left upper extremity with the spasticity that she had, and now she was not able. But she had a significant improvement in her sleep and she liked going to therapy. So the MES score decreased significantly in all muscle groups and wrist extension to 40 from neutral, and even her hip flexor tightness decreased and also the hamstrings and ankle dorsiflexion range improved. Her gait slightly improved, not significantly, but subjectively she felt much better and with less pain and improved sleep. So considering the significant decrease in spasticity and dystonia, she received repeat injections, but not two wrist flexors this time. And patient, this patient number five, a 43-year-old woman spastic quad CP. She had, again, worsening of pain spasticity and function over years. She was walking using a walker at home and wheelchair outside, and referred many times in the past for ITP pump, but patient was not considering it. And she was on different medications, including Baclofen. And this significant spasticity in legs was affecting her hygiene care. She had pain in lower back and legs. So on her exam, this patient was significantly like in the flexor position, like hips, knees, and also hip abduction was very limited. Hygiene in care was very poor because it was very difficult for me to do range, like to be able to do hip abduction. And you can consider how difficult it could be for the patient herself. And she received injection to hip flexors, 80 doctors and hamstrings and also erector spinal muscles, and was referred to neurosurgery for ITP pump. She has seen several neurosurgeons and finally is considering pump placement. But in her follow up visit, she was feeling less tight, less pain in lower back and legs by 90%. Hygiene care improved, and reported that walking and taking steps is easier than before. And she mentioned that she has, she and her physical therapist noticed some decrease in lumbar hyperextension. I did not notice it. But so she continues that she had her last injection, but I know that she has seen a neurosurgeon for ITV placement recently. So her exam improved significantly in her hip flexors and also abduction. And as I said, this increased pain, I scheduled, she has received several times botulinum toxin injection so far. The last patient is a 42 year old woman, deep diaplegic CP, GMF CS2. She had Achilles lengthening done and since then she had also some ankle pain. When she came, she's not using any assist device and independent with her ADLs. She had a history of DBT in left leg and was on Xarelto and had been referred for ankle MRI by Ortho. So she had muscle pain and spasms at night, mostly in her hamstrings and difficulty with hip abduction and also ankle pain. So she had a Thomas, positive Thomas test and ankle dorsiflexion was neutral, and hamstring tightness. So and also some tenderness over Achilles and calcaneus with spastic gait. So for her after, because of the increased tone in lower extremities and spasms, which were affecting her quality of life, she received botulinum toxin injection to hip flexors, AD doctors, hamstring and gastric muscles and referred to PT. She lives in another state. So I just followed up with her after over phone and she mentioned that she had lived with spasticity for so long that she didn't know how life could be without it. But when she came back for her next injection, she also I was able to examine her of course, but she reported that tightness is decreased and it's easier for her to walk and take taking the stairs was easier. And her movements were easier, more fluid when walking, and the less muscle spasms at night improved sex life. And other people told her that she walks better and she was having PT and home it's doing home exercises. And she was wearing a right custom made foot orthosis, which was given by ortho and the ankle MRI showed heterotopic ossification in Achilles tendon, likely post surgical. So again, she has received another time botulinum toxin injection, most of them because of COVID, it has been a delay. But every five to six months, they receive the injections. In summary, in patients with CP pains associated with lower quality of life, we should always discuss the goals of spasticity management with our patients and consider the effect of decreased tone on function. Sometimes the tone could be helpful for them. And for patients with severe spasticity, we should always consider ITB pump placement. And also just to mention it again, subjectively patients after botulinum toxin injection, subjective improvement also matters a lot. Sometimes we are not able to see a big difference in the range of motion after being living with spasticity for 40 or 50 years. These are references. Thank you. Hi, welcome to On Demand course on re-establishing musculoskeletal care for those with cerebral palsy. We're going to focus on spasticity management. And I'm going to talk about trajectory of spasticity across lifetime. As I said, I'm going to focus on chemoneuralysis. And I'm currently working at Columbia University Medical Center as a pediatric physiatrist. And this is my disclosure. And I have a lot of adult patients as a pediatric physiatrist nowadays, because life expectancy of people with cerebral palsy is approaching that of the general population. So in the past, we didn't have that much experience with adults with cerebral palsy problems. But now we have to really focus on those problems, what they are experiencing at this time. So now this lady is 56 years old, a diaplegic CP. She was GMF-CS2. She had no problem with walking, working, exercising. But now, last three years, she is having severe knee arthritis, and she is deteriorating her ambulatory function. And she even finally lost her job because she cannot walk. So now she is a GMF-CS3, she walks with crutches. But if you look at her next slide, this is she is trying to walk, but if you look at her knee MRI, there's a teeny tiny muscles left and then this is the right side which is less painful knee, has more muscles. Can you imagine with her body, she has a teeny tiny muscle which is allowing her to walk. So rest of all the structures are actually adipose tissues. So you can imagine what's going to happen to a patient with cerebral palsy as they get older. So the issues with aging in adults with cerebral palsy, early-onset sarcopenia. So as you see more disused muscle atrophy and early-onset arthritis. Can you imagine that, you know, 15 to 25 years old, young people have 27% of arthritis already compared to the 4% in general population. And they will increase the fracture because they have been on anti-seizure medications, they are poor nutrition and difficulty with walking. And pain, as Dr. Azizi and Dr. Roy said, they have significant pain as they get older. So some study shows that 82% of adults with cerebral palsy is experiencing pain. And there's other core mobility which is a bowel and blood problems, sexuality, high blood pressure, cancers. So the deterioration of ambulatory function with the aging, there's two harms according to Morgan's study in 2013. So around 20 to 25 years old, which is by the time they graduate the high school, they are losing their ambulatory function. And around 45 years old, they also lose their ambulatory function. So we have to really pay attention to help them not to lose their ambulatory function. This is a very interesting article I found that the healthcare use in individuals with CP, actually I found it in a pediatric journal. And as you can see, right side of the graph is non-ambulatory participants and left side is ambulatory participants. As you can see, the use of physical therapy, use of orthosis or seeing PMR doctors is going down as they get older. However, the medication use has gotten continuously increased. So most of medication they're using is psychotropic because most of my patients have anxiety disorder, depression, and also they have a lot of pain as we discussed. So they're on psychotropic and analgesic drugs. So this is what we have to pay attention to improve their quality of life. So this is the data from the Columbia University Medical Center. We reviewed adult with cerebral palsy psychotropic medications. About 50% of patients had depression and anxiety disorder and most of patients were on SSRI. But among SSRI, actually Prozac causes more muscle stiffness. So after you start medication, after you start Prozac, if your patient complained more spasticity, then you should change it to other type of SSRI. So Zoloft, Lexapro, those things are actually much better in terms of muscle stiffness. Now I'm going to talk about chemoneuralysis in adult with CP. So 75% of people with cerebral palsy has spasticity. So you can imagine how spasticity impacts on their movement or quality of life. So the effect of spasticity is they cause certain tasks difficult to perform or it causes severe spasm and pain and spasticity causes joint contractures or because they cannot use very well as you know spastic muscle is very weak so they feel very fatigued easily and then they don't allow long bone to grow because spastic muscle doesn't allow them to grow and then they have inhibition of protein synthesis. So let's take a look at spastic muscles. There is an increase the sarcomere length and increase the collagen in the extracellular membrane which is causing the actually contractures. So as you see on the right side MRI findings, top picture is the pronator teres of the younger patient who didn't develop the chronic spasticity yet. So you can see nice dark muscles. But lower picture from the GMSS5 who is 10 years old has very severe spasticity and contractures. You can see hyperecogenicity which is going to reflect which is the reflection of the muscle stiffness. And now I think we have to ask ourselves, should we treat chronic spasticity in adult with the CP? Because as you see MRI, it's very interesting to see there's no muscle that much so should we continue the spasticity management with the Bachelor M toxin or how Bachelor M toxin works for the stiff and atrophic muscles? I don't think there are that much research has been done at this time. And when is the best time for injection after they finished their growth? Because usually I talk to my patients that you know what when you guys finish your growth I'm not going to recommend Bachelor M toxin injection to you but even after they finish their growth I still recommend because they start to deteriorate their ambulatory function. So when is the best time for injection after they finished their growth? And how often do they need repeat injections? Most of my adult patient doesn't require every three to four months injections but sometimes once a year sometimes once every other year. So we have to really know how to assess the patient and how to make the plan for the chemoneuralysis. What else can we use for adult with spasticity? I know I'm talking about Bachelor M toxin injections and then Dr. Roy is going to talk about surgery. Is there anything else we can offer? Let's take a look at the checklist before you do chemoneuralysis. Because a patient comes to you but you never met that patient before but patient keep telling you that oh my god I'm too stiff I cannot do anything. So you have to ask the questions is this new? Or you have been stiff like this continuously? So we can imagine what is causing more spasticity at this time. And what is the reason for the deterioration of the function? You have to ask the function because we are the physiatrists we always work on working on the function. So if you don't talk about the function I think we are failing the patient care. And any joint pain? Any weakness? Because as you learned the people with cerebral palsy developed the cervical myelopathy very younger ages and a lot of patients according to our retrospective study was more than I think a lot more than a normal population. I cannot remember the percentage at this time but it was a lot higher. And any new neurological deficits? So let's talk about the chemoneuralysis for adults. Now this is a retrospective study from my clinic. I analyzed 78 adults with cerebral palsy who was not my patient for a long time but this is all new patient for me. And then the average age was 30 years old and the hemi but mostly half of them were tetraplegic and GFS45 was very high. Since we are working in the University Hospital I think we have a lot of severe cases. So if you look at this table the reason for the refer most of patients was referred by orthopedic surgery and they asked us to control their spasticity but when I meet the patient actually they are they are requesting botulinum toxin injection for pain control actually. So there's some discrepancy. So spasticity of pain is similar. Spasticity of pain that are the main reason for us to recommend botulinum toxin after they engage this function or balance problems. So this is we analyze about 227 procedures. So about three procedures per patient had it and then 20% of patient had the botulinum toxin and 45% phenol at that time. And you can see it's interesting right the botulinum toxin dose is 287.1 unit average. So it's not even 400 average right because they're big bigger than children but we were using smaller dose because of the adverse event. And then average ethanol was very low dose 2.75 milliliter. So the injection site as you see according to study on pain in CP low limb the pain in the low limb is the most common. So most common site was low limb that's why my procedure the most common site for the injection was low limb and then upper limb and then you can see actually back they complain a lot of back pain sometimes salivary gland injections we do to control the their saliva and sometimes neck pain and then trismus we treat that. And then as you see goal achievement or goal attainment is extremely important. So before I do any procedure I set the goal for the procedure because the medication what we have is such a small dose for these people and they were not so sure how much we can change their function. So we are setting the goal based upon their need. So actually the goal was met almost 80% and then partially met was 14% unmet was 1% actually. So it was very successful. So you can imagine adults also can have a benefit from the chemoneuralysis with the botulinum toxin and or phenol or ethanol. So we should not ignore their spasticity and pain when we see them in the clinic. And the first event was just weakness. It wasn't bad. So I learned from the patient. So initially I started with a small dose and then I changed to the larger dose. Then let me go the next one. Next slide is so another I was looking for the studies in adults with this sort of palsy on botulinum toxin use. Not many available but Dr. Magnum their team did a double-blind placebo control study to the patient who is cognitively intact and then they can walk without the assistive devices. And the interesting enough they were not able to see the change in the gait kinematics but they were able to see the change is in six minutes walk test or time up and go which means there was improvement in the aerobic capacity and endurance and also they did show static and dynamic balance. So now we learned that we may not be able to change their gait patterns but we will be able to help with their balance. We'll be able to help with their aerobic capacity and endurance so they may not be that much tired after they walk after the injections with botulinum toxin. Then another study in 2014 there is a multi-site botulinum toxin injection on gait quality so they always want to take a look at the gait with any procedures right. So they were doing the gait analysis 3D gait analysis and gait deviation index but unfortunately there's not much difference in gait analysis or gait deviation index which means this outcome is the same as the previous study. We may not be able to change the gait pattern but we however we are able to improve their balance and aerobic capacity and their endurance. So now I'm going to review a couple of cases before we end. So I had a 56 years old diaplegic CP X20 weaker and then used to be GFSS2 now become 3 so she is showing deterioration of her function but she her chief complaint was stiffness and spasm but she has a history of spinal fusion for spondylolisthesis she does also have rheumatoid arthritis. So her treatment, so I said she said she keeps saying that I'm so tight okay so I'll try the botulinum toxin injections but it didn't help at all. So I gave the PO baclofen which it didn't help that much. It made her very loose. So I said I'm not going to do botulinum toxin injection but let's take a look what's going on in your back and then I was able to see her L4 L5 spondylolisthesis is very stable but when we get the spinal MRI you can see multi-level spondylolisthesis changes so you can imagine how much pain she's gonna have. And then we got the c-spine of MRI and then which she showed multi-level cervical myelopathy so you can imagine this patient is having a lot of pain from the spondylolisthesis, I'm sorry the degenerative changes and cervical myelopathy. And then so proposed therapy it's very hard actually. I'm not going to recommend the botulinum toxin injections unless there's a other reason but it's operable because she has multi-level problems. Is oral medication is going to help? I think we have to try and a lot of patients I recommend intrathecal baclofen pump to control the pain. Case 2, this is 46 years old very successful lady who had all of a sudden sudden back pain. She had an x-ray which showed Schumer's nodule at L1. This is not her x-ray and then later she found that she actually didn't know that but she found that she had breast cancer and then that was a metastatized tumor in her spine so she's in chemotherapy. So when don't try to do just chemoneuralysis if they don't respond to your management you have to really do necessary studies because many times we blame cerebral palsy that's not fair. We always should treat them as just like other people so we should do necessary studies. And then case 3, 50 year old lady with left hemiplegic CP when she came she said my arms are jerking I have increased stiffness actually meanwhile she was diagnosed with Parkinson's disease so I was doing injections and the neurologist was giving her dopaminergics but she kept complaining that she cannot type so I did the injection to her because she had a claw-handed deformity she cannot reach for the object that much and then she has a tightness in the knee and ankle joints. So these all the muscles I did the shoulder muscles, elbow muscles, finger extensor flexors to help her typing. So this is not showing that much but you can see left side the screen is prior to injection but right side picture actually is after the injection she was able to go back to her typing skill so she was able to type without any problems at the time. But her Parkinson's disease is progressing at this time so I'm not so sure we are really considering botulinum toxin injection but I know that she moved to other institution because close to her house so I saw her she contacted me that she's continuously having botulinum toxin injection for finger muscles at this time. So what is the next step? Worsening rigidity, no response to L-DOPA, rigidity and jerking movement are getting worse in this case. So we have to think I think I was actually working with a neurologist at that time but they are continuously contemplating with dopaminergic at this time. Case 4, 36 year old, very successful man in finance district and he was a GMSS1 actually. He attended, participated marathon multiple times but he started to fall. He didn't know why he's falling but and one time he had a really bad fall which caused the concussion and the disc herniation. So he has a problem with the memory, attention deficits and he cannot pay attention to his job and then he went to rehabilitation doctors and he said why don't you go to Dr. Kim she does a lot of CP. So he came to me and then when I did a thorough history taking I was able to find a lot of problems from his balance issues. So he had a herniated disc L1 L4 which was treated with adult physiatrist with steroid injections and before the botulinum toxin injection I did a vertebral balance test which showed the 36 and the multilevel injection to lower limb was done. And so the chemo neurolysis was done on a hamstring bilaterally and the gastrocnemius and soleus, right side posterior tibia is and his pain was 8 out of 10 at the time and then after the injection actually his vertebral balance improved from 36 to 49 is amazing and his pain improved from 8 to 2 and then he feel much more flexible he stopped all the anti-inflammatory agent and pain medication he was able to go back to his running actually he was able to go to his gym and he was running. So he is now coming to my clinic for the botulinum injection usually once a year or once every other year. And this is my summary so we should understand trajectory of spasticity across lifetime and botulinum toxin injection for adult with CP is beneficial and indications for botulinum toxin is pain, spasticity, deterioration of the gait, sitting balance and then as you learned core setting is very very important without the setting the ball you should not do a chemo neurolysis and then dosing start with the low dose because their muscle is already very atrophic. Cytopenia already happened so you don't need to use higher dose from the beginning then you can find out what's the right dose. And if there's no response you should do find out is there any other causes which cause the functional problems and spasticity problems or pain problems as I said do the right studies don't just say oh there's cerebral palsy so just get the injections you know that's not going to work and more data more studies are needed for the adult with the cerebral palsy. Thank you very much.

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