Good afternoon, everyone, and welcome to our talk this afternoon. This is on spasticity practice guidelines for physiatrists, the latest in assessing, diagnosing, and treating spasticity in adults and children. We hope you are all in the right place. Our session faculty today, sorry, I have to put on my glasses, are Monica Verdozco Gutierrez. I'm sure I screwed that up. I'm sorry. I've gotten my whole life having my name screwed up, so I apologize. From University of Texas, San Antonio, Preeti Raghavan from Johns Hopkins in Baltimore, Daniel Moon, who is at Jefferson Moss McGee, myself, Joseph Horniak from the University of Michigan, Susan Biffle, who is at University of California San Diego Rady's Children's Hospital, and Andrew Gordon at the end, US Physiatry, Vienna, Virginia. These are our financial disclosures. I apologize that I have nothing to disclose. It would be nice after years in academics if I did, but I will work on that. This is our agenda today. We will have a brief overview of where this talk came from. We will talk about introduction and methodology for this process. We'll talk about initial follow-up and assessments, oral medications, injectables, surgical options, non-pharmacologic options, and then we will discuss future areas of research, and then where we are going with guidance for statements from AAPMNR. So I will start off with the introduction and overview. So specificity guidance, how did we get here? I've been on committees for AAPMNR for about 19 years and started on the research committee and then shifted to the evidence committee. I was preceded by Elliot Roth and Thiru Anaswamy, and we were all very passionate about physical medicine rehabilitation, having evidence to support what we did. And so during our tenures, we were trying to advance this. During this time, the registry was developed. While we were there, we saw the birth of it. We had wanted to – it started off with low back pain and then stroke was added, and then we were looking to do something with pediatrics for the registry. But as we talked to our subject matter experts, we thought this was going to be a little bit challenging to put in the registry, and so we thought about first doing some type of review paper and looking initially at cerebral palsy as a pediatric topic and thinking that was too large. Then we shifted to spasticity and then thought as a group, well, spasticity is great in children, but this is also a problem in adults, so we expanded to children and adults. During this time, there was a COVID pandemic, and the AAPMNR was instrumental in developing some guidance statements for that, and so we settled as a group, EQPC, to put together guidance statements for the management of spasticity. We initially really wanted to do formal guidelines, and I think that is our long-term goal, but formal guidelines require a fair amount of work and a fair amount of money, and we weren't quite there with the academy yet, so we started with guidance statements. In fall of 2021, the Board of Governors approved EQPC's recommendation to develop clinical practice guidelines on spasticity as the first statement for these guidance topics. So this was our timeline, so we were approved in fall of 2021. In November of 2021, we had technical expert panel applications open. In January of 2022, the EQPC blindly selected TEP members. In February of 2022, we had our first TEP meeting, and then several meetings throughout 2022 and 2023. As you can see, there is a list of our TEP members. I would like to thank them all. I screwed up this presentation because the first thing that I wanted to do but neglected to do was I wanted to thank the staff from AAPMNR, Kavitha Nirakondu, and Beth Radke, as well as Sarah Samsel. They've been very instrumental in this. They've been herding cats. You're all wonderful, but we're all physicians, and sometimes we're difficult. They've done a wonderful job. Their service was invaluable, so quickly give them a nice hand. Thank you. So our original plan when we met in February of 2022 was really kind of a six-month plan that we had hoped to put these guidelines out in fall of 2022 and really had planned to give this presentation a year ago. One of the lessons we learned is that we can't go that fast, but we've moved on, and we've been able to present this year, and our guidance statements are in submission to PMNR, so hopefully those will be formally published soon. So that has been our process so far. Monica, if you'd like to come up. All right. Thank you. I will now get to talk a little bit about the introduction section, the methodology a little bit more, and then go into a little bit of detail about the health equity piece in here. I definitely want to say it was a labor of love. That is definitely one thing that this was, especially during pandemic times and doing everything virtually. So what is this guideline? So it's clinical recommendations, and they are kind of distinguished for best practices because we are requiring a structured review of the evidence and an assessment or a grading reflecting the quality of the evidence. So again, it's condensed. It was very much review the evidence, review the evidence, and then we came up with consensus based recommendations at the end to guide the management of patients who are presenting with spasticity. And so with this in mind, we're hoping, okay, here we have these recommendations. They're all evidence based. They're graded, and we'll talk a little bit about that. And it can help endorse what has the highest quality of evidence, so hopefully that it can be used to guide your practice, and then also help us realize where there is not evidence because if there isn't evidence there yet, then maybe that's where we need to develop more evidence and do future research. So definitely this was not a pathophysiology paper where we went into detail about what is spasticity and is the LANS definition better than the, you know, PANDA's definition, better than Dr. Lee's new definition. You know, we're not doing that kind of stuff. It is definitely also not preclude your clinical judgment on an individual patient, so we still expect you to, you know, you can have these guidance statements, but you're the one treating your own individual patient, and you have to keep that into consideration. I also don't expect it to always be, you know, is it something that you can go to the insurances companies with, maybe, if it's, like, going to help your case. So what is the method? So you heard about the TEP. So TEP is Technical Expert Panel, which even in doing these slides, I was like, what does the TEP stand for? But you know, we applied for it, and we're part of the expert panel, and we did these virtual meetings over 16 months, and the Evidence, Quality, and Performance Committee also was involved in the process, and also helped review and grade the evidence. We came together, we did a modified Delphi panel, so, you know, we had recommendations based on the sort grades that we gave everything, and had some consensus voting to see, to discuss each of the different areas, and to come up with a final grade, so we could give recommendations. And then we used SORT, which was the Strength of Recommendation Taxonomy. And this was, this rated the quality of the individual studies, and so that could give us a strength of recommendation. And even though I know in Spassity City there's some things that we all do, but always there isn't maybe the best evidence behind it, so you might be a little bit shocked to see some of the, you know, the SORT grades that some things got at the end, but again, that guides what we can do in the future, and we have to look at the evidence that we have right now. And so we approved six clinical recommendations for Spassity City management, and six best practices that looked at assessment and management of Spassity City. And again, this came from the Evidence, Quality, and Performance Committee wanting to do, improve the care of adult and pediatric patients with Spassity City, so. Here are the, the first table from the paper is the best practice for Spassity City assessment, and so we have for assessment the A in one through five, and so I'm not going to read it each thing one by one, but, you know, it's talking about initially evaluating the patient and looking at the impact of Spassity City on their movement and function, and how to use that to guide the treatment management, that you should be reassessing Spassity City throughout the course, especially if you're doing interventions along the way, that standardized measurements should be used at each evaluation, so that way it's consistent across the board, and then measure the response when you do an intervention. Again, the fourth one has to talk about optimizing medical treatment, so making sure that, you know, they don't have UTI or wounds or whatever it might be that may be making their Spassity City worse, and make sure they're medically stable and not having these exacerbating issues, and then also identifying some way of goal setting, and that their goals are being met, and maybe doing a guess for some of your patients or other measures to see what their response is for each reassessment. In the next clinical recommendations, this is the SORT grades that we gave, and so A and B is the highest grade for the SORT, and so for those, we put TEP recommends, and then if it was a C, then we put suggests. So we, you know, what got grade A was for injections, we, you know, recommended clinicians consider using botulinum toxin A for management of focal upper and lower limb Spassity City, and that's based on a lot of evidence that's randomized control trials for using botulinum toxin A for Spassity City, and so that got a level A, and that got a recommend. The other A's was the surgical, and you'll, well, can go and, you know, everyone's going to talk about it a little bit more, for intrathecal baclofen, for selective dorsal rhizotomy especially, you know, there's a little note about it's how it's usually used in children. The C grade was oral medications as well as phenol or alcohol blocks, just looking at some of the data that's behind that, and so that was, we did still put suggests, so that was part of, you know, what we have for Spassity, and then there was also a no grade, which was the non-pharmacologic interventions. The other thing that was very important that we had that we started doing when we were doing all the consensus guidance statements for PASC for Long COVID, and that was having a health equity statement in there, so it is something that, you know, in our other statements we've had tables, and this one we had, you know, a couple of paragraphs that's embedded in the guidance, and so what is the point of the health equity is just to be able to look at what's happening holistically, to look at the data. There's unfortunately not a lot of data in Spasticity where it comes to health equity. That's definitely another place where more research needs to be done, but we know that there's disparities in, you know, certain populations in PM&R getting access to rehabilitation services in stroke where, you know, black, Hispanic patients or people who live rurally are less likely to get to stroke care right away and therefore have worse strokes and therefore worse outcomes and more likely to develop spasticity in those cases, and there's also literature on children with cerebral palsy, and so we talk a little bit about those disparities, about addressing the primary causes, about education through our own society and in the community, as well as encouraging training of underrepresented groups so that we have these patients that are from underrepresented groups also being served by physicians who look like them, so a little bit about what we talk about in the health equity piece. So now, Dr. Raghavan. Thank you, Dr. Gutierrez. So in terms of the assessment, I'm going to talk a little bit about how we came up with the best practice guidelines for assessment. So why should we assess the patients before and after treatment of spasticity? Well, first of all, to guide the spasticity management plan. Today we have many more choices as to what to give the patient than we had before, and so the idea is that when you assess them in a standard manner, you might actually have data to inform the management plan. The other, of course, is to set collaborative goals. So ideally, you would set it with the patient and the caregiver or the family member so that one can also manage expectations of the treatment. It's also for periodic reassessment and follow-up. Seems like somebody is pounding up there, or a cart, and ultimately to objectively measure the response to interventions, and I think this is extremely important, and Monica mentioned that. The idea is that if, for example, with botulinum toxin, if we are seeing the patient every three months, maybe there's an expectation that at that three-month time point, they will be back to square one, right? And so maybe they are better, and we need to switch to a different type of management plan, or maybe they are worse, and we need to switch to a different management plan. If we don't assess, we wouldn't know. So what kind of assessments do we use? So as Monica mentioned, definitely a patient-centered history and physical exam, and there's literature supporting the use of a five-step assessment, which I'll just go into. So clearly, the first step, as we all know, in managing patients with spasticity is to understand if there are any medical factors that might be exacerbating their spasticity, because then you would treat that rather than use any other tools in your toolbox. So there was a very nice chapter written by our president, Dr. Flanagan, on exactly what the pathophysiology might be and how to identify and treat genitourinary issues, gastrointestinal issues, vascular, musculoskeletal, and neurologic medical issues that might exacerbate spasticity. So once you identify and treat those triggering factors, you might actually realize you don't need any other treatment. The five-step assessment was proposed by Dr. Jean-Michel Gracie's in 2010. And the idea here is that spasticity has many different presentations. It's not one entity. And so the assessments should be helpful to distinguish between generalized hyperexcitability that maybe is amenable to intervention with oral spasmolytics or, in severe cases, with intrathecal baclofen. You could have predominantly a neural focal muscle overactivity, which most of us are familiar with and we treat with focal neurolysis, either with botulinum toxins or phenols or alcohol blocks or some of the newer things on the market like maybe cryo neurolysis. What Dr. Gracey talks about a lot is that a number of patients just have muscle shortening right and maybe it isn't accompanied by the classic overactivity that you see. So those may be treated with non-pharmacologic methods. Maybe you have to be a little bit more aggressive with stretching. Maybe you need surgical treatments and there may be other emerging methods. So the five step assessment itself consists of assessing passive range of motion. So this is where you can assess for muscle shortening or extensibility to what degree is that the problem. Passive range of motion how much underlying neurological ability do they have. Can they repeat movements when they have spasticity they may be able to perform the motion once or twice but if they keep performing it it may deteriorate. So it could be spasticity. It's an assessment for spasticity related coordination and fatigue and then upper limb and lower limb function where you can assess how long somebody is taking to do either a battery of tests with the upper limb or even a single test single task for example drinking from a cup. Right. That could be a marker of what you want to be able to improve. And so you could use a task like that and look at the quality of movement and lower limb function relatively easy 10 meter walk test is very well standardized. You can look at gait speed but you can also look at the quality of movement. We do want to improve these two aspects to improve function. So the tools for assessment should be ideally standard measures that are shown to be valid and reliable regardless of what we use. They should we should use the same measure to optimize consistency and repeatability and use the measure before the treatment the intervention as well as after what measure should you choose. Right. There are so many measures out there. You want to choose one that will inform your intervention and also consider a level of impairment and function. So clearly if somebody is non ambulatory you're not going to use a 10 meter walk test the type of you know maybe all you can do is measure range of motion but that would be important to do. So there are many tools for assessment out there. The modified Ashwood scale has been written about a lot but it's also been criticized a lot. The key take home here is you could use it if you can justify it and if you can use it repeatedly. Modified Ashwood scale is great to use when you're doing passive range of motion because it can at least tell you about the extensibility of the joint. But if you really want to assess past the city or the velocity dependent component then the Tardu scale is better. Goniometers is used a lot to measure range of motion but it's not very repeatable or reliable just because you could put the goniometer in different areas. So something that is you know to be considered especially after today's amazing plenary on you know bringing all of medicine into the present age the high tech age is that we could use marker based or marker less technology. Right. So for example you can use video based motion capture and you can use that for active and passive range for the rapid alternating movement so repeatability and you can also videotape the upper limb and lower limb function. So these are some parts to consider which the TV thought was a good place to begin. So I'll pass it on to Dr. Moon I thank you. So I'll be talking about oral medication options for spasticity management. The spasticity P suggests use of oral medications and manage generalized or systemic spasticity and this can be used either exclusively or as a component of a multimodal treatment approach. I tend to prefer a multimodal treatment approach and these patients is really about you know balancing your benefits and adverse effects. And this is how you know you gain compliance in the medication. So really the benefits have to outweigh the adverse effects by a lot because a lot of our patients cannot tolerate the adverse effects of these medications. Now I'm not going to really read this whole list to you but I find it interesting that oral diazepam and Dantrolene are only FDA approved for children 5 or 5 years and over. However we do tend to use I think of the pediatric population on children younger. I compare this to like when we have our newborn kid or our young kids and we're using Tylenol or ibuprofen on them to break their fever before they even turn 2 even though if you read the insert it tells you not to use it in children younger than 2. But anyways we'll move on. You know there are other medications to Xanadine and Dantrolene as well. And I think this is all very familiar to most of you guys. So we'll talk about injectables now. So the AAPMNR spasticity TEP recommends clinicians consider use of botulinum toxin A management for management of focal upper and lower limb spasticity. There's level A evidence for use of abobotulinum, incobotulinum and onobotulinum toxin in the upper extremity and also onobotulinum and abobotulinum toxin A for lower limb spasticity. In addition abobotulinum toxin A is approved for treatment of upper or lower limb spasticity in pediatric patients 2 years of age and older. And for these patients you should use a weight based protocol in determining your dosing. And again it's important to note there's lack of interchangeability between botulinum toxin products. So if you're trying to switch from one to another you can't just multiply it or divide it in order to go from. You just want to dial it back and start over again. With injectables we also want to consider use of phenol or alcohol blocks for management of focal spasticity. This is sort of lower level evidence, sort C. Phenol is commonly injected at a concentration of 3 to 6 percent whereas ethyl alcohol is commonly injected at concentrations of 40 to 50 percent. These alcohols serve to denature the protein causing a neuroplastic injury and subsequent wall laryngeal degeneration of the targeted nerve. And we find these effects to last typically 3 to 9 months. However they do have some side effects such as resulting in fibrosis, local vascular injury or even muscle necrosis due to nonspecific protein denaturation. There are also adverse effects that can occur when phenol or alcohol can inadvertently spread to adjacent nerves or when injected onto motor nerves with sensory fibers. They estimate the rate of dysesthesia, well getting dry mouth, with these blocks between zero and 30 percent. Now common motor nerves that can be a candidate for neurolysis we found evidence for were musculocutaneous nerve to the biceps and brachialis, thoracodorsal nerve to the latissimus dorsi and the obturatory nerve to the hip adductors. You can also target motor branches where they can be targeted more distally and separated from the sensory nerve fibers. These include the radial nerve motor branch to the brachioradialis, femoral nerve motor branch to rectus femoris, the vastus muscles, sciatic nerve motor branches to medial hamstrings and the tibial nerve motor branch to gastrocnemius or soleus. Common injection sites for children are the obturator nerve, the musculocutaneous nerve and the sciatic nerve motor branch to the medial hamstring. Key thing to note when you are doing these neurolysis blocks is the technique. You should ideally use electrical stim guidance to carefully localize the motor nerve. A strong muscle contraction should be obtained as stimulation less than one milliamps. Volumes vary but are usually less than one to two milliliters per site. There is some evidence to suggest that use of ultrasound can aid in localization of the nerve and may reduce overall volume of phenol. In here I'll just, you know, I'm sort of a sadomasochist and here I am injecting myself. But I use cold spray so it actually does help. You can see here I surface localized it first. In here you can see I'm focusing on the motor branch to brachioradialis. I have a catheter attached to the needle and this allows me to find the motor branch and when I actually find it and localize it I can push the phenol or alcohol in without moving the needle tip. And you can see as, I think you should be able to see a contraction there on the big screen and I don't know if you can see the screen but I will turn it all the way down to I think about 0.3 or 0.4 milliamps and you can still see a contraction. All right, I'll turn this presentation over to Dr. Biffle. I'm very impressed by your bravery of injecting yourself. I don't think I've ever done that. So I'm going to start with our surgical options and we have a few things that are very straightforward and some that are decidedly not. So as far as sort A grade, intrathecal baclofen pump therapy is an effective treatment for spasticity of cerebral or spinal origin. This has been shown to be effective in large varied populations, children, adults, spinal cord injury, acquired brain injury, cerebral palsy, even less common things like hereditary spastic paraparesis and stiff person syndrome. It tends to be very consistent and spasticity is a very commonly measured outcome of this intervention. Now for physiatry involvement we do work with our surgical colleagues of a variety of surgical subspecialties in this but we are very integrally involved in the selection and the management of these interventions. So it's still part of our guidance section. So it's very, very effective. It's more effective than enteral baclofen. So why doesn't everybody do it? Well of course we all know this. Patient selection is extremely important because the risks are somewhat higher. You need to be healthy enough to have the surgery. You need to have a body habitus and size that will allow placement of the pump and you need to very importantly have a strong commitment from the patient and family to avoid what can be a life-threatening complication. So ideally patients will have tried an oral option of baclofen with an inadequate effect or with intolerable side effects as it's been titrated up and they haven't had any negative effects to baclofen. So it is a recommended intervention to have tried oral baclofen first. It is also recommended to consider a test dose that can be done with an LP or with a catheter less commonly and it is recommended to consider fluoroscopy to decrease the risk of trauma with this intervention as well. The commitment from the family has to include an understanding of what signs and symptoms are involved with withdrawal or overdose, that the importance of regularly attending refills and access to a medical system promptly so they're able to get in for refills appropriately. The risk that we need to consider with this is that there would be bleeding, infection, all the other surgical risks that we are commonly used to. There's also the risk of overdose or withdrawal. As we well know that can be life-threatening and you do need to have a healthcare system that can help you manage those issues if you require more intensive care. So the next intervention is selective dorsal rhizotomy or non-selective rhizotomy that is also sort A. That's very consistent in decreasing spasticity. Without question that seems to happen. Proper patient selection is very important as this is a permanent procedure and that's one of the most important things to remember about it and if you are trying to do this for the reason of improving function, it involves spasticity management of the lower extremities only and you cannot come back from it. So you have to have adequate strength and not just be relying on your tone for mobility if that is the reason you're doing it. I won't go into the details of how one does a selective dorsal rhizotomy as I'm assuming our audience is familiar. The most commonly studied patients with this are ideal patients tend to be children with spastic diplegia, good strength, purely spasticity who are very cooperative and GMFCS 1 to 3. That doesn't mean that other types of patients would not benefit but that's the most commonly studied and has the most robust evidence. It can also be very beneficial for patients with severe spasticity such as those who perform more at a GMFCS 4 or 5 that have intractable spasticity especially at the lower extremities and that is often more of a palliative or non-selective procedure that involves both the dorsal and ventral roots. Possible side effects to consider with this in addition to the weakness and the fact that it is permanent is there can be issues with dysesthesias, urinary retention, numbness and those tend to be more related to the number of nerve rootlets sectioned during the procedure. So those were the topics that we had that were very straightforward and we're going to get into the ones that were very much not. So these these other options surgically tend to be very heterogeneous and so it wasn't just one procedure that we're looking at to be able to assess the literature on it. Also with some of them spasticity was not a commonly measured outcome though when it was in studies there was evidence that it did decrease the spasticity. So one would be with orthopedic surgery the correction of bony deformity or soft tissue contracture caused by spasticity. The thought is that decreasing pain will decrease that trigger for spasticity, improved biomechanics and taking the muscle that is on stretch and that's very taut and stiff and making it more flexible that it can alter the viscoelastic properties of the musculotendinous unit and thus the responsiveness of the muscle spindle and triggering of a spastic response. So by decreasing that, improving the range of motion that really is helpful in that. Tendon transfers can do the same thing but also redirect spasticity to more balance the forces and decrease the deforming forces and support the lack of reciprocal inhibition. So again most of the studies on those are with regard to function or comfort, quality of life, gait, all sorts of things like that but spasticity is sometimes measured as well. There's also a selective peripheral nerectomy or neurotomy that will section 50 to 80 percent of the nerve branches going into a spastic muscle and so it affects the peripheral nerve specifically to be able to stimulate an active contracture in a spastic muscle and that does tend to very consistently decrease spasticity but there's not a great deal of literature out there to meet the criteria of a sort A. And even less homogenous would be our non-pharmacologic options. Our recommendations are that we would consider the use of non-pharmacologic interventions individualized to patient goals, their tolerance and the risk profile and these interventions though heterogeneous are kind of the backbone of how we've managed spasticity over many many decades and appropriately a lot of the interventions have been shifting to measuring function as far as an outcome rather than specifically just for spasticity or range of motion, but looking more at function and quality of life, which is wonderful, but it would be really helpful to include more measurements of spasticity. So in looking at these interventions, it is hard to find anything that is being executed in exactly the same way with regard to dosage or what the intervention is or who it's on or the duration of effect. And so a lot of that is why we were not able to come up with a specific sort grade for this. But we did find that many of them had a goal of enhancing the effects of other interventions, improving overall function, and decreasing the deleterious effects of spasticity on the body. In trying to kind of group these, we looked at interventions that increased flexibility, and that could include passive active stretching, dynamic stretching, stretching with orthotics, serial casting, positional stretching, anything that would do similarly to what the orthopedic interventions did by increasing the flexibility of that muscle and how it interacts and triggers spasticity. The variability in the response to this, many of these interventions were effective, and we could find some smaller, even randomized control trials looking at this, but it wasn't enough that we were able to say this is exactly the way to do it. The next category would be things that improve strength and endurance. And so that would work with a similar mindset, as well as decreasing more of the deleterious effects of having spasticity, including impairment in a large amount of body systems, including cardiovascular, as well as muscles and bones and discomfort and function. One thing that had been shown in a couple of larger studies, such as with multiple sclerosis, that it did improve spasticity is one of the endpoints. And the other thing that was very clear is that it did not increase spasticity, which was a very old belief that you should not exercise a spastic muscle because it will increase the spasticity, so that's really been debunked by this. The next are interventions designed to improve motor learning, proficiency, and control, and that could include task-specific interventions, gait training, constraint-induced therapy, robotics, VR training, anything that is increasing your function and control and decreasing your reliance on spastic muscles and consistent patterns. There is a thought that these interventions might work at more of a central level with kind of reorganization of the cerebral cortex, and there's been some suggestion of that, especially in the constraint-induced therapy literature. And again, there's been, depending on the dosage of these interventions, differing outcomes with several strong ones that encourage that it did have an effect on spasticity. The next group is a group of modalities that either work by decreasing discomfort or improving motor control, such as functional electrical stim, or affecting peripheral nerve function directly, or inhibiting by facilitating the antagonistic muscle. And I don't want to forget any of them. And dry needling and acupuncture. And again, the dosage of this and the outcomes and the types of patients that they were on were not homogenous enough to make any of these higher sort grades. We then had a group of interventions that were mentioned in the literature, but that we were not able to make any sort of recommendation. and theta burst transcranial magnetic stimulation electromagnetic therapy whole-body vibration and shockwave therapy evaluate them I'll pass this on how spasticity as we know it is not a static it was first defined or identified and documented by John Hewling's Jackson as a release phenomenon where there's a taking off of the higher but a letting go of the lower so this hyper excitability is because of taking off of the higher centers that are inhibiting these lower centers but it wasn't until 1980 when it was defined as we tend to recognize as a velocity dependent increase in tonic stretch reflexes but even that definition did not necessarily lead to any specific treatment until Pandian's definition in 2005 where the idea was that it was due to disordered sensory motor control and the part that should have also been underlined is that there's sustained involuntary activation of muscles right so in other words is this muscle overactivity and that led to the treatment with botulinum toxins and all of your neurolytic agents well more recently in 2019 our own dr. Sheng Li proposed a new definition where the manifestations might be similar to what we see but the pathophysiologic mechanism is not just the release phenomenon as John Hewling's Jackson described it but it is increased excitability coming from the unaffected motor cortex right and that how that that might affect the reticular spinal tract so the whole idea of this is that you know the definitions are evolving the evidence behind the pathophysiology is still evolving and that's going to lead to more emerging treatments we are already seeing that you know as we as dr. Biffle discussed there are non pharmacologic options out there they seem to be so many not non pharmacological options we know that spasticity and motor impairment or recovery definitely interact the more impaired an individual is the more likely they are to have some sort of a manifestation of spasticity and so enhancing motor recovery with newer agents might be a potential emerging treatments focal treatments for overactivity I mentioned cryo neurosis is on the horizon and they've been there are likely to be more investigations of TMS TDCS tens other electrical stimulation modalities and focal treatments for muscle extensibility like shockwave fascial release and pharmacological treatments for muscle extensibility like hyaluronidase are potential options in the horizon but clearly we need to gather more evidence to be able to recommend them or even make a suggestion and secondly as a practicing physiatrist we hope that this will putting together these guidelines will help us all monitor our patients better so that we can select the right treatment for the right patient pass it on to dr. Gordon Thank you to all of my fellow speakers. Great job and thanks to the academy for having us and supporting us. Special thanks to Beth Kavitha and the rest of our staff. Also like Dr. Horniak said, it's like herding cats. I'm pleased to be able to talk to you about the future of guidance like this at the AAP Menar. So hopefully soon we'll see something published on this work in spasticity, AAP Menar consensus guidance statement on spasticity assessment and management. That's work that's in process. And hopefully a year or two from now we're doing this again for what we have in development now. We took a lot of care to figure out what topic we might develop next that would serve much of the physiatrists in our association here. So our next topic is in development. It is on biologics and osteoarthritis of the knee. So many of us are now diving into orthobiologics for general medicine. There's a lot of emerging evidence particularly with regard to using this specifically for osteoarthritis of the knee. So this seemed like a good target to identify as our next guidance statement. So in April 2022, the Academy's Biologics Workgroup did indeed recommend this topic to the Board of Governors for guidance development. And that June, the topic was approved and my committee, the Evidence Quality and Performance Committee began collaborating with the Biologics Workgroup to, you know, lay out a timeline and identify experts in our field, you know, who would be able to carry this to fruition. So Dr. Joanne Borgstein and Dr. Pratap Jayaram were selected as co-chairs of this TEP. The work kicked off this year and, you know, we identified who was going to be on that TEP in February. They've had their initial calls and now they're in the writing phase. So they're getting into the meat of things. The plan is to submit something peer-reviewed in the PM&R Purple Journal in spring 2024. And we're looking forward to see how that develops. Roy's, you know, trying to think about what's next after all of this. And with that, if you're interested in learning more or proposing, you know, the next topic for development and hopefully, you know, to be presented in a forum such as this, you know, a year or two or three from now, please email guidance at aappmnr.org. With that, thank you for attending the session and we'll open up the floor to questions now. Hello. Anecdotally, there's lots of folks who are using compounded Baclofen and Tizanidine topically, although not for spasticity. Did you come across any research or is that again too heterogeneous like much of the modalities? I'll take the heterogeneous questions that, no, I did not actually find the topical in any of the literature that I was looking at. But again, there's so many emerging studies that it's hard to classify everything, but it's interesting to think about. Thank you. Hi, I have a question about the dorsal rhizotomy in adults. Are you aware of the resources to find surgeons willing to do it in adults? So the question is about dorsal adults, and as far as finding resources for it, that wasn't really something that we came up with in the literature, but there definitely are places that do that. Likely it would be an area where they do it for children and then find out if they are aware of who can do it for adults, but I'm not aware of a very specific way to find those folks. Hey, folks, that was fantastic. Regarding health equity, I really like what you were saying up there about that, Monica. Has anybody looked into states that have accepted funding from the Affordable Care Act and the expansion of Medicaid and maybe impacts it's had on our vulnerable patient population versus states that haven't accepted Medicaid expansion? All right, great question. I've not seen any literature on that, but if you ever look at a map of the U.S. and it shows the Stroke Belt, which the Stroke Belt's supposed to be the place where there's most morbidity and mortality from stroke, which is mostly in the Southeast United States, and if you look at a map of states that have not expanded Medicaid, those almost overlap exactly like a circle, if it was a Venn diagram. So that might tell us some. Maybe we need to write something about it, but yeah, there's not great data out there. Thank you all for your presentation. In regards to the long-term management of spasticity, I know in the grand scheme of things chemodenervation and chemical neurolysis hasn't been around for too long, so we're not really aware of the long-term consequences of repeatedly doing these injections every three months. I was wondering what your guys' opinion was in regards to the long-term consequences of constantly injecting spastic patients with these botulinum toxins resulting in the denervation, sprouting, re-enervation process, and if that's going to lead towards any sort of abnormal or unintended long-term consequences for these patients with upper motor neuron lesions. Is it on? Oh, sorry. So that's a great question. Phenol actually has been around for decades, and it's been proven to be safe long-term as well as botulinum toxin injections, but I do agree, I think if we keep repeating them, there could be chance of atrophy and other side effects from that, but that is something that we could probably look at from a case-by-case basis as well. Just to add to that, I think that, you know, as we utilize more, you know, ultrasound, that we get to see a lot of the quality of muscle now. We get to look at like modified HECMAT score and see, you know, the fibrosis and the quality of the muscle. I think you have to also think about the patient that you're injecting, their functional outcomes. If you're injecting someone and they keep on walking, their muscle is not going to atrophy the same way someone who may have a different, more passive goal, maybe just range of motion. And then I've, you know, seen some people who followed their own patients for many years and have ultrasound pictures related to them where they're not having issues with it. And like we said, we've used these for years and for, you know, 30 plus years or even more with phenol. So, you know, more research. I think it just, your question brings up the point that we need to assess the patients on a regular basis. And, you know, we talked about the five-step assessment, but perhaps, as Monica mentioned, you can do other things too, like ultrasound has become a very helpful tool to look at the muscles, structure, so that could be really helpful. But I think there could be more data, there is data out there that people have published on this and I think as we practice, perhaps we need to check it in our patients. Any other questions? Again, I'd like to thank our speakers. I'd like to thank everyone who worked on the TEP. I'd like to thank our academy staff. Thank you all for coming and for your questions. We're done a little early, so have a nice afternoon.

spasticity practice guidelines

assessment strategies

management strategies

evidence-based recommendations

standardized measures

botulinum toxin A

surgical options

non-pharmacologic interventions

improve patient outcomes