Um, so we'll get some of the housekeeping out of the way. So, um, welcome. It says I'm supposed to welcome you guys. So welcome. Um, this is a reminder that cell phones and audio or video recordings remind the participants that please silence all cell phones. These sessions are videotaped, so, um, we'd prefer that they're not. There are evaluation forms, so please fill them out at the end of the session. And please visit the PM&R Pavilion, um, there we go, uh, and remember to claim your CME. So without further ado, um, Dr. Leung and I are going to talk about the use of ultrasound in the pediatric rehabilitation practice. As many know that ultrasound is a relatively new technology and not always adapted as easily into the pediatric practice as it is to the adult practices that are using it for things like, uh, musculoskeletal and ultrasound injections. So the purpose of our discussion today is to show you ways that ultrasound may be able to enhance your pediatric practice. Um, so I'm Enoch. I'm a more of a pediatric physiatrist at the Children's Healthcare of Atlanta with Dr. Leung, um, and I appreciate the opportunity to chat and speak in front of you all today. So I think to start the session, my talk is going to be mainly just outlining the use of ultrasound in pediatric spasticity management. So getting this out of the way, I have no relevant financial relationships or non-financial relationships to disclose, um, but I will take donations, you know, for my talk today. That aside, where do we currently stand, I think, in terms of utilizing ultrasound, especially in the pediatric setting? Um, so just a quick show of hands, and I think even those that are attending virtually, how many here use ultrasound in some capacity? Okay. How many of you are comfortable using an ultrasound? Okay. How many feel that their ultrasound skills have room for improvement? Okay. Same here. And how many of y'all use ultrasound for Botox injections? Okay. What about for alcohol blocks? is that the hardware is just really cumbersome. Or is it the space within kind of your setting that kind of prevents you from using a big ultrasound? Or is it just because you're either a $6 million person who has bionic vision and can sense things and adjust it for inflation, you're actually $25 million? So I think a lot of times what we do know is from the adult side of things, when inquiring about where their hesitation is from in terms of ultrasound, all of these things kind of come about. So I think one of the goals of my talk today is kind of just present ultrasound as another diagnostic and also therapeutic tool, especially in your clinical practice. So like I mentioned, specifically for my talk and Dr. Boba's talk today is to kind of highlight how ultrasound can be utilized specifically for spasticity management and the use of botulinum toxin injections, phenol alcohol or ethanol injections. Other types of injections that you may be doing in your clinic or practice, diagnostic nerve blocks, as well as neurotomy, whether it can be cryo or thermoablation. So overall, one of the things today is what are the pros and cons of using an ultrasound, especially for those who have never really ventured into that realm or using it as a tool for your practice. I want to highlight some evidence-based practice improvements that has been done and studied, especially with patient care, and also what are the future opportunities when it comes to utilization of an ultrasound. So some of the big pros of an ultrasound is that it technically is a very cost and time effective imaging modality, especially when you're comparing it to things like a CT scan or an MRI. In addition, it is non-radiation based image modality. The nice thing is, is that it provides you with real-time evaluation, and a lot of times, especially in our practice and setting when we're doing our botulinum toxin injections, being able to see the muscle movement during the injection to make sure you're targeting the right muscle is huge for us. Also, it's relatively minimally invasive, right? A little bit of ultrasound gel, probe, and that's about it. It's non-painful or minimally painful, where some children do report of pain when an ultrasound probe is utilized because of soreness in the muscle, trigger points, and such. Otherwise, no real known side effects with the utilization of an ultrasound, except for females who are pregnant or in gestation. Too much exposure to it, to the fetus, may have some changes, but again, that's yet been really clarified. In terms of disadvantages, kind of going back to what I alluded earlier, different ultrasounds are available, just like any type of scanner. One of the big things is whether or not, in your practice, you're comfortable with more of a handheld ultrasound versus a standalone kind of ultrasound unit. Size, image quality, those things are all fluctuating and depending on cost. Other things is that recently more ultrasounds have gone with the wireless modality, so Bluetooth connectivity, some lag time in that real-time evaluation, or also kind of components that may draw you or push you away from a certain model. Other things to consider is that pending your setting or your hospital requirements, sterility is also a big thing. So buying probe covers, buying TROFON units for sterilization, those are all things that need to be considered. And lastly, with a lot of ultrasounds that are available on the market, for adults especially, tissue depth and penetrance is also a big key and I think all of us can kind of attest to, we've also had patients who are with a larger body habitus where an ultrasound may not give us as clear of a picture. Because of that depth issue. So these are just a couple of examples of what's available in terms of the more affordable options. On the top left we have the Clairsonic. We have the V-Scan Air from GE, the Lumify, as well as the Butterfly, which I think a lot of us have heard of. So most of these options are under that five-digit mark and do provide good kind of capability in terms of portability, as well as relative good tissue quality when you kind of utilize them. And then if we were to kind of step up a little bit higher, we have things like the Sonosite and also the GE, like the Venue, but these again, despite the fact that they have really good image quality, I think the space that you're working with, especially in certain clinic settings, as well as the cost is a lot of times the big drawback. So kind of laying the groundwork for all of that, one of the things I do want to focus on is how we utilize or how things have sort of changed over the last several years with the introduction of ultrasound and botulinum toxin injection methods. So as we all have grown up training, most of the time when we do botulinum toxin injections, anatomic guidance is probably our go-to. That's laying our hands on the patient, palpating, landmarks in terms of bony landmarks, and then kind of doing the injection there. But as we've sort of learned, other things can be utilized like EMG, electromyography, as well as electrical stimulation for guidance. So I think the trend recently has been to utilize and incorporate kind of a combination of these techniques so that we are getting the best result and the highest accuracy for what we're targeting. And so lastly, of course, for today's talk is the use of ultrasound. So a study that was done a couple years ago kind of looked at and polled the medical community in terms of what their reliance was in it for botulinum toxin injections. Um, with different types of techniques. So the breakdown, as you can kind of see on the screen, is that for the larger muscles, a large portion of individuals and practitioners still relied on anatomic guidance. And certainly if we re-poll and re-do a similar study, those numbers may shift, but I think it still kind of falls in line with what's up here. Um, because secondarily, use of e-STEM and EMG is still a pretty large population. Um, ultrasound is actually still kind of on the bottom compared to the other three types of guidances. For smaller muscles, interestingly, um, it sort of still falls under kind of a breakdown of 75%, but in that case, because of how small these muscles are, um, e-STEM and EMG are probably the preferred choice. Followed by anatomical guidance and then ultrasound. So it's pretty interesting to kind of highlight, I think, you know, a lot of people stick with what they're comfortable with, um, which still anatomic guidance and EMG slash e-STEM is still sort of the preferred method. So kind of with training, anatomical guidance kind of was taught to us as identifying sort of landmarks where we can kind of grossly estimate or approximate where each of these targeted muscles would be. So for example, kind of the gastroc where we would typically locate it would be the mid-belly of the muscle, about a quarter of distance from the popliteal fossa to the heel. You kind of measure it by your fingers or if you have a ruler to be more accurate. That's kind of how things were done. Um, nice thing about anatomical guidance is you should know your anatomy and it's relatively quick, right? You should be able to kind of identify, your landmarks, kind of visualize it in your head if you're able to, um, and kind of go from there. However, one of the difficulties is with some other muscles which are a little bit deeper, less superficial, kind of like the posterior tip. Although we may be taught that, you know, the media approach would be midway between the heel and the popliteal fossa, behind the interosseous membrane, accuracy is still a little bit subjective. Um, and I will kind of highlight why as I kind of move on in this presentation. Because optimally, we would want our patients to look like him, right? We're able to localize and visualize every little muscle fiber within this gentleman's body. Um, but that's not always the case. And even if we have the Rock, Ryan Gosling, Mark Wahlberg, every one of their biceps look a little bit different. Um, so this sort of again highlights that between patients there is still a large amount of variability that may make anatomical guidance just a little bit difficult or less than optimal. The other big piece is with anatomic guidance, um, we always reference back to training with cadavers or with, you know, training sessions. But there are certainly other things that need to be considered, right? Because there are always going to be, again, anatomical variations. Um, patients may or may not have a palmaris longus. They may or may not have contractures that shorten that belly of the muscle. Um, in addition, if especially among some of our population with cerebral palsy, the muscle atrophy kind of plays a huge role in terms of how we're identifying these muscle landmarks. Um, and then like I referred to earlier, muscle depth also plays a huge role. Right? If we can't really gauge how deep our muscle is, do we really know whether or not our injections are targeting the right muscle and the right area? Um, and again, you know, other things like deformities, fibrosis, those are things we can't really visualize or characterize without some sort of an aid. Um, and more importantly with some of our patients, especially in the pediatric setting, contractures having set in early, it makes it very difficult for us to really see where the position of these muscles are. So among the other three modalities, with EMG, one of the nice things is that it does provide you good feedback. Right? So you can actually hear, um, that muscle activity so that you hopefully are in the right area. But a lot of times, you know, being able to identify the right muscle can still kind of be confounded by muscle activity related, um, to muscles in the area, such as in your forearm kind of compartments. Um, one of the things that it may be very useful for is for patients who have focal dystonia, um, and those with upper motor neuron syndromes. Right? So you can kind of, you know, characterize those activities and identify which are your spastic muscles a little bit more so compared to your normally activated muscles. Um, and one of the things that, you know, has been sort of the trend now is to try to utilize EMG to try to identify your motor end plate, um, complexes to further help you be more, um, accurate in your botulinum toxin injections. But again, with EMG, there are cons to it in that, one, patient positioning would be an issue. Two, it's really only helpful, um, especially for targeted muscles with spasticity involved. Um, and again, because we're not visualizing it, pending the muscle tissue variations, sometimes you may be too deep within the muscle, but picking up kind of surrounding signaling. Um, or, you know, with co-contractors, you may have other sort of signal changes involved as well. The other piece is, one of the big ones is pain. Um, and especially in the pediatric setting, that's always a big no-no when the parents are in the room. Um, and lastly, a lot of times EMG machines are expensive on their own because of the supplies, such as the needles that you need to obtain for them. And now if we were to compare that to electrical stimulation, again, it does provide you with some feedback, um, with the targeted muscles that you're hoping to inject. Um, it may be a little bit more helpful, um, And now if we were to move on. Also because of that real-time The thing is, is that it will provide you with additional information such as tissue hypertrophy, atrophy, or anatomical or tissue-based variances. But again, the big pieces in terms of the pros and cons of using an ultrasound is that it does cost quite a bit of resources. And to get comfortable with it, repetitive use, training is also needed. But again, that's just like all the other modalities that I've talked about, which is the anatomical guidance, eSTEM, and EMG. And also, some physicians, especially in the adult population, once polled, they do find that ultrasound is cumbersome because of size, as well as time-consuming, especially when they have no familiarity with the modality. So after all that kind of groundwork, where do we kind of go from here? One of the things that I would want to move on, especially in this section, is then highlight some of the research that's been done, which kind of helps us, or in my sense, helps me sort of identify how I can utilize ultrasound to really improve my skillset as a clinician, as well as doing what's more comfortable and more effective for my patients. So one of the earliest, well, one of the more recent reviews in terms of utilization of localization techniques in 2015 noted that a combination of EMG with ultrasound or eSTEM overall did result in better blind needle placement than just simply anatomical guidance. So the other thing that they kind of highlighted was that eSTEM and ultrasound did demonstrate better evidence than EMG for spasticity. In addition, like I alluded earlier, EMG is useful for use in kind of targeting focal dystonia, especially during botulinum toxin injections. And then overall, especially in the adult population, EMG is more effective than just eSTEM and spastic aquinas for adults. And also, the European group in 2018 did kind of lay out groundwork for utilizing ultrasound in terms of spasticity management under that neuromusculus kind of protocol. So again, this is all based off of adult population predominantly, but it is giving us a good sense that more and more practitioners, even up until about 2018 thus far, have found better utilization, better accuracy with using an ultrasound. Because one of the big things, like I had sort of alluded to earlier, is that pending on your patient population, and especially in the pediatric world where we do see a lot of kids with cerebral palsy, especially spastic cerebral palsies, that an anatomical change is one of the biggest kind of difficulties we encounter, especially when we're trying to target focal spasticity management. Because studies have been done, especially in 2015 by this group, where if we do have these flexure synergy patterns that even in the upper arm, the bicep actually rotates more medially, and the brachialis is rotated more from the far lateral to the middle of the ultrasound screen. So it's not always kind of where you would think your muscles would be based off of quote unquote normal anatomy. So I think that's sort of where kind of the utility of ultrasound is very helpful, kind of giving it a leg up on anatomical guidance, EMG, and eSTIM. Other things that they've kind of highlighted in their study in 2015 is that the pronator teres, especially with this kind of torsional positioning, it's actually, you know, it shifts not only the pronator teres, but also kind of that flexor carpi radialis as well. And again, especially in some of these more sensitive areas, like in the forearm compartment where you do have your neurovascular bundles, being sure you're targeting and hitting the right spot is key. And so the rest of it just kind of highlights what they had noted kind of among their patient study population at how different musculature... So to kind of further highlight this, I think one of the earliest studies to kind of look at injection accuracy came out in 2005 where they kind of looked at purely just blind injections and how good clinicians were in hitting their target. And as you can kind of see, that number kind of fluctuates a bit. So especially for a lot of our kids with a lot of spasticity in what I call that magical trinity of hamstring adductors and gastroc, if I was only hitting that 46% of the time, I should fire myself. So other groups have kind of done similar studies looking at just being able to localize and target appropriately the gastrocnemius, medial versus lateral head, and even then there is a lot of variability with just anatomical guidance. And kind of this list just kind of goes on. But if you kind of look at kind of towards the bottom, blind placement versus the use of an ultrasound, accuracy does increase. It's not perfect still, right? But as Yoon and his group kind of demonstrated, blind placement in terms of a needle, we get about 72% accuracy of the targeted muscle. With the ultrasound, we're at about 97%. That 3% variability comes from, again, training, technique, and also interpretation of the image, right, captured by the clinician. And then again with 2012, Pacelli also kind of compared the use of manual versus e-stem compared to ultrasound, gastroc medial versus kind of your gastroc lateral. Again, we're still having some differences in terms of how well we're able to target some of these muscle groups. This sort of also further highlights in a nice slide in 2011 by Boone et al, sort of where that accuracy kind of falls still. We're doing injections of guided versus non-guided. It's almost like... But again, you know, whether or not it really maximizes that accuracy, but this I think certainly highlights a portion of that. So as I mentioned earlier, it is nice to be able to kind of see what your different anatomical landmarks would be with the use of an ultrasound, right? Because especially like this picture demonstrates, being kind of in that groin, inguinal area, we do have a lot of things going on. More medially in that thigh, we do have your neurovascular bundle, your vein, nerve, and artery. And then we have your iliopsoas, your sartorius, your rectus. And then we even see kind of the head of that femur. But again, if these identifiers were removed, right, one of the big keys in training for ultrasound is recognizing each of these structures. And I think to some certain degree that training kind of gradation is still there because without these sort of markings, not everyone may be able to say, oh, the sartorius overlies the rectus or the sartorius is lateral to your iliopsoas. So as I kind of mentioned or touched on earlier, one of the other big things is with the utilization of botulinum toxin is understanding the concept of a motor point and a motor end plate complex or an innervation zone. Because that's a big key where we are trying to be more effective in our botulinum toxin targeting. And so we should be able to target areas where the toxin, once injected, will have the maximal amount of efficacy, right? We don't want to just really nilly just throw some toxin in there and just cross our fingers and say, okay, well, let's just see how it works. The key point is that anatomically a motor point is pretty much where the nerve, like I said, enters the muscle. So with a motor point, it is technically where you kind of get the most amount of contractility when it's stimulated, right? And that kind of makes sense because when you're stimming that area, that signal travels to all of the motor end plates. However, the difference is that a motor end plate complex in an innervation zone is pretty much where your neuromuscular junctions are pretty much localized. And if we kind of go back a little bit, botulinum toxin works predominantly at the neuromuscular junction, right? At the pre-synaptic complex, right? So this is where it's key. So one of the things is that by targeting mainly more of that motor end plate complex or innervation zone, we're going to be able to maximize kind of what we do with botulinum toxin. Doing so kind of helps us decrease the cost of procedure, right? We can also optimize dosing. And also, we're not willy nilly throwing a toxin in an area to run that risk of antibody development. So one of the nice studies that came out in 2016, Yang demonstrated the different localizations in just the forearm compartment of how you kind of actually can visualize, if able, where the motor points are versus kind of where your MEC slash innervation zones are. So if you kind of look at both of these areas, you can kind of see the difference between the two. So also, other studies have kind of notified, or have shown and demonstrated that by injecting more away from your innervation zone sort of actually decreases your overall efficacy of your botulinum toxin injections. And this was also subsequently demonstrated by other studies as well. And I think one of the big thing is that if you were to try to identify... And again, the whole goal of utilizing the ultrasound then is to be able to take into account all of these anatomical variabilities. So with this picture, we're highlighting both just structurally, based off of where your localized difference is between the heads of the gastroc, as well as the head of the gastroc. So the other nice thing with ultrasound is that you can kind of characterize muscle morphology Not just in the kind of the spasticity setting This study done in 2018 kind of demonstrates even with other conditions that we may see in a pediatric setting like Duchenne's Myositis and SMA they have sort of their distinct kind of muscular morphologies that you can actually see under an ultrasound but for the Point of this discussion and talk focusing on more in kind of that and everything kind of then correlate to what we're seeing in the ultrasound. So from seeing this, one of the things is that over time what we do tend to see with increased spasticity is this increased echogenicity. And I'm going to talk about it in the next upcoming slides, but this sort of helped us kind of define and characterize whether or not it's a healthy versus a non-healthy tissue, especially when we're using ultrasound. So one of the things is that with a lot of kids we see with cerebral palsy, that spastic myopathy does lead to atrophy, loss of sarcomeres, increased connective tissue and fat. And again, ultrasound is able to kind of help us detect some of those changes compared to normal tissue. So one of the scales that's been developed is the modified HECMAT score, which kind of then highlights the echogenicity of muscles based off of that tissue replacement. So it's broken down into one through four, and you can see that echogenicity or that brightening of the muscle structure is sort of what you kind of classify or what each muscle would kind of fall into. Why that's important is that lots of studies have actually demonstrated that with increased HECMAT there is decreased response to our interventions. And that would be either in terms of botulinum toxin or even selective nerve diagnostic nerve blocks. And this kind of just highlights one of the studies that has been done more recently. And also one of the other things is with using an ultrasound, you can actually start to then measure muscle growth in terms of muscle tissue that is botulinum toxin naive versus those that have had the intervention done. So this kind of sets the groundwork for future sort of practices of what we can do to kind of help optimize care, especially for our patients. Other things that has been looked at and which is way beyond my brain can kind of handle is measuring elastography, which is sort of the stretchiness of muscle. Because one of the things is with increased fibrotic tissue and connective tissue, we do know that there's a decreased change in that material property of the muscle. So one of the things is, do we then utilize this information to, again, help us target muscle treatment and optimize dosing? Because such as for Furukawa, their group, they've noted that with injection of botulinum toxin, you do get some changes in the elastography. Then that was demonstratable in their study where after injection, the increased areas of red sort of then highlights how much stretchier that muscle kind of gets. But again, this takes a lot of computation, a lot of brain power that I don't have right now. To kind of finish this talk, I just want to go through other clinical utilities, especially in the use of ultrasound for spasticity management in the pediatric setting. This includes baclofen pump refills, where we've all had baclofen pumps where there's a lot of tissue, making it very difficult for us to find the port for refilling. Why this is important is that there are a lot of instances of pocket filling where we think we're in the reservoir, but the medicine never actually gets injected. At times, this has been shown to be detrimental and also fatal. So by using an ultrasound, we can This way we can optimize the refills, do it safely, and minimize risk to the patient. Other things you can kind of do, which Dr. Bobo will talk about a little bit more, is the use of diagnostic nerve blocks and cryoneurotomy. This is to, again, another modality to help with pediatric spasticity. So what does it all mean? Using ultrasound I do believe will kind of help optimize patient safety, comfort, and efficacy of procedures. And with using an ultrasound, again, we can kind of characterize tissue and how it looks, whether or not we think it's going to be responsive to modalities. And then also kind of plan ahead in other ways that we may be able to help our patients by understanding the morphology. So, we're running a little behind, so shockingly, I'm going to talk fast as soon as they load me up. There we go, all right. So we're going to talk beyond botulinum, right? Innovative uses of ultrasound to manage spasticity. So I know it's early in the morning, especially after the president's reception. And so thank you guys for waking up. I appreciate that. Anyone who was stuck out with Dr. Scholz last night, I apologize because this is going to be quite difficult for you to wake up this morning, but thank you for being here. And if anybody attended the community sessions, you'll be happy to know that Dr. McLaughlin was able to figure out how to use the Spanx. He looks wonderful in his outfit from last night. And so on with the show. Okay, so the objectives of this talk is to discuss the use of diagnostic or selective motor nerve blocks in a pediatric physiatric practice, discuss the novel use for it in serial casting, and also briefly discuss the upcoming of cryoneurotomy. So disclosures. In the past, I have done research for Allergan, Ipsin, Mertz, but luckily we're not really going to be discussing botulinum toxin, but I still like to make things... And I will be discussing an off-label use currently for cryoneurotomy in terms of spasticity. So how did these ideas come to me, at least how these thoughts of diagnostic nerve blocks? So back in the beginning of the pandemic, you know, May of 2020, when we were all just kind of sitting at home as things were not as busy, people were afraid to come out. The Canoss Group in Canada did a lecture on ultrasound-guided botulinum toxin injections and strategies to enhance the delivery of botulinum toxin. I'm like, wow, that's something I do. I want to listen to this talk. And so it was actually a Thursday afternoon when I have my half days, and so I kind of sat down and watched the talk. And interesting enough, there's Dr. Winston in the corner who spoke on cryoneurotomy. He was talking about how he was using nerve blocks as a training to do a neurectomies and how he's working with his neurosurgeons. And in France, they were doing a lot more neurectomies than we do over here on the North American continent. And I was like, wow, diagnostic nerve blocks, we don't use that much in the pediatric practice, and so this kind of piqued my interest. And so I wrote a little note and I said, well, have you guys ever used this for like acute patients or serial casting? And they're like, no, no, that would be a bad idea. Don't do that. And so I said, hmm, I like bad ideas. So let's see what we can find out. And so I started reading about diagnostic nerve blocks because, again, being that pediatric side, it's not something that we do very often because we're afraid of putting needles into children if we don't have any reason to put a needle in, right, because we're always afraid of causing more injury to children. So I found that, you know... So what is the value of doing a diagnostic nerve block? And it helps you... The prediction of functional changes, understanding impairment mechanisms, like what muscles are working. Maybe our previous strategies in doing our injections weren't as successful as we thought. You know, what muscles are involved? Sometimes we think it's one muscle and it's something else underneath, you know, especially if you can think about maybe sometimes those patterns that you have with elbow flexion, right? Is it the brachialis? Is it the brachioradialis? Is the bicep somewhat involved? And sometimes when you have these kids, instead of utilizing more and more toxin or phenol or whatever that you're using, maybe it's, you know, it may be a little bit more beneficial to say, okay, my strategy isn't working. What else can I do? And also what are the strengths of the antagonist muscles, right? So if you're injecting a gastroc over and over again and you're trying to come up with a strategy, the question is if you block it, are you able to find... Does that tibialis anterior have really any function? Is it just not functional from your years of spasticity or is it just being overshadowed by your gastroc? So this may be able to give you some ideas if you want to do a surgical intervention or to have that talk with your surgeons about what surgery they should do. And so again, I went diving through the literature, kind of looking around, and I found way, way back in 1997, they were already talking about using nerve blocks and anesthetics for spasticity management. And even back in 1919, they were using anesthesia to help with spasticity management. And even back in the 1950s, they were able to figure out that there was sensitivity to different nerve fiber types so that there was value to using anesthetic in spasticity. And the French do a lot of work on this and they use diagnostic nerve blocks to even help them with their chemoneuralysis, phenol, alcohol, botulinum toxins, and so they use a lot of these strategies. And back before they used ultrasound, they actually would map out how to find these nerves using e-stim. So there's this whole guide, if you go back through the literature, where they tell you how to kind of local... After using dissection on cadavers, they would kind of localize and so that the... They would map out and figure out exactly where they wanted to go for their phenol blocks in order to block or if they want to do a diagnostic nerve block. So this has been going on for quite some time. And then they started using ultrasound and they started using it a little bit more. And they use these diagnostic nerve blocks to actually help define where the spasticity patterns are and what are the more predominant muscles for spasticity. So even if you talk with the neurologist versus the physiatrist, like what is the more dominant elbow flexion, right? And so you have lots of people doing elbow flexion nerve blocks and they're like, do you inject the biceps? Do you inject the brachialis? Do you inject the brachioradialis? What is the predominantly more? And so they were actually able to use nerve blocks to prove that actually in stroke patients, it's the brachialis which is the more dominant elbow flexor as opposed to the biceps. The French also have a whole guideline on how to use peripheral nerve blocks. And so if you want to look up this paper, they give you recommendations on how they would do it because it's such... So predominant over in France. And what are the risks of doing these selective nerve blocks aside from like just sticking a needle into a child, right? You know, bleeding, infection, allergic reaction like we do everything else. Can you cause injury to the nerve, right? So that's where your ultrasound guidance is really beneficial because you don't... Even when you're doing a diagnostic nerve block, you don't want to continuously stab your nerve, if you will, poking around because that is going to increase your risk of injury. And then of course the risk of injecting, you know, lidocaine or any other anesthetic into a blood vessel are your main risks. And so the interesting thing is, you know, Pacelli back relatively recently in 2020 started using diagnostic nerve blocks to prove if his botulinum toxin was more effective. And what they had actually found was that, you know, botulinum... You know, doing a nerve block would be able to tell you if your botulinum toxin injection was effective. But they also found something interesting. They actually found that the diagnostic nerve block did... Had a greater reduction in spasticity as compared to actually injecting botulinum toxin. And you're thinking, well, okay, maybe that makes sense because, you know, botulinum toxin is a partial denervation, right? That's the whole purpose of using botulinum toxin, right? But if you do a nerve block, that's a complete, you know, mimics a denervation because you're affecting the nerve directly and not just partial nerves. And so that may give you a better idea of, in the future for this patient, do I need to... Can I continue to use botulinum toxin or do I... Or if it's not working, do I need to do something a little bit more drastic like, you know, a nerve... A nerectomy or something to that effect or phenol or cryoneurotomy. So the big question is, right, why does this work? How does an anesthetic affect a nerve? Well, how an anesthetic, you know, affects a nerve, it creates a conduction block which decreases or prevents a large transient of the sodium ions, right? So it just blocks sodium from causing that depolarization down a nerve. But the interesting thing when you do a nerve block, right, it... Not only does it affect the 1A fibers which mediate the myotactic reflex and the alpha motor fibers which mediate voluntary contraction, but also really affects the gamma efferent fibers, right? And so that helps us for that spasticity component that also helps define where that muscle is in space. And that reduction of reflex excitability also gives us kind of a value of determining where the ankle passive stiffness is, right? And so anybody who's injected botulinum toxin knows that sometimes we're looking at these muscles in these patients and we're going, hey, is this spasticity or is this inherent muscle stiffness, right? Is this a factor of the spasticity or is this just what's happened to that muscle over time which is causing this tissue tightness? And so by doing a nerve block, you're able actually to be able to determine, all right, do I keep injecting more botulinum toxin? Is this going to work? Or maybe do I really need to think of this as more of a permanent contractor and I need to think of, does this patient need surgery or can I think of another option? So when you're thinking about anesthetics, right, things that you know about, small nerve fibers are blocked more rapidly than the large nerve fibers. The small gamma fiber supplying the muscle spindles are actually more rapidly blocked than the alpha motor and so you can actually see that distensibility relatively quickly. The smaller the internodal distance, the faster the onset, but inversely, the slower the recovery time. So that's going to actually be... That muscle tissue distensibility is actually going to recover slower and the degree produced by a local anesthetic also depends on how much the nerve has been stimulated. Meaning if it's a spastic muscle, it actually has more susceptibility to the anesthetic than if it's a non-spastic muscle. And mixed nerves, it diffuses from the outward towards in and so therefore the more proximal muscles are usually more affected than the distal muscles depending on where you do your nerve block. So that kind of gives you an idea of how to do it. So here was my problem, right? Being my... Being a... Sometimes I pretend I'm an inpatient rehab doctor too. Is that I had a lot of patients who are coming to me from other centers. And being from the rehab unit, who are being seen by colleagues or neurologists or something. And they've already gotten botulinum toxin before they made it to the rehab unit, right? And so we've all had this problem where you have your patient who's a Rancho 2. They're in extension pattern. Their toes are flexed and the first thing people go is, oh my gosh, we're going to lose that range in the Achilles. So they inject the botulinum toxin really quickly early on in their rehab stay. There's lots of stroke literature for stroke literature saying that's a really good thing to do because we can reduce spasticity. So all of a sudden the botulinum toxin is in the gastroc. And then they come to rehab and they start waking up and they start doing more and they start progressing and now their arms are locked and their hands are locked and you're like, I can't do anything about it because they just used my botulinum toxin. And so I'm either stuck doing phenol, but maybe it's a mixed nerve and I don't really want to stick phenol into a mixed nerve or I have nothing to do and I kind of have to wait to my three month period before I can use botulinum toxin again. Or we've had these other patients, especially some of our anoxic brain injuries, submersion injuries who come in, who have these most significant dystonia that you've ever seen and no matter what we inject, they don't change their position. And I was like, this stinks. I don't know what to do because I've already injected them with botulinum toxin. They're in a lot of pain. Do I need to put a pump in? What's my next step? Then you have the patients who are clinical contracted on admission, right? You don't know what to do with them and they have changing tone patterns. Like I said before, right? First you have the person that's all extension, then their flexion, then all of a sudden they have a whole completely different tone pattern. So what do you do for this, for this population in the acute setting? So we do know for about muscle contracture after a traumatic brain injury, it's listed as almost high as 84%. And the most common are elbow flexion and plantar flexion contractures. Seventy-four percent of patients with dystonia get muscle contractures. And what we know is that there's insufficient evidence that non-pharmacologic methods work, including casting. And in severe anoxic brain injuries, what they've also found is that there's actually a reduction in joint mobility, which precedes muscle stiffness and spasticity. So regardless, these patients are already getting tight. And so a lot of times, like we talk about casting. What does casting do, right? And casting reduces the excitatory input of the muscle spindles, preventing that change in length, right? So we put, we try to get the muscle into a different position, stretch out those sarcomeres. And that's what's causing this adaptation in the tissues to improve its tolerance to stretch. Back in Liang, not this one, different one, in 2019, it showed that actually if you did casting in two groups with botulinum toxin after a brain injury, the ones who got botulinum toxin earlier did better than the ones who got botulinum toxin later. So there is a big advocacy for inject early, inject early. We can help the ankles, but you know, do you sacrifice the ankles or save the ankles to sacrifice the arms, right? And so you kind of have to put this into your thinking as an inpatient physician. So again, my brain was working. And so this was May where I was listening to this lecture in 2020. So in June, I said, hmm, I had some really bad dystonics. It's summertime, right? We got a lot of anoxic brain injuries from submersion injuries. And I was like, okay, I've just been, my mind has just been pumped up by these great lectures I heard from my colleagues in Canada. What am I going to do about it? So I was on service in June and I said, you know, let me try some selective nerve blocks. And so I had four patients, again, it was a bad summer. And so there were four nerve blocks. So I did four nerve blocks to the tibial nerves, to the gastrocnemius and soleus, six to the radial nerve, to the brachioradialis, and two musculocutaneous ones. So I'm going to tell you a little bit about these patients so you can understand. These are patients who are a little bit out of the ordinary. So my first case I looked at was this four-year-old who had a significant dystonia from an anoxic brain injury. He had a ITV placed and it was titrated. He was on five different drugs to control his dystonia. And he even had botulinum toxin and phenol. So we're running a little bit low so I'm going to do this real quick. And so then we had to, so then I serial casted him and that didn't work very well. So then I used bupivacaine to his radial nerve, to the brachioradialis, and then in two casts over seven days, because in our institution, if they're inpatient, we cast every three to four days as opposed to weekly like you would do as an outpatient just for safety purposes and to monitor skin, especially in these acute patients. So two casts in seven days. He went from 55 degrees of flexion to seven degrees. And then the next week I'm like, hey, this kind of works. So you don't have to have a time period and you don't want to put multiple casts on a patient at one time, right, because you don't know about pain or something's bothering them. So I did it again to his gastrocs and then he was able to go to eight degrees of dorsiflexion on one and to neutral on the left without any pain. And then again, this is a 14-year-old who had an MVC and an anoxic brain injury from a traumatic and cardiac and she had also... She had received botulinum toxin at her institution that she came from and also we were able to do four rounds of serial casting. I'm sorry. We're going a little bit... So I'm just going to go past and just get to the results here, because we're a little bit behind. And so here are just the review of my four patients. And so what we can see from all these patients is that your pre- and post-cast, where pre-cast you have 60 degrees, we're able to change in three to four casts, maybe two casts over the course of less than two weeks, changing of 53 degrees, 24 degrees, 28 degrees, 75 degrees. So we're able to really not only change people who've already had botulinum toxin and people who are resistant to therapy, but also able to change without pain or injury by using anesthetic for a nerve block as opposed to using botulinum toxin in these acute patients. And so when we looked at all... In the lower extremities we had the average time of casting of 9.75 days with an average of 3.25 cast changes and we're able to change range of motion of average of almost 22 degrees. And even with that change the modified AASHRA score changed of one. The upper extremity, the average casting time was 6.8 days, so literally a week, and we're able to change that range of motion in the elbow flexion by 50 degrees, also with an average modified AASHRA score change of one in the muscle tone. So I want to talk about what some of this logic is between the nerve blocks, right? And so why did I use bupivacaine as opposed to the traditional lidocaine? And mostly I would say the honest answer was I was kind of initially going by the seat of my pants when I had done this, but I wanted something that really lasted a little bit longer. So when you look at the lidocaine versus the bupivacaine, I decided to use bupivacaine to kind of account for the fact that not only did I want it to work, but I wanted my anesthetic to continue to work while my therapists were casting. I also wanted to be able to have that patient to be able to be in that new position without them having pain as well. So be able to really change that position. So that's why I chose bupivacaine as opposed to using, like you would use a 2% lidocaine block if you were to do this in your office setting. And there are definitely some risks, you know, when the French, when they, in their article, they actually mentioned doing ropivacaine as opposed to bupivacaine if you're doing these, because they said there were some inflammatory changes to the nerve in animal studies. And ropivacaine has a quicker onset, but also has a quicker return to function. And I did try ropivacaine actually a little bit later, incidentally on some patients. I personally didn't find it to be as effective as using bupivacaine, so... But ropivacaine is also less lipophilic and has less penetration into those large myelinated nerves. And it may be because I was using some of those larger nerves when I was doing these blocks why the ropivacaine may not have been as effective as the bupivacaine. So why did this work, right? I think that's the other question is, okay, you put this anesthetic into some nerves, but why did it actually work? And what we did find is that it did have a... When you're thinking about spasticity, my idea is that it has a loss... You know, spasticity is a loss of inhibition to the alpha and the gamma neurons, right? And the gamma neurons are what regulate the amount of tension to the inset and the neurofibers. And if you're using something like botulinum toxin, right, it affects all the acetylcholines kind of non-selectively. And so even though it does work and reduce your H-reflex in reducing spasticity, it's not necessarily selective. So you may have some in the alpha motor, you may have some at the motor neuron junction, but it doesn't really affect those gamma motor neurons like an anesthetic block will. And so it's probably those gamma motor neurons that control the muscle response to external forces like a cast, and we can use that to kind of help reset that position. And using those gamma neurons now that your spasticity is at a different position. So our patients who we did the blocks on, do they still have spasticity a couple of weeks later? Yes. But the idea wasn't necessarily to stop their spasticity. The idea was to change that position and what we consider that perceived muscle, quote unquote, muscle contracture. And even though we were able to... the spasticity did return, they still needed medications, we're actually able to change those positions and make them braceable. And that was really the more important thing. Braceable in a functional position without using botulinum toxin or where botulinum toxin was not helpful. So it definitely was a very small sample size. I only used one anesthetic as opposed to other anesthetics and there was definitely variability in use. One of the patients did not receive botulinum toxin. I actually tried doing the anesthetic block before I used botulinum toxin to get them into a better position. And then I used botulinum toxin because they still had the spasticity, which was successful. The other question is, did it have anything to do with the gamma motor neuron at all? Maybe these were very dystonic patients. Maybe it was all a pain component. And maybe it wasn't injecting the nerves at all that had anything to do with this effect. My view is just the fact that they were just in pain because they were so dystonic and they were storming and things like that, that maybe it was a complete pain issue. And again, what about things with mixed innervation? You know, I really didn't say how that would affect somebody with mixed innervation, at least in this small sample size. So this was last week or actually two weeks ago. And I kind of threw this in. And so this was a patient who actually came from another institution. She had multiple gunshot wounds to the head and abdomen. And she and our colleagues who they came, she came from another institution and they injected her elbow flexors, which were great because her elbow flexors are great, but her hand was stuck. And so at that time when they injected her elbow flexors, her hand was not stuck. So I and her, her fist was stuck like this. So I did an injection to her median nerve. You know, and you can see it right there, you know, Dr. Alter is in the audience, so she'd be proud that you can see you're in your FCR biting your pronator teres if anyone needs some orientation. And you can see our median nerve just hanging, it was in a slight different position on her than you would always see it anatomically, which is, it was slightly lower. But I injected there and lo and behold, her hand opened up immediately. So those, those shot, those pictures were taken within, you know, two minutes after doing the injection. And I put a, I put her in a cast over the, over a weekend and it was perfectly fine. We took off the first cast after three days. I think I did this on a Thursday. We took the cast off on Monday and her hand stayed open and we're able to, and we're able to brace her and put her into a better position. And so it's that instantaneous. And so now I want to talk a little bit about cryoneurolysis because now that we've used our ultrasound and we've gotten these ideas about diagnostic nerve blocks, what about something new? And I know Dr. Winston talked about cryoneurolysis yesterday. That's his baby. I was fortunate enough to go and spend some time with Dr. Winston in Canada about three weeks ago. And so I can at least tell you what I learned. And so what is cryoneurolysis, right? It's the application of cold temperatures using axontomiesis, right? So what it does is you, you have a tip and you fill it up with a gas, either nitrogen or carbon dioxide, they use carbon dioxide in some others, and it basically uses your, the own fluid in the body to create this ice ball. And this ice ball causes degeneration of the myelin and the axons while keeping the external structures intact. So you have minimal structural changes to the scaffolding of the nerve, but you're able to do basically not chemoneurolysis, but very similar to what we do with phenol in terms of degenerating the axons and the myelin, but preservation of the endoneurin, perineurin, and epineurin so that the structures of the nerve remain intact, but we're able to degenerate the axons. So then the nerve axon later is able to regenerate along the previously established pathway without any, without any, so when you compare this, so the top picture is your phenol and your bottom picture is your cryo. So the difference between cryo and phenol is where when you have phenol, you know, I call it like the, the atomic bomb, right? You just destroy that nerve, you destroy that tissue, you cut that continuity. Now your cryo is kind of like your nitrogen bomb, right? It destroys everything around it, but keeps the structures intact, you know? So if you ever talk about a nitrogen bomb, it's where they, you know, drop it on a city, the buildings are fine, but, you know, all the people are dead, and that's kind of what cryo does. It retains your structure, but causes that degeneration and get that Wollerian degeneration, and so when, theoretically, when the nerve grows back, it grows back less spastic. It does not have to have those re-sprouting. It's growing around the same structures, and so I was fortunate enough, so you'll see axonal degeneration within seven days, but continues for a period of time, so the epineural and perineural structures remain intact. The nice thing about it is all the tissue around it in this brief period of time does not, there's no fibrosis and no scar tissue. So anybody who's done repeated phenol injections knows that if you're doing phenol and you go back six months later, a year later, whenever you're going back, or you've had a child over years who's had phenol, it's, you know, and you're sitting there with your ultrasound, you're looking at scar tissue, you're looking at fibrosis, and you're looking at nerves that have regrown, and you may, that when you're stimulating those nerves and you see the ultrasound, you're not even getting a stimulation, but that patient has spasticity, and you're like, well, this is horrible, what do I do for the, what do I do for this kid, because I'm running out of places to stick phenol. With cryo, it lasts longer, and you don't get scar tissue, and you don't get fibrosis. And so the device I used was the iovera, this is not a plug for iovera, it just happens to be the one that I use, and for demonstration purposes. And what this is a, basically the liquid refrigerant goes to the expanding gas issues. And so the nice thing about this device, it's about the size, if you've done cryo in the past, you know, there's these big devices that they would drag in with these tanks of gas behind you, and you drag it into the operating room. The nice thing about this device, it's about the size of, you know, I say an immersion blender or electric toothbrush. It's a little bit cumbersome when you first start to use it, but its principles of using it are almost the same as if you do phenol. And so this is what the, they have two tips, one is a small tip and one is a longer tip. So I kind of just took that picture at the booth the other day, just so you can see what size the bubbles are in relation, just to give you an aspect of what it looks like. The other thing that's really confusing if you do this compared to when you do, is that the electrical stimulation is not at the tip, it's a little bit further in. So you're like, well, if the tip is there and the Q, that Q-tip type end is sticking out, how are they even getting the ice ball? No, it's because the stimulation portion is further back, so where you see your stimulation, it gets encaptured in that frozen ice ball. And so Dr. Winston was nice enough to lend me a couple of his pictures, and you can see under this ultrasound, the ice ball forming around the nerve on the right tibial trunk. And then here's another one for a pec, and you can see where the ice ball is forming around that nerve. Usually it takes about two to three blocks, depending on the size of the nerve. And so when it starts, it goes through a cycle of about 120 seconds or so, 108 seconds I think is the right number. So if you were to do this on a patient that was awake, which is the way that I did it, they get some pretty significant cramping for about a minute, and then it kind of dies down. The screening protocol, if you were to do this, is again, I'm going to use about a 2% elaticane block in clinic. And if you decide that you want to do a mixed nerve, if the patient has dysesthesia or sensory response, then you do a lower nerve or intramotor neuron block as opposed to a trunk branch. So if you look at a lot of the adult literature, right, where you have insane stroke patients, they'll do a lot of phenol blocks on all nerves, median nerves, things that we would never consider doing in the pediatric patient or didn't want to because of that mixed dysesthesias. The nice thing about doing the cryoblocks is it really does a more complete block with... Compared to the phenol, you have a little bit more control and you don't get those dysesthesias the way you do if you would do phenol. There are some contraindications to using cryo. You know, if you have cryoglobinemia, cold uric area or Raynaud's, obviously don't use it. Bleeding, bruising, redness, and infection, just like pretty much any time you stick a needle into a patient. And you get hyper or hypopigmentation, which may occur... There's a risk of some alopecia as well. So again, in comparison to phenol, what are the advantages? It lasts longer than three months, six months. When I was with Dr. Winston, I saw a patient coming in after three years of getting a block, coming in for a second block. So this was definitely the length of time. His current... He's doing his long studies right now, but we're talking over six months of complete things. You get immediate results. So immediately after injecting these patients, we watched them... I watched them put their foot down for the first time. I have some videos that we'll show you. You can get a complete block from the mixed nerves. The reason why you don't get, at least the theory behind why you don't get this, because it's not as ablative as phenol. You don't get a neurotropin release, and that's usually what they feel causes the dysesthesias. Because the dysesthesias that happen in a lot of patients after doing a mixed nerve block happen a few days later, a week later, not necessarily immediately after. And because this doesn't cause that same destruction, and there's still blood supply going to the nerve and area, that's the theory of why possibly you don't get that neurotropin release. And then again, there's no damage to blood vessels or surrounding tissue. So it provides a significant advantage, as opposed to phenol, like, yeah, phenol, kill Disadvantages, right? It lasts a long time, right? So if you don't do that in a diagnostic nerve block, and you're not really sure what's going to happen if you take out that patient's tibial trunk, well, you're going to find out. So it lasts a really long time. There's a lot of cramping during the procedure. So in the pediatric patient, you may want to consider doing this while they're awake. I did do it on some pediatric patients in Canada. And they tolerated it fine, but, you know, sometimes it was a little difficult to watch. You can't control the size of the ice ball, right? The ice ball is going to come out. And so if you're in a small patient with limited space, you know, you kind of have to worry a little bit where that encroachment of that ice ball is going to end up. And again, it requires ultrasound. This is some, you know, phenol you can use. We've used anatomical land points forever. So people who do phenol can say, oh, I can do phenol blind. You can't necessarily do this blind because of the lower stimulation that you use. So it does require use of an ultrasound. And the one thing, like I said, is I always joke with my patients. Like, if you don't like the medication I give you, oh, we stopped the pill. No worries. You hate me for a day. If I give you an injection and you don't like the results of the injection, okay, you're going to hate me for a few months. But if I, you know, I send you to surgery, well, and it's a bad result, well then I can't undo that. So you're just going to hate me. And but the thing with cryo is it works really well. And so we have to finally make those commitment issues of what we're going to do with these patients. We are demonstrating a patient that has had botulinum toxin and phenol injections for the severe spastic positioning and contractures in the lower extremity and upper extremity. We're demonstrating here that the pelvis is tilted to the right side and in fact he cannot lie straight on the bed because of the tightness in his hamstrings pulling and the pulling together of his legs. And the knees will not extend to 90 degrees. You can see the buttocks are raised off the bed. We are going to target him for cryoneuralysis of the lower extremities. By inserting a percutaneous probe through the skin and generating an ice ball, we will target two sets of nerves for the patient. Here we see what the ice ball looks in some saline. It generates from the water inside a patient's muscle and no drugs are injected. This is the percutaneous approach that we use with ultrasound guidance. Here is a demonstration of cryoneuralysis of the obturator nerve. We do two branches, the anterior and posterior of each nerve to make sure that we target as many muscles as possible as the legs pulling together is the greatest problem. After the procedure to the bilateral obturators and sciatic nerves, we can see that the legs the next day are open more apart and he is already beginning to extend. We expect improvements over time but already one day later his pelvis is lying flat on the bed, his knees are opening apart much better and in fact the hip feels like the right hip joint is back in its socket. Parents are demonstrating already after the first day that the legs are also more extension. A couple of weeks later he is able to fit back in a jogger that he had not been able to fit into because of the positioning. And at one month we can see that the legs are more extended and resting. We're also able to target the pectoral nerves for the tightness in the shoulders. You can see the father is able to lift it much more loosely two weeks after the procedure but what he noticed was the shoulders relaxed and he was able to breathe better. And this was a patient that he had shown me who had been getting repeated botulinum toxin and phenol injections for a period of several years without much result. And the next one I want to show you, this is one that I did when I was in, when I went up to Canada and this is a patient who has a leg length discrepancy. You can see her on the left and they're after one week after on the right. So she still has, so that's her before and so she was actually referred to get a orthopedic surgery, a TAL, because she couldn't bring that foot down at all. She was completely contracted before we did the procedure. That leg did not move an inch. And then afterwards you can see, this is the video he took one week after, and you can see how nicely that heel comes down significantly better again. She's got that leg length discrepancy, but again, this is after one week and the process continues in that looseness up to at least another month, he's telling me he's still getting results. And she was able again to go to foot flat and a lot of that, what you're seeing is why she's not getting down as much is secondary to that leg length discrepancy. But on physical exam, when we were examining her after she got to neutral. And so questions, I know I'm over and I probably lost the people online. So I'm sorry, people online. But any questions about any of the stuff that I had to go through real quick? Yes, we use the angiocath technique. So that's something I should explain. So the cryoprobe is more of a blunt instrument and so in order to get it through the skin what you do is you use an angiocath and then you place the angiocath through the skin as your guide and then you put the cryoprobe through that angiocath. Yeah, so that's, you know, and you do have to... Because it's long and we use pediatric patients, it definitely creates some technical learning curve on how to do it. The other thing is, at least a nice thing when I saw when Paul was doing it, is that the nerve stimulation that he used was really low, and so it really did help. So typically, like when I do a phenol block, I'm using about 1 milliamp, and so when we did the cryo blocks, we were using like 0.6, 0.8, you know, definitely under 1 milliamp in order to make sure that we got to that correct placement. And again, the other thing that makes it a little bit harder is, again, where that stimulation is on the catheter as opposed to where we're typically seeing it on the needle. So it's definitely... There is definitely a learning curve. I did about three or four with him when I was in Canada, and the first one was definitely a little shaky, but by the second or third one, I kind of got the feel of it a little bit better. So it definitely does take a little bit of a learning curve. It's not as intuitive as you'd like to think, and so there's definitely a little bit of a skill set you have to acquire. Well, I mean, I'll look at it this way, you know, and you're looking at your pluses and minuses. First, accuracy versus pain, right? And so, half the doctors in our practice use ultrasound. The other half use e-STEM and we... and patients who've had both won't necessarily, you know, say, if I have the option I want the doctors that use ultrasound because it hurts a lot less and so it definitely... There's a learning curve when you're using it for sure, but I think once you get that, I think that the pain aspect and the comfort aspect of the patient outweighs anything else. Right? And then when you talk about the accuracy, that's really the part that becomes a little bit more, like I say, difficult, right? Because you're talking about theoretically, you know, how much effect do the FECs versus MECs placement and that's really where the studies have to be more than ultrasound versus e-STEM accuracy, because if you want to justify, at least in my mind, what's more accurate, it's like are you hitting those points, not necessarily where the needle is and do those points make a difference? Because I can tell you when I was first learning and I map in my mind and I have all these big sheets of, okay, the MECs are a quarter distance here and a third distance here, yada, yada, yada, and so that's all. Sometimes you'll stick the e-STEM needle on the area where the muscle is and you can see that needle going into the muscle and it's not stimulating and I know that's where the point's supposed to be. And so when I first started doing it and I was like, well, do I inject here or not, because the muscle's not moving and I know I'm in, I see it in, and I found that to be just as accurate. So if I look at it the other way when you're talking about if I'm using my e-STEM and I'm going in and, oh my gosh, I don't see the needle move, I'm going to have to replace and move the needle, well it could have been in the right place, but you don't know. You don't have that... You don't necessarily get that feedback. So I think your advantage is there and again, the amount of patients who used to go to get sedated for botulinum toxin injections, now don't get, you know, because they're anxious, I show them what we can do with ultrasound and just based on the diameter of the needles that we can use with ultrasound compared to even your typical e-STEM or... It's a thinner, smaller needle and so even if you don't have the STEM on, the patients are more comfortable. landmark, but again, that's a range. And so I think the utility of the ultrasound is to enhance this sort of accuracy. Does it replace all these other modalities? I don't think so, but it's just another tool that I think we can be effective with. And there's also that degree of speed that you can add to, right? When you have ultrasound, you know you're not in a vessel. You don't have to aspirate your needle, right? You can go and inject. And so what you think you're taking up of time, you have the needle actually in the patient less time, quicker. So it actually ends up speeding up your procedures, and especially in those kids that have distortional anatomy, if you will, and you're going, oh this is where the pronator teres should be. Oh, wait a minute, you know, the fingers are moving. What am I doing? When you have that ultrasound, it really decreases the amount of time that you sit there poking around and, you know, muttering under your breath as a child's crying. So I think there's definitely some huge utility to it. Well the answer is yes, but not necessarily. I think as this becomes... Right. So when you look at what cryo-neuralysis is currently approved for in the United States, it's approved for pain or quote-unquote pain with spasticity, but it's not approved yet for spasticity. So I think we really need to go and hopefully in the next several months we'll start doing some trials in the U.S., maybe some trials on children and trying to figure out is this truly a reasonable thing to use? Is this giving us... I mean we have all these theoretical things and Dr. Winston, I want to say, has over 100, 200, 150 patients that he's done already. What's the number? Something like that? Yeah. 150 patients that Dr. Winston has done with really great results according to his data. Like I said, when you go and... I saw his videos because he showed cryo-neuralysis and I was like, that's interesting. And I'm like, but what are you really showing me? I'm really seeing the best patients. What are you actually seeing? You know, because we've all seen these videos. You only see the best videos when you go online. And I have to say, I drank the Kool-Aid. I was there. I saw the instantaneous results. I mean I'm interested in starting how to start to do this on my patients, you know, and hopefully somewhere in the beginning, in the first quarter of 2023, I'll be able to start figuring it out. I applied for credentialing and so I've got to do my Proforma and try to figure out research protocols, etc. But this is definitely something that I'm interested in doing and there are a couple other pediatric physicians who are on the same... You know, so we've talked about whether or not we want to do some cross-country collaboration, do a protocol. So as we start to get through these hurdles of how we can do this, then hopefully we'll have some multi-center data that we can actually present and determine how viable this is and if it's really what it cracks up to be. I know I had to talk fast, because we were running short on time and I have a big mouth. Any other questions? Thanks people for staying awake. Thank you.

ultrasound

pediatric rehabilitation

spasticity management

injections

botulinum toxin

phenol

alcohol

baclofen pump refills

diagnostic nerve blocks

patient safety

nerve blocks

cryoneurolysis