Muscle function and pain management post stroke. Spasticity the change in muscle fluidity after stroke is a leading cause of disability and pain. We will discuss what causes spasticity and how to treat it with current and novel treatments.
Bio: Dr. Paul Winston is a physiatrist and conducts research on spasticity, spinal cord and nerve injury and Complex Regional Pain Syndrome through the Victoria Perpheral Nerve and Spasticity Clinic.
And hand it over to you perfect I’m just going to get my uh video going here so we can see okay can everyone see my presentation here Perfect all right see if I can oops it has there it goes okay so uh my name’s
Uh it’s you know who I am so I’m out in Victoria on the west coast I am from Ontario but I’ve traveled most of the country happy to answer your questions in English or French anyone uh so needs that help and we’re going to talk about spasticity today and I know it’s a
Really broad audience so you know if you see any burning questions in that chat box uh Cheryl please you know bring them to my attention absolutely what I always say in um in my career when someone asked what the heck is a physiatrist I said well we are the doctors that care
With how you interact with the world so our job is to give you the function and ability to what is realistically possible so for example if you look at this image on the bottom we call it a meme today but most people who go into the hospital
They want to come back out the way they were or better and so you know you could insert whatever image on this character but people want to be able to walk as smoothly as possible or wheel their wheelchair or move or think or eat with as minimal effort as possible and we’re
The doctors that work with our rehab teams to kind of give you back that function and I think medicine often forgets to ask people what are your goals when you come CS so that’s our goal is to get you backed as much as possible within the context of
Disease now the term spasticity is really challenging it is 300,000 people in Canada have uh spasticity probably more with the growing population yet everyone will Define it differently so some people will call it muscle overactivity so to kind of give you an example now no one can see you so don’t
Worry is I would like you to grab two hands if you have two hands that move if you have one if you can’t move your arms at all maybe a caregiver in the room can do it but I would just like you to grip your fingernails in as hard as you can
And and almost like herts that your nails go in and I want you to hold it there and pull in as hard as you can and then in slow motion I want you to take one arm that moves and try to reach out but resist as much as possible and
You’re going to slowly open your fingers so it takes about a minute to pick up a cup and I want you to think about how much that hurts and how much effort that takes to do that well that’s kind of what spasticity is spasticity robs you
Of the ability to move the muscles the way you want to move them so we need to open an arm by relaxing it opening it letting gravity help and then we need to move it back but in order to move a limb we have to want to move it consciously
Or consciously and everything else has to relax but in spasticity everything gets stuck together so in the upper extremity it looks like this and the lower it points down generally there’s many patterns so that’s what spasticity it is and it affects a lot of people so
In the arm it often causes this position but it can cause this position it can cause this position it can cause almost any position in the lower extremity it often makes your legs so long that your foot won’t clear the ground or you can’t bend your knee or you’re stuck in a
Wheelchair with your legs together each patient has their own pattern so I’ll give you an example that even when we treat it so this was one of my uh patients he was a a wood carver uh he had a stroke in hospital and we treated him very early with botum toxin after a
Stroke because he was so tight and I’ll talk about botum toxin or Botox later but even after we treated him and his arm works so well this was an amazing outcome he still wants to walk like he has a stroke so his brain causes his arm
To externally rotate to come up and his knee is stiff and we have to say to him hey drop your arm relax don’t you know you can bend your knee because his brain is not working the way his brain wants to the stroke took over so even when we
Treat it we have to constantly remind our body how to work because after a stroke we don’t have full connection to our body it might not feel the ground or the the environment well this is some patients have problems in the lower extremity in the leg that
We call a dystonia so this man when he walks his toes curl under it’s a really hard way to walk because when he walks his toes clench up and curl and they dig into a shoe and you can see his right hand is actually in a fist as well so
When he wants to go use that hand it gets in more and more of a fist now my colleagues from Germany put together this nice um sort of diagram of where the most common stroke patterns are and if you’ve had a stroke yourself you might look like this or have a loved
One but it’s not just stroke it’s cerebral palsy brain injury spinal cord injury multiple sclerosis many things will cause this now the interesting thing about um a stroke is that your nerves are still alive your muscles are still working and we know that we have a
Nerve that attaches to a muscle and it causes that muscle to relax or contract in a stroke it’s like it’s going all the time you can’t shut it down so when you want to relax you can’t relax your muscle and stretch now the first question is do we need to treat it
And there’s a lot of arguments um I know in centers where they don’t have as much access to Physicians or Specialist Care they might say well we need to let the spasticity play out but in most of my colleagues many were physiotherapists or occupational therapist before they
Became a doctor they said well why do we let a bad pattern play out shouldn’t we be getting rid of the problem when it starts like right after a stroke in order to normalize movement at work so for me the first question is the spasticity causing a problem is
Something else causing it is there some kind of Trigger or bad thing happening how do we measure it and should we treat it like is it impacting the patient or not now one thing that we know the urgency of treating spasticity after a stroke early is that half the patients
Will develop a contracture and a contracture means the limb is so stiff that no matter what we do we can’t move it anymore we can’t open the hand more we can’t bend the wrist anymore can’t lift overhead the knees are stuck together the foot on the ground so even
The best therapy won’t stop contracture from forming we also know that we can try to stretch and do as much therapy on its own but therapy on its own won’t stop it now of course therapy is extremely important and we work uh together with our physiotherapists every day but it
Won’t prevent that body from getting tighter so we need to have lots of teams so this would be an example of a woman that was on in my service that she has a really stiff painful shoulder and you know you you think it’s a contracture but we have developed a technique here
That we learned from our European colleagues where we actually freeze the nerves that cause the tightness with some lidocaine which is just a pop top sorry an anesthetic that you get for dental cream or working on your fingers and we paralyze the nerve and lo and behold she didn’t have a contracture we
Can actually treat her to get a range of motion back in my clinic we um we are doing a lot of Novel stuff so I’ll talk about but this is your classic shoulder this man his his his shoulder is actually coming out of the socket a couple weeks after stroke and because of
That his muscle of his chest muscles his pecs are so tight he can’t get his arm overhead and he is developing pain every day on the ward so the therapists are telling us he can’t participate he’s in pain and we do our novel procedure and we paralyze that te muscle and let the
Arm go overhead if you’re a therapist you might know that we use something called the modified asro scale and it just measures how much stiffness is in the muscle it’s a really not a great scale it’s very changeable someone with a stroke will say in the morning my hand opens but in
The afternoon it doesn’t and it just lets me speak with another therapist or doctor to let me kind of know where the patient is but it’s not a real reflection of how they move now one of the most common treatments in Canada because we have mostly free access for
Most stroke patients is botch linum toxin now we often say BOTOX for the trade name but there’s multiple brands on the market and what it does is it stops the the nerve ending from Contracting to make that muscle tight so imagine you want to do the splits and
You can’t do the splits because the muscles are tight it would kind of relax the muscle so you could open your legs a little bit more and that’s what the botum toxin does is it stops the neurotransmitter to relax that muscle for about three months so it’s this very
Incredibly um Hightech mechanism it’s not botulism the disease but it is defined so people will say that botulinum toxin is the world’s most deadly um molecule in a large in a large quantity you know kill a large population and it’s the most expensive it’s about four to five billion dollars
A gr so very expensive molecule but we use tiny amounts so it’s not going to hurt you it’s safe but we do need to know side effects of H dois so when you see your clinician for botum toxin if that’s something that you’re considering gr or getting they
Will look at the pattern of muscles in your body so whether your hands like this open or close and they will decide where you should get that U toxin to relax those muscles now it does mean in most people they’re going back every three months indefinitely some people
Are lucky a few rounds relaxes them up enough and they don’t need to go back so this would be a another case of someone who and I’m a huge advocate of getting treated right after stroke so if you listen you can hear that catch in his elbow so he was getting a contracture
And stiffness in that muscle about 5 days after his stroke so his um occupational therapist and physio said can you help him out so we injected Botox into that upper extremity and he’s getting better we also really take advantage of bracing because I said to you physio on its own won’t help the
Therapist will brace them to maintain the stretch and then a month later he’s getting much better function so by treating him early he was lucky we kind of got rid of his tone other people we will keep treating this was another gentleman unfortunately where I live in DC we have
A lot of Strokes out there overdose which is really tragic and this man was getting stiffer and stiffer in his arm so we treated him very early with Binum Toxin and the arm relaxed so it stopped him from getting worse so we in in multiple centes across Canada you can
Get treated early if there is a physician that will do the treatments so I’m extremely lucky I have a team of spies they are very um aggressive spies they’re called physiotherapists and occupational therapists and nurses and they look at all of our patients in the hospital and they phone us and say I
Don’t like how Mr Jones is going uh Mrs sidu she’s developing tone this isn’t good can you come see so we work really strongly with our therapists to decide when we’re going to intervene to help the patient so their tone doesn’t get worse so the physiotherapist examining
It and then me after treatment so we work as a team with our spies now most patients will not get treated early in the hospital they’ll get treated later so this this gentleman was sent to me because he’s he’s actually guitarist and he just can’t open those fingers and he
Had tried some uh treatments with Boton Toxin and it wasn’t strong enough so I did one of those paralyzing blocks with lto and a nerve right here in his wrist to open up the fingers and lo and behold with just a little bit of lid for an
Hour and a half he can open his fingers so we add on some electrical stimulation on the back of his arm so that he can start practicing so this would be a treatment option we know that he has the ability to open his hand he just has a
Lot of spasticity and we’re going to try to help them along um this would be the classic case of someone in the hospital who developed tone in their leg very fast so you can see where her toe is going up and we used to have a really nasty neurologist
We called him Voldemort because he was so mean and he wouldn’t let us treat the patients and you know he he he didn’t even believe this well B I said I’ve never met a person who can bring their toe up that high so she was in a lot of
Discomfort walking and look where her toe is so she was developing really bad spasticity quickly so we were able to inject her when another neurologist was on call and and L us to come get help and we treated her and she was up and walking the next week when she couldn’t
Get her foot on the ground so she was quite happy we rely a lot on braces so if you’ve had a stroke yourself you may have different types of braces there’s little simple ones that will support your foot there’s more rigid ones and then there’s some electronic stimulators
Based on where you live in Canada and how much insurance you have that would cover an electrical brace to stimulate now a lot of people will have tone that’s just too bad and there’s very select centers in Canada where surgeons will help and the surgeons are amazing
So this is an anesthesiologist that I work with and you can see this poor woman her shoulder does not move so we did a block to release the but it’s still so tight that I called the surgeon to help and this was one of our first surgical cases she did nerve surgery
Relax the elbow and she did a tendon lengthening so she relaxed the chest muscles to open her so This Woman’s now in a much more comfortable position after working with a physiatrist like me an anesthesiologist and a surgeon so we need a team to do
This now I’m going to talk a little bit about novel innovation today because this is sort of my life right now and we created an association called Canadian advances in neuro Orthopedics for spasticity Congress or Consortium we have a free website we actually have a conference coming up on November 11th
Virtually you’re all welcome to attend because it’s free online on Zoom we have experts coming from all over the world coming in person and online to teach and we’re going to be doing a really deep dive in how to treat spasticity now this is my research over
The past four years on how to come up with a new way to treat spasticity and we are doing it by getting rid of all drugs getting rid of surgery as much as possible and treating people by freezing the water in their body so we are giving
The body an ability to treat itself through a little twist of physics so it’s quite an exciting time in our in our world right now and we are treating them with what is called curis so we are going to inject that needle in your body it’s going to get so cold minus 88
Degrees that it’s going to cause the nerves to break down without drugs we are doing a lot of teaching and training these are the people that have attended our workshops in the last while um we also go and travel so I taught in Oxford this summer in Italy Copenhagen
And people all around the world are trying to figure out what the heck is going on in Canada um it’s really fun for me to teach this team came up from Harvard recently so our patients were treated over two days with the team from Harvard uh learning on our novel
Treatment we created a lot of Buzz with our new technique and there’s so many great doctors around the world doing really great things so my colleague Dr Vincent and I the anesthesiologist we asked about 30 experts around the world if they would help us create a book on
How to do nerve blocks to improve spasticity care whether you’re going to get injected with botum toxin Botox there’s some drugs called phenol whether you’re going to get um surgery or our treatment of chis this textbook which you can scan the code and go right to it
Um this will tell you how to optimize your care so the providers uh people are therapists or healthare providers uh it’s something you could look to see if your library would get don’t worry we don’t make a lot of money off the book and it all goes back into
Research now you started with the land acknowledgement so I’m going to do my own here this is lisaa she is doing her PhD at UFT in rehab Sciences she is a force of nature um she will share her story so it’s her story not mine but we are
Exactly the same age but because her father had Polio which is a a western disease she was taken away unknown to her as a scoop Survivor same age as me and raised by uh a family and only found out an adult that she was taken from
Home and the reason was is her father had Polio so he was a and couldn’t raise his child so she met her birth family she’s got two loving families but she really talks about how we take people and we don’t really get consent and we don’t ask them what they
Want and we force them to do things in medicine and her father was sent to Edmonton from the far north multiple times for really invasive surgeries to rebuild his body from polio and he had to keep escaping and at the end of the day whatever they did for the polio
Surgery when he finally made it back home his mother who would just pull him on a sleigh for much of the year um turned him into a warrior um dog sled uh Champion so her father was actually a champion in their culture but we called him a because hospitals were for
Crippled children back then so Lisa has really taught me how to celebrate the uniqueness of each patient so everyone who comes to our Clinic we need to know their story and we need to know why they’re there and what they want and how they want to change and so that’s how I
Bring in indigenous teachings into my clinic is to make sure everybody feels safe with what we’re going to do and the way we do that is we are going to tell the future with them so we developed cry neuralis now this is actually another indigenous patient who was admitted to
Hospital with quite a a serious nerve disease she had been declining for about many months and was given a lot of medical therapies as we do in the hospital we got rid of mass mandates and she got coid poor thing and was in the Intensive Care Unit on
Oxygen when she decided you know sorry when they let her come out on the ward and got rid of her oxygen she could walk because she had such severe pain in her knee from arthritis and she has an arthritic knee on the left which was
Meant to have a surgery but she was just way too sick to undergo surgery so cryonis is something that’s been used to freeze nerves and Destroy them that cause pain for years so what we did was um we froze the nerves to her left knee
Got rid of her pain and she went from walking with my student who now doing his PhD at Western in London to walking on her own very fast independently because she didn’t have so we know that cryo works for pain and it’s been used for 50 years so in our Clinic we decided
To have informed consent by doing nerve WS so we have taken every patient that has spasticity and instead of having a crystal ball and saying we’re going to put you on some drugs or inject you with bot toxin or another drug or do surgery we’re going to do nerve blocks with
Ultrasound guidance you’re going to watch everything live on TV we’re going to block you and you’re going to end up at the Disco parlor because you’re going to know what’s going on with all the excitement so we’re going to tell you the treatment that we think you’re going
To have so we feel that this is true informed consent because we’re going to tell you what we expect for you to get we have designed this new technique this is Dr EV wasano who is my fellow she is in Montreal now uh independent practice and she’s showing this is the
Live technique it’s fast forward just for your speed but we put a needle catheter into the chest wall here and we are going to look for the nerve and in this case it’s the white line the second white line in the middle of the screen that’s the nerve where she’s going to
Start approaching with her needle you can see the needle going in we are going to press a button and gas just like your whipped cream maker or your soda stream is g to go through that tube it’s going to make the tube so cold that the water
In your body will freeze that nerve will get destroyed for up to six to nine months and goow back perfectly fine and you’re going to see the way that man his muscle just relaxed so that’s what cryo is and here’s another example so it’s a handheld procedure that we can do in the
Clinic at your bed at your long-term care facility and even at home if needed so I see a lot of patients that have failed treatment so my colleague in Vancouver asked me to see this patient of hers um so he is very stiff he doesn’t have
Active movement in his arm but you can see if you’ve had a stroke you might recognize this pattern himself so we figured out that if we froze the the muscles with well temporary paralyze the muscles to the chest to the elbow and a nerve the funny bone nerve which
Controls a lot of the hand we could get him to relax in the lower extremity we have the problem that the leg is too long so this woman actually has multiple sorosis she doesn’t have a stroke but it looks like a stroke leg and she had been getting her treatments not getting
Enough result so we actually froze and destroyed the nerve behind the knee that causes all the muscles to work and the pain and Sensation that she had it will grow back about 9 to 12 months but you can see how much better her leg moves and she’s actually able to lift that leg
Now and walk without brace so we are doing this every week in our Clinic more and more patients through our research and our Hospital funding so this is a man who has a very painful shoulder hemiplegic shoulder is the fourth most common disability after stroke a painful shoulder it is horrible
And we have no good literature in the Canadian best practice on how we should be treating it so we actually take out the sensory branch that that serves 70% of the shoulder we can get rid of his pain and then that contracture that he was told he’d never remve his arm we can
Get rid of it as well as the one that keeps the hand um stiff so patient by patient we are sent these people that we are told that have tone that I would almost call malignant tone because they can’t get their arm overhead they have pain they can’t open
Their hands they have a tight fist they can’t hold their spouse’s hand they can’t touch their their their grandchild’s face they can’t clean their nails we are able to get rid of that with our novel procedure there are surgical options as well in some parts of Canada and we are starting to get
This approach out so you can see how stiff her hand was Dr finless and she’s trying so hard to open it but after our procedure it’s immediate this is the man that I showed you had the toe curling at the beginning so he also his stroke affected his whole
Right side and he has difficulty opening his hands they get stuck we call that AIA so we did one of the nerves that the funny bone nerve that causes the hand to close and we found by blocking that we could get his hand to move and because
He has he is not a paralyzed stroke he is movement he has a beautiful moving hand now it’s quite emotional when this happens in clinic everybody generally bursts into tears including the patient and me and everyone else when someone gets their their paralysis back and this
Happens every week we are able to uh return a degree of function to different patients some we can’t because they don’t but some can you know pick up a water bottle or or feed themselves which is really really special you can see how tight he was
Before um EV and I um both have a dance background and so we use a lot of movement analysis and um it’s a very heavy research load and a lot of work so we try to burn Steam on our own just by figuring out movement together all the
Time on how to make things work so this is the treatment that we’re using um the the freezing of the water so just this handheld machine with a one-time usable probe that’s one per patient and this is what it looks like we we just pass gas
So we actually don’t um we don’t pass gas that’s quite funny we pass gas through the aperture and we cause it to drop in temperature and it freezes your water so there’s no drug so we are replacing a very you know strong chemical with nothing
And for those of you that are a little bit nerdish this is what it looks like what’s amazing about this procedure is that at the temperatures we choose when we touch a nerve we get the picture of the the neuron that you’ve may maybe seen a picture of what a nerve looks
Like to destroy now you live in s St Marie much colder than Victoria so we don’t get minus 20 degrees ever but you would get frostbite and when you get frostbite it’s reversible it would come back so up to minus 20 degrees you would get a frostbite when you go to past
Winnipeg temperature to likeus 88 you actually destroy the nerve so what happens is we get the nerve tissues to die but nothing else what’s an amazing part of physics that the blood vessels the tissues the structure of the nerve everything is still there but just the nerve disintegrates so it can grow right
Back so it’s really fascinating that this procedure allows it to grow back cryo is also used to kill tumors at a colder temperature and they use the gas arone to do that we don’t want to touch or damage any other tissue other than the nerve and we don’t harm blood
Vessels because they’re full of seits so it’s good so when we develop this technique this would be a typical patient who had come to my clinic that I had injected he was getting his Botox injections or actually it was it was a different brand uh and he you know he
Doesn’t have much movement in that arm and we’re showing that he you know if you move it fast it get stuck if you move it more you get a bit more movement but not a lot of functional movement when we do our lidocain block we got rid
Of that fast catch and went right to his end so it’s easier for him to move that arm so we knew he had potential so this was our Ground Zero patient the first patient we decided to do cryo because my anesthesiologist said well why don’t we
Do cryo to make this nerve block last and he had been doing it for pain for decades his machine was made in 1980 in the Oxford so we went ah head and we decided we figured out how to localize it on ultrasound and we did cryo and you
Can see he has no patch anymore his arm goes fully open so that man who to the best of our ability was stiff he’s going oh wait I can kind of um open my arm he had never praticed it before because he doesn’t really pay attention to that arm
And what’s happening rather than having to repeat his injections he’s better at six months he is now lifting up his grandkids he clamps his hand on the lawn mower he’s Lo he’s mowing the lawn he’s doing all kinds of tasks and two years later he was still good we have put uh
Cryo in multiple parts of his body ever since that time so we went through case after case muscle after muscle and this is a child that has Cal poles he’s a teenager now and he has this really tight muscle and when people saw us starting to do this treatment they
Thought well aren’t you going to kill the nerve and shrink the muscle but if you look on the left side in the green his his muscle’s quite Spin and small and he’s got a he’s got a tendon sticking out there but after the cryo the muscle’s big and long and quite
Beautiful looking so if you look at the the the before and after he’s got a bigger muscle and we’ve been noticing that when we lengthen the muscle so this is the approach Dr boso can you explain what you’re doing so I’m doing um I’m going to do a cryonis to the motor
Branch for the bracho radialis uh coming from the radial nerve so she showing how she does this now we I know this is through March of dime so we have just started a pediatric program at our hospital I’m very excited about because unfortunately lots of children have
Strokes people don’t realize that but we have strokes in the you know from birth so we have children who have strokes and cereal paly uh brain surgery and other causes we we do it under laughing gas on the Pediatric unit to help them with their anxiety and and pain for the
Procedure so we developed this technique one by one of figuring out which muscles that people needed to get better and we uh I work a lot with International uh so if anyone who’s in therapy wants to take a screenshot of this or a picture we developed something called the Viva algorithm which is
Verona Victoria because um it was done in Verona and my colleagues and we show how to decide to treat someone after a stroke and it’s something that we work a lot with our physiotherapists to identify the patients so again this is a man who just had a stroke on
A and you can see he’s got a lot of pain in that shoulder and he’s really stiff but immediately after the procedure can’t get his arm overhead his arm goes right overhead and it’s really tight the biceps muscle is preventing him from opening the wrist is a little bit tight
But after the procedure wrist is looser and you can tight the biceps is on the left and it’s you see on the right so we are now doing uh one of our funded studies from our Hospital Foundation is to treat people within 16 weeks of this is another one of our patients
Who chronically had a stroke she was getting her uh Botox injections by my colleague but wanted to do better so we did nerve blocks to all over her body to decide which muscles we would Target and then you can see her after the procedure at one month she has got
She’s able to lift it better on her own but look how Loosey Goosey and she’s over 2 and a half years from her procedure and she’s thrilled she never had to have it again we also did her leg and she’s part of a documentary that
We’ve just filmed she had to hold on and wear a brace she now walks around her apartment vacuuming on her own and doing lots of cleaning and homemaking she actually went back to work as a bookkeeper because she can now um you know sit better and her hand actually
Works now this was a patient that we just treated when the team from Harvard was here he he was born with this difficulty with his right arm and at Vancouver Children’s and the Shriner Hospital in um or in the states they they don’t know what is his condition but he can’t lift
His arm overhead on his own and he’s a teacher but you know a month later he started lifting his arm and physiotherapist said he gained 50 degrees of range of motion because she asked him to because he never thought of opening his arm before because he didn’t
Know how so we’re really excited for the function that he is going to gain with physio over the next year this is how it looks for shoulder pain so we go to the back of the the the shoulder and we put in our um needle and we freeze the nerve
That provides shoulder pain we are doing this for people who have arthritis and who can’t get operations on their shoulder because it gets rid of 70% of the pain now I’m just going to share one of my favorite and to the let us show her
Picture in her face and down and up I shouldn’t have favorites lift up right and then bring it down and bring it out to the side this way down good Perfect all right and then so her shoulder pain was just getting worse and worse years after her stroke perfect
So not really high tone but that’s the range she has her V3 or V1 maximum B3 so she just doesn’t like being moved very sore shoulder that’s it so I’m bending the elbow but it’s only 90 degrees and then her rotation it’s very painful she cheats well we treated the the nerve
Pain muscle the chest muscle and the elbow movement muscle and this is her right after the procedure lift to the sides and then rotate it out to the side and then towards me perfect oh and straight it out she’s laughing and back crazy okay now I’m going to do it
I’m like a little raggedy an I’m like a little Ry so I’ll just let you know she just came back about a year and a half after procedure because she has pain on the other side she actually has another condition that affects the other arm but her rotator cup was quite destroyed so
She asked us can we take out the pain and she went from barely moving arm to over but in we didn’t have to repeat any of the muscles we treated before but we now do some of the muscles under the uh under the um in the armpit area which
Really relaxed the muscles more so we gave her more range of motion again so this is another case of a man who’s just had a stroke in hospital and the occupational therapist said you know Paul he’s it’s a shame because he’s starting to get recovery of his
Movements but he’s in so much pain he can’t participate and he’s getting something called clonus where when we move them and if anyone’s had a stroke on this line you may have clonus yourself where your body shakes uncontrollably so we we did prior to the shoulder pain muscle chest muscles the
Elbow and the one that was causing the shaking and stiffness in the hand and actually my colleague just finished residency in Ottawa it was his first week with me and I trained him to do the procedure and the guy is Loosey Goosey shoulder pain is gone he’s able to lift
His arm overhead and you know what we do it on Friday sorry Thursday at four o’clock and he goes back to therapy on Friday and they’re like what the heck did you just do to my patient because he showed up ready to go for therapy really
Happy in no case Okay excuse the crazy hair but I want y’all to see something that I’ve been able to do for 12 years so we get a lot of traveling patients this woman comes from Texas and you can see on the left her movement before the procedure on the right she is
Showing me how she can box after the procedure so she’s quite happy uh she could never touch her head um and then when she came back a year later we added in the shoulder blade muscles and her thumb is quite if you see on the on the
Left side so by relaxing her thumb you know not only can she box but she can now get up and do really fine motorc and now I don’t have to do it and get yelled at because I do it Terri she’s very very happy with her procedure now we the side
Mention we see children with stroke so this is a girl who had a stroke at the age of 10 go like this and and um the surgeon center to me because we wanted the lengthen the arm the elbow the biceps family didn’t want to do any surgery yet so we did
Cryo and you know she never used that left because it was very hard to open and she walks with a brace and a limb and again she came back a year later so to the side over the to go like this up and down good and straighten the arm out
Good open the hand you open your fingers open and close good she uses that whoa box you I can box myself oh my God and yes she can box so after the first procedure and after the second proced procedure you can see how good use of her arm she has
Now now this was her walking so after her stroke on the left side you can see she’s got a floppy way and her arm is held so tight at the side she can’t relax it and when she comes back four months later sorry a year and so later she’s running now
She’s playing soccer so this is quite an emotional case she’s one of our patient Partners um that helps raise money for us um the family is just so happy that you know she has so much more function and that was her walking before the procedure and this is one of our
Other over the top go further know session as far as you can go behind you and all the way here wow okay and straighten it out and I just want to acknowledge for anyone who’s had a stroke particularly if you see your doctor in the hospital you had
A stroke it’s a pretty traumatic Place many of our kids with Falls you know stroke Pati very traumatized by the hospital because they had you know they they were in the ICU they’ve had own problems oh my holy cow and these kids had a lot of
Hospital and a lot of needles from us over many years so they hate the hospital they hate needles and the fact that we can do it once or once every few years is going to be really nice for them not to come back all the time any we’ve introduced a few extra technique
So uh my colleague from France is sitting beside me here who trains and in France they do a lot more surgery so this patient had a stroke and I injected her with vin and toxin for 12 years and her arm always stuck in front of her
When she walked got in the way and we couldn’t raise it we did cryo and we got her to about here so I decided that we would do our new technique which is taking a little needle putting it under skin and scraping away at the tendon on
The chest and we we’re doing a case now we’re up to about 15 of these patients so we just take a little needle and we scrape away the tendon and that’s why her arm goes so high so what was your hand like before we you
Know one of the things that we do this is because a lot of people so was it closed all the time or part of the time all the time and why person and it was really embarrassing to him so we started doing these ones to open up the hands even if
They could use them so they they looked easier to use didn’t smell and people might not noce it as much and this is how we are starting to get people with stroke and cereal paly to get more hand function with the procedure so this woman and she just came back two months
After procedure and she was another patient who her goal was to run so you could see her jogging there she wasn’t able to run before now I’m just going to try to uh get through in the last five minutes to end so about % of people who
Live in a nursing home have what’s called you may have a loved one that has how does this feel oh good does feel bad bro doesn’t feel bad bro so the difference between what we we do all the take away the sensory part and the motor function so he had
Skin breakdown all over we can see there’s some mation in the skin that we’ve opened up and then these fingers so these patients are in Care Homes and homes all the time with skin breakdown infections going to hospital and we now have a way to try to help it
And that’s one of the clinical studies I have going right now on the contracted hand this would be another dementia patient who you know her her nails are digging in so her poor husband you know every time he tries to move her she’s screaming out in pain for him and he
Can’t help her and none of the treatments helped but by doing our treatment you can see her her Palm healed within a month and this is another Nursing Home Patient you know he’s got a really tight hand um that we can’t open and my colleague asked to help because the the
Staff were getting were having a really hard time helping him oh okay putting up with kids so we can open it now so now we can trim his nails clean is this hurting at all he says I have no pain it again no pain okay can now see that finger that was digging
Inated painkillers that make them sedated and we’re getting them off this is before a block can you open your hand all right um You can just raise your hand chever you um we have quite a few questions okay so I’ll just stop on this case because I
Have dozens of cases but this is quite a fun case so this is a man that has a stroke at a young age as a teenager and he had a really good surgeon operate on him but he had that Donia so he couldn’t open the hand when he wanted to so we
Did one of our blocks and figured out would relax hand so we did the block and then we did the cryo to relax those mus so now he has a trick that he can do he can make it stay open on his own now enough to pick something up and
Carry nice all right so I’m just gonna oh I’m just gonna show you this one because it’s fun okay can you move your foot up and down for us and what’s different it moves it’s never moved before let me see that again oh that’s quite exciting move look at
That so this is this is what happens in ner block Clinic every day so um yeah last last foot case here so here is a typical stroke patient he had been my patient for years he we call him Mr GID up because he GID UPS he can’t catch up to his
Leg and we do the cryo and he is able to start walking better and then we bring him back for Physiotherapy and he is walking very nicely so a lot of these patients are able to get rid of their brace or wear their brace more comfortable
All right so I’m going to just end there because I have too many cases all right thank you it’s uh no wonder that you’re you’re quite passionate about that looking at the results um the biggest overwhelming um question across that we’ve seen is cost um does Private uh insurance cover it uh
Does do any provinces cover it and what is the cost sure so for stroke in Canada and just about every Province I think maybe Pei might be the outlier we actually did a paper on this called access to Boton and toxin therapies fcal it’s covered in virtually every Province
And that would be on your provincial regulations so I know in Ontario it’s covered for stroke sometimes it depends on the age everyone up to 18 everyone over 65 each province will be a little bit different but every private insurance covers it for stroke so in my province in British Columbia we have
What’s called a deductible you pay based on your family income so everyone pays down their deductible toxin’s expensive so generally it knocks out their deductible so most patients don’t have to pay cash but I have had patients that had to pay $2,000 treatment because it
Costs up to um $2,400 four times a year that the vast majority of my patients haven’t had to pay and they shouldn’t through up in Canada there might be a deductible based on where you live all right so I hope that that it answers because many many questions came through about
That um would the Cairo um procedure work two years after a stroke yes so the the majority of our patients are like 10 12 20 30 60 years after a stroke so we basically do a block um first to see if it will work and that’s why particularly
When patients have had to travel to see us we do a video my my research is assistance because I’m not allowed to do tah Health in another Province they will see the patient go through it we’ll get their doctor to send us a note and then
We would consider so yeah most of our patients it’s it’s been a long long time okay thank you um has this been tried with patients with severe arthritis yeah so really wonderful question so the um one of the main uses of the device that I have in the states
Is actually to numb the knee before you have knee surgery to replace so you don’t have pain so we do patients who can’t have surgery on their knee um because I’m funded for so limited unless you have MS or stroke or something I’ve had to tell those patients unfortunately
We’re so limited uh it costs us $800 for the probe there are clinics in Ontario and now there other techniques that work on arthritis called radio frequency which is which is offered in pain clinics around Canada so that’s an option we are increasingly trying to offer but we’re really reserving our our
Lotman of probes to neurologic disability but um many of my patients who had a stroke they need it on the knee on their good side so we will just do it at the same time uh we’re doing a lot of non-operative people who have cancer who can’t undergo surgery so I
Will give I I I I hate charging patients it’s my least thing so it’s only like four or five% of patients we’ve had to charge and it’s simply because we ran out of stock that month and they wanted it for pain not for neurologic disability okay um how many times can you repeat
The C Cairo treatment on the same nerve is there a limit that’s an amazing question so cryo started in the 70s um as a pain treatment for things like trial neuralgia or nerve pain so they can repeat it they would do it when the nerve grw back and the pain are on an
Average about six months so it’s unlimited the nerve grows back perfectly well and there’s good studies from on animals showing that it grows back so you destroy it but it comes back we have thankfully not had to repeat it that often there’s some people with that Donia where they have that weird
Twisting movement as soon as the nerve grows back the brain tells it to go again but very few people have had multiple treatments you know the average would be maybe to and it’s so easy to repeat on that one nerve that it’s no problem okay um H and you just actually mentioned trienal
Neurological uh would this work on that yeah so the probe that I have is too big there’s a smaller probe and there’s a woman in um Florida Andrea trescot she invented most cryo she’s an amazing woman and she does it for that procedure uh but it’s not my
Forte and I’m not going to do it just because I’m worried about weakening the facial muscles but there are options okay um do you know of anybody in the US doing this so um I have been training a lot of Americans so Dr Shang Lee that’s Li in Houston now has two
Clinics and Dr Clay Gwen at g u YNN in Atlanta uh the Harvard group is looking at purchasing many groups are looking at starting it’s the same thing it’s about getting insurers now the US is crazy because when you get one botox injection they will charge your insur
$20,000 even if the medication here cost 2,000 and they’re 5,000 or 4,000 because they charge all kinds of fees just to use the hospital so in in Dr Gwyn will do it in his clinic so it doesn’t have this what kind of weight list is there
To see you we have four doctors in my clinic that are doing it and this is our priority so the weight list is pretty short we generally book people and then um you know book them for treatment within six weeks so sometimes the weight list is two days sometimes it’s four
Weeks six weeks but it’s pretty short because we’ve done that and we’re really in the process of trying to find more funding the hospital is giving us more because we’re not allowed to really charge the patient in the hospital so we’re in this weird just to give you an
Example this treatment which would C we buy it for about $650 that replaces up to $9,000 in apprx in a year so we’re trying to convince the government that you could save you know between between five and $9,000 per patient for year uh and and that’s every year um
So hopefully we’ll get it on formulary my colleagues in Alberta are working hard to get it covered okay will this help neuropathy really good question so my colleague I’m probably going to Copenhagen soon so Copenhagen is where norvo Nordisk is the biggest wealthiest company in the world that does diabetes
Care and they have a lot of money so he starting a study at diabetic neuropathy on freezing the nerves that cause the diabetic pain so we have been doing some pain at the top of the foot it’s something that these are all things in order for me to get it funded I needed
Test Pati but I need a a research Grant and these are the things that we’re trying to partner so I I’d love to do that study but again I need a a research uh Grant fun so if anyone has diabetic neuropathy and has connections and want
To find out I’m your guy um we just need some kind of funding to make happen Okay um in patients with connective tissue disorders such as aers Danos how does spasticity uh need changes in treatment that’s a wonderful question so uh ERS downlo is is is flexibility hypermobility so these are
Bendy bodies and in some people it can be very protective in spasticity because they have more looseness more play so they they might be luckier but they also have joints that might sort of dislocate and sublux so they’re more prone to having pain so in my experience ERS
Downlo patients have a lot of pain with fast to sleep okay so this would potentially help that okay uh neuros I’m sorry I’m butchering these names neuros sarcosis neurosarcoidosis yeah um when uh lower muscles are tight when straightening legs are turn over in bed the body suddenly tightens for a few seconds is
This actually spasticity no it’s probably a different pathway it’s probably it depends on what’s happening in the brain it could be spasticity to have to assess it uh I was just talking to my colleague today that our procedures even toxin toxin is meant for spasticity but we use it in
Parkinson we use it in many disorders relaxed muscles so there’s many treatments that might have different disorders it’s basically a disorder of muscle if someone just has a tightness that relaxes we generally don’t treat that because we don’t want to make them weaker but there’s always a possibility that’s happening a lot
Okay um is this recognized by all physiatrists uh my new technique or or My so I’m I have a lot of friends across Canada and all my colleagues are there and I’ve presented so a lot of people it’s still new we’re be doing a major data dump in the next uh six
Months we we’ve got multiple papers going to publication which hopefully will change um so I don’t think I’d have a single colleague that would say no you can’t see my patient because they’re sending me their patients um many of them want to do it they’re they’re coming for training it’s literally that
How do I raise the $650 per patient because that’s how it works in Canada we don’t look at Cost savings we look at what’s covered or not so I don’t think anyone would would say no you can’t have this and what I’m trying to do with our textbook is get my
Colleagues to uh even even the company that makes Botox bought 100 copies of our book to give to people to do blocks to see how they could give care better so I’m encouraging my colleagues to try to do the blocks themselves to see if they need treatment and we’re trying to
Get more clinics across Canada so one in Montreal should be opening soon there’s someone in OT there’s a doctor in Ottawa who will do it and the doctor um they just have to get all the equipment and stuff okay so in Ontario there’s Ottawa is there any in
Toronto no uh I just treated a patient from Toronto who to a child and an adult from Toronto who loved it their doctors are very supportive um my PhD student is starting a research project at Western so they will be recruiting people when that’s funded so in London there will be
The possibility to be treated okay and what is the actual referral process um to see me it’s a bit convoluted because you’re not all under Canadian law you can’t get referred to me if you’re from out of BC so what I generally do is just get people to uh
Contact not hard to find our contact in Victoria and send a referral and then as I said my research assistant will contact you because we you know those Canadian colleges the last thing they’d want me to do is help you they’re protecting the public they hate they
Hate out of Province they hate other doctors and patients no one knows why so we do a screen and my my research who’s actually a physician a trained physician in Iran she’s highly talented she will tell you if if you would benefit or not and then
We come out and I generally have been doing the out of Province people on our our big study days because I’ve get a donation of probes for those treatments so it doesn’t cost me anything so I can argue I’m not taking money away from people in
DC right um uh Sor can you just clarify is the chyo method done before after or in conjunction with uh the botox take treatment so generally 99% of people unless they’ve just had a stroke have had multiple rounds of Botox and that’s why they refer to me because it’s not
Lasting or working enough um you can always have it after but what we find is they generally don’t need it after uh we might do it in a small group of muscles that we didn’t treat just to kind of top it up or if you lived in another
Province you might need to get that topped up because you can’t get it you know we are not getting rid of toxin I still inject toxin this is our our research area um they’ve been actually very supportive of me in terms of funding the difficult patient so you
Know in rehab we say you know just like I work with a physio andot I work with Toxin and cryo and surgeons like we’re all working to give the best outcome we don’t want to pick aide okay um what about headaches from a stroke very interesting so headaches
With stroke um when they’re migraines we treat those with botox I have a large Botox program the company that did this one has a really small little probe and they just did a study on headaches so I’ve done a few um on this and it’s kind
Of like when people come in for their spce a stroke I do their migraines at the same time you know I have one patient that’ll probably be doing the headaches with their spasticity as well okay um just the last couple um there are a few people in
Ontario who are looking for the doctor in Ottawa would they find that on uh yeah um that’s a tricky one no no no I don’t know if she she got a demo of the device she’s very talented with nerve procedures Dr Jennifer McDonald’s um you know if if if someone your
Association could take an email I could get that information but I don’t want to give out her information she’s not set up for it yet but she would really like to do it okay um and I think I think that we’re going to end there um you have definitely answered uh
The good proportion of of the questions in the chat this has been absolutely fantastic uh thank you very much if anybody does have more questions please email them to me and uh I can forward them as appropriate I’m also on Twitter where most people find out about us it’s
Just Dr Paul Winston all lower taste it’s not Doom and Gloom it’s the only place without Doom and Gloom on Twitter right now um so many people have seen our cases and got in touch with us I have to tell you I have never seen 58
Questions in a chat box so um that’s such a great um erors I don’t know if you have some way to um print these out for me or save them I don’t know because there’s too many to read but if you have some way um I could try to answer then
Send them back to you for sure sounds good okay okay thank you very much for taking your time out of your day to be with us today and the um recording of This will be ready roughly at the beginning of next week and a thank you will go out tomorrow with uh the
PowerPoint presentation attached to it sure say one last thing like all of my colleagues across the country want to do this so if any of you are connected to you know through March of Dimes through other agencies you know if we can come up with a protocol I can easily find the
Doctors who will do the study in your center it’s just as Physicians the Canadian granting Association see us as full-time clinicians we score very low on the to Totem Poll for funding because they’re looking at full research Labs but most of us are in full-time clinical practice doing research so if anyone
Wants it in their Center you know happy to partner with you to get something funded the doctors are easy to train perfect thank you very very much have a great day everybody take care