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International audience; Objective: To establish international recommendations for the management of spastic equinovarus foot deformity. Design: Delphi method. Setting: International study. Participants: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). Interventions: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. Main Outcome Measures: A consensus was established when at least 80% of experts agreed on a statement Results: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. Conclusion: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

The COVID-19 global pandemic has resulted in significant changes to delivery of care in the field of physiatry. Most prominently, in-person visits have fast tracked to virtual visits. As we are forced to quickly adopt this new technology for our doctor-patient interactions, many questions remain with regard to structuring telemedicine visits for optimal outcomes. Little has been written on virtual evaluations of patients with spasticity. The intent of this article was to provide a framework for conducting a virtual spasticity assessment via telemedicine. We will provide tips on how to conduct a person-centered virtual examination assessment and how to document goals related to the virtual assessment.

Highlights • A subset of Canadian physicians, orthopedic surgeons, and plastic surgeons are using perioperative botulinum toxin (BoNT). • Forty-one percent of Canadian respondents stated that they were not notified of their patient's surgical date. • Increased collaboration between specialties and the creation of national guidelines will increase the benefits of perioperative BoNT surgical outcomes., Objective To investigate the practice patterns of Canadian physicians who use perioperative botulinum toxin (BoNT) injections to improve surgical outcomes on spastic limbs. Design A cross-sectional national survey composed of an invitation email and an 18-item questionnaire was disseminated by a national physical medicine and rehabilitation (PMR) society to 138 physician members involved in spasticity management. Setting Not applicable. Participants Twenty-five percent of the participants (N=34) fully completed the survey. Interventions Not applicable. Main Outcome Measures Participants completed an online questionnaire that examined the practice patterns and surgical outcomes associated with perioperative BoNT injections. Results The majority (n=21; 84%) of Canadian physicians who inject BoNT perioperatively to improve outcomes of surgeries performed on spastic limbs are specialists in PMR practicing in academic settings. Most respondents (74%) used BoNT injections for perioperative treatment for patients with limb spasticity undergoing surgery. Of those surveyed, 65% of physicians used BoNT preoperatively, 21% used BoNT intraoperatively, and 24% used BoNT postoperatively. Of the physicians who performed BoNT injections preoperatively, 6% performed BoNT injections 7 to 12 weeks preoperatively, 32% performed BoNT injections 4 to 6 weeks preoperatively, 47% performed BoNT injections 2 to 3 weeks preoperatively, and 15% performed BoNT injections 0 to 1 week preoperatively. The majority of physicians (85%) responded that injecting BoNT perioperatively may improve a patient's surgical outcome and all of the participants (100%) stated that BoNT did not contribute to any perioperative complications or adverse effects. Qualitative responses emphasized that successful outcomes from the perioperative BoNT were linked to enhanced collaboration with surgeons and that more research is needed to determine the optimal timing of perioperative BoNT. Conclusion Canadian physicians, mostly PMR specialists, administer perioperative BoNT to improve outcomes of surgeries performed on spastic limbs. The optimal timing for perioperative BoNT was suggested to be 2 to 3 weeks before the surgery by 47% of survey respondents. All participating physicians responded that perioperative BoNT did not contribute to any known perioperative complications or adverse events. This study highlights the importance of conducting more robust research to better understand optimal timing for perioperative BoNT injection, enhancing collaboration between physicians and surgeons, and increasing awareness of perioperative BoNT when planning for surgeries on spastic limbs.

DEAR EDITOR, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the consequent coronavirus disease 2019 (COVID-19) are spreading all over the world, with human, economic and health consequences that are, at present (April 12th, 2020), still difficult to fully predict. [...]

This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4-25 years; average 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an extensive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but, instead, aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this; however, where evidence is not yet conclusive, the group members issued statements and, in some cases, made recommendations based on their clinical experience.

Objective: To investigate changes in hemiparetic gait parameters after treatment of elbow flexor spasticity with botulinum neurotoxin (BoNT) injection and adjunctive casting. Design: Prospective case series. Subjects: Ten participants with spasticity secondary to acquired brain injury (8 stroke, 2 traumatic brain injury). Interventions: Participants received BoNT injections for their spastic elbow flexors under ultrasound guid-ance. Two weeks post-injection, an elbow stretching cast was applied for 1 week. Outcome measures: Assessments using the Modified Ashworth Scale (MAS), Tardieu scale V1 angle of arrest at slow speed and V3 angle of catch at fast speed, 2-min walk test (2MWT), Edinburgh Gait Score scale (EGS) and video gait analysis for step-length symmetry were conducted pre-BoNT injection (t0) and at cast removal (t1). Goal attainment scale (GAS) was used to assess changes in spasticity and gait 3 months post-injection (t2). Results: At t1, participants showed a mean increase of 16.7° (p

Objectives To determine the reliability and validity of the Modified Heckmatt scale in assessing muscle echotexture in spasticity. Design Prospective, observational, 2-center study. Two residents and 2 ultrasound experienced staff physicians each rated 100 ultrasound images that were also analyzed using quantitative gray-scale. Setting Academic ambulatory spasticity clinic. Participants Participants (N=50) included 45 patients with upper or lower extremity spasticity and 5 healthy references. Interventions Not applicable. Main Outcome Measures Modified Heckmatt scale ratings and quantitative gray-scale scores Results Inter- and intra-rater intraclass correlation coefficients were 0.76 and 0.81, respectively (P, Highlights • Spasticity can alter muscle architecture as viewed with ultrasound. • Spastic muscles can show increased echointensity (EI). • Spastic muscles with increased EI may respond less favorably to botulinum toxin. • Muscle EI can be quantified using the Modified Heckmatt scale. • The Modified Heckmatt scale demonstrated good reliability and validity.

COVID-19 pandemic is rapidly spreading all over the world, creating the risk for a healthcare collapse. While acute care and intensive care units are the main pillars of the early response to the disease, rehabilitative medicine should play an important part in allowing COVID-19 survivors to reduce disability and optimize the function of acute hospital setting. The aim of this study was to share the experience and the international perspective of different rehabilitation centers, treating COVID-19 survivors. A group of Physical Medicine and Rehabilitation specialists from eleven different countries in Europe and North America have shared their clinical experience in dealing with COVID-19 survivors and how they have managed the re-organization of rehabilitation services. In our experience the most important sequelae of severe and critical forms of COVID-19 are: 1) respiratory; 2) cognitive, central and peripheral nervous system; 3) deconditioning; 4) critical illness related myopathy and neuropathy; 5) dysphagia; 6) joint stiffness and pain; 7) psychiatric. We analyze all these consequences and propose some practical treatment options, based on current evidence and clinical experience, as well as several suggestions for management of rehabilitation services and patients with suspected or confirmed infection by SARS-CoV-2. COVID-19 survivors have some specific rehabilitation needs. Experience from other centers may help colleagues in organizing their services and providing better care to their patients.

Objective To determine current evidence for casting as an adjunct therapy following botulinum toxin injection for adult limb spasticity. Design The databases MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials were searched for English language studies from 1990 to August 2018. Full-text studies using a casting protocol following botulinum toxin injection for adult participants for limb spasticity were included. Studies were graded according to Sackett's levels of evidence, and outcome measures were categorized using domains of the International Classification of Disability, Functioning and Health. The review was prepared and reported according to PRISMA guidelines. Results Five studies, involving a total of 98 participants, met the inclusion criteria (2 randomized controlled trials, 1 pre-post study, 1 case series and 1 case report). Casting protocols varied widely between studies; all were on casting of the lower limbs. There is level 1b evidence that casting following botulinum toxin injection improves spasticity outcomes compared with stretching and taping, and that casting after either botulinum toxin or saline injections is better than physical therapy alone. Conclusion The evidence suggests that adjunct casting of the lower limbs may improve outcomes following botulinum toxin injection. Casting protocols vary widely in the literature and priority needs to be given to future studies that determine which protocol yields the best results.

Objective: To provide a proof-of-concept study demonstrating that the decades old procedure of cryoneurotomy, used traditionally for analgesia, is a safe adjunctive and effective treatment for limb spasticity. Design: Case series. Setting: Publicly funded outpatient hospital spasticity clinic and community interventional anesthesia clinic. Participants: Patients (N=3) who had plateaued with standard of care spasticity treatments including botulinum toxin. Two hemiplegic stroke patients with elbow spasticity and 1 pregnant patient with multiple sclerosis and a spastic equinovarus foot for whom botulinum toxin was now contraindicated. Interventions: Selective anesthetic diagnostic motor nerve blocks with ultrasound and e-stimulation with 1cc of 1% lidocaine to the motor nerve to the targeted spastic muscle were performed to either the musculocutaneous nerve to brachialis, radial nerve to the brachioradialis or the tibial nerve. If the benefits included improved active and passive range motion and or decreased clonus, a percutaneous cryoneurotomy was performed. Main Outcome Measures: Active and passive range of motion were measured using the Modified Tardieu Scale. The change in resistance to passive stretch was measured using the Modified Ashworth Scale (MAS). Videos of the before and after treatment were collected. Results: Both elbows’ treatments resulted in MAS improving from a 3 to a 1+. Greatly improved active range of motion was noted at 94 and 64 degrees, respectively, as well as improvements in passive range on the Modified Tardieu Scale. The tibial nerve cryoneurotomy resulted in improvements in all parameters with a much improved gait. Results were maintained up to 17 months of follow-up. Conclusion: Cryoneurotomy as a treatment for spasticity is a novel safe adjuvant treatment. Our initial results suggest patients can achieve significantly increased active and passive range of motion in the upper extremity and decreased clonus, and improved gait after tibial nerve cryoneurotomy. Keywords: Cryosurgery, Denervation, Hemiplegia, Muscle spasticity, Nerve block, Rehabilitation