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ICC Sydney

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Optimizing the Utility of Ultrasound for Assessment and Treatment of the Spastic Muscle: Practical Clinical Pearls

Session outline

Ultrasound (US) is an important tool for chemodenervation and performing diagnostic nerve blocks in the treatment of spasticity. The role of ultrasound in spasticity management has been well discussed literature. (Alter & Karp, 2017; Winston et al., 2023).. In addition, US guidance may help clinicians in the long-term assessment and follow-up of muscle quality. (Moreta et al., 2020) There is great interest amongst physicians specialized in spastic motor disorders regarding the ability to differentiate the degree of echo intensity in patients with an upper motoneuron pathology due to recent literature suggesting that echogenicity has the potential to influence response to spasticity treatment, including response to botulinum toxin injections. (Picelli et al., 2012; Hara et al., 2018) Our group of physiatrists with expertise in spasticity management has been collaborating and contributing to the literature on the use of US for spasticity assessment and management over the last few years. (Francisco et al., 2021; Lagnau et al., 2021; Winston et al., 2023; Kassam et al., 2023). The focus of this workshop is to provide clinical pearls to enhance the use of ultrasound in the research and clinical settings.

Our workshop will be divided in four sections:

  • We will first review the literature on muscle architectural changes in neurologic conditions, with a focus on spasticity associated pathologies, from histological methods to imaging modalities. We will explore different US modalities to assess the spastic muscle: morphological changes, sonoelastography and echogenicity. We will present the Modified Heckmatt scale and will discuss its reliability and validity in assessing muscle echotexture in spasticity.
  • Through a live demonstration, we will share clinical pearls on:
    • Proper US scanning and injection ergonomics
    • Tackling difficult patient positioning and difficult muscles to inject
    • Utility of US for spastic muscle assessment
  • We will continue with live demonstration to explain how to incorporate the validated scale for assessing echointensity in the spasicity muscle, the Modified Heckmatt Scale in a clinical setting.
  • Finally, we will demonstrate the application of ultrasound as a tool to assess spastic muscle architecture and how it may influence our treatment algorithm. We will share reflections and exchange with the audience on those hypotheses and on other potential applications.

Learning outcomes

At the end of this activity, learners will:

  • Gain valuable insight into the evidence based literature on spastic muscle architectural changes.
    • Architectural changes in spastic muscle are now considered by many as a cornerstone of spasticity pathophysiology. A good understanding of the literature that led to this conclusion is key to understanding the importance of muscle architectural changes in spasticity presentation and management.
  • Be able to use strategies to enhance ergonomics, knobology, comfort, clinical flow and muscle assessment with the Modified Heckmatt scale when using US in their spasticity clinic.
    • Ergonomics remains an overlooked aspect of US-guided chemodenervation education courses in spasticity management. Yet, improved ergonomics in US-guided BoNT chemodenervation could improve clinical outcomes by increasing the accuracy of injections and allowing a more reliable evaluation of spastic muscle.
  • Acquire practical clinical pearls in assessing the spastic muscle to optimize spasticity evaluation and treatment.
    • Recent literature suggests that echogenicity has the potential to influence response to spasticity treatment.  At the end of this activity, learners will be able to assess muscle echo intensity with the spasticity validated Modified Heckmatt scale to optimize their spasticity management algorithm.

Target audience

  • Allied health
  • Medical practitioners
  • Students
  • Trainees