INTRODUCTION/AIMS:When spasticity occurs after a stroke, peripheral changes in spastic muscle architecture may develop. The primary objective was to determine if an association exists between spastic muscle echointensity (EI) measured by the Modified Heckmatt Scale (MHS) and changes in insertional activity detected by electromyography (EMG). The secondary aim was to investigate whether these changes are due to the effects of botulinum neurotoxin (BoNT). METHODS:A total of 55 patients with poststroke spasticity were enrolled from three outpatient spasticity clinics. Muscle EI and needle EMG insertional activity were assessed for 8 muscles in each subject. Chi-square tests or Fisher's exact tests for categorical variables were used to evaluate the association between muscle EI and EMG insertional activity, as well as the association between BoNT exposure and muscle changes. RESULTS:For MHS Grade 1-2 muscles, 91.7% had normal insertional activity compared to 46.4% of MHS Grade 3-4 muscles (p < 0.001). In muscles with abnormal insertional activity, reduced or absent insertional activity was seen in 67.3% of MHS 3-4 muscles compared to only 16.7% for MHS 1-2 muscles, while increased insertional activity was seen in 32.7% of MHS 3-4 muscles and 83.3% of MHS graded 1-2 muscles. Exposure to BoNT did not impact the observed association between MHS and abnormal EMG insertional activity. DISCUSSION:Increased EI is associated with abnormal EMG insertional activity. Exposure to BoNT does not explain the observed EI and EMG changes. Further research is needed to elucidate the significance and causes of muscle architectural and electromyographical transformation in poststroke spasticity.

Inconsistent and variably interpreted definitions of spasticity, alongside evolving mechanistic understanding, highlight the need for a clear, clinically relevant consensus definition. An international expert panel used a modified Delphi process to develop a concise, clinically applicable definition that reflects current understanding and supports consistent assessment and management. Participants reviewed existing definitions, completed a pre‑meeting survey, and engaged in structured discussions, with draft definitions iteratively refined through successive rounds of voting to achieve consensus. Key components identified included disordered sensorimotor control, central nervous system involvement, and velocity‑ and length‑dependent resistance to passive stretch, while existing definitions were considered either overly narrow or insufficiently relevant to clinical practice. The consensus definition characterizes spasticity as "A disorder of sensorimotor control resulting from upper motor neuron disease. It is characterized by velocity- and length-dependent involuntary muscle overactivity, which is intermittent or sustained, during passive stretch." This definition integrates contemporary mechanistic concepts with clinical applicability and is intended to improve conceptual clarity, facilitate communication, and promote consistency in diagnosis, measurement, and treatment.

Background/Objectives: The aim of this study was to compare the efficacy and safety of a single cycle of incobotulinumtoxinA versus placebo in pooled data from older patients (aged ≥65 years) with upper limb spasticity (ULS). Methods: This study was a post hoc analysis of pooled data from seven prospective, multicenter, phase II or III trials of incobotulinumtoxinA in adult patients aged ≥65 years from across the world with post-stroke ULS or upper and lower limb spasticity, including a subgroup with moderate-to-severe ULS. Changes from baseline in ULS severity were evaluated using the (modified) Ashworth Scale across different spasticity patterns at 4 and 12 weeks after incobotulinumtoxinA injection. Results: In 267 older patients with ULS, including a subgroup of 207 with moderate-to-severe ULS, all ULS patterns statistically analyzed (elbow flexion, thumb-in-palm, clenched fist, wrist flexion, and pronated forearm) were improved more by incobotulinumtoxinA than placebo at week 4 (p < 0.05). For most of these patterns, the difference remained significant at week 12 (p < 0.05). IncobotulinumtoxinA was generally well tolerated. Conclusions: This study, which analyzed data from the largest cohort of older patients in the literature, provides information regarding the use of incobotulinumtoxinA in ULS, the efficacy and favorable safety profile of incobotulinumtoxinA for the treatment of ULS in older patients, particularly in those with moderate-to-severe spasticity, was confirmed.

BACKGROUND:Intramuscular injection of botulinum toxin type A is a first-line pharmacotherapy for adults with upper limb spasticity (ULS). However, reemergence of symptoms within 12 weeks of treatment is common and longer-lasting treatments are needed. OBJECTIVE:To evaluate the efficacy and safety of three doses of DaxibotulinumtoxinA for Injection (DAXI) for treatment of ULS in adults with stroke or traumatic brain injury. INTERVENTION:Intramuscular injections of placebo (N = 24), DAXI 250 U (N = 22), DAXI 375 U (N = 19), or DAXI 500 U (N = 18) to the suprahypertonic muscle (SMG) and other muscle groups. DESIGN:Randomized, double-blind, placebo-controlled study. SETTING:Twenty-six study centers across the United States. PARTICIPANTS:Eighty-three adult patients with ULS were randomly assigned to each treatment group and followed for up to 36 weeks. OUTCOME MEASURES:Co-primary endpoints were the Modified Ashworth Scale (MAS) score change from baseline in the designated SMG and Physician Global Impression of Change (PGIC) at Week 6. RESULTS:The mean changes from baseline in MAS score for the designated SMG for placebo and the DAXI 250 U, 375 U, and 500 U groups were -0.6, -0.9, -0.9, and -1.8, respectively, at Week 4 and -0.8, -0.9, -1.0, and -1.5, respectively, at Week 6. Statistically significant improvement in MAS score compared with placebo was reported only for the 500 U dose (Week 4: p < .001; Week 6: p = .049). Significant improvements in PGIC ratings compared with placebo were reported for DAXI 375 U (p = .015) and DAXI 500 U (p = .009) at Week 4 but not for any DAXI doses at Week 6. All DAXI doses were well tolerated with no trend toward more adverse events with increased dose. CONCLUSION:Results from this Phase 2 study indicate that DAXI 500 U is effective and well tolerated for treatment of adults with ULS.

Botulinum Neurotoxin Type A (BoNT-A) injections using Ultrasound (US) guidance have led to research evaluating changes in muscle architecture. Controversy remains as to what constitutes increased Echo-Intensity (EI) in spastic muscles and whether this may affect outcomes. We aim to provide a narrative review of US muscle architecture changes following Central Nervous System (CNS) lesions and explore their relationship to spasticity. Medline, CINAHL, and Embase databases were searched with keywords: ultrasonography, hypertonia, spasticity, fibrosis, and Heckmatt. Three physicians reviewed the results of the search to select relevant papers. Reviews identified in the search were used as a resource to identify additional studies. A total of 68 papers were included. Four themes were identified, including histopathological changes in spastic muscle, effects of BoNT-A on the muscle structure, available US modalities to assess the muscle, and utility of US assessment in clinical spasticity. Histopathological studies revealed atrophic and fibro-fatty changes after CNS lesions. Several papers described BoNT-A injections contributing to those modifications. These changes translated to increased EI. The exact significance of increased muscle EI remains unclear. The Modified Heckmatt Scale (MHS) is a validated tool for grading muscle EI in spasticity. The use of the US may be an important tool to assess muscle architecture changes in spasticity and improve spasticity management. Treatment algorithms may be developed based on the degree of EI. Further research is needed to determine the incidence and impact of these EI changes in spastic muscles.

BACKGROUND:We used electromyography to characterize hypoglossal nerve function among radiation-treated head and neck cancer survivors with later onset unilateral tongue immobility. METHODS:Patients with unilateral tongue immobility without evidence of recurrent cancer were seen at a tertiary academic institution between February and September 2021. All patients were at least 2 years post-treatment with radiation therapy for head and neck squamous cell carcinoma. Participants were under annual surveillance and displayed no evidence of operative injury to the hypoglossal nerve. RESULTS:The median symptom-free interval for the 10 patients included in this study was 13.2 years (range 2-25 years). Myokymia alone was present in 3 of 10 patients, fibrillation potentials alone were present in 3 of 10 patients, and 1 subject displayed both fibrillation and myokymia. Three out of 10 patients had normal hypoglossal nerve function. DISCUSSION:These findings highlight how disparate mechanisms may underlie similar clinical presentations of radiation-induced neuromuscular dysfunction.

Laryngeal electromyography (LEMG) is a technique used to characterize neuropathic injuries to the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN). The RLN and SLN innervate the laryngeal muscles to produce vocal fold (VF) motion and elongation, respectively. VF motion deficiencies can affect voice, swallowing, and breathing, which can greatly affect a patient's quality of life. Neuropathy-related VF motion deficiencies most often result from surgical interventions to the skull base, neck, or chest likely due to the circuitous route of the RLN. LEMG is ideally conducted by an electromyographer and an otolaryngologist using a team-approach. LEMG is a powerful diagnostic tool to better characterize the extent of neuropathic injury and thus clarify the prognosis for VF motion recovery. This updated review discusses current techniques to improve the positive and negative predictive values of LEMG using laryngeal synkinesis and quantitative LEMG. Synkinesis can be diagnosed by comparing motor unit potential amplitude during vocalization and sniff maneuvers when recording within adductor muscles. Quantitative turns analysis can measure motor unit recruitment to avoid subjective descriptions of reduced depolarization during vocalization, and normal values are >400 turns/s. By integrating qualitative, quantitative, and synkinetic data, a robust prognosis can help clinicians determine if VF weakness will recover. Based on LEMG interpretation, patient-centered treatment can be developed to include watchful waiting, temporary VF augmentation, or definitive medialization procedures and laryngeal reinnervation.

A strong correlation has been reported between patient-reported quality of life (QoL) and the investigator-rated Disability Assessment Scale (DAS) in patients with spasticity. The current analysis evaluates the effect of incobotulinumtoxinA on QoL-related outcomes (limb position abnormality, as well as dressing- and hygiene-related disability, measured with the DAS) in adults with upper limb spasticity, using pooled data from six studies. Separate analyses for each DAS domain were performed using data from patients with disabilities for that domain (DAS score ≥1). Results showed that a significantly greater proportion of incobotulinumtoxinA-treated compared with placebo-treated patients achieved a ≥1-point reduction from baseline in each of the DAS domains (improvement) 4 weeks after the first injection. The benefits of incobotulinumtoxinA were observed regardless of the baseline severity of DAS impairment and of the time elapsed since stroke. The effects of incobotulinumtoxinA 4 weeks after injection were maintained or enhanced over multiple injection cycles for all three DAS domains, supporting the use of repeated injection cycles to provide sustained QoL benefit. IncobotulinumtoxinA represents an important treatment option to achieve better QoL-related outcomes for patients with upper limb spasticity, irrespective of the duration of their condition.

BACKGROUND/OBJECTIVE:Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform. METHODS:Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making. RESULTS:A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered "very easy," 32.1% were considered "mildly challenging" and 23.9% and 12.8% were considered "moderately challenging" and "extremely challenging," respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55). CONCLUSIONS:Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care. LEVEL OF EVIDENCE:3 Laryngoscope, 134:831-834, 2024.

The patient is a 49-year-old male with a left wrist disarticulation in the setting of work-related trauma complicated by thrombosis and osteomyelitis (Figure 1). His case was complicated by severe constant grabbing pain in his distal residual limb, refractory to conservative treatments, functionally limiting his ability to use his prosthesis for more than 30 minutes at a time. His examination revealed significant allodynia with palpation of the left distal forearm with an intact integumentary exam.

To determine if chronic motor deficits secondary to traumatic brain injury (TBI) can be improved by intracranial implantation of SB623 cells.

Objective: To examine onabotulinumtoxinA (onabotA) treatment utilization patterns in the United States (US) for pronated forearm and intrinsic plus hand postures in patients with upper limb (UL) spasticity over a 2-year period. Background: In 2021, onabotA received approval in US for injection into 8 additional muscles in the treatment of adult UL spasticity including muscles of the elbow and forearm (brachialis, brachioradialis, pronator teres, and pronator quadratus), as well as intrinsic hand muscles (lumbricals and interossei) and thumb muscles (flexor pollicis brevis and opponens pollicis). More information is required to maximize effectiveness in patients with UL spasticity. Design/Methods: This post hoc analysis utilized US data from the multicenter, prospective, observational Adult Spasticity International Registry (ASPIRE) study (NCT01930786) which ran from 2013 through 2017. Participants were adult patients who received onabotA (total dose ≤400 U per treatment session) to UL muscles for spasticity. This analysis was centered on 2021 onabotA expanded label and evaluated treatment utilization for pronated forearm and intrinsic plus hand postures in patients with UL spasticity to determine educational opportunities for optimized treatment in the real-world setting. Results: Of 316 US patients in ASPIRE treated for UL spasticity, 135/316 (43%) had pronated forearm and 89/316 (28%) had intrinsic plus hand postures. OnabotA (≤400 U) treatment was delivered to select UL muscles of 45 patients consistent with expanded US label. Baseline characteristics of these 45 patients included a mean age (SD) of 51.3 (16.0) years, 23/45(51%) who were onabotA-naive, and 26/45 (58%) were male. New postures treated included intrinsic plus hand (9/45; 20.0%) and pronated forearm(14/45;31.1%). Of the 36 adverse events (AEs) that occurred, 1 was treatment-related (muscular weakness); no treatment-related serious AEs were reported. Conclusions: This analysis provides real-world evidence of the opportunity to educate on the treatment of pronated forearm and intrinsic plus hand postures in accordance with the expanded label for onabotA. Disclosure: Gerard Francisco has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Merz. Gerard Francisco has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Allergan. Gerard Francisco has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Saol. Gerard Francisco has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Shionogi. Gerard Francisco has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ekso. Gerard Francisco has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Sword Health. Gerard Francisco has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for The Journal of ISPRM. The institution of Gerard Francisco has received research support from Allergan. The institution of Gerard Francisco has received research support from Merz. The institution of Gerard Francisco has received research support from Ipsen. The institution of Gerard Francisco has received research support from Revance. Gerard Francisco has a non-compensated relationship as a Director with American Board of PM&R that is relevant to AAN interests or activities. Gerard Francisco has a non-compensated relationship as a Vice-Presdent with International Society of Physical and Rehabilitation Medicine that is relevant to AAN interests or activities. Dr. Feng has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for HuaMed Tech. Dr. Feng has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Precision Neuroscience. Dr. Feng has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Namsa. The institution of Dr. Feng has received research support from NIH. The institution of Dr. Feng has received research support from American heart association . Michael C Munin, 25482 has received personal compensation for serving as an employee of Pacira. Michael C Munin, 25482 has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Merz. Dr. Ngo has nothing to disclose. Marc Schwartz has nothing to disclose. Dr. Sadeghi has received personal compensation for serving as an employee of AbbVie. Dr. Sadeghi has stock in Abbvie/Abbott. Dr. Zuzek has received personal compensation for serving as an employee of AbbVie Inc.. Dr. Zuzek has stock in AbbVie Inc.. Dr. Esquenazi has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Ipsen and Allergan. Dr. Esquenazi has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Ipsen and Allergan. The institution of Dr. Esquenazi has received research support from Ipsen, Allergan and Merz.

Objectives/HypothesisLaryngeal electromyography (LEMG) is a diagnostic tool for patients with suspected neurogenic abnormalities of the larynx. LEMG is often used with the assumption that any abnormality is symptom‐/disease‐related. We sought to determine the prevalence of abnormal LEMG findings in a group of healthy asymptomatic adults across a large age spectrum.Study DesignOpen, prospective study, gender‐match and age balanced by decade.MethodsForty‐six healthy participants (age 20–78) underwent LEMG, including 178 muscles. Participants had no history of voice problems, normal VHI‐10, and normal flexible laryngoscopy. Qualitative and quantitative LEMG (bilateral) were performed involving the thyroarytenoid–lateral cricoarytenoid muscle complex (TA‐LCA) and cricothyroid (CT) muscles. LEMG parameters included evaluation for fibrillation potentials, sharp waves, reduced recruitment, polyphasic potentials, electrical synkinesis, and measurement of turns per second.ResultsOf participants, 4% had at least one abnormal qualitative finding (slightly reduced recruitment or two to three discrete polyphasic potentials). There were no findings of fibrillation potentials or sharp waves. There were no abnormal qualitative findings in the CT muscles tested. Of participants, 16% had at least one abnormal synkinesis finding. LEMG qualitative abnormalities and quantitative abnormalities do not appear to correlate with gender or age.ConclusionAbnormal qualitative and quantitative LEMG findings were uncommon and minor in severity in our group of asymptomatic healthy adults. The likelihood of abnormal LEMG results in asymptomatic adults was 2.2% for qualitative findings, 9.3% for synkinesis, and 5.4% for turns/s.Level of Evidence3 Laryngoscope, 131:2065–2069, 2021

OnabotulinumtoxinA treatment for spasticity varies according to numerous factors and is individualized to meet treatment goals.