Frozen Patients – Cryoneurolysis and the reduction of spasticity and associated pain

A journey to create an entirely new procedure to combat spasticity, a leading cause of disability after neurolgical injury worldwide. Spasticity occurs after stroke, spinal cord injury, or brain injury, or may onset at birth due to cerebral palsy. A team at Island Health, in Victoria, BC Canada, created Dr. Paul Winston and Dr. Daniel Vincent developed this mini-invasive procedure to reduce spasticity to improve movements, restore function and reduce pain. They are training the world to perform it.

[Music] look at your arm yeah can you touch it with your other hand you ever done that before no I haven’t that’s awesome right that is amazing [Music] I’m a physical medicine and Rehab specialist here in Victoria which means I’m a physician that uh really specializes in the functions of the body so medicine was a late choice for me most people know about me my first career was in the Arts I was a dancer I trained through Canada National Ballet school from the age of 10 to 18 and I had a very fulfilling dance career with the national valy of Canada one day I was in Toronto on the way to a theater rehearsal and I had an unexpected injury I had a little 10-speed bike and I just went over the bike I went to the orthopedic clinic the next day and he said you know you got to be in a sling for 6 weeks you you know you can’t do anything and Meanwhile my arm won’t move it’s feels paralyzed a friend suggested I read Oliver Sachs book called uh a leg to stand on he wrote a whole book about how the brain shuts down when you have an injury and how you have to reprogram it and it was through his book I really started to understand why people get injured how to get better and it really made me fall in love with this concept and I rehabbed and then 6 weeks later I was performing at the Kennedy Center that really hit for me that there was a way that we could control our bodies on top of the injury your recovery pattern is going to really rely on the support system you had and it was really at that moment that I realized that I had fulfilled my goals for myself and expect ations and dreams and that I probably needed to explore that part of my life that I was suppressing I finished my dance career about 6 years later I get home and there’s a message on my machine and it was a phone call from the Mar antonet Theater at the palace of versailes from Opera atellier and they said hi Paul we understand that you are now not with the National Valley we really need a dancer could you come work in two weeks don’t worry we’ll work around your school schedule so that took me full circle and I worked in Boke opera during my undergraduate at U performing in broke theaters and Toronto so I always say when Versa calls you go Flash Forward 2017 my really good friend and co-collaborator reie rebi told me about this great spasticity conference first of its kind that would be happening in Versailles and I went there as a really good expert in spasticity knowing how to manage it know how to treat it as the two days went on I was actually getting really distressed in how advanced they were they’re offering their patients things that I’ve never dreamed of and I just you know I looked around I started to tremble I said you know what I I got to do this like I’m going to go home I have no money no team no funding but I’m going to introduce this European technique that I learned in [Music] Versailles after my stroke I did have spacy and it was bad and it was painful having the spacity is frustrating because you can’t stop your own limbs doing it it automatically does it spicity for me limited my movement I you know couldn’t reach my head I mean it was very hard to walk it made my movement very difficult life before my brain injury was fun I like to do soccer and I like to do [Music] gymnastics after my brain injury I had like a huge this big of a scar so [Music] yeah this big spasticity will Cur any part of the central nervous system which is the brain the brain stem into the spinal cord if you gripped your arms as hard as you could to you hurt to your fingernails or in here and you pull as hard as you can and then in slow motion try to reach out forward to grab something but resisting as hard as you possibly can that’s what spasticity it is it is a co-contraction of muscles you can’t relax what you want to relax and you can’t use what you want to use what I learned in France was they had an incredible surgical neurectomy program surgeons would use micro surgery to dissect nerves to the muscles first they did a diagnostic lidocaine block to the nerve they wanted and paralyzed it with an anesthetic it was great but we found the procedure a little bit cumbersome and slow as you kind of had to search blindly with a stimulator and I thought you know we could probably do this with ultrasound faster we actually returned to Canada and started our neurectomy program with Dr Emily Krauss and she was doing neurectomies very well my goal was to work with Dr Dani Vincent to create efficient fast diagnostic nerve blocks all over the body and turn this temporary procedure into something long lasting months to years Dr Winston knew that I had been providing Diagnostic and therapeutic nerve blocks using fluroscopy and ultrasound for chronic pain management and I said Dan you’re an ultrasound expert in nerves I’m an ultrasound in muscles Could you teach me 2 weeks later we are in Dan’s office and we were doing ultrasound guided nerve block block because there’s no literature describing the targets we had to discover our own targets so over the course of patience of several years we started to map out each area a review of the available published research showed that diagnostic nerve blocks were able to temporarily relieve muscle spasticity we started with the treatment protocol in terms of determining which patients were appropriate for cryon neurois this depended on the response of patients to the diagnostic local anesthetic nerve block if there was a relaxation of the affected muscle group then there was a high probability that they would benefit from cryoneurolysis you’re going to inject a local anesthetic we see a response or we don’t see response the fact that um Dr Winston would would start off before doing the liis with um doing a neurop with a short local anesthetic that these were all very reassuring facts this is an technique used in pen fields for decades and um this is very interesting to have the idea to develop a specific technique to treat the motor nerve so treatment of the uh motor nerve with only a perous treatment with just a local anesthesia it was amazing pennies of lidocain that is more powerful than the most potent neurotoxin that we have on a temporary basis so a $4 billion molecule that we inject for our wrinkles our body which works really well this is so immediate it works faster and stronger it just doesn’t last like it’s not an option for long term so we went back to the patients that we treated and said did you like it and they said well yeah it was amazing how much my elbow opened up it was Dan who suggested Paul this is so beautiful the result why don’t we do Crown our liis and Dan has been doing that as a pain specialist there’s only a couple machines in Canada that have the capacity and he said well my machine which was built in 1980 has a motor button for stimulation he goes no we can do this and the patient came back to me I think 9 or 10 days later and my heart just leapt because he was 2 years after stroke he had a really stiff arm that he couldn’t move and his arm just thumped open and not only that he was always in this position he was able to move that arm and his arm over the coming weeks became so strong he lifted up his grandkids he told me he was mowing the lawn and then we did a second patient and then more and more and because there’s no literature describing the targets we had to discover our own targets week in week out we practice ultrasound guided blocks and we were getting better and better and then Dan would go back and do the cryo the patients kept saying this is so amazing can you do my shoulder can you do this can you do that so over the course of patience of several years we started to map out each area and we realized everyone was interested but how do you do it how does it work so that’s when the idea of our textbook came out and March 2020 I was in Orlando with a group of international doctors and I said would you join me in creating a book on advanced practice and spasticity based on the Block Dr EV baso arrived from Montreal to do her fellowship with me together we spent the year mapping out all these parts of the body that had never been described for neurectomy or cryonis we had to figure out where to position the body and which nerves to Target we hired frasia McCrae a co-op student from yvck who’s now doing his Masters in PhD in physiotherapy at Western University on what happens in the brain when you do cryonis EV just happens to be a dancer like myself and we decided to celebrate everying single new protocol that freed a patient movements by doing a choreography and it really became this amazing sense of joy to dance around the empty corridors of the hospital and empty rooms when everyone was gone for the day but it really allowed us to relax and celebrate what we were [Music] creating going have two years and one another and one the actual happen it took like 45 seconds yeah um and that was very very just say one very my arms really good so far I cannot do that the world needs to hear about cryo I’m a pediatric anesthesiologist I see I see kids with spasticity and now now I’m looking at them like oh my goodness you just need cryo you need cry and at a young age okay and now do that on that side oh look at that what’s different that moves what normally happens it [Music] doesn’t in the summer of 2021 we had huge changes Dr Vincent closed his practice and we had no more access to the machine thankfully a company from the United States was opening in Canada and they agreed to sponsor us so just as he closed his practice this incredible handheld machine came instead of having a big oxygen tank like structure which was actually carbon dioxide which powered it it was a tiny little machine that has a little gas cartridge the gas is what you’d use to make whipped cream to pump up your bike tire uh in many devices that we have commonly so that was the generation one we could go up to the ward we could go to a nursing home anywhere the patient was we could take it it was so portable and it’s designed for the clinic it doesn’t need a special Suite so that literally changed our practice we put in our gas canister we close it and then It prepares for the cycle the way that cry Neurosis works is we are going to take this and insert it in the body the gas is going to flow into this tube when it drops to -88 de it will freeze everything around [Music] it there’s no drugs in this process it’s the water in your body that will create an ice ball and each cycle lasts 106 seconds so no drugs are going into the body it’s just so cold that the water is starting to freeze what will happen is when this tip touches the nerve and drops to- 88° it is so cold that the nerve will begin to disintegrate or degenerate we call that waran degeneration what’s really fascinating about physics is that at minus 88° only the neuron breaks down we get loss of the axon through the myin sheath and the axon inside it no other structures are damaged the blood vessels are not damaged the uh tissues are not damaged we know at this temperature nothing else will hurt if we used a different gas because this boils at- 88° you would actually get tissue destruction so you can see how big that ice ball is it will cover a large segment so basically we are causing targeted destruction of that nerve which will completely regenerate in about 6 to 9 months but should have a longer lasting effect when I’m getting cry done from Dr Winston it hurts like a son of a gun um well he sticks me and then it hurts and then it’s like it’s gone my life changed cuz like my foot can Flex a lot more and my arm can stretch out a lot more for anyone who feels the way that I do it’s going to be okay after the cryo I have not had any SP I it’s been wonderful I can actually now walk without falling over and without Furniture surfing anymore it’s incredible how much um it has improved my life I was very skeptical in the beginning of this treatment it’s been 12 years since my accident how can he really do anything and I told Dr Winston after I when I came back for a followup I was like know you would have never seen me again if this hadn’t worked he’s like oh I know and so yeah I’ve come back to every followup every 3 months taking the freaking fairy from the you know what I mean so yeah I I would I would go to China to see Dr Winston I really would [Music] [Music] so you lift her arm up overhead it’ll be sore oh my God okay okay seriously did you see that do it again sh am I the only one who’s amazed here so I no I’m happy wa can you believe that Jeff look at that look look Jeff look at this this is my hand touching my right ear and and with respect to the therapy that Dr Winston has done and continues to do it just continues to increase her quality alive I want y’all to see something that I’ve been able to do for 12 [Music] years Tada now I don’t have to do it and get yelled at because I do it terrible Sunni has CP as a result of bre is fix it so just low oxygen at Birth it has been a journey of therapies and intervention um fortunately he’s um rined his baby a bit too well um so I keep saying that my job is to make sure his body keeps up with his brain to that end I have tried to explore every single possibility to just make life easier for him and give him as much Independence as possible nothing beats being able to you know do things for yourself if you can the really new and exciting portion for for us here is this you know targeting motor nerves targeting spasticity stiffness rigidity um to improve range of motion and function um in terms of you know long-term use like there’s so many different applications even just a combination of increasing uh ultrasound Comfort which is I find a very challenging skill um the diagnostic nerve block which is also um a newer introduction certainly for me where I trained it and then lastly the curis um you know those three components I think uh there is so much utility in in using those uh all those different Tools in whatever combination and it’s very exciting to to see how it is changing uh you know really before my eyes um and how patients are are literally much better afterwards um and it’s immediate and it’s the immediacy I think which is the the newest um feeling from a practitioner to see the results then and there um I think that that’s quite special so then I just Oh no you’re not going to go into your I love this we we’ve had a whole day like this today I know we’ve already been this today so we’re well [Music] prepared we like tears of joy when I started doing medicine I realized it was about human relationships and Rehab is something physical and tangible every patient is putting their trust into me you see the reach I feel the reach did it yourself by myself okay do it again do it again I mean is no one else Amazed by I haven’t done this for 12 years by myself I stumbled upon the work of Lisa bavan and her work is so incredibly powerful on indigenous informed consent about how we really need to know the person that we’re dealing with I had to know who my patients were give them the plan give them the options and ask them if they wanted to change because not everyone wants to change so our whole pattern is based on assess ing a patient getting their goals getting their stories doing nerve blocks to show them this is what you’re going to look like when we’re done and in this we do an intervention and it’s immediate we see what the pattern is we change it until we get the perfect amount of change that we like but more importantly the patient likes seeing the patient in real time getting feedback it’s just the most I it’s almost a form of euphoria I can’t describe it any other way oh beautiful wow okay now I’m going to cry it’s so Beau [Music] okay thank you you’re welcome that was a lot to go through our journey is now what can I keep adding to get that patient well and not a population the patient in front of me [Music] it became this really emotional experience like sometimes closing the door and like bursting into tears or bursting into tears of the families because someone would open their hand and touch their parents face or they the spouse would grab their hand or they get up and walk without their brace or walk for the first time and the things the results are immediate when you do cry out you get the result and then it gets better over months and suddenly in front of our eyes people were unfolding I really believe in the theory that medicine is movement and movement is medicine everything we do in physiatry is to keep your body moving when I’m with my patients I’m sitting at their level squatting on the floor watching them from every angle I’m not just in front of the computer typing or looking at results and I try to practice this in my own life as well I know that is one of the things that not only brings me joy in my day but it actually makes me feel human so I will do everything in my power to help other people experience joy and freedom of their own in the world that surrounds them just to even have one new position or movement of the body that lets them experience life a little bit more good and lift to the side and go like this way overhead not that crazy the other side side like stra out this right perfect okay thank you thanks for coming down oh more hugs I’m really glad we did the second [Music] one what Dr Winston for persevering with this idea and just believing there was possible pushing through with you know next to no funding and just making it happen it’s just incred ible that people like documents in exist in this world and I would happily fly halfy cont we have no funding there’s no team I needed to have people and I found this huge group of medical students University students Co-op students my colleagues everybody wanted to learn and help and by doing under a teaching model creating those uh teaching roles through UBC UVC having residents and medical students come across the country they help me they are my co- authors and they all entered that patient Journey during treatment days we have many people in the room many different types of uh Physicians surgeons and therapists we want to be able to maximize the patient care through diverse input of many people we want to provide Hands-On learning training for healthc Care Professionals from all over the world so that they can learn to use this technique with their patients I do believe that knowledge is power and the more our patients and caregivers know about what is being done to them the more likely they are to feel empowered to continue to help themselves and to help [Music] others it’s really slowing down and listening to what the patient needs they watch the ultrasound on TV they see the procedure we have a book that we wrote we show them everything we have stickers for the kids I’m trying to make it more fun because the procedure is uncomfortable and at times very painful for people so every step of the way I need them to trust that they can give me feedback that they didn’t like it that they wanted it a different way or it was too painful or a lot of people say it was nothing after my accident I was in a coma um for 3 weeks I was in the hospital for 4 months you know the doctors will say but for the fact that she was in such great shape she probably wouldn’t have lived through her injury it’s been an inspiration to um to be to our kids to see [Music] how uh how difficult but just how strong she’s been to fight to get better and and I mean she’s been an inspiration we have a set of outcome measures that nobody likes and it’s how much stiffness and resistance when you do a fast catch and a slow catch or what the patient can move and that’s basically it and you can look at maximum range but it’s one plane and it absolutely is non-functional it’s it’s not what happens when you’re moving when you’re breathing so all these studies that come from surgery or especially the botum toxins they don’t really show change as a movement person it it was the antithesis of what I do I needed to know what was the change in life oh my gosh and down we see what the pattern is we change it until we get the perfect amount of change that we like but more importantly the patient likes wow our results demonstrated that a substantial number of patients have benefited from cryon neurois we had to show that cryo was safe so other people could do it and when we did have side effects how we fixed it we studied 113 patients who underwent cryonis involving a total of 277 nerves remarkably 96.75% of 277 nerves reported no side effects following the procedure when I started this journey was all through research so every patient getting treatment had to be within our research I needed to be able to tell my patients and tell my International Community my University that we understood what we were doing we had to know everything had evidence and experience so right now after about 3 and 1/2 years we have over like 250 cases most of them received um cry neuralis for multiple muscles for in different sessions so we have a really big data set the results so far so promising and we are really um excited to share our result with the other physician and also with the people who suffers from as spasticity cry neurolysis has been used for pain control since many years ago but the use of crry curis for spicity is a novel procedure Dr Winston’s research has had Global impact he is a Pioneer not only of this therapy but he’s also a Pioneer in as a physician integrating research as part of the care that he delivers to patients research is not separate from care research when embedded into practice creates a learning cycle so that every therapy given to patients becomes part of a learning program through research there’s always room for learning especially where you have Innovations so the Innovation comes in okay well what new muscle have we not blocked what new muscle could we add they now have a new pattern of tone how do we do that can we do a brace can we use a theraband for strength working with my physiotherapists I’ve been involved with the studies that Dr Winston has been doing for the last um couple years and my role is primarily treating the people who have received the cown neural IIs I’m also involved with measurement and uh some of our outcomes as well so taking range of motion videoing gate and then I provide the treatment for these people after they have received um the cryon neurois with Dr Winston after the treatment they are able to start to gain some movement a lot faster than they may have with other forms of uh treatment we have lots of way to go we need more funds to have um more training sessions to train other other fellows and other Physicians so they can offer this procedure to more patients we would not be able to do what we’re doing without the island health research department but even more importantly is the support of Victoria hospitals foundation so that represents the people of the island and the region so without their support we we have nothing so it allows me to hire a team have the technology to do what I need to do what we need to do a couple things we need to increase awareness we need to finalize a lot of the research and data that Dr winon has done and publish it and have it peer-reviewed and and disseminated so that more and more people like he’s already doing and we’re already doing now with visiting experts coming and trying and seeing uh it just needs to be spread and the dialogue will continue and and uh it will be refined um so that patients everywhere can benefit that we don’t have to take people from the states and from from wherever else so that people can get it done locally um and that comfort with it can improve um and also that it as a concept in the medical world can be accepted and then on the other side too is practically speaking as a treatment it’s not covered for the patient um so we need to get that side done [Music] well I think the future is actually here for us now because Dr Winston has been very active with his colleagues in this area in creating a movement almost about this research about the evidence to support it and about the outcomes that are possible for patients that previously had the option of surg are sometimes no option available to them so the future I think is is one of spread which is which can be a challenge for Innovations as well but I think that Dr Winston is well on the path to a global adoption of a research driven Innovation that wouldn’t be possible in this way without him I think the future the development of this technique all around the world uh in many many experts centers and uh I think we have a multidisciplinary treatment and we can work together surgeon physiatrist physiotherapist um occupational therapist for the best care for the patients and I think pertin closis is the future of the care and maybe a next gold standard in in the field of uh neur Orthopedic treatment [Music] this is a game Cher for the treatment of spasticity before this it was either surgical options or temporarily paralyzed the muscle which is so limiting this is so much more Limitless of a treatment we are talking hundreds or thousands of patients lives can be drastically improved by making this therapy number one known and number two available so that practitioners across the world can bring the same benefits to their patients for me it’s hope that we’re just in the empy that there’s so much potential if we could do children before they develop their their deformities and need surgery so hope is the number one thing but the really important thing has been acceptance so when you come up with something new you can be an outsider you can be an outcast people don’t accept you and because I’m such a transparent person and that I’ve documented every step of the journey with videos with presentations sharing teaching people coming from all over the world for me it’s been that a sense that it belongs and people want this to succeed that are people are coming from Harvard and Oxford and Michigan and Toronto and Calgary and Peru and Australia and they all want to learn this technique to take it back to Italy and Switzerland it’s not just going to be my technique that we have created this awareness there’s so many more things we can do but the fact that we can now with exquisite detail figure out any motor pattern in the body and figure out if we can change or not has been the most joyful Discovery for me [Music] [Music] [Music] [Music]