Spasticity Fellowship

The goals of the fellowship program are to develop a strong foundational knowledge of the pathophysiology, diagnosis, and treatment of spasticity and related sequelae. At the completion of the fellowship, it is expected that the fellow will be competent in the assessment of spasticity and related functional impairments, defining reasonable treatment goals with patients and setting appropriate expectations, communicating goals and treatment with patients, caregivers, and other members of the rehabilitation team. It is expected that the fellow will develop competence in the procedural skills related to advanced spasticity management including chemodenervation, chemoneurolysis, diagnostic selective motor nerve blocks, and intrathecal pump management. It is expected that the fellow will contribute meaningfully to a scholarly project in the area of spasticity.

Objectives to be demonstrated by graduating fellows include: 

• Knowledge of the pathophysiology of spasticity and the upper motor neuron syndrome 
• Recognition of signs of the upper motor neuron syndrome other than spasticity 
• Obtaining clinical history and medical information specific to spasticity 
• Knowledge of clinical presentation of various spastic postures and muscles involved 
• Clinical assessment of the impact of spasticity on function and quality of life 
• Recognition and management of potential noxious stimuli that can exacerbate spasticity 
• Performance of Ashworth or modified Ashworth scale 
• Knowledge of Tardieu assessment method 
• Goniometric measurement of spastic limbs 
• Ordering of appropriate diagnostic tests 
• Understanding of the role of gait and motor control analysis in the management of the spastic patient 
• Appropriate treatment goal setting 
• Prescription of oral spasmolytics to appropriate patients 
• Performance of botulinum toxin chemodenervation including toxin preparation 
• Performance of phenol or alcohol neurolysis 
• Performance of diagnostic nerve block using local anesthetics 
• Use of EMG amplifier and stimulator guidance for injections 
• Use of ultrasound for injection guidance 
• Troubleshooting suboptimal outcomes of botulinum toxin chemodenervation or neurolysis 
• Management of adverse effects relative to botulinum toxin injections or neurolysis 
• Identification of appropriate candidates for intrathecal baclofen therapy 
• Execution of lumbar puncture for intrathecal baclofen trialing 
• Observation of continuous intrathecal catheter trialing 
• Observation of intrathecal delivery system implantation 
• Performing intrathecal baclofen pump refills, including fluoroscopic and ultrasound guidance 
• Performing intrathecal baclofen reprogramming, including complex programming, and bridge/priming bolus delivery 
• Performing of side port aspiration of intrathecal delivery systems 
• Interpretation of CT myelogram and nuclear medicine cisternogram studies 
• Troubleshooting intrathecal baclofen therapy-related problems 
• Management of intrathecal baclofen overdose and withdrawal syndromes 
• Identification of appropriate candidates for tendon lengthening 
• Identification of appropriate candidates for functional neurotomy 
• Identification of appropriate candidates for dorsal rhizotomy 

Learning will occur within the context of an intended focus on the six core competencies of medicine: medical knowledge, patient care, professionalism, systems-based practice, interpersonal and communication skills, practice-based learning. The fellow’s performance will be regularly evaluated throughout the year by fellowship faculty.