Revolutionizing Stroke Recovery: The Future of Spasticity Treatment

In this episode of the Stroke Buddies Podcast: Real Stories. Real Recovery., world-renowned physiatrist Dr. Paul Winston shares a groundbreaking approach to treating spasticity—a common and often debilitating condition for stroke and brain injury survivors.

Dr. Winston introduces cryo-neurolysis, an innovative, non-surgical procedure that uses targeted nerve freezing to reduce muscle stiffness and improve mobility. He explains what spasticity really is, why traditional treatments often fall short, and how this new approach is changing the future of rehabilitation.

You’ll also hear inspiring patient stories that demonstrate real, lasting improvements in movement, comfort, and overall quality of life.

Whether you're a survivor, caregiver, or clinician, this episode offers a powerful look at what’s possible when innovation meets recovery.

The future of stroke recovery is evolving—and new hope is here.

Transcript

SPEAKER_11 0:11

Hi, I'm Ralph Preston, and every Tuesday we have these Stroke Buddies Recovery and Science Zoom meetings. And today we're really honored. Dr. Paul Winston with us. Dr. Winston's a leading Canadian physiatrist and clinical associate professor at the University of British Columbia, and he's renowned for his pioneering work in rural rehabilitation and spasticity management. He serves as the medical director of rehabilitation and transitions for Isla and leads the rehabilitation medicine team at Victoria General Hospital. Dr. Winston's career is distinguished by his innovative approach to patient care, including the development and global dissemination of ultrasound guided diagnostic nerve blocks and cryoneurolysis for spasticity, a groundbreaking non-surgical treatment now being adopted internationally. And probably the reason a lot of you are here today. So let's welcome Dr. Winston. We really appreciate your time taking time away from your busy, busy schedule.

SPEAKER_09 1:22

Thank you so much. I'm just going to see if I can get the slideshow to launch and let me know if you can see all my slides. We're good. Perfect. Okay. Well, thanks everyone for joining in. I like doing these talks because I've tried to shorten it enough. So there's lots of time to ask for questions. If you have a burning question during the talk, I'm absolutely fine with you asking the question or just making notes yourself. So we're going to talk about a new treatment for spasticity. And I guess if this is a stroke group, most of you have a pretty good idea what spasticity is. You either live with it or you have a family member. And we're going to talk about why we had to come up with a new treatment. And the simple reason is that people were not getting well enough. One of my biggest mentors is Dr. Lisa Boivin, who is a bioethicist in the University of Toronto, but she's also from the Dene Nation in the far north. And in her work with indigenous consent and artwork, she really describes that when we engage a patient into the medical field, we actually have to see who the patient is. We have to explain what the patient has and do our best to inform the patient about what's going to happen to them. And let's face it, in medicine, we're really, really bad at that. We rush, we tell people to do things. We don't truly tell them what's going on. And often a lot in other fields, we don't actually know what the patient does day to day. So we don't take into account what happens when we're not in the room for 10, 15 minutes, what their needs are. So I'm going to show you a lot of patients, and they've given me their consent to share their story, but these are unique people that gave us their trust. So I'd like you to think about and thanking them for being part of this. When we give a talk, we're meant to give disclosures. So I have received funding, education from multiple companies that make botulinum toxin and cryoneurysis. And this is my colleague, Dr. Daniel Vinson, an anesthesiologist, who had the eureka moment to decide to do cryo for us back in 2017-18. The purpose of the talk today is we're just going to review what spasticity is, why we really need treatments, and to see how cryoneurysis fits in that window of ever-expanding treatments. The problem with spasticity is nobody understands it. And we're still debating internationally what to call it. So I like the term my colleague Theodore Daltome says spastic muscle overactivity because it's muscle overactivity to understand all the different types. So if you do not live with spasticity, the simplest thing that I'm going to just ask you to do is just create a tight fist with an arm that moves and pull it towards your face as hard as you can. And I almost want it to hurt so that your fingernails are digging in and I want to keep it there. And over the next minute while I'm talking, try to extend your arm and open something up, but take a minute, resist every moment. And that's the fight in your body. So when we go to open and close our arm, our muscles go to relax and stretch as needed. We don't think about it. But in the spasticity, when the brain is injured or the spinal cord, the muscles can't relax. So all the muscles contract at the same time. So you can't just open and close your hand at will. You're trying to open your hand, but the closing muscles are working, and vice versa. But when you wake up in the morning, the hand might be wide awake. When you look around, your hand might open without your control. So it's a lesion in the control of relaxation and movement. And that's what makes spasticity so hard to treat. Now, what's really shocking is that half of patients who have a stroke, because we're focusing on stroke today, will develop a contracture within six months. And a contracture just means is that no matter what we do, the limb can't move past its endpoints. Your arm can't go up, it can't straighten it open, you can't get your heel on the ground. And we don't treat it very well. And we talk about spasticity, but not the actual contracture, the unbreakable limitation in movement. Another group from Australia said, no matter how much physical therapy you get, you can't stop a contracture. You can't improve it by stretching. You can maintain it, but all that stretching on its own will not work. Now, when work started looking at how we could change it using medicine, there was a lot of work started looking at a drug called phenol, which is still used. So used a lot more in America than other countries because botulinum toxins are outlandishly expensive in America. But phenol, you know, you can't use it in Germany today because it was a favorite way of the Nazis to kill people. So you would inject their heart and they would have an excruciating, instant, painful death. Uh, well, not instant, enough to cause pain. So it's banned because of its abilities and it causes damage to structures. It's used many places, it's used on kids because you can't give them enough toxin, but it is a corrosive, deadly uh drug. The same thing with botulinum toxins. They were developed by the military in the United States and around the world as a bioweapon. It is a it is a at high doses, it could kill a country. It's used very safely. I use lots of toxin. You're not at risk using it, but it is developed from a strain that is biomedical warfare. So you have two structures that were used traditionally as deadly in a safe dose, but this is the potential. So neither of them, phenol is not FDA approved in America. And in the United States, toxins have very limited indications, and you can't treat it in a lot of body parts, and you can't treat it everywhere, and you have a maximum dose. So it's just not possible to treat a whole body with botulinum toxin. And evidence, particularly in kids, has not shown that it would increase function. So we decided that we needed more ways. Now, Paul, you mentioned Dr. Peter Ree. If you don't like blood, close your eyes. But this is some of the surgeries from Dr. Mark Mahan, who's a wonderful pediatric surgeon in Salt Lake City. Surgery works, but there's a limited number of targets you can have surgery. And if it reinnervates and grows back, what do you do? How many scars you can have? And there are very, very few surgeons in America that can do this. They're phenomenal, and it's really good when it's combined with other surgeries. Like Dr. Re is a master of what he can do, but it's a limited approach. So not that many people can access it. So we've created the Crowder Lysis. We did our first case in 2018. And Ralph, you mentioned so we do do training. I like it when a whole group comes together to teach. So this was the group up from Harvard, and we've had five of their doctors training. They get a Canadian license to treat patients, so it's really exciting when they come. And this is our global outreach. So we have patients in the white who travel very far distances to get treatment. We have doctors in green that travel from all over the world, and purple are the centers now offering this treatment. Pink of where I've gone to train. So it's really expanding around the world very quickly. And just to give you an idea, these are some of the names that people I've trained, and they might be near you. And these are a lot of the top American spasticity experts that have come for training, really wonderful people. If you want your local center to learn a little bit about it, we we published this book in 2023 and just really updated it for this purpose in 2025. 31 authors, many Americans, everything to do with nerves for spasticity. So not just cryo, phenol, toxin, a way for people to really understand how to do it better. We get very little money for each copy. So we sell it to teach. And there's about 65 videos in the book that you can share and learn from. So the important thing that I need to tell you is what I learned from my journeys in Europe is there's something called a reducible deformity. And a reducible deformity is when I ask a patient with spasticity, is your hand always in a fist? And they'll say, no, when I wake up in the morning, my partner can open my hand. Or sometimes when I'm not looking, my hand opens. But as soon as I go to move it, it clenches it. Other people, yeah, it never, I've never lifted my shoulder up here. It's impossible. I get skin breakdown. So what we normally did when we saw a patient for botulinum toxin is we kind of ref on their arm, see if it would move or stretch, inject, and then hope for the best. And we didn't show that the range of motion could get better. In France, they really figured out that if you did something called a nerve block, if you put an aesthetic, lidocaine, dental freezing around the nerve, you could paralyze the nerve and see how far it could stretch. So in that case, you could do a surgical procedure on the nerve or ebotylam toxin or an alcoholic phenol and get a better result. But if it didn't move, you would need another type of procedure. And no one really taught me that here in North America. So this is what a reducible spasticity is. This is from our documentary. This is the worst case scenario. And we we show worst case scenarios every single day. This woman has severe pain. Her pain is her limiting factor. She doesn't have function in that arm. So she understands after our nerve blocks that we did that her arm will move better, but she won't be able to do it on her own, but her pain would go away. Because what cryo does is it treats the pain nerves and the muscle nerves. So you can see her two months after the procedure. I was able to predict her outcome before we treated her because it relaxed with lidocaine. So look at the range of motion change. It's quite dramatic. She doesn't have the motor power to move on her own. So when patients come to see us, we are very clear you have paralysis under there. You won't be able to move your arm a lot more yourself or a little, but she is moving it better. But the stroke took away her power to move. But the pain is gone and the relaxation. And now the thing about cryo, people say, well, how long does it last? This is one year later. It has lasted very well. She's maintained almost all of her gains, but she wants more. And as we keep training patients and treating them, we we add more and more muscle groups. So we added a new group of muscles under here, and her arm really relaxed. There is no way she could have done a Superman before the procedure. She just couldn't even get the arm up. So instead of being in pain when I uh moving her after the second procedure, she's laughing, right? So this is her immediate recovery. You couldn't do that after surgery. You'd have scars, you'd have severe, you'd have total anesthetic, you'd have to heal. We treated so much on her the first time, we exhausted our like two hours and uh she was done. So we just treated her foot the first time, but at a year her leg was stiff. So we treated uh a thigh muscle, and look how high she can lift her leg and march. So what we've done over the years is we add more and more muscle groups. So that's what a reducible deformity is, one that responds to a nerve block. So the reason why we have hundreds of videos that we share, and people still say do do best case scenario, we don't have bad outcomes to share on videos because we always block them first. So we know what the patient's going to look like. So we can say we have a pretty good idea, this is what you're going to look like. If we can't change it, we don't do the procedure. We don't just ram you full of drugs and hope for the best. So this is Cynthia. And if you've seen our movie, Cynthia is one of our uh hero patients, one of our first study. She came up from Fort Worth for treatment. And she is a never stop, you know, energizer bunny who had a traumatic brain injury. She has a bacylofin pump in her back. She had surgical lengthening in uh in Texas, wonderful care, but she wants more. And one of the things with her spasticity is she said if she closed her eyes, she could do a punch. And she actually punched me. And I was like, whoa, okay. But then she can't do it again. Her arm is stuck. And her hand so she didn't want me to treat her hand, but her thumb gets stuck. So when her thumb gets stuck, she can't use her hand. But she was afraid to lose hand function. So we put her in our first study, because that's how we treated patients. But you can see how her thumb goes over. So we decided to treat the shoulders and elbow for her first. So if we look at her after her treatment about a few months, she's getting much better range of motion. But it's still, there's paralysis, right? And stiffness. So even though Dr. Boissineau can get her overhead, she hasn't unlocked that power. But this is way better. She can get it open, external. She said, I can do so many more tasks. I don't need to go overhead, but the stiffness, it's getting so much better. So all of these movements are better. And she still has a little bit of tightness in her elbow. So that's a not reducible, and some tightness in her shoulder. But she said it was life-changing for her. We also did one of her leg muscles as well. And she said she wished she had not had surgery on the leg because we would have treated that. So you can still see there's a little bit of tightness in that arm. So, you know, she goes off and she can do. So she went from one punch to really punching on the power she can generate. She came back after a year, our study was complete. And I said, you know, we have new things to treat under the armpit.

SPEAKER_12 14:56

Okay, excuse the cranky hair, but I want y'all to see something that I've been able to do for 12 years.

SPEAKER_09 15:02

So I want you to see the power that she can generate with her punching now. But the fact that she can reach her head is completely different. But she's still in this position. So even though she can do her head and she really likes it, I wish I had that much hair so I could do my own. But you know, she she can't do this. So this is the non-reducible part. She still has some stiffness that a nerd procedure will not do. But she's thrilled. She can do all these new things. So I said to her nine months ago, you know, I'm trying some new things, come back for treatment, and we'll do something. And this is a technique I also learned in French called Le Scrunch Crunch. And scrunch is the sound of scrunching tendon. So you hear. So this is described in the book Madame Bovary in the 1800s. You take a needle and you scrape away a tendon. So it's actually less painful than cryo because you don't numb the tendon.

SPEAKER_05 16:04

Oh my okay. Okay, seriously. Did you see that?

SPEAKER_10 16:08

Let's do it again.

SPEAKER_05 16:12

Am I the only one who's amazier?

SPEAKER_10 16:14

So I know, I'm happy.

SPEAKER_05 16:19

You believe that, yeah. Look, yeah, look at this.

SPEAKER_09 16:28

So for her, it was that tendon residual that we had to treat to do a tonotomy. This is right after the procedure.

SPEAKER_00 16:36

I feel the reach did it yourself. Okay, do it again. Do it again.

SPEAKER_05 16:44

Okay, is no one else obeyed by I haven't done this for 12 years by myself.

SPEAKER_09 16:50

And now she had to go and do aggressive physical therapy to regain movement and power in her new range of motion. You know, she went right to the gym from clinic. So, you know, this is there's not this is the recovery for her. Other people are very exhausted from the procedure and might need a couple days' rest. So we created this whole procedure. And every patient that comes to us, you know, everybody wants to be like Cynthia or other patients. And we say, well, no, your stroke left you with this capacity for movement, we expect that. So every patient that I treat, whether it's toxin or cryo or other, I like to do blocks first and say, look, this is where we're gonna get you. Is that okay? Do you want to want to go under a treatment? Do I have your consent to proceed, even if it means you can't walk again, you can't lift your arm overhead, but things are better, but just not perfect. We we can't undo the stroke or the multiple sclerosis. So here's another case. A young woman, she had a stroke in 18. And high, high functioning, regains her life, works. She just hides that arm, doesn't let anyone see her arm, which has no tasks. She's now left-handed. And just look at her face when I try to move her. So shoulders quite good, but elbow, wrist, and fingers really fight her with activity. She can run, but she has clonus. And for those that you don't know, clonus is that shaking that you get with spasticity, which gets in the way. So when she tries to run, she limps, uh, it's stiff, and her whole leg feels tight and resisting. So she doesn't like it. So she's just accepted that she doesn't use her right arm for function. So we did nerve blocks and immediately everything relaxed. I actually put little splints on her fingers just because she doesn't have power to say, look, you can get the power back. You just have to learn, and I'm just gonna stretch your fingers. And she loved this. And the clonus immediately got better. So we planned for cryo about a month later for her really to, you know, understand what this meant. And she came back and she documented her changes with me on videos and with text. So this is the day of the procedure, learning to use her hand again. This is the day after. No, okay, this is uh an amazing outcome, but I bet a lot of you can't throw a tennis ball as good as her, uh, you know, and she hasn't done it in 19 years. One of the things that people tell me all the time, and therapists get worried, patients get worried, doctors get worried, you're gonna paralyze my patient and make them weak. And many have said when they had toxin before, they had weakness. Well, we are so selective in choosing muscles that we leave some of the finger flexors and do others. So we take out the ones that are spastic most and leave the others for power. So she's relearning how to work immediately. And, you know, every day she's sending me a video of a new activity. This is one of my favorite shots because she did the video herself of, you know, getting that wrist all the way back.

SPEAKER_00 20:05

And she's retraining her brain right now. This is brain training now.

SPEAKER_09 20:23

They both look the same. Trying to play tennis again, you know, each each activity running much faster, looser. And she said, I I don't fight my therapy anymore. So the interesting was at 10 months, she called and said, I feel like it's wearing off and getting stiff. So she came in at a year and it was wearing off. It was still really good. And we retreated her and she sent me a video that night, like, everything's back. So if we need to retreat at a year, big deal. Like it, it's it's great. And hopefully, if we treat her once a year, maybe for three years, we won't have to treat her again. So, what is cryo? Cryo is putting a needle in the body on a targeted nerve, causing immediate destruction and breakdown of the nerve, so complete that the muscle relaxes. We have learned through our research and our publications and our hours and hours of studying where each nerve to each muscle exists. We can do an individual muscle or an entire large nerve, like the median nerve or your funny bone nerve, the ulnar nerve. And we've learned how to do it. So man who just had a stroke a few weeks before, and in Canada, both lime toxin. Is free in hospitals and free for people mostly. So we can do it all the time. And we treat our patients early, but we had a stiffness, a resistance to movement. And we do the cryo and the moths and completely gone. This is another patient that we treated who was two years post-stroke, had had a lot of toxin injections, a non-functioning hand. But when we did the nerve blocks, I said, you know what? I think your hand's gonna open. And we treated her. So she is learning how to use her arm. And, you know, the change in flexibility and mobility was great. She's one of these really like, you know, I call bulldozer patients. You're not gonna get in her way of her therapy. And she's really worked hard to stretch. Not everybody can. A lot of people have fatigue, tightness, other illnesses, and that's okay. Just getting you in a good position is okay if that's what you want. So Dr. Hashemi is showing how tight the hand was before, and now she can pick up things and feed herself.

SPEAKER_10 23:01

Any movement?

SPEAKER_09 23:02

A lot of the patients need to anotomy. And we're just going to publish a paper on 15 patients like this, where this is a published case report as well, where she was so tight after 10 years of botulinum toxin, we did cryo, we can see the tendon popping up, we cut it, and the range of motion is so much better. So we do the cryo for the spasticity, then we can see the tendon, and then we cut the tendon. So, how is it working? I've been talking a lot about cryo, but what exactly happens? So, what we do is we freeze nerves. So we put a needle, and there's different manufacturers, we put a needle in a body, we put gas, in this case, laughing gas, through the needle. It passes through an aperture, causing the needle to freeze very cold to pressure, minus 88 for nitrous oxide, and that makes the water around it freeze. So just to understand with cryo, we don't put anything in your body. There are no drugs. It is a probe that gets cold, like licking a pole in the winter. You can't move your tongue. They get to get stuck. Your water creates ice. So the catheter that we put in, we just put gas through it. As the gas goes through, it goes through the aperture, and then the probe gets really cold and it's really fast. What we know at the temperatures that we use up to minus 100, we put our ice probe on the neuron, and the neuron breaks down and it has to degenerate, kind of like getting sciatica, a nerve damage in your back, and you get foot drop, you can't move it. So that nerve breaks down, but after it breaks down, it starts to regenerate. So at these temperatures, it's very safe. The nerve will lose its motor or sensory phenomenon, but it will grow back. If we do really cold temperatures of minus 100, which is a special equipment with argon gas, that will kill the nerve. And that's only used when you have a tumor that you want to kill the tumor and all the blood supply. We do not damage tissue. It is like freezing a chicken breast. You can put it in the freezer, take it out, and eat it. There is no damage to anything else. It just damages the nerve, no other structures or blood vessels. As we've gone along, patients became very greedy, very selfish, and wanted to be better. How damn them. And what we they started seeing, but I want more. I want more. But as we could move them more and more, we suddenly had access to muscles that we could never treat before. So we started adding more muscles and publishing these approaches. So we have a lot of, lots and lots of case reports and publications in our book to teach them. This was a woman that we treated in Copenhagen who, you know, the neurologists didn't even want her to come see us because they said there's nothing you could do. You broke your shoulder, your shoulder won't move because you fractured it. But I'm like, I don't think so. So we did her muscle, and you can see, again, it's not perfect after the procedure. It's still quite tight, but it's much, much better. And now she can get access to cleaning her armpit, getting thrust, many things. But that tone in the shoulder was so bad, and it was not all due to the fracture. And the reason why I know this is after we are muscles, that's what I found in her armpit. This broken down skin, all cut pain and discomfort that she did not know existed. She was horrified to see this picture of her armpit. We cleaned her up, we did the extra muscles, and she was so much better. So the neurologists were wrong. The great thing about cryo, when people say is it new or experimental? No, it has been used since the 1960s and 70s. We have been freezing nerves for even longer. It has been used to get rid of pain for many, many decades. So when we do cryo, if you have pain in an area, we can also treat the sensory nerves to get rid of pain. So I always people are always worried about numbness. Yes, we do have some patients that will get unwanted numbness, but I can tell them I'm super, super sorry, but it will come back. We know it will regenerate. So even if you're numb in your knee or your hand for a few months unexpectedly, it will return to normal. His elbow can't go straight because his bone was formed in that shortened position. It will not, you can't reset the bone. But rather than shrinking and atrophying, which we know when we do botulinum toxin, the muscle can get atrophied. We see that on imaging, we lengthen it, we open the muscle. So on the left is two months after, on the right is before. And that's why the patients are stronger. We are generating bigger movements, bigger muscles that can generate more power, not taking them away. And this is Dr. Guassano showing the muscle stimulating. We are just getting the muscle we want in this case and freezing it. So when you come see me, you'd get a nerve block. Or my colleagues, we do a nerve block for people who have active movement. Yeah. And we say, Do you like this?

SPEAKER_10 28:23

Yeah.

SPEAKER_09 28:24

And then we do the cryo after. Because we want to make sure the patient isn't too weak or numb in the procedure. So this woman travels from Vancouver, so we would do the block in the morning and the cryo in the afternoon. So she can really decide if she wants it. We have a lot of patients like this. 9% of people who live in care homes in America have fisted claw hands. It is very painful. It is not neglect. It is not the nurse's fault. It's not family's fault. It's not the patient. It is severe spasticity with contracture. Typically, patients have dementia. So if you try to move them, they scream. So it's nobody's fault. But we know that toxins might open it a little bit, but it's contracture. It is pain. So we treat the motor nerve and the sensory nerve in these cases. So we numb them and relax them. So it's a double whammy. You basically make the hand have no feeling so they don't feel pain. This was a man, again, that we treated in Denmark who, you know, he had advanced dementia. So it was very uncomfortable for him. His family was very distressed, and he had contracture of the hand. He you on the left, you can see the tendons popping up. So that's what they would call contracture. But I knew it was reducible deformity and I could fix it. And then when we did the hand, I actually just forced the fingers open because they were now numb, and you hear you actually breaking scar tissue. So we were able to relax everything.

SPEAKER_06 29:56

Bear with me. I'm just going to try to open this as much as we can. Start with that one there.

SPEAKER_10 30:01

I'm going to try to say as far as we can get there. Open and close your hand now. Open and close. Can if I do this. Okay, painful. Sorry.

SPEAKER_09 30:17

We won't do it again. So my colleague Dr. Mews, there's five of us in the clinic that do the procedure. This was her patient that entered our study and I just filmed for her. And she's selectively just doing the two fingers that were a problem. She doesn't have to do anything else. And in this case, we felt it was all stiffness, not really sensory pain, because the other fingers were okay. So she can selectively go after just the flexor digitorum superficialis or FDS muscle, which is right here. And then we just break the tissue of the joint that's stuck. And relax and stretch her, and she'll be better. She had a stroke as a very, very young child. So she's developed with what's called spastic dystonia. And spastic dystonia is this when she tries to use her arm, the hand just contracts. So it will relax if she's not doing anything. And we know that toxin does not work here. Surgery is very complicated. You don't want to cut the tendons because they actually relax. But she has a completely non-functional hand.

SPEAKER_14 31:33

Much looser and much easier.

SPEAKER_10 31:35

And bend your elbow and strain that so that you put pressure. Good. And come back. Good now. Tell your hand away from the wall. Wow. And now turn it over to face the sky.

SPEAKER_05 31:50

And then you can just find it because you can do it.

SPEAKER_10 31:52

And just your arm is very relaxed now. Relax the arm, straighten the elbow out. That's good. Simon says, Simon says, touch your nose. Simon says, put your arm down. Simon says, can you reach all the way up to your head? Good. And can you like play with your hair? Good. And then open your hand. Good. And then touch her nose.

SPEAKER_09 32:19

And then I followed up with her. She had just started university, college. And I said, you know, what are the things, you know, I I said, you're gonna have a hard time using that arm because you have it. She said, well, one of the best things is I live in an old dorm. So there's doors everywhere. So I can now um I can now um open doors with that hand. So I can carry things in my other arm, I can do all my things, and now I can use that hand as a helper. I can open doors, I can you know lift things, which is life-changing for her. So feet are really difficult and complicated. And you know, in America, some of the botch line toxins don't even have indication of the leg. We just got one in Canada from Xeoman because the evidence is very low and it's below the knee only, the treatment. You can't treat above the knee for some of the toxins because they haven't been shown to be effective enough. So this is an example of a multiple sclerosis patient who is walking on her toes. But we do a nerve block and discover that we can actually relax the foot. So it is possible for her to get a heel down. And now do that on that side.

SPEAKER_05 33:32

Oh, look at that.

SPEAKER_09 33:34

What's different?

SPEAKER_05 33:35

That moves.

SPEAKER_09 33:36

What normally happens?

SPEAKER_05 33:37

It doesn't.

SPEAKER_09 33:38

So by relaxing up that foot down, you can suddenly regain the power that you don't have. So this woman said to me after she has cerebral palsy, she said, Do you think I could jog? And I'm like, I don't see why not. Uh and she came back the next week jogging.

SPEAKER_10 34:02

What's different?

SPEAKER_04 34:04

Oh, that was incredible.

SPEAKER_10 34:06

Keep going the other way. Okay, don't worry about holding it. You are walking so fast.

SPEAKER_15 34:12

You haven't walked this fast in years.

SPEAKER_09 34:15

I've been walking this fast so every time she took a step and she couldn't advance her foot. And really, really, I'm getting quite bossy with uh myself when a patient says it's not right. We keep keep trying to see if we can get more. Some of our patients, though, I say, look, you actually need surgery. Your your calf muscles are too short, and they will decide if something eventually sometimes I can more easily convince them to get surgery. But she had a very nice outcome. This guy had a lovely outcome. Uh, and you know, two years ago, I would have said you needed surgery, but we've been able to add more and more muscles. So we do a block, get up and walk, block, get up and walk, block, get up and walk. And after we did all those blocks, we brought him in for this cryo and immediately he is better. So he's quite happy. He just kept swearing because that's one of the few words that he has. So we he he we effectually call him the OF guy because he he loves that, because he was so excited walking away. Interestingly, one of the comments families tell us all for patients that have speech disorders and aphasia, they are more understandable after they they start moving their body more and seem to have more motor connections. So incidentally, many parents and family members have said, you know, they talk more easily now. We can do any muscle group we want now, which is really exciting to meet the goals of the patient.

SPEAKER_06 35:47

One of a one of a pie.

SPEAKER_09 36:00

And as we patient, we're not looking for perfection, we're not asking for quote normal. We're asking for improvements that meet your goal. This was a young man we treated in Switzerland in February with cerebral palsy, and just it was so hard for him to sit in his chair. His legs were cramped. When he'd go to transfer, his dad, you know, who's getting older, has to lift him because the legs were just stuck together and flexed. And he just sitting in the chair after, he just scooched over, really simple. Legs are relaxed, he can do it on his own, very happy. We're not going to make him walk, we're not going to be able to give him big movements, but look how relaxed he is after. So for him, that's a huge improvement. People tell me every day your patient should be getting weaker. This is a soldier. He has multiple sclerosis, his legs are stuck, and we treat the muscles, and now he can march. And when he came back a month later, he was that much better. We lengthened a lot of hamstrings. We've been adding more and more muscles, and it's quite crazy to see how much more lengths you can do. But what does that mean functionally?

SPEAKER_13 37:12

Lift.

SPEAKER_01 37:12

Yeah, band it, band it, band it.

SPEAKER_09 37:17

So after the procedure, she just kicked her foot right after her head, grabbed her foot, and said, Wow, I am way looser. Good. She went back to yoga the next day. So just to wrap up, um, because we're talking about stroke, there are a lot of children that have strokes either at birth or shortly after, or kids or teens. We see them in our clinics because we are the referral center. And Children's Healthcare Atlanta has done over 60 patients. They'll probably easily hit over 100 this year. And we have trained Shriners, we've trained Yale, we've trained Sanford. I've got a pediatric hospital coming from uh San Diego. Uh, the team in Lexington, Kentucky is ready. We are going to be treating a lot of children soon.

SPEAKER_06 38:55

I don't care, I don't care, so call me crazy. We can live in a world that we desire. The brightest colors fill my head.

SPEAKER_09 39:32

So I have an anesthesia project, and I've really convinced my colleague. So I'll be able to do up to six children a month, which is absolutely incredible. We have a lot of studies. They are mostly listed on trinclinicaltrials.gov in America. And I get asked all the time where I can get treatment. So before I go there, I'm just going to mention safety. So safety has been my number one concern. I've had many, if I got criticism or even dismissal, people were worried about pain or side effects. And I kindly point out that this is a treatment for pain. The machines are called pain ease. Pain. It is a pain treatment. It was designed to treat pain. So when we looked at our first 113 patients, 277 nerves, 96.75% reported no uh side effects after. The procedure itself can be quite painful, but after they did not. And the patients that had pain after, there were nine of them out of 113, we discovered that you have pain if you don't do enough cycles of freezing. So if you leave the nerve partially intact, they will get some burning and twitching. So you just treat them again. So if they at the end of the procedure, they're saying my foot's starting to burn or my arm is cramping, we do one more treatment, meaning there's a few nerve fibers left we didn't do. Of the nine patients, five of them needed a treatment and they all resolved it. Of course, every side effect is horror to me. I will wake up, I will feel terrible. But the other thing is we've discovered that most of the time when people call back with pain, it's not always the treatment. It's the change in the muscle, it's the stretching and the fact that they moved it. You are in such a different way, you're walking on new muscles. So we have to treat those. Those are side effects and the change in function and movement. So I'm I'm happy to say when we have a side effect, I, you know, I die a little bit inside when someone's in pain, but our patients are really good about it. They come. Many have said, oh, you know, I was in agony for two weeks after, but I didn't bother calling you because I expected it. Uh, you know, like it just but if I compare it to a surgical recovery, it's very fast. So changing all the structures, tendons, and your body, you know, has problems. I do want to share with you, I was given permission. This is a current study. If you want to take a screenshot, this is a study going on in the USA right now. It is a multi-center study treating the muscles of the shoulder and the elbow. Um, all across America, there are recruiting patients. And what you need to know when you get a study, though, it is what's called a sham control. So two-thirds of the patients will get cryo treatment. One-third will get a machine that doesn't actually produce the lesion. And this is how for the FDA, when you treat pain in the knee, you have to give a third of the patients a sham. The good thing though is if you go to a center and you get a sham, the study is only four months long. You will go back and you can have the treatment. So you will be part of that clinic. So, you know, I'm hoping that all patients who are getting connected to these treatments can then get treatment outside of the treatment area, but you'd be really helping America to get approval. And if you I hope you can see the QR code. Can you see the QR code on your screen? Yes. Okay, you can't photograph it. Yeah.

SPEAKER_11 42:59

Also, Dr. Winston, I can, if you have a link to your survey, I can put it in the description underneath the video so that people can Okay.

SPEAKER_09 43:06

I will I will just send you the slides after you can put it.

SPEAKER_11 43:09

Anything, anything that you want, contact information, surveys, anything, anything you want, send to me and and I'll make sure to include it.

SPEAKER_09 43:17

So you can share this with your group. We do a lot of everything we have done has been grassroots of social media and training. Uh the all the manufacturers of cryo are small companies. They are not, they don't have billions of dollars to spend on RXD education promotion. So we are doing a lot of it ourselves. Um, we have an international society and my website, Academy of Rehabilitation Cryo. I'm very excited. We just created a huge number of educational videos, and I'm literally fundraising from the manufacturers right now. If you follow me, you know I'm about free. I don't like people, people with disabilities don't have money. So we try to do all education for. Free around the world. Um, but uh my students have just created this new website. You can go to this website. And if you actually want to be on the website and do a personal story video about what it is to live with spasticity, you could contribute. And we are putting in education about spasticity every day. This is self-funded by my students. Cool. And finally, like I said, uh every Ralph, you mentioned at the beginning that you spoke to my nurse. So my just about my entire team, except for my research lead, are funded by research grants. Um, our positions are not unionized, they don't have research positions and assistance in our union. So we have to fundraise for them and through grants and monies. So everything, so even when American patients come up, I do all treatments pro bono. I don't make any money. I give up my time for free and I ask Americans to pay my foundation. So by paying my foundation, I can continue to train and hire my team because the the treatments are long. We're taking a lot of data. So every American that's come to me has been pro bono to me. Um, but they pay for the fee that they're meant to pay to the foundation so that I can keep training and doing research. And patients donate because they know that it means other people can get care as well. So I'm gonna stop sharing here and open it up for questions.

SPEAKER_11 45:28

Wow. Wow. If you send me the links to those to the patient website and other things, I'll make sure they're also in the description.

SPEAKER_15 45:43

Dr. Winston, my name is Mindy, and um I want to uh thank you for coming on here and Ralph for having him. Um I was just reading, who do I go to in Winnipeg? I know this was kind of ass, but I was just going online going, oh, where do I go? Where do I couldn't, and I couldn't find it, I couldn't find this different ones that come up. And my family position said it's not available. I don't, I never heard of it. So I need help to where to go and to talk to her about that.

SPEAKER_11 46:26

Um by the way, um, she's in Saskatchewan and Canada and for and Manitoba. Well Manitoba, sorry.

SPEAKER_09 46:36

I didn't know if you said that anyway. I will tell you this. So one of my patients, one of someone who follows me on social media, actually bought the equipment for um Winnipeg Health Sciences. So it's at the University of Manitoba for Dr. Karen Ethens. Um, so she has the equipment. The the patient actually bought the equipment and donated it so he could get the treatment. We did it as a workshop there. So Dr. Ethens has the capacity um limited because the hospital is not being very easy about opening it up to patients. However, I've trained more patients in Saskatchewan than anywhere else than Harvard. So uh Saskatoon and Regina have some wonderful doctors who uh would do. And then I treat here as well. So you're covered by um Manitoba Health is is free here, but for out-of-province patients, you do have to buy the probe from the company. And that costs in Canada$700 in the US. I think it's about if you do in the US, they have different ways. So we we treat you for free in Victoria. Uh, you can even get Hope Air to fly you out if you don't have the funding. Um so it's free from me because I get paid by the government to treat you. But Dr. Ethens would be someone that you could talk to. She could also do an assessment for you. Uh, she's an amazing doctor. Um and we would like to have more people in Manitoba.

SPEAKER_15 48:00

How do you spell her last name?

SPEAKER_01 48:02

I s A N S. E Sons.

SPEAKER_15 48:13

Thank you. Yeah, okay. Thank you.

SPEAKER_09 48:20

Like I said, I've had patients fly across the country on Hobire that pays for all your costs.

SPEAKER_15 48:26

Thank you. That's hopeful.

SPEAKER_11 48:35

Surely there are other questions.

SPEAKER_00 48:37

Yeah, I I've got a question. Who at Yale have you trained?

SPEAKER_09 48:42

So her name is Dr. Jennifer Hankinson. And she's amazing. A really, really hungry doctor. She came up and actually asked to have a longer training session. I also trained her colleague, so there's two of them. Um, and they've they've been underway and treating. They really want to start doing kids, they just have to get approval. But uh Dr. Hagginson now has a long waiting list because she needs more time. Uh, but she's treated, she literally went home and just started treating like the next week.

SPEAKER_02 49:15

And down in uh uh Burke in White Plains, is there someone?

SPEAKER_09 49:21

White Plains in in here in the best place possible. So uh Dr. Jasm uh uh Jasmir uh sorry, what's the uh Guman, G-H-U-M-A-N. Uh I've trained two doctors at Burke and also at Burke in in the Bronx, Brian Lee. So uh Jaz Guman, she's amazing. G-H-U-M-A-N, and there's a couple doctors from her center that I've trained. Uh they're great. So you're in a perfect place to get treatment.

SPEAKER_00 49:54

Beautiful. That's very close for me too. That's okay.

SPEAKER_02 49:59

Yeah.

SPEAKER_09 50:00

Mount Sinai. There's Mount Sinai. Um, you can get Dr. Eskalon's group who trained Dr. Gooman. Uh, so two in Burke, there, Philadelphia, a wonderful team at UPenn. Uh, I just trained another doctor uh in Philadelphia, so we have a lot of people in that area now.

SPEAKER_00 50:17

What's the name of Dr. Dr. Mount Sinai?

SPEAKER_09 50:22

Escalon, E-S-C-A-L-O-N.

SPEAKER_13 50:27

Hello, this is Valeria Holland, and I'm in Dallas, Texas. Do you have what about doctors in this area?

SPEAKER_09 50:34

I sure do. So Houston was our first American center, and one of their fellows is now in uh in Dallas area. Yes. And we're we're training a bunch of people there. Um, let me just uh it's I'll just get her name there. It it's her name is let me just get it spelled correct. It's Tulsi, T-U-L-S-I, Pandat, P-A-N-D-A-T. I think in Dallas I get a little bit confused because they're all U T hospitals. So there's a bunch of U T hospitals between um San Antonio, uh Dallas, Houston, but it's Panda, P-A-N-D-A-T. You can ask for her.

SPEAKER_14 51:18

P-A-N-D-T?

SPEAKER_09 51:21

D-A-T.

SPEAKER_14 51:23

Okay. And that's in the Dallas Fort Worth area.

SPEAKER_09 51:29

I think I have to check. Um Dr.

SPEAKER_14 51:32

Wonder. I have had uh cryoneurolysis. I had it in early January of this year by Dr. Wonder in Regina, Saskatchewan.

SPEAKER_01 51:44

Yes.

SPEAKER_14 51:44

And for me, from what I understand, it should last about six months. For me, it seemed to only last about a week. I'm planning to get it again here in Saskatoon by Dr. Jeremy Hood.

SPEAKER_07 51:59

Okay.

SPEAKER_14 51:59

And I'm wondering if there's something I should be doing to make sure it lasts longer this time.

SPEAKER_09 52:06

Yeah, so the question is the first time he did it, what the muscles were, if there was the underlying dystonia, which is the movement disorder, or not enough muscles. So it depends on what condition you have. Some people we have to treat a lot more muscles, and when we first start, we're a bit nervous to treat a lot. And so the feedback we got from patients was treat more rather than less.

unknown 52:29

Okay.

SPEAKER_00 52:32

Yeah.

SPEAKER_02 52:34

Is there something that would make someone ill ineligible? I mean, I've been getting Botox for like every three months with very minimal uh benefit. Uh I happen to have uh central pain syndrome. I have a very severe head to toe on my right side, my dominant side. And so I have intractable pain. And so something like this would address that pain.

SPEAKER_09 53:07

So unfortunately, central pain comes from the brain. So a lot, most people with spasticity have pain around their joints because of stiffness and tightness, which cryo helps very well. It will not address central pain because central pain um is irrespective of the nerves. It might make movements easier, but we have not been able to address central pain. It would make the muscles move more relaxed, it would be help with the spasticity and like movement of a joint. But in my experience, people have central pain, it's just everywhere. It doesn't matter what the movement is.

SPEAKER_02 53:42

Yeah, I have both spasticity and I have uh I had the pin severe pins and needles and body spasms. So would it would it address one of those?

SPEAKER_09 53:56

It would address the spasticity for sure. Well, I would hope. You would know with nerve blocks. Uh the the central pain is we all hate it as physicians because we hate it for our patients.

unknown 54:07

Yeah.

SPEAKER_02 54:07

Yeah.

SPEAKER_09 54:08

Brain stimulation is probably the best thing.

SPEAKER_02 54:12

Well, but that's invasive, correct?

SPEAKER_09 54:15

Yes. And no guarantee as well.

SPEAKER_04 54:19

Correct. Dr. Winston?

SPEAKER_09 54:22

You've got a couple questions in the ball. Okay, go ahead.

SPEAKER_04 54:26

I just wanted to say I have been diagnosed with philemic pain syndrome, central post-stroke pain. That's what I like. And I have been using transcutaneous spinal cord stimulation in physical therapy. And that is non-invasive, and it's a form of electrical stimulation. And I just had it this morning, and I came back, and the pain and spasticity is gone from my leg. Right. So now it's temporary. It's all I'm getting about 48 hours from 40 minutes of active overground gait training using the T the transcutaneous spinal cord stimulation. But I have a personal unit on the way so that I can use it at home. So if I'm getting two days of pain relief from 40 minutes of electrical stimulation, that's pretty good.

SPEAKER_02 55:40

I had when I had the stroke, it grazed the thalamic. So they say I have thalamic pain. And that's why I have centered CPS.

SPEAKER_09 55:49

But then some people are getting implantable now. Like our I know uh some doctors are doing implantable nerve stimulators. There's one other question in here. Uh um that a phenol can damage the surrounding environment of the nerve, which is not preferable. So, what we know about cryo is phenol, as I mentioned to you, it's a toxic corrosive substance. So it will, it will destroy whatever it touches. And we see that in the form of fibrosis in the tissues. You know, they will say reassuringly that should get better over time. Cryo does not damage the surrounding structures. We ultrasound the patients before and after. And at the temperatures we're doing it, does not damage the structures. If you want to do an ablation for a tumor, it's very good at that, but it's at a much colder temperature. So that's why we feel that it's very safe. And when they've done uh cell studies on rats, when you take a transection, that the tissues are clean and they grow back well. So that's my colleagues in the states that do a lot of phenol have all said they've enjoyed that aspect, that there's no maximum dose and it's not, they're not worried about damaging other structures. Very good question.

SPEAKER_16 57:04

I'm in New Brunswick, England. Is there any in the Maritimes?

SPEAKER_09 57:11

Um not yet. Um my colleague in Montreal, Dr. Bursek, would be the closest. B-U-R-S-U-C.

SPEAKER_16 57:20

I don't mind traveling.

SPEAKER_09 57:23

Okay.

SPEAKER_16 57:23

What are the wait times usually?

SPEAKER_09 57:26

You know, I think for this, because we we're all really promoting it, it's not long at all. People wanting to do it quickly. Um Quebec's a little bit funny, though, in Canada, it has its own healthcare system. So that's funny, period. So is they're the only province that aren't covered on reciprocal agreement. So like it's free for you to come here, but there you may have to pay and get reimbursed. Um, this is Canada, folks. We don't charge for things like this. Um but um yes, that would be the closest to you.

SPEAKER_16 57:59

Okay.

SPEAKER_04 58:01

Well, I have some good news for the people in the US. When I went in March, I had to pay in advance because it was not covered by insurance. I submitted a claim and they covered the nerve blocks and they covered the ultrasound guidance so that it could go, my claim could go to Medicare, which does cover cryo. And I'm going back in two weeks, and it was actually approved by my primary insurance. So I'm getting insurance coverage from Cryo. So that's a big huge step also to making sure it becomes more available in the US.

SPEAKER_09 58:47

And it is covered by Medicare. So a lot of my complications are still hard, yeah.

SPEAKER_03 58:52

Can you just talk? How do you get the hold on? Am I okay? So can I ask a question? How do you see it? Oh can you hear me? Yes. I've never done this, so um like my dang. Sorry, I went blank. So I'm a bit worried. I'm traveling by myself. And uh, you know, I infected left side and it's very and I broke my hip about a year ago. The stroke is about almost three years. And so the leg, I don't understand the leg really, because I try to mow with the you know, the memo put the mower outside. I'm trying to, but I've been so tired lately. Like the leg, when I wake up, it's a little bit like this, and then I step on it to kind of make it, you know, more even. And I can't even tell if I'm progressing or not anymore. Sometimes like I can walk around my house without the cane a little bit. But um sorry, I hate talking in public like, you know, on the thing. So anyway, um so I do have a little bit of the supination, especially when I, you know, I get the supination a little bit. When I get tired, I'd even get the pronation. And then the meaty, I'm very disappointed because I ordered a stair stepper. I have a treadmill, but I have to hang on. And the stair stepper before the guy, Amazon guy left, I said, please can I get on it with you here? And it was such a nightmare. I thought it was more progressed along. I tried to get the other leg, the left one on the other side, and I had to have him taken back because it was too weak. So uh, you know, and I'm a fighter, I want my damn leg back, and so would this work? Like, like would you be able to for the knee to bend more? And what was the other thing? And I I guess is that my ankle, but anyway, um would the cryo weaken that? Like would it would would that help at all? You know, happen so for the knee? Oh, and hyperextension a teeny bit.

SPEAKER_09 1:01:16

Yeah, so these are all great questions. We we don't know until we see someone in person and try blocks, and that's why we do the blocks first to see if it helps. One of the things to explain to people with stroke as well, like for you that have central pain, is the brain often doesn't know where to do it.

SPEAKER_10 1:01:31

Oh, I have no pain.

SPEAKER_09 1:01:33

Okay, but for some of the other pain. Some of the other people, um, the there are body perception problems. So some people experience pain, some people have no feedback. So not always your body knows where you are in space when you're walking, which contributes to the problem. So that's why we always do blocks first and see how the body responds, but we don't know until we assess someone in person. And we can't legally give advice over out of out of state or province. So we we have to see people in person to see, yeah.

SPEAKER_11 1:02:07

Well, she has an appointment to see you later this month, I believe.

SPEAKER_03 1:02:12

Yeah, so actually I had to reschedule my puppy went in heat, and I couldn't take her to the boarding place, so it's not till September. And I have been kind of scared like traveling because I go to I mean, going to Walmart is like a big deal, you know. But I mean yeah, so but I'm scheduled in September.

SPEAKER_11 1:02:32

Oh, September.

SPEAKER_02 1:02:34

Yeah, I'm working on my yeah, so if I could just ask as a follow-up, so just so I'm clear, with regard to the intractable pain that I have, the chronic pain syndrome, it would not address the severe pins and needles, but it would address the spasms. Is that correct? As I understand it, yes.

SPEAKER_09 1:03:02

Yes.

SPEAKER_02 1:03:03

Okay.

SPEAKER_09 1:03:03

Because the the the pain from central pain is actually not in the nerve or the muscle, it's coming from the brain perception. Okay. It's already up there. Like when by blocking it lower down, that's not where the problem is. The problem is actually in the brain.

SPEAKER_11 1:03:18

Is that true? Numbness also.

SPEAKER_09 1:03:21

Uh um so the thing is cryo addresses numbness. So we are able to knock out the sensory nerves for many people because they actually don't feel. So I always say if you're already numb, we can't give you back sensation. But amazingly, a lot of people, when we treat their spasticity, they say, I feel more. And the reason why they feel more is they're getting more foot contact, more grip, more their book, their brain is perceiving more stimuli. So it's not that they're unnumb, it's just that they have more points of contact. Their brain is feeling the movement in space better. But patients that are actually completely numb are great candidates because they don't have any pain with procedure. And if we take away large nerves that have sensation, they don't notice at all. So, in fact, when a patient says we're numb, we're like, yes, because uh there's way less chance of it allows us to do a lot more if you're completely numb.

SPEAKER_16 1:04:14

What type of doctor does that scraping for that crunching? I've developed that crunching in my knee.

SPEAKER_09 1:04:22

Traditionally, it is surgeons, so orthopedic surgeons or plastic surgeons would do them. Um we're just starting to do it here in North America, but it it's it's routine for because uh pediatric orthopedic surgeons have been doing it for children forever. Yeah, so yeah. It is.

SPEAKER_16 1:04:39

Oh, it's really loud.

SPEAKER_09 1:04:41

We put it on music.

SPEAKER_16 1:04:42

My father said the other day, is that your leg making that noise when it was going up the stairs?

SPEAKER_09 1:04:48

Yeah. But that might be the joint as well, which is a different issue, but if it's the tendon, yeah. All right, I have to get to clinic, everyone. So thank you so much. Ralph, I'll send you those extra slides. Thank you, thank you, thank you. Thank you very much.

SPEAKER_02 1:05:02

Yes, thank you very much. Thank you.

SPEAKER_00 1:05:05

All right, thank you. Okay.