What is your approach to the management of worsening dystonic spasms that are painful and refractory to standard dystonia medications?

Agree with Dr. @Dr. First Last, my friend.

I would also add physical therapy specifically asking for a muscle mobilization therapist within a week after chemodenervation.

Physical therapy really helps after treatment or without treatment.

Also, set realistic expectations about pain management: remind of the refractory nature of the disease and offer behavioral consult.

For the chemodenervation, focus on muscles with increased tone and use an inching pattern: spread the toxin across the muscles.

If the problematic area of dystonia is focal, botulinum toxin treatment should be considered which is the treatment of choice for focal dystonia.