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Few studies have examined the effect of intensive therapy on gross motor function and trunk control in children with cerebral palsy (CP). This study evaluated the effects of an intensive burst of therapy on the lower limbs and trunk by comparing qualitative functional and functional approaches. This study was designed as a quasi-randomized, controlled, and evaluator-blinded trial. Thirty-six children with bilateral spastic CP (mean age = 8 y 9 mo; Gross Motor Function Classification II and III) were randomized into functional ( n = 12) and qualitative functional ( n = 24) groups. The main outcome measures were the Gross Motor Function Measure (GMFM), the Quality Function Measure (QFM), and the Trunk Control Measurement Scale (TCMS). The results revealed significant time-by-approach interaction effects for all QFM attributes and the GMFM's standing dimension and total score. Post hoc tests showed immediate post-intervention gains with the qualitative functional approach for all QFM attributes, the GMFM's standing and walking/running/jumping dimension and total score, and the total TCMS score. The qualitative functional approach shows promising results with improvements in movement quality and gross motor function., Competing Interests: The authors declare no conflicts of interest. The funders had no role in the study’s design; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

The aim of this paper is to provide a clinically applicable overview of different tone reducing modalities and how these can interact with or augment concurrent physical therapy (PT). Botulinum toxin (BoNT), oral tone-regulating medication, intrathecal baclofen (ITB), and selective dorsal rhizotomy are discussed within a physiotherapeutic context and in view of current scientific evidence. We propose clinical reasoning strategies to identify treatment goals as well as the appropriate and corresponding treatment interventions. Instrumented measurement of spasticity, standardized clinical assessment, and 3D clinical motion analysis are scientifically sound tools to help select the appropriate treatment and, when needed, to selectively target or spare individual muscles. In addition, particular attention is given to strength training as a necessary tool to tackle muscle weakness associated with specific modalities of tone reduction. More research is needed to methodologically assess the long-term effectiveness of such individualized tone treatment, optimize parameters such as medication dosage, and gain more insight into the kind of PT techniques that are essential in conjunction with tone reduction., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: This study aims to achieve an international expert consensus on joint patterns during gait for children with cerebral palsy (CP) by means of Delphi surveys., Method: In Stage 1, seven local experts drafted a preliminary proposal of kinematic patterns for each lower limb joint in the sagittal, coronal, and transverse plane. In Stage 2, 13 experts from eight gait laboratories (four in the USA and four in Europe), participated in a Delphi consensus study. Consensus was defined by a pre-set cut-off point of 75% agreement among participants., Results: After the first stage, 44 joint patterns were presented in a first survey and 29 patterns reached consensus. Consensus improved to 47 out of 48 patterns in the third survey. Only one pattern, 'abnormal knee pattern during loading response', did not reach consensus. The expert panel agreed to define six patterns for the knee during swing, most of them representing characteristics of a stiff knee pattern., Interpretation: The defined joint patterns can support clinical reasoning for children with CP as joint patterns during gait might be linked to different treatment approaches. Automating the classification process and incorporating additional trunk, foot, and electromyography features should be prioritized for the near future., (© 2015 Mac Keith Press.)

Background: Cerebral palsy (CP) is characterized by a heterogeneous nature with a variety of problems. Therefore, individualized physical therapy might be more appropriate to address the needs for these children., Aim: The first aim was to compare the effectiveness of an individually-defined therapy program (IT) and a general therapy program (GT) on gait and gross motor function in children with CP. The second aim was to evaluate interaction-effects, time-effects, treatment with botulinum toxin A, age, gross Motor Function Classification Scale (GMFCS), treatment frequency and quality as factors influencing outcome., Design: An evaluator-blinded, randomized controlled trial., Setting: Outpatient rehabilitation unit., Population: Forty ambulant children with spastic bilateral CP (mean age 6 years 1 month)., Methods: All children were randomly assigned to receive either IT or GT over a 10 week period. Nineteen of these children were enrolled into a second and/or third program, resulting in 60 interventions. Primary outcome was assessed with the Goal Attainment Scale (GAS) for gross motor function goals and z-scores for goals based on specific 3D gait parameters. Secondary outcome included the Gross Motor Function Measure-88 (GMFM-88) scores, time and distance gait parameters, Gait Profile Score, Movement Analysis Profiles and time needed to complete Timed-Up-and-Go and Five-Times-Sit-To-Stand tests., Results: There were higher, but non-significant GAS and z-score changes following the IT program compared to the GT program (GAS: 46.2 for the IT versus 42.2 for the GT group, P=0.332, ES 0.15; z-score: 0.135 for the IT compared to 0.072 for the GT group, P=0.669, ES 0.05). Significant time-effects could be found on the GAS (P<0.001) and the GMFM-88 total score (P<0.001). Age was identified as a predictor for GAS and GMFM-88 improvement (P=0.023 and P=0.044)., Conclusion: No significant differences could be registered between the effects of the IT and the GT. The favorable outcome after the IT program was only a trend and needs to be confirmed on larger groups and with programs of longer duration., Clinical Rehabilitation Impact: Both programs had a positive impact on the children's motor functioning. It is useful to involve older children more actively in the process of goal setting.

Objective: To investigate the agreement between live and video scores of the Gross Motor Function Measure-88., Design: Reliability study., Subjects: Forty children with bilateral spastic cerebral palsy., Interventions: Fifty evaluations were administered according to the test guidelines, and were videotaped. After a minimum interval of one month, the video recordings were again rated by the same assessor. Two physical therapy students also each scored the recordings twice, with a minimal interval of one month., Main Measures: Agreement between live and video scores as well as inter-rater and intra-rater agreement of the video scores were assessed using intra-class correlation coefficients (ICC), standard error of measurements (SEM), and smallest detectable changes (SDC). Weighted kappa coefficients were used to analyse individual items., Results: The live and video scores from the same assessor showed good to very good agreement for the total score (ICC, 0.973; SEM, 2.28; SDC, 6.32) and dimensions B (ICC, 0.938), D (ICC, 0.965), and E (ICC, 0.992) but lower agreement for A (ICC, 0.720) and C (ICC, 0.667). Live-versus-video agreement for the total score was higher than inter-rater agreement by video (ICC, 0.949; SEM, 3.15; SDC, 8.73) but lower than intra-rater agreement by video (ICC, 0.989; SEM, 1.42; SDC, 3.96)., Conclusion: The Gross Motor Function Measure-88 can be reliably scored using video recordings. The agreement between live and video scores is lower than the intra-rater reliability using video recordings only. Future clinical trial results should be interpreted using the appropriate SEM and SDC values., (© The Author(s) 2014.)

Objective: A pilot study to compare the effectiveness of an individual therapy program with the effects of a general physical therapy program., Design: A randomized, single-blind cross-over design., Participants: Ten ambulant children with bilateral spastic cerebral palsy, age four to nine years., Intervention: Participants were randomly assigned into a ten-week individually defined, targeted or a general program, followed by a cross-over., Main Outcome Measures: Evaluation was performed using the Gross Motor Function Measure-88 and three-dimensional gait analysis. General outcome parameters were Gross Motor Function Measure-88 scores, time and distance parameters, gait profile score and movement analysis profiles. Individual goal achievement was evaluated using z-scores for gait parameters and Goal Attainment Scale for gross motor function., Results: No significant changes were observed regarding gross motor function. Only after individualized therapy, step- and stride-length increased significantly (p = 0.022; p = 0.017). Change in step-length was higher after the individualized program (p = 0.045). Within-group effects were found for the pelvis in transversal plane after the individualized program (p = 0.047) and in coronal plane after the general program (p = 0.047). Between-program differences were found for changes in the knee in sagittal plane, in the advantage of the individual program (p = 0.047). A median difference in z-score of 0.279 and 0.419 was measured after the general and individualized program, respectively. Functional goal attainment was higher after the individual therapy program compared with the general program (48 to 43.5)., Conclusion: The results indicate slightly favorable effects towards the individualized program. To detect clinically significant changes, future studies require a minimal sample size of 72 to 90 participants., (© The Author(s) 2014.)

The primary aim of the study was to investigate how a clinical decision process based on the International Classification of Function, Disability and Health (ICF) and the Hypothesis-Oriented Algorithm for Clinicians (HOAC-II) can contribute to a reliable identification of main problems in ambulant children with cerebral palsy (CP). As a secondary aim, to evaluate how the additional information from three-dimensional gait analysis (3DGA) can influence the reliability. Twenty-two physical therapists individually defined the main problems and specific goals of eight children with bilateral spastic CP. In four children, the results of 3DGA were provided additionally to the results of the clinical examination and the GMFM-88 (gross motor function measure-88). Frequency analysis was used to evaluate the selected main problems and goals. For the main problems, pair-wise agreement was calculated by the number of corresponding problems between the different therapists and using positive and negative agreement per problem. Cluster analysis using Ward's method was used to evaluate correspondence between the main problems and specific goals. The pair-wise agreement revealed frequencies of 47%, 32% and 3% for the identification of one, two or three corresponding main problems. The number of corresponding main problems was higher when additional information of 3DGA was provided. Most of the specific goals were targeting strength (34%), followed by range of motion (15.2%) and GMFM-D (11.8%). In 29.7% of the cases, therapists could not prioritize and exceeded the number of eight specific goals. Cluster analysis revealed a logic connection between the selection of strength as a main problem and as specific goal parameters. Alignment as a main problem was very often associated with specific parameters like ROM and muscle length and with hypertonia as a main problem. The results show a moderate agreement for the selection of main problems. Therapists are able to use the proposed model for a logic and structured clinical reasoning. Setting priorities in the definition of specific goals is revealed as a remaining difficulty. Further research is required to investigate the additional value of 3DGA and to improve priority setting., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The Dyskinesia Impairment Scale (DIS) is a new scale for measuring dystonia and choreoathetosis in dyskinetic Cerebral Palsy (CP). Previously, reliability of this scale has only been assessed for raters highly experienced in discriminating between dystonia and choreoathetosis., Aims: The aims of this study are to examine the reliability of the DIS used by inexperienced raters, new to discriminating between dystonia and choreoathetosis and to determine the effect of clinical expertise on reliability., Methods: Twenty-five patients (17 males; 8 females; age range 5-22 years; mean age = 13 years 6 months; SD = 5 years 4 months) with dyskinetic CP were filmed with the DIS standard video protocol. Two junior physiotherapists (PTs) and three senior PTs, all of whom were new to discriminating between dystonia and choreoathetosis, were trained in scoring the DIS. Afterward, they independently scored all patients from the video recordings using the DIS. Reliability was assessed by (1) Intraclass Correlation Coefficient (ICC), (2) Standard Error of Measurement (SEM) and Minimal Detectable Difference (MDD) and (3) Cronbach's alpha for internal consistency., Results: Interrater reliability for the total DIS, and for the dystonia and choreoathetosis subscales was good for the junior PTs and moderately high to excellent for the senior PTs. SEM and MDD values for the total DIS were 6% and 15% respectively for the junior PTs and 4% and 12% respectively for the senior PTs. Cronbach's alpha ranged between 0.87 and 0.95 for the junior PTs and between 0.76 and 0.93 for the senior PTs., Conclusions: Reliability of the DIS scores for the inexperienced junior and senior PTs was sufficient in comparison with scores from the experienced raters in the previous study, indicating that the DIS can be used by inexperienced PTs new to discriminating between dystonia and choreoathetosis, and also that its reliability is not dependent on clinical expertise. However, based on the measurement errors and questionnaire data, familiarity with operational definitions of dystonia and choreoathetosis is crucial to improve scoring reliability., (Copyright © 2012 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

Background: There is considerable variability in the amount of response to BTX-A treatment between and within patients with cerebral palsy (CP)., Aims: The purpose of this retrospective cohort study was to evaluate the clinical responsiveness of Botulinum toxin type A (BTX-A) treatment in children with CP and specifically delineate features of treatment success and failure., Methods: Four hundred and thirty-eight children (251 boys, 187 girls; mean age 8 years 2 months, SD 4 years) were included into the study. Goal Attainment Scaling (GAS) was used to classify and evaluate treatment efficacy. Two study groups were defined: one group with an excellent response (GAS≥60.0) and one group with a lack of response (GAS≤40.0) to BTX-A., Results: Seventy-five patients (17.1%) had an excellent response and treatment was found to be unsuccessful for 31 patients (7.1%). Children with a lack of response to BTX-A were significantly older compared to children with a high responsiveness (p=0.0013). In the latter group, more children received multi-level injections and fewer children had injections in proximal parts of the lower limb compared to the low responsiveness group (p=0.0024). Moreover, there was a significant difference in the use of different types of casts between both study groups (p=0.0263)., Conclusion: Age, level of treatment and casting seem to be crucial features of BTX-A treatment success or failure in children with CP., (Copyright © 2011 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

Objective: This systematic review provides an overview of the effectiveness of conceptual approaches and additional therapies used in lower limb physical therapy of children with cerebral palsy and supports the development of clinical guidelines., Data Sources and Study Selection: A literature search in 5 electronic databases was performed, extracting literature published between 1995 and 2009. Studies were evaluated using the framework recommended by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), which classifies outcomes according to the International Classification of Functioning, Disability and Health (ICF)., Data Extraction: Three evaluators rated the strength of evidence of the effects according to the AACPDM levels of evidence classification, and the quality of the studies according to the AACPDM conduct score system., Data Synthesis: A total of 37 studies used conceptual approaches (neurodevelopmental treatment (NDT), conductive education, Vojta therapy, sensory integration, functional training and goal-oriented therapy) and 21 studies focused on additional therapies (aquatic therapy and therapeutic horse-riding)., Conclusion: Level II evidence was found for the effectiveness of therapeutic horse-riding on posture and for NDT and functional training on gross motor function. Goal-oriented therapy and functional training were effective on the attainment of functional goals and participation. With level IV evidence, NDT was effective on all levels of the ICF.

Objective: This systematic review provides an overview of the effectiveness of basic techniques used in lower limb physical therapy of children with cerebral palsy. It aims to support the development of clinical guidelines for evidence-based physical therapy planning for these children., Data Sources and Study Selection: A literature search in 5 electronic databases extracted literature published between January 1995 and December 2009. Studies were evaluated using the framework recommended by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), which classifies outcomes according to the International Classification of Functioning, Disability and Health., Data Extraction: Three independent evaluators rated the strength of evidence of the effects according to the AACPDM levels of evidence classification, and the quality of the studies according to the AACPDM conduct score system., Data Synthesis: A total of 83 studies was selected and divided into categories (stretching, massage, strengthening, electrical stimulation, weight-bearing, balance-, treadmill- and endurance training). Interventions targeting problems at body function and structure level generally influenced this level without significant overflow to activity level and vice versa., Conclusion: The more recent studies evaluating strength training mainly demonstrated level II evidence for improved gait and gross motor function. There was limited evidence for specific information on intensity, duration and frequency of training.

Aim: The aim of this study was to examine the reliability and validity of the Dyskinesia Impairment Scale (DIS). The DIS consists of two subscales: dystonia and choreoathetosis. It measures both phenomena in dyskinetic cerebral palsy (CP)., Method: Twenty-five participants with dyskinetic CP (17 males; eight females; age range 5–22y; mean age 13y 6mo; SD 5y 4mo), recruited from special schools for children with motor disorders, were included. Exclusion criteria were changes in muscle relaxant medication within the previous 3 months, orthopaedic or neurosurgical interventions within the previous year, and spinal fusion. Interrater reliability was verified by two independent raters. For interrater reliability, intraclass correlation coefficients were assessed. Standard error of measurement, the minimal detectable difference, and Cronbach’s alpha for internal consistency were determined. For concurrent validity of the DIS dystonia subscale, the Barry–Albright Dystonia Scale was administered., Results: The intraclass correlation coefficient for the total DIS score and the two subscales ranged between 0.91 and 0.98 for interrater reliability. The reliability of the choreoathetosis subscale was found to be higher than that of the dystonia subscale. The standard error of the measurement and minimal detectable difference values were adequate. Cronbach’s alpha values ranged from 0.89 to 0.93. Pearson’s correlation between the dystonia subscale and Barry–Albright Dystonia Scale was 0.84 (p<0.001)., Interpretation: Good to excellent reliability and validity were found for the DIS. The DIS may be promising for increasing insights into the natural history of dyskinetic CP and evaluating interventions. Future research on the responsiveness of the DIS is warranted.

Aim: To distinguish the effects of different physiotherapeutic programs in a post BTX-A regime for children with Cerebral Palsy (CP)., Design: Retrospective, controlled intervention study., Participants and Interventions: A group of 38 children (X¯ = 7y7m, GMFCS I-III, 27 bilateral, 11 unilateral CP) receiving an individually defined Neurodevelopment Treatment (NDT) program, was matched and compared to a group of children with the same age, GMFCS and diagnosis, receiving more conventional physiotherapy treatment. All patients received selective tone-reduction by means of multilevel BTX-A injections and adequate follow-up treatment, including physiotherapy., Outcome Measures: Three-dimensional gait analyses and clinical examination was performed pre and two months post-injection. Treatment success was defined using the Goal Attainment Scale (GAS)., Results: Both groups' mean converted GAS scores were above 50. The average converted GAS score was higher in the group of children receiving NDT than in the group receiving conventional physiotherapy (p < 0.05). In the NDT group, overall treatment success was achieved in 76% of the goals, compared to 67% of the goals defined for the conventional physiotherapy group. Especially for the goals based on gait analyses (p < 0.05) and in the group of children with bilateral CP (p < 0.05), treatment success was higher in the NDT group., Conclusion: In a post-BTX-A regime, the short-term effects of an NDT approach are more pronouncedthan these from a conventional physiotherapy approach., (Copyright © 2011 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

In this study the psychometric properties of the Trunk Control Measurement Scale (TCMS) in children with cerebral palsy (CP) were examined. Twenty-six children with spastic CP (mean age 11 years 3 months, range 8-15 years; Gross Motor Function Classification System level I n = 11, level II n = 5, level III n = 10) were included in this study. To determine the discriminant ability of the TCMS, 30 typically developing (TD) children (mean age 10 years 6 months, range 8-15 years) were also included. For inter-rater reliability, two testers scored all children simultaneously. To determine test-retest reliability, participants were reassessed on a second test occasion. For construct validity, the Gross Motor Function Measure (GMFM) was administered. Intraclass correlation coefficients (ICC) ranged from 0.91 to 0.99 for inter-rater and test-retest reliability. Kappa and weighted kappa values ranged for all but one item from 0.45 to 1. The standard error of measurement was 2.9% and 3.4%, and the smallest detectable difference for repeated measurements was 8% and 9.43% between raters and test-retest, respectively. Cronbach's alpha coefficients ranged from 0.82 to 0.94. Spearman rank correlation with the GMFM was 0.88 and increasing coefficients were found from dimension B to E. Subscale and total TCMS scores showed significant differences between children with CP and TD children (p < 0.0001). The results support the reliability and validity of the TCMS in children with spastic CP. The scale gives insight into the strengths and weaknesses of the child's trunk performance and therefore can have valuable clinical use., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Aim: This prospective double blind intervention study aims to evaluate the effectiveness of an individually defined physiotherapy program on the function and gait pattern of 16 children with diplegia (age 3-12 year, GMFCS I-II)., Method: A 6 weeks general training program was followed by a specific training program based on individual goals determined by the results of 3D gait analyses, GMFM-88 and a clinical evaluation. Goal attainment scores were used for the evaluation of the achievement of individual goals., Results: After the general training program, 6.7% of the children achieved the treatment goals, 33.3% stayed at the same level and 60% worsened and this in comparison to 40, 33.3 and 26.6% of the children respectively after the individually defined training program. The improvement for walking, running and jumping of the GMFM-88 was significantly more pronounced after the individually defined (p < 0.05), compared to the general training program. Whereas ankle dorsiflexion, spasticity of the hamstrings (p < 0.01), selectivity of hip abductors, knee extensors and ankle dorsiflexors significantly improved over the complete period of study (p < 0.01), hip extension, step length, stride length, ankle power generation and all hip parameters changed specifically after the individually defined training program (p < 0.01)., Conclusion: A quantified effect is manifest with the application of an individually defined training program over a six weeks period., (Copyright © 2010 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb., Background: The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, "reflection is more important than injection" remains an actual statement.

At the University Hospital of Pellenberg (Belgium), more than 1000 patients have been treated with Botulinum toxin type A (BTX-A) over the last decade. Ten percent of these patients (n=106) received multiple (at least four times), multi-level, high-dosage treatments. The aim of this study was to evaluate the stability of dosage and treatment intervals in long-term, multi-level, high-dosage treated children with cerebral palsy and to evaluate the evidence for a safe and stable response to this treatment. Data on disease, age, dosage and target muscles were extracted for each treatment session of 106 patients who received multiple BTX-A treatment sessions. Patients had a follow-up of 4y 6mo (range 1y 8mo-8y 9mo) on average and received 4 to 12 BTX-A treatments within the period of January 1996 and December 2005. Patients received a mean dosage of 23.5+/-5.2U/kgbw at first treatment with stable subsequent values. Mean dosages for children with diplegia, hemiplegia and quadriplegia were 24.5+/-4.7U/kgbw, 15.9+/-3.7U/kgbw and 22.0+/-4.8U/kgbw, respectively. Mean age at first treatment was 4y 6mo (range 1y 11mo-18y 10mo) with a majority of patients (76.4%) first treated within 2 and 4y of age. Treatment intervals of approximately 1y remained stable within four, five and six subsequent treatments. Long-term, high-dosage, multi-level BTX-A applications can be considered as a safe and stable treatment option for children with cerebral palsy and the formation of antibodies, responsible for secondary non-response, can be indirectly precluded.

This study evaluated the effects of multilevel botulinum toxin type A (BTX-A) treatments on the gait pattern of children with spastic cerebral palsy (Gross Motor Function Classification System Levels I-III). In this nested case-control design, 30 children (mean age 6y 11mo [SD 1y 5mo]; 21 males, nine females; 19 with hemiplegia, 11 with diplegia) were treated according to best practice guidelines in paediatric orthopaedics, including BTX-A injections. A matched control group of 30 children (mean age 7y 8mo [SD 1y 10mo]; 13 males, 17 females; 19 with hemiplegia, 11 with diplegia) were treated identically, but without BTX-A. Motor development status at 5 to 10 years of age was assessed by means of three-dimensional gait analysis at a mean time of 1 year 10 months (SD 10mo) after the last BTX-A treatment. The control group showed a significantly more pronounced pathological gait pattern than the BTX-A group. Major differences were found for pelvic anterior tilt, maximum hip and knee extension, and internal hip rotation. These results provide evidence for a prolonged effect of BTX-A and suggest that BTX-A injections, in combination with common conservative treatment options, result in a gait pattern that is less defined by secondary problems (e.g. bony deformities) at 5 to 10 years of age, minimizing the need for complex surgery at a later age and enhancing quality of life.

Botulinum toxin A represents a significant development in the management of children and adolescents with spastic cerebral palsy. Prerequisites for an adequate result are a correct indication, an exact injection technique and an intensive post-treatment programme. Spastic muscle overactivity and the constant tendency of the involved muscles to shorten with growth cannot be treated by only one method. Therefore a multilevel approach and an integrated treatment schedule including plaster of Paris, orthoses and physiotherapy are currently the best ways to modify the disease process. The inclusion of objective clinical documentation techniques combined with 3-D instrumented gait analysis allows the determination of the indications more exactly and for monitoring the post-treatment results. If started early and correctly, this integrated management approach has the potential to modify the natural history of the disorder, and to reduce the frequency of later surgery.

It is recognized that objective gait analysis is of great value in planning a multilevel botulinum toxin type A (BTX-A) treatment. After BTX-A treatment, objective outcome measures can provide new and interesting information for each individual child with cerebral palsy (CP). Moreover, by studying group results, we may evaluate our treatment hypotheses. The present prospective study attempts to document the effect of integrated multilevel BTX-A treatment on objective gait parameters and to define the optimal strategy for the combined treatment of BTX-A with casting in children with cerebral palsy. Objective three-dimensional gait analysis (3DGA) data were collected pre- and 2 months post-treatment, in two randomized patient groups: a first group of 17 children treated with lower leg casting prior to BTX-A injections, and a second group of 17 patients who received casting immediately after injections. The present study demonstrates that improved gait can be achieved after a multilevel BTX-A treatment, combined with casting, using a set of 90 gait parameters. The most pronounced improvement was seen at the ankle joint. The results in the knee, hip and pelvis imply that multilevel treatment of the child with CP should start at an early age, in order to prevent development of muscle contractures. Slightly more pronounced benefits, mainly in the proximal joints, were seen for the children who were casted after injections as compared to the children who were casted before injections.

The present study attempts to provide objective evidence of two treatment options for children with cerebral palsy (CP): multilevel botulinum toxin type A (BTX-A) injections and multilevel surgery. The purpose of the study was to clarify the differences and the similarities, and common treatment principles of both treatment strategies. Objective three dimensional gait analysis data were studied retrospectively in two patient groups pre- and post-treatment (randomly selected from a group of children that were treated between 1998 and 1999). In the first group, 29 children with CP were managed with BTX-A injections according to an integrated multilevel approach (Molenaers et al., 1999a). A second group of 23 children with CP were managed by a more traditional single event multilevel surgery, also according to an integrated approach. Our aim was to evaluate the differences as well as the similarities between both patient groups, using a set of 56 parameters selected from three-dimensional gait analysis. The unifying concept between management with BTX-A injections and orthopaedic surgery was the adoption of a multilevel approach at one session. The groups demonstrated considerable differences with respect to age, pretreatment condition and amount and level of improvement after treatment. The children who received BTX-A were typically younger, and showed primary gait problems in the distal joints, whereas the children who underwent surgery demonstrated a higher frequency of gait deviations in the transverse plane and had more complications. Although the benefit of both treatments was confirmed by the present study, a difference in the amount and level of improvement was also demonstrated. In conclusion, these treatment modalities should be regarded as complementary rather than mutually exclusive treatments, with both calling for an integrated approach.