Botulinum toxin A (BoNT-A) is a substance that requires repeated application due to its effectiveness being lost 12–16 weeks post application. Performing these intra-muscular injections under anesthesia reduces pain and distress during applications, ensuring effective and successful functional results. This study evaluates motor development of patients undergoing 3 or more repeated BoNT-A application in a tertiary pediatric hospital and the safety as well as effect of 3 different types of anesthesia. 75 children with cerebral palsy who underwent BoNT-A application at least three times consecutively with 6-month intervals and a total of 320 procedures admitted between January 2008 and January 2018 were retrospectively examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. To observe the improvement in motor development, those with 2-1-0 level decreases in GMFCS classes were grouped and compared in terms of birth time, birth weight, cerebral palsy type and first BoNT-A application age. The 3 types of anesthesia methods (sedation analgesia, larengeal mask anesthesia (LMA) and inhalation mask anesthesia) applied during the procedures were compared in terms of sedation, procedure, recovery and total operation room time. The mean age of the children for all procedures was 45.51 ± 22.40 months. As a result of procedures, significant motor development was observed in 60 (80%) patients (p <0,000∗). No significant difference was observed when the children with cerebral palsy whose GMFCS declined in the form of level 2, 1 and unchanged were compared in terms of first application age, birth weight and gestational age. It was found that 106 (33.1%) were applied sevoflurane with anesthesia mask, 103 (32.1%) were administered sevoflurane with laryngeal mask, and 111 (34.6%) were sedation-analgesia. Only 10 out of 320 procedures were seen to develop side effects (8 vomiting, 2 bronchospasm). In the patients who underwent sedation analgesia during the first 3 BoNT-A procedures, the duration of recovery and total operating room time was seen to be significantly shorter than the others, while there was no difference between the anesthesia methods in the 4th and subsequent procedures. Regardless of the type of anesthesia, the recovery and total operating room times of those having undergone 6 or more procedures were longer than those with less than 6 procedures (p <0.009, p <0.016, respectively). As conclusion, repeated BoNT-A applications in children with CP provides progress in motor steps, it can be applied safely and effectively under anesthesia. Sedation analgesia application provides easier recovery compared to general anesthesia with LMA and mask only in the first three applications. However, recovery time increases with 4 and more repeated applications as the number of applications increases

We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved

Introduction: The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial. Aim: To assess any improvement following upper limb Botulinum toxin A injections and to evaluate patient’s and parents’ expectation and satisfaction of the procedure. Method: During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with a mean age of 6 years old. A questionnaire was devised to assess the outpatient consultation, peri-operative care and the post-operative outcome. Subjective improvement and the patient’s and parents’ evaluation of the procedure were also recorded. Results: Good to excellent results were achieved in most areas. Daily activities were improved by 52% with an average duration of 4 months. The majority of the patient achieved their expectation. Most patients/parents were satisfied with the procedure and would consider further injections. Conclusions: Botulinum toxin A injection to the upper limb was generally well received with good short term results. Most would consider further injections

Aim: To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles. Methods: In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months. Results: Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001). Conclusions: The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection

Purpose of study: To describe the histological effects of botulinum toxin on gastrocnemius muscle affected by cerebral palsy. Method: Samples of gastrocnemius were obtained at the time of surgery. Ethical committee approval had been obtained for the study. Details of timing and doses of botulinum toxin previously administered to the muscle were recorded. A variety of immunohistochemical tests were employed to identify any changes in the muscle. Alterations in the distribution of myosin isoforms were identified with antibodies for fast, slow and neonatal myosin. The presence of persistent denervation was inferred from fibres deficient in neuronal nitric oxide synthase (nNOS). Mitochondrial abnormalities were assessed with an NADH stain and the presence of chronic atrophic fibres (nuclear clumps) noted. Results: Our first case had received 3 botulinum injections over a period of 5 years, the last one 3 years prior to biopsy. Histology showed pronounced abnormalities with a wide variation in fibre size, areas of myofibrillar disruption and 50% of fibres co-expressing fast and slow myosin. Other samples showed less change but showed more frequent nuclear clumps than controls, indicating chronic atrophy and more hybrid fibres than controls, but always less than 10%. Treated muscles also showed a small, variable number of atrophic fibres without nNOS. Treated samples showed no apparent fibre type grouping, a feature associated with collateral sprouting of peripheral nerves following denervation. Conclusions: Moderate doses of botulinum toxin appear to produce an alteration in muscle histology apparent several years afterwards. No correlation could be found between the timing of the previous injection or the dose of botulinum toxin injected and the severity of the changes. Botulinum toxin remains a valuable aid in the management of spastic muscle. However consideration should be given to other methods of treatment if an effective non surgical alternative exists

The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial, moreover only selected few orthopaedic surgeons have experience in managing it. The aim is to assess the functional improvement following an upper limb Botulinum toxin A injections to the upper limb and then to evaluate the patient’s and parents’ satisfaction after the procedure. During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with an age range between 2 to 17 years (average age was 2 years). Following the surgery, all patients received a course of an intense exercise regime with the physiotherapist and occupational therapist. All patients were prospectively followed-up by the clinic with no loss to follow-up. We also assessed the functional movement of the patients as well as the patient’s and parents’ subjective evaluation of the procedure. Overall, the range of movement of the upper limb has improved following the Botulinum toxin A injection. Most patients/parents were satisfied with the procedure and would consider further injection in the future. Botulinum toxin A injection to the upper limb is generally well received with good short term results. Many would consider further injections to sustain improve function

To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles. In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months. Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001). The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection

The purpose of our study was to prospectively evaluate the effectiveness of Botulinum toxin in patients with involuntary positional instability who had failed a specific rehabilitation programme. Patients with Involuntary Positional Instability present with a muscle patterning problem that results in active dislocation of the glenohumeral joint. Botulinum toxin is used to inhabit the patterning muscle and therefore facilitate rehabilitation of optimal movement patterns. Materials and Method: 14 patients referred to a tertiary referral unit were included. All patients had failed rehabilitation, reported multiple recurrent dislocations, repeated surgical interventions (Range 2 – 6) and mean duration of symptoms 5 years (Range 2 – 9). Patients were assessed with Constant and ASES scores, psychological scores (HADS and DRAM) and the Ashworth muscle tone scale. Botulinum Toxin was injected into the muscle dominating movement (identified with clinical assessment and EMG) and patients were re-entered into the rehabilitation programme post-injection. Results: At an average of 2 years follow-up (8/12 – 4.1) 11 out of 14 patients demonstrated a statistically significant improvement in all parameters. 1 patient required a repeat injection at 4 months but at 2 years remains asymptomatic. Of the 2 patients who failed both demonstrated the highest scores on psychological screening and 1 of them had a severe connective tissue disorder. Conclusion: Our early experience of Botulinum suggests that it is an effective tool in patients with involuntary positional instability resistant to rehabilitation. Psychological scores may be a useful tool to aid patient selection

Purpose of the study: Spastic hypertony of the upper limb produces pronation of the forearm with flexion of the wrist and fingers. Treatment is generally based on injections of botulinum toxin and sometimes on selective neurotomy. Material and methods: In order to achieve better selection of the motor branches innervating the muscles requires a precise knowledge of the extramuscular innervation. Similarly, for botulinum toxin, injections must be made as close as possible to zones with the greatest density of intramuscular nerve endings, considered as the zones having the greatest number of neuromuscular junctions. Knowledge of these zones is currently insufficient. We therefore conducted a macroscopic then microscopic dissection of the muscles of the ventral forearm in 30 specimens to study extra- and intra-muscular innervations and the distributions of the nerve endings. Results: Surface maps were drawn to describe the precise localization of the motor branches for each muscle. These maps were designed as guides for surgical approaches for selective neurotomy. Then for each muscle, the zones with the greatest density of nerve endings were delimited in segments which could be used to define optimal zones of injection of botulinum toxin

Aims: The aim of this study is to evaluate the effectiveness of a treatment with botulinum toxin type A (BTX-A) in children affected by CP. Methods: Between May 2001 and July 2002, we treated 12 children affected by CP: 11 males, 1 female, mean age 6,42 years; 1 child suffered from tetraplegia, 5 from diplegia and 6 from emiplegia. The injection was carried out in gastrocne-mius muscle (medial and lateral) in 11 patients, in hamstrings in 1 patients in a dose of 6 Units per kg of body weight per muscle. Post-injective treatment included intense physical therapy and orthoses. A clinical and video-recording evaluation, Gross scale and gait-EMG were carried out before injection and 1,3,6 months after. Results: BTX-A treatment has a good functional result: at the þrst control after injection all patients had a complete foot-ground contact instead of toe contact during stance and gait. Conclusion: The results of BTX-A treatment are positive, accordingly to literature: in all patients there was a reduction of spasticity and a complete foot-ground contact, with functional improvement in stance and gait. Good results can be achieved only if the indication is correct: spasticity of the muscle without muscle-tendinous retraction. BTX-A treatment has an effective role in the management of children suffering from CP, where there is no indication for surgical treatment

Tennis elbow (lateral epicondylitis) is a common upper limb condition, possibly resulting from angiofibroblastic degeneration. Conservative treatment comprises corticosteroid injections, rest and splints, however, occasionally surgery is necessary. Recent data comparing Botulinum Toxin Type A (BTX-A) (Botox®, Allergan Inc, Irvine, CA) with surgery suggested BTX-A is effective in treating resistant tennis elbow by providing temporary, reversible paralysis of affected muscle, thereby alleviating tensile forces and allowing tissue healing. This double-blind, randomised, controlled trial compared BTX-A with placebo in 40 patients with chronic tennis elbow (> 6 months). Recruited patients were randomised to 50U BTX-A+2mL normal saline or 2mL normal saline (placebo). Injections were administered 5cm distal to the maximal area of lateral epicondyle tenderness. Quality of life (SF-12), pain (visual analogue scale) and grip strength (Jamar dynamometer) were assessed pre- and 3 months post-injection in both affected and non-affected arms. Following BTX-A treatment patients had average 19% improvement in grip strength in the affected arm compared to average 2% for placebo, however, this difference did not reach statistical significance (p=0.08, 95% CI −2.31, 35.64). No difference between the groups was seen for the unaffected arm (BTX-A 4% improvement, placebo 1% improvement). Both groups showed similar improvements in pain assessment and also in quality of life. BTX-A treated-patients demonstrated improved grip strength in the affected arm compared to placebo, however this difference was not statistically significant

Background. Administration of Botulinum toxin type A (BTX-A) in patients with spastic cerebral palsy aims to improve mobility by increasing joint range of motion and decreasing passive resistance. However, our recent animal experiments indicated that BTX-A can decrease muscle”s length range of force exertion (Lrange), and increase its passive forces and extracellular matrix (ECM) collagen content. Moreover, BTX-A injected into the tibialis anterior (TA) was shown to spread into non-injected synergistic muscles in the whole anterior crural compartment. These effects that contradict the treatment aims deserve further investigation. Aim. To test in a rat model if: (1) BTX-A injected into the medial and lateral gastrocnemius (GM&GL) muscles spreads into the synergistic soleus (SOL) as well as antagonistic TA and extensor digitorum longus (EDL). (2) The muscles exposed show a wider Lrange, decreased muscle passive force and reduced ECM collagen. Methods. 2×0.1U/20µl of BTX-A (BTX-A group, n=6) or only 2×20µl of saline (Control group, n=6) were prepared and each was injected into the mid-belly of the GM and GL separately. 5 days post injection, forces of all muscles were measured in passive state and also on activation. The GM&GL length was changed whereas; all other muscles were kept at constant length. After biomechanical testing, the muscles were histologically analyzed using Gomori trichrome stain to detect ECM collagen. Two-way ANOVA (factors: GM&GL length and animal group) was used to assess BTX-A effects on forces, and the Kruskal-Wallis test was used to test the change in proportion of collagenous tissue for each muscle. Differences were considered significant at p<0.05. Results. Injected muscles: ANOVA showed significant main effects of both factors on GM&GL total forces and a significant interaction. Force reductions are more pronounced at shorter lengths (increase from 80.8% to 88.4% with decreasing length). Lrange decreased (by 24.1%). ANOVA showed significant main effects of only muscle length on GM&GL passive forces and no significant interaction. Non-injected muscles: ANOVA showed significant main effects of both factors (for SOL), or only of BTX-A (for TA and EDL) only on muscle total forces, but no significant interaction. Force drops for the SOL (89.8%) and anterior crural muscles (57.0% and 51.0% for TA and EDL) do indicate spread of BTX-A intra- and extra-compartmentally. Histological analyses showed increased ECM collagen contents of BTX-A group for the GM&GL, TA, and EDL. Conclusion. Narrowed Lrange and increased ECM collagen content are not in accord with the clinical purpose of the treatment. BTX-A did not reduce passive forces, but did not cause an increase either. Remarkably, the results show that BTX-A leakage is a major issue that can affect muscles of even antagonistic muscle compartments. Hence, our animal experiments indicate much more complex BTX-A effects than considered, which requires further testing in patients

Introduction: Many specialists believe that neuromuscular blockade is most effective if the injection is placed close to the major motor points of the muscle. This study aimed to produce a ‘user-friendly’ map of injection sites by combining data from existing literature, recent anatomical dissections and information obtained clinically at the time of botulinum toxin injection. Methods: A literature search collected all clinically relevant anatomical data regarding the identification of motor points in various muscles. Where data was lacking, anatomical dissections were performed on cadaveric specimens. These specimens were also used to ‘confirm’ the existing published data. All motor points measurements were then related to a series of surface anatomy lines that were easily identifiable in a patient with neuromuscular disability. Over the last year, 150 ‘motor points’ have been identified in patients undergoing neuromuscular blockade using a nerve stimulator and related to the same surface markings used in the cadaveric studies. Good correlation between existing literature and our cadaveric studies was found. New data was collected for forearm flexors, adductors and shoulder muscles. The correlation between clinical and anatomical motor points was good with errors averaging 5% of the measured distance. Conclusion: A ‘Body Map’ is being produced that can be displayed in clinical areas to facilitate the use and improve the efficacy of neuromuscular blockade and encourage its use in the outpatient setting

Neonatal brachial plexus palsy (NBPP) is frequently associated with internal rotation contractures of the shoulder as a result of muscle imbalance due to muscle fattening and/or fibrosis which favour the internal rotation of the shoulder. Botulinum toxin A (BTX-A) injection in the subscapularis (SC) muscle could weaken the SC and thereby restore muscle balance. The purpose of this study was to assess the effect of intra muscular injection of BTX-A in the SC on the passive external rotation and the need for external rotation surgery in NBPP patients after BTX-A injection. A prospective comparative study was performed with 93 patients with progressive internal rotation contractures. Al patients underwent an MRI to determine the percentage of the humeral head anterior to the glenoid (PHHA) and glenoid version. Patients younger than 48 months old and with a minimum deformity (PHHA> =35%) or moderate deformity (PHHA< 35%) were included. Patients with a severe deformity or complete posterior dislocation were excluded. Fifteen consecutive patients were injected with BTX-A (2 U/kg body weight, botox. ®. ) at two sites of the SC of the affected shoulder immediately after the MRI under general anesthesia. Seventy eight patients were included as a control group before the new BTX-A treatment was introduced. The passive external rotation was measured pre-MRI and at follow-up. The indication for external rotation surgery was determined after the MRI was performed. No adverse events were observed. Pre-MRI, the mean passive external rotation in adduction in the BTX-A group was −5° (SE 8°) and in the control group 3° (SE 3°). In the BTX-A group, the mean passive external rotation in adduction increased with 53° (95% CI 31°–74°, p< 0.001) compared to the control group. After stratification the beneficial effect of BTX-A was observed in patients with a minimum deformity (54°, 95% CI 37°–71°, p< 0.001), but this was not significant in patients with a moderate deformity (47°, 95% CI −20°−115°, p=0.13) compared to the control group. The patients in the BTX-A group were less frequently indicated for external rotation surgery compared the control group (27% vs. 89%, p< 0.001). The maximum effect of BTX-A injection was observed at a mean follow-up of 3 months (SE 1). The control group was followed for a mean of 7 months (SE 0.4) to observe the natural history of internal rotation contractures. The groups were comparable regarding type of lesion, primary treatment, age, PHHA, glenoid version and passive external rotation pre-MRI (p 0.09–0.74). BTX-A injections in the SC of NBPP patients reduce internal rotation contractures. This effect was mainly observed in patients with a minimum glenohumeral deformity. Restoration of muscle balance could prevent further glenohumeral deformation and could prevent external rotation surgery

The aim of this study was to investigate upper limb botulinum toxin A (BTX-A) injections in children with spastic hemiplegia. Ten children with hemiplegia, aged 10–17 years, received upper limb BTX-A injections and 6 weeks therapy. BTX-A was injected using EMG guidance into elbow and wrist flexors, and forearm pronators (dose 1–2 units/kg body wt (Botox®) per muscle). Follow-up assessments continued to 24 weeks post BTX-A. Outcome measures included three-dimensional (3-D) upper limb analysis of functional tasks, Melbourne Assessment; passive range of motion (PROM), and muscle tone. There were no serious adverse effects. Elbow flexor muscle tone was reduced to 12 weeks post BTX-A (p < 0.05). Mean passive elbow supination increased by 19 degrees (not significant, p= 0.3). Pre-injection 3-D analysis showed that, compared to controls, children with hemiplegia were slower at performing upper limb reaching tasks, using less elbow extension and supination, and utilising increased compensatory trunk forward flexion. Post BTX-A, the time to complete upper limb tasks did not change (p> 0.15). However, at least six subjects had increased elbow extension (average 17 degrees) and decreased trunk forward flexion (average 16 degrees) during upper limb reaching tasks. Five subjects improved their Melbourne Assessment score by 5% or greater. Decreased tone and individual improvements in upper limb functional tasks were seen post BTX-A and therapy. However deficits in timing of upper limb movements did not change post BTX-A

Intramuscular injections of botulinum neuro toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last two decades. In India, the treatment is now offered to children with spastic cerebral palsy (CP). However, despite its use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A will not reduce energy cost during walking, improve walking capacity, reduce pain or improve self-perceived performance and satisfaction.

Between the period of 2012 and 2014, 35 children with spastic CP less than 10 years of age were included. The patients were classified according to their gross motor function classification system (GMFCS) and their pre-and post-injection gait analysis were performed. Spasticity assessed by Modified Ashworth Score [MAS]. Trained parents were utilised for the post injection physiotherapy as these children will be more complaint to them. GMFCS and MAS scoring done every three months till one year follow up.

Therapeutically, effect was found in 90% of the patients, an average duration of the medical effect was 6–12 months. The improvement in GMFC functional score in serial measurements was seen in these patients though some deterioration in spasticity scores at one year. Despite mild recurrence in spasticity, majority maintained independent (42%) or assisted ambulation (48%) at one year. No major side effects occurred. Botox may prove a useful adjuvant in conservative management of the spasticity of cerebral palsy. Apart from being very cost effective in these financially deprived populations, successful management with these injections may allow delay of surgical intervention until the child is older and at less risk of possible complications, including the need for repeated surgical procedures.

Our aim was to evaluate the effect of adding inhibitory casting to the treatment of young children with cerebral palsy who received injections of botulinum neurotoxin A (BoNT-A) to gastrocnemius for equinus gait. Of the 20 patients in the series, 11 in group A had inhibitory casts applied on the day of the first set of BoNT-A injections and nine in group B did not have casting. Both groups received another BoNT-A injection four months later. The patients were followed for eight months and examined at five intervals.

Both groups showed significant improvement in gait parameters and function (p < 0.0001) and selective motor control (p = 0.041, − 0.036) throughout the study. Group A had significantly better passive dorsiflexion of the ankle (p = 0.029), observational gait score (p = 0.006) and selective motor control (p = 0.036). We conclude that the addition of inhibitory casting enhances and prolongs the results of treatment and mainly influences the passive range of movement, while BoNT-A mostly influences the dynamic motion. The second injection further improved the results of most parameters. The gross motor function measure, the selective motor control test and the modified Tardieu scale correlated well with the results of treatment.

We recommend the use of inhibitory casting whenever augmentation of the effect of treatment with BoNT-A is needed.

Serial casting (SC) and Botulinum toxin-A (Btx-A) have been used to treat ankle equinus contractures in cerebral palsy. Previous studies that examined the effects of combining Btx-A injections with SC and either one of the treatments alone in terms of passive ankle range of motion (PROM) have shown mixed results [two-four]. Therefore, the goal of this study is to examine PROM and gait characteristics in children with CP who have undergone SC, either with or without Btx-A injections to the plantarflexors.

Patients who underwent SC +/− Btx-A injections were evaluated for improvement in PROM at the end of treatment. The participants’ age at beginning of SC treatment, Gross Motor Function Classification System (GMFCS) level, treatment duration, PROM, and gait characteristics observed by the treating physiotherapist were obtained from the charts. Only one side per treatment is included in this study (treated side for unilateral treatments, randomly chosen side for bilateral treatments). Table One shows the characteristics of the two groups.

Independent samples t-tests showed that the two groups are similar in terms of age, treatment duration and pre PROM. A repeated measures ANCOVA, using the pre- and post- treatment range of motion as the within subject variables, treatment type as the between subject variable, and GMFCS and age as the covariates showed that the PROM changed significantly regardless of treatment type (p< 0.001). However, the treatment type does not influence the outcome (p=0.411). The changes in range of motion obtained from the two types of treatments were not significantly different using the independent t-test (p=0.957).

Based on these results, it appears that both types of interventions resulted in significant changes in ankle passive range of motion, which is in agreement with Kay et al [4]. Similar ranges of motion at the end of the treatment were obtained from both treatments, and the treatments have similar success rates. Future work is needed to further explore the outcomes associated with serial casting only and Btx-A and serial casting treatments