Short-term effects of "botulinum toxin a" as treatment for children with cerebral palsy: kinematic and kinetic aspects at the ankle joint

Botulinum toxin A (BTA) therapy plays several roles in the management of paediatric cerebral palsy (CP). However, few studies contain objective documentation of gait changes. The main aim of this study was to provide objective information on the outcome of the treatment. Gait analysis data from 20 normal subjects and 23 CP children were collected before and after BTA injections into the gastrocnemius-soleus complex. The follow up was performed 1 month after the first injection. The kinematic and kinetic data revealed significant improvements in dynamic ankle dorsiflexion, both in stance and in the swing phase, an improvement of equinus foot upon initial contact and better support in stance. The results of this study are promising, but studies of other joints involved in gait, such as the knee, are also needed.     

Effect of multilevel botulinum toxin a and comprehensive rehabilitation on gait in cerebral palsy

To evaluate the effect of multilevel botulinum toxin A and comprehensive rehabilitation on gait pattern, muscle length, and spasticity, a multicenter randomized trial was performed in 46 children with spastic cerebral palsy who walk with flexed knees. Their mean age was 8.0 years (range 4 to 11 years). They were randomly allocated to the intervention group (multilevel botulinum toxin A and comprehensive rehabilitation) or the control group (usual care). After 6 weeks, a significant treatment effect in the intervention group was observed on: improved knee extension during midstance and terminal swing (7 degrees and 5 degrees , P < 0.01, respectively); hip rotation during terminal swing (4 degrees , P = 0.02); gait score (1.7, P < 0.01); decreased spasticity in hamstrings (11 degrees , P < 0.01), gastrocnemius (6 degrees , P = 0.01), and soleus (5 degrees , P = 0.02); and increased muscle length in hamstrings (9 degrees , P < 0.01) and gastrocnemius (5 degrees , P < 0.01). The improved muscle length was maintained up to 24 weeks. This study demonstrated that multilevel botulinum toxin A and comprehensive rehabilitation improves knee extension during gait, increases muscle length, and decreases spasticity in injected muscles after 6 weeks in children who walk with flexed knees. Although the effect on muscle length was maintained after 24 weeks, the effect on gait and spasticity had disappeared.     

Botulinum toxin A in the management of spastic gait disorders in children and young adults with cerebral palsy: a randomized, double-blind study of "high-dose" versus "low-dose" treatment.

The present study was performed to assess dose-response relationships of local botulinum toxin A (BtxA) treatment in children and teenagers with spastic gait due to cerebral palsy (CP) in a randomized, double-blind study employing a "high-dose" (200 units Botox per leg) and a "low-dose" (100 units Botox per leg) treatment arm in 33 patients with CP. Response parameters included changes in muscle tone assessed by the Ashworth scale at knee joint, range-of-motion (ROM) measurements at knee and ankle joint, objective analysis of longitudinal gait parameters as well as subjective assessments of improvement. Patients in the "high-dose" arm received 40-80 units Botox/muscle versus 20-40 units Botox/muscle in the "low-dose" group. Patients in both treatment arms showed significant improvement of Ashworth score (p<0.001) and ROM (p<0.01), while gait analysis revealed significant increase in gait velocity (p<0.01) and stride-length (p<0.001) over baseline. Subjects in the "high-dose" group showed significantly greater improvement on objective response measurements compared to "low-dose" patients. Also, children aged 7 years or less had greater functional benefit compared to the subgroup of patients older than 7 years. Incidence and severity of side-effects were similar in both treatment groups. The present study demonstrated dose-dependent functional improvement of dynamic deformities and spastic gait pattern in children and young adults with CP treated with local injections of botulinum toxin. A dose of 200 units Botox per leg distributed to 4 or 5 muscle bellies per leg is superior compared to 100 units Botox per leg without significantly affecting the risk of side-effects.     

Gait analysis to assess the effects of botulinum toxin type A treatment in cerebral palsy: an open-label study in 10 children with equinus gait pattern

Botulinum toxin type A (BTX-A) injections induce a dose-related decrease in muscle tone and increased joint mobility in adults with spasticity and children with cerebral palsy. The aim of this study was to address the question of whether BTX-A-related improvements in joint mobility and muscle tone are associated with changes in instrumental gait analysis in children with cerebral palsy. Ten children with cerebral palsy and equinus gait were given a single dose of BTX-A (5 U BOTOX®/kg body weight per leg) into the gastrocnemius muscles. At follow-up (mean, 32.6 days post-injection), a significant ( P < 0.05) increase in both passive and active ankle range of motion was observed, together with a decrease in the modified Ashworth score. Instrumental gait analysis showed improvements in ankle and knee kinematics as well as in time-distance parameters, with a significant increase in step length observed ( P < 0.05). Semi-quantitative analysis of rectified electromyographic (EMG) recordings of the tibialis anterior muscle during gait showed a reduction in EMG activity during the stance phase and an increase in EMG activity during the swing phase. This study demonstrated the benefits of BTX-A treatment in improving joint mobility and ambulatory function in children with cerebral palsy, and showed that changes in tibial anterior muscle activity as a result of BTX-A injections into the gastrocnemius muscle can be measured by instrumental gait analysis.     

Botulinum toxin a in management of cerebral palsy

The efficacy of local injection of botulinum toxin A in selected skeletal muscles to relieve muscle hypertonia and muscle contracture, and increase range of motion in children with cerebral palsy was studied in an open ABA (baseline-treatment-posttreatment phase) type of study. The first 6 months were the baseline phase, the day of injection the treatment phase, and the next 6 months the posttreatment phase. The patients acted as their own controls. Fifteen children with cerebral palsy (mean age: 6 years, 8 months) were included in the study. All had limb deformities associated with nonfixed joint contractures that had not responded to physical therapy. Clinical assessment of passive and active muscle tone was performed using a modified Ashworth scale. The range of motion to passive movement was measured with a manual goniometer. Botulinum toxin was injected directly into the muscle at several sites. The postinjection scores of muscle hypertonia were significantly lower (P < .01) and the range-of-motion values demonstrated a significant increase (P < .001). Functional improvement was measured by decreased scissoring on standing in all 6 children with adductor muscles injected; all 6 children with knee flexor muscles injected were able to straighten the knees. The 3 children with injected gastrocnemius muscles were able to achieve heel-strike while barefooted. The study provides evidence that the intramuscular injection of botulinum toxin A in selected skeletal muscles decreases muscle tone and contractures, and increases range of motion and motor function.     

Botulinum toxin A injection for spasticity in diplegic-type cerebral palsy

Botulinum toxin type A can be both safe and effective in relieving spasticity in pediatric patients with cerebral palsy. In our prospective study, we evaluated the functional effect of botulinum toxin A in spastic diplegic-type cerebral palsy. Patients were examined on enrollment and at 1, 3, and 6 months after injection. Passive dorsiflexion of the ankle joint was measured using a goniometer as an angle of possible maximal dorsiflexion with the knee extended and flexed. Spasticity was graded using the Modified Ashworth Scale. Selective motor control at the ankle was assessed, and observational gait analysis was done. The functional status of the patients was determined by using the gross motor classification system. Botulinum toxin A was injected into the gastrocnemius muscle in all patients, and in four patients with concomitant jump knee gait, a hamstring muscle injection was added. Fourteen patients were included in the study. The mean age was 58.81 +/- 15.34 months. Following injection, spasticity was clinically decreased and statistically significant improvement was noticed in all clinical parameters after 1, 3, and 6 months of injection. The improvement in the clinical parameters decreased after 6 months but not to the baseline. One patient was Level II, four patients were Level III, and six patients were Level IV according to the Gross Motor Function Classification System at baseline. Improvement in the gross motor classification system is continued after 6 months in 12 children. The main goal of spasticity treatment in cerebral palsy is functional improvement. In our study, most of our patients had functional improvement according to the gross motor function classification system and did not change at 6 months.     

Gait patterns in hemiplegic children with Cerebral Palsy: Comparison of right and left hemiplegia

The aims of this study are to compare quantitatively the gait strategy of the right and left hemiplegic children with Cerebral Palsy (CP) using gait analysis. The gait strategy of 28 right hemiparetic CP (RHG) and 23 left hemiparetic CP (LHG) was compared using gait analysis (spatio-temporal and kinematic parameters) and considering the hemiplegic classification based on four gait strategies.Our results demonstrated that velocity was a significant parameter to differentiate RHG and LHG: all hemiplegic types revealed in fact that RHG walked with higher velocity than LHG. The ankle strategy displayed an increased number of differences between RHG and LHG from hemiplegia of Type I to Type III. In all the comparison, the LHG showed the less physiological gait pattern. As for knee kinematics, differences between right and left hemiplegic gait pattern were evidenced only in children with hemiplegia Type II: the LHG walked with a more flexed knee at initial contact, marked hyperextension in midstance and reduced knee flexion ability in the swing phase. The hip strategy was quite normal in both groups in hemiplegia Type I. In the other two types, LHG showed a limited extension ability in midstance in comparison to RHG. In conclusion, our data revealed that RHG and LHG were in general characterised by different gait patterns, evidencing a general a progression of involvement in the different types of hemiplegia; in particular in all the hemiplegic types the LHG patients revealed a more severe involvement than the RHG individuals and the differences were more evident at the distal joints, especially at the ankle joint.     

大鼠局部肌肉萎缩实验模型的设计与建立

背景：目前研究肌肉与骨骼关系的常用动物模型均存在不足。已经有研究表明A型肉毒素可以使局部肌肉萎缩,而不影响周围其他的肌肉。 目的：尝试是否可以用局部肌肉注射A型肉毒素的方法建立一种较为理想的肌肉萎缩的动物实验模型。 方法：4月龄雄性Wistar大鼠25只,采用氯胺酮(0.2 mL/kg)和速眠新(0.2 mL/kg)肌注麻醉,在股骨背侧中部做一0.5 cm切口,暴露股四头肌,右侧股四头肌肌注2 U (0.2 mL)注射用A型肉毒毒素,左侧股四头肌注射等量生理盐水作为对照。分别于模型建立后的1,2,4,6和8周各取5只做肌肉大体、组织学观察。 结果与结论：肌肉大体观察发现：与生理盐水侧对照组相比,注射A型肉毒素侧股四头肌体积明显缩小、质量明显降低(P < 0.01);肌肉组织学观察发现：注射A型肉毒素侧股四头肌较生理盐水侧明显萎缩、肌纤维变细、肌纤维细胞核聚集、肌纤维与肌纤维之间间距变小。肉毒素侧1周和2周出现肌肉质量突降,4,6,8周之间肌肉质量增加缓慢,而各时间点生理盐水侧肌肉质量呈显著增加的趋势。通过对局部肌肉注射A型肉毒素可以理想地建立单个目的肌肉萎缩的实验模型,此模型操作性强、重复性好、特异性高,可应用于肌肉与骨骼关系的相关研究。     

Treatment of hip adductor spasticity with botulinum toxin type B

For the treatment of focal spasticity using botulinum toxin, only studies using type A have been published.Botulinum toxin type B (Neurobloc) is registered for cervical dystonia, but there is increasing interest in ist effectiveness for treating other diseases. Four patients, each with seriously disabling hip adductor spasticity of different origins, were treated with botulinum toxin type B following the failure of other therapeutic options.Total doses of 10,000 IU to 22,000 IU were injected bilaterally into the hip adductor muscles. A reduction in muscle tone or painful spasms was observed in all patients within 2 weeks, leading to an improvement in gait and increased ease of nursing care. Therefore, botulinum toxin type B may be a more cost-effective treatment for hip adductor spasticity than botulinum toxin type A.     

A multilevel approach to botulinum toxin type A treatment of the (ilio)psoas in spasticity in cerebral palsy

In spasticity, flexion deformity of the hip is frequently associated with contracture or hyper-reflexia of the psoas muscle. Botulinum toxin type A (BTX-A) has been used for some considerable time in the management of paediatric gait disorders. We have been using a multilevel approach to manage spasticity in cerebral palsy for several years, the combination of gait analysis and clinical evaluation being important for the selection of target muscles for BTX-A injections. Twenty cerebral palsy children (12 female) with spasticity were treated with BTX-A injections (BOTOX® mean dose, 2 U/kg body weight) into the psoas muscle. Patients were monitored using range of motion measurements of maximal hip extension, clinical estimates of hypertonia in the hip flexors, gait analysis (three-dimensional kinematics and kinetics) and surface electromyography of major lower limb muscles. Full gait analysis was carried out on 12 of the patients. Significant clinical improvements were observed following 15 of the 21 psoas treatments. Furthermore, the kinematics results of gait analysis showed improvement in one or more parameters in nine of the 12 patients. In conclusion, we have demonstrated the value of a multilevel approach to BTX-A treatment in the management of spasticity in children with cerebral palsy.     

No clinical or neurophysiological evidence of botulinum toxin diffusion to non-injected muscles in patients with hemifacial spasm

Botulinum toxin injected into a muscle may diffuse to nearby muscles thus producing unwanted effects. In patients with hemifacial spasm, we evaluated clinically and neurophysiologically, whether botulinum toxin type A (BoNT-A) diffuses from the injection site (orbicularis oculi) to untreated muscles (orbicularis oris from the affected side and orbicularis oculi and oris from the unaffected side). We studied 38 patients with idiopathic hemifacial spasm. Botulinum toxin was injected into the affected orbicularis oculi muscle alone (at 3 standardized sites) at a clinically effective dose. Patients were studied before (T0) and 3-4 weeks after treatment (T1). We evaluated the clinical effects of botulinum toxin and muscle strength in the affected and unaffected muscles. We also assessed the peak-to-peak amplitude compound muscle action potential (CMAP) recorded from the orbicularis oculi and orbicularis oris muscles on both sides after supramaximal electrical stimulation of the facial nerve at the stylomastoid foramen. In all patients, botulinum toxin treatment reduced muscle spasms in the injected orbicularis oculi muscle and induced no muscle weakness in the other facial muscles. The CMAP amplitude significantly decreased in the injected orbicularis oculi muscle, but remained unchanged in the other facial muscles (orbicularis oris muscle on the affected side and contra-lateral unaffected muscles). In conclusion, in patients with hemifacial spasm, botulinum toxin, at a clinically effective dose, induces no clinical signs of diffusion and does not reduce the CMAP size in the nearby untreated orbicularis oris or contralateral facial muscles.     

A randomized study of combined botulinum toxin type A and casting in the ambulant child with cerebral palsy using objective outcome measures

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.     

To what extent is mean EMG frequency during gait a reflection of functional muscle strength in children with cerebral palsy?

The aim of the current paper was to analyze the potential of the mean EMG frequency, recorded during 3D gait analysis (3DGA), for the evaluation of functional muscle strength in children with cerebral palsy (CP). As walking velocity is known to also influence EMG frequency, it was investigated to which extent the mean EMG frequency is a reflection of underlying muscle strength and/or the applied walking velocity. Surface EMG data of the lateral gastrocnemius (LGAS) and medial hamstrings (MEH) were collected during 3DGA. For each muscle, 20 CP children characterized by a weak and 20 characterized by a strong muscle (LGAS or MEH) were selected. A weak muscle was defined as a manual muscle testing score <3; a strong muscle was defined as a manual muscle testing score ≥4. Patient selection was based on the following inclusion criteria: (a) predominantly spastic type of CP (3-15 years old), (b) either (near) normal muscle strength or muscle weakness in at least one of the studied lower limb muscles, (c) no lower limb Botulinum Toxin-A treatment within 6 months prior to the 3DGA, (d) no history of lower limb surgery, and (e) high-quality noise-free EMG-data. For each muscle, twenty age-related typically developing (TD) children were included as controls. In both muscles a consistent pattern of increasing mean EMG frequency with decreasing muscle strength was observed. This was significant in the LGAS (TD versus weak CP). Walking velocity also had a significant effect on mean EMG frequency in the LGAS. Furthermore, based on R² and partial correlations, it could be concluded that both walking velocity and muscle strength have an impact on EMG, but the contribution of muscle strength was always higher. These findings underscore the potential of the mean EMG frequency recorded during 3DGA, for the evaluation of functional muscle strength in children with CP.     

Functional outcomes of multilevel botulinum toxin and comprehensive rehabilitation in cerebral palsy

The objective of this study was to measure the effect of lower extremity multilevel botulinum toxin A injections and comprehensive rehabilitation on spasticity and to determine the functional gains in ambulatory children with cerebral palsy. Sixteen ambulatory children with spastic cerebral palsy (9 hemiplegic, 7 diplegic), aged between 3 and 8 years, who were able to walk with or without assistance (Gross Motor Functional Classification System I-III) were recruited to the study. Botulinum toxin A injections were applied to a total of 23 extremities, followed by a comprehensive rehabilitation program. Walking distance and walking speed (evaluated by the Six-Minute Walk Test) were significantly improved after treatment. Similarly, scores on the Observational Gait Scale (assessed by video gait analysis) increased significantly. Improvements in muscle length, spasticity, and selectivity were recorded. Reduced muscle spasticity after botulinum toxin A injections in children with cerebral palsy, with a comprehensive rehabilitation program, enabled clinically relevant improvements in functional ability.     

Effectiveness of botulinum toxin A for upper and lower limb spasticity in children with cerebral palsy: a summary of evidence

Botulinum toxin type A (BoNT-A) therapy has gained wide acceptance in the management of spasticity in cerebral palsy (CP). Clinical experience from numerous case reports and series, retrospective and prospective open label cohort studies, and randomized controlled trials (RCT) has grown over the past 10 years. Several independent systematic reviews on the role of BoNT-A for upper and lower limb spasticity have been written by various authors. The objective of this paper is to summarize past systematic reviews and recent RCT not yet included in the systematic reviews that assess the effectiveness of BoNT-A in upper and lower limb spasticity in children with CP. We reviewed four Class II RCT discussed in five independent systematic reviews and two new Class II trials on the use of BoNT-A alone or with occupational therapy compared to placebo or occupational therapy alone in children with upper limb spasticity. There were 229 children recruited in these six trials and of those, 115 children received BoNT-A in the upper limbs. Five of six RCT showed a time limited decrease in muscle tone most especially at the wrist. Four of six trials showed improvement of hand function on a few specific functional tests. Four systematic reviews concluded that there is insufficient and inconsistent evidence to support or refute the effectiveness of BoNT-A in upper limb spasticity but one recent review recommended that BoNT-A should be considered as a treatment option in upper limb spasticity. For lower limb spasticity, we reviewed 13 RCT discussed in six systematic reviews and two new trials comparing BoNT-A with placebo or other rehabilitation modalities such as physiotherapy, occupational therapy, casting or electrical stimulation. In these studies, 617 children were recruited and of those, 360 children received BoNT-A in the lower limbs. There were six Class I and nine Class II trials. Three Class I trials documented significant improvement in gait pattern in children with gastrocnemius spasticity and one Class I study showed significant reduction in tone in the hip adductors. The most recent review establishes BoNT-A as an effective treatment for equinovarus deformity. Adverse events in these trials were mild and self-limited. The most common complaints were pain in the injection sites and transient weakness. BoNT-A is considered safe for use in children. In conclusion, there is now growing convincing evidence for the time limited beneficial effect of BoNT-A in decreasing muscle tone in children with upper and lower limbs spasticity associated with CP. Decrease muscle tone in the lower limbs translates to improved gait in CP children with spastic equinovarus however more systematic studies are necessary to show sufficient evidence for improved hand function from BoNT-A injection in the upper limbs.     

Preliminary trial of botulinum toxin A therapy for lower extremity spasticity in children with cerebral palsy

Eleven children with gait disturbance due to cerebral palsy (mean age, 5.6 years, ranging from 2.4 to 11.5) were treated with Botulinum toxin A (BTA, BOTOX, Allergan) for improvement of spasticity and walking difficulty. BTA was injected into the gastrocnemius, adductors, and hamstring muscles with an initial total dose up to 8 units/kg or 100 units. Spasticity and gait disturbance were significantly improved in all patients 4 weeks after the treatment. Their parents also reported that BTA was helpful for brace tolerance and assistance of caregivers. No side effects including worsening of gait or signs of systemic adverse effects were observed. Management of leg spasticity with BTA is thought to be useful and safe, and approval for this use in Japan is recommended.     

Botulinum toxin treatment of muscle cramps: A clinical and neurophysiological study

Botulinum toxin is now widely used in the treatment of severla hyperkinetic movement disorders. To evaluate its efficacy in treating muscle cramping syndromes, we studied clinical and neurophysiological variables before and after botulinum toxin injections into calf muscles and small flexor muscles of the foot in patients with an inherited benign crampfasciculation syndrome. At each assessment the clinical severity of cramp was scored and the cramp threshold frequency was measured with repetitive electrical peripheral nerve stimulation. Botulinum toxin injection signifcantly lowered our patients' clinical cramp severity scores (mean ± SD: before, 3.80 ± 0.44; after, 1.40 ± 0.54), left muscle strength unchanged and significanlty increased their cramp threshold frequencies (before, 4.22 ± 2.26 Hz; after, 10.0 ± 3.74 Hz). The clinical beefit induced by botulinum toxin lasted about 3 months. Boutlinum toxin injections also significantly reduced fasciculation potentials in relaxed muscles (before, 0.86 ± 0.19 fasciculations/sec; after, 0.45 ± 0.11 fasciculations/sec). These findings show that local intramuscular injection of botulinum toxin provide effective, safe, and long-lasting relief of cramps possibly by reducing presynaptic cholinergic stimulation of motor nerve terminals and by impairing the input/output function of intrafusal and extrafusal motor end plates.     

Muscle histopathology in children with spastic cerebral palsy receiving botulinum toxin type A

Introduction: Botulinum toxin A (BoNTA) is routine treatment for hypertonicity in children with cerebral palsy (CP). Methods: This single‐blind, prospective, cross‐sectional study of 10 participants (mean age 11 years 7 months) was done to determine the relationship between muscle histopathology and BoNTA in treated medial gastrocnemius muscle of children with CP. Open muscle biopsies were taken from medial gastrocnemius muscle and vastus lateralis (control) during orthopedic surgery. Results: Neurogenic atrophy in the medial gastrocnemius was seen in 6 participants between 4 months and 3 years post‐BoNTA. Type 1 fiber loss with type 2 fiber predominance was significantly related to the number of BoNTA injections (r = 0.89, P < 0.001). Conclusions: The impact of these changes in muscle morphology on muscle function in CP is not clear. It is important to consider rotating muscle selection or injection sites within the muscle or allowing longer time between injections. Muscle Nerve 53: 407–414, 2016     

Spread of botulinum neurotoxin type a at standard doses is inherent to the successful treatment of spastic equinus foot in cerebral palsy: short-term neurophysiological and clinical study

To evaluate whether botulinum toxin type A at standard doses spreads to antagonist leg muscles in dynamic equinus foot, we studied 18 ambulatory children with hemiplegic cerebral palsy. The gastrocnemius muscle on the affected side was injected with botulinum toxin type A (Dysport) (mean ± standard deviation, 14.3 ± 0.9 U/kg). Compound muscle action potential areas were assessed in the lateral gastrocnemius and tibialis anterior muscles on the treated and untreated sides before botulinum toxin type A injections and on days 10 and 30 after injections. In all patients, compound muscle action potential areas recorded from both the muscles on the treated side decreased from preinjection values at day 10 (P < .05) and 30 (P < .002). After injection, ankle spasticity had diminished (P < .05), equinus foot excursion increased (P < .05), and functional gait improved (P < .05). This study shows that botulinum toxin type A spreads from foot flexors to antagonist extensors and suggests that spread may be partly responsible for improving gait in children with cerebral palsy.     

Progressive response to botulinum A toxin in cerebral palsy.

Botulinum A toxin (BT) has been successfully used for the management of spasticity in cerebral palsy (CP). However, the long-term results of BT have not yet been determined. We have studied the evolution of a homogeneous group of patients with CP treated with BT. All these patients had an equinus gait resulting from calf muscle spasticity without other muscle group involvement. All of these patients were treated with the same total dose (4 microg/kg) at the same time interval (three months). The mean follow-up time was 33 months. Gait evaluation was made blind on videotape recordings by two independent physicians according to five point scale. All our patients exhibited a progressive improvement in their gait pattern. None of our patients developed fixed contractures nor did any of them need surgical correction. No significant side-effects were seen. The response observed in our study could be due to a progressive symptomatic effect of BT, but it might be also explained by a change in the natural history of the spasticity related to CP, at least in this selected group of patients.