Gross Motor Function In Children Research Articles

Delivery of Nusinersen Through an Ommaya Reservoir in Spinal Muscular Atrophy.

Spinal muscular atrophy (SMA) is a common rare neuromuscular disease responsible for very high mortality during infancy and high morbidity during childhood and adolescence. It is caused by autosomal recessive mutations in the survival motor neuron gene. In 2016, the Food and Drug Administration approved the first disease modifying therapy for use in all patients of any age. Nusinersen is an antisense oligonucleotide that showed dramatic benefits with achievement of motor milestones in infants and improved gross motor function in children. This was a retrospective chart review of all SMA patients seen at a single site between 2016 and 2020 for treatment with nusinersen. We report 8 patients who underwent placement of an Ommaya reservoir and lumbosacral catheter for drug delivery. Complications included infection and revisions due to catheter separation. One patient required fluoroscopy for injections because of location of port site. We conclude that placement of an Ommaya port is a viable option for patients who have challenges for access to intrathecal space. Practical innovations have the potential to control administration costs, achieve therapeutic value, and promote patient safety.

Reproducibility and validity of the Functional Communication Classification System for young children with cerebral palsy.

To examine interrater agreement and validity of the Functional Communication Classification System (FCCS) for young children with cerebral palsy (CP) aged 2 or 3 years. Speech-language pathologist (SLP) and parent FCCS ratings for 31 children with CP (aged 2y, n=16; aged 3y, n=15; 18 males, 13 females) were examined for interrater agreement using a weighted Cohen's kappa statistic. Relationships between FCCS (SLP) ratings and: (1) concurrent validity with the Language Use Inventory, a standardized pragmatic assessment for children aged 18 to 47 months, (2) gross motor and fine motor function, (3) associated impairments (visual and intellectual), and (4) primary expressive communication mode were examined using Spearman's correlation coefficients. Almost perfect interrater agreement between SLP and parent FCCS ratings were found (kw =0.94). Correlations with FCCS (SLP) were excellent for pragmatic function (rs =-0.83,p<0.001), intellectual function (rs =0.89, p<0.001), and primary expressive communication mode (rs =0.92,p<0.001). Correlations were good for gross motor function (rs =0.72,p<0.001) and visual impairment (rs =0.70,p<0.001) and fair for fine motor function (rs =0.53,p<0.002). Analysis was unwarranted for epilepsy (n=1 out of 31) and hearing-associated impairments (n=0 out of 31). The FCCS has excellent interrater agreement and validity for communication classification of children with CP aged 2 or 3 years and is highly suitable for surveillance and research purposes. What this paper adds The Functional Communication Classification System (FCCS) is a valid instrument for children with cerebral palsy (CP) aged 2 or 3 years. Excellent agreement exists between speech-language pathologist and parent FCCS ratings. The FCCS has excellent correlation with intelligence, pragmatic function, and primary expressive mode. Stronger correlations with the Gross Motor Function Classification System and vision exist for children aged 2 or 3 years. Weaker correlations with manual ability exist when compared to older children with CP.

The effects of dual-task training on balance and gross motor function in children with spastic diplegia.

The purpose of this study was to investigate changes in dynamic balance and gross motion function when dual-task training was performed on an unstable support surface by children with spastic diplegia. The subjects of this study were 14 children (experimental group n=7, control group n=7) who were medical diagnosed with spastic diplegia. Both groups were administered treatment for 30 min, 2 times a week for 8 weeks, with the experimental group performing dual-task exercise in which cognitive tasks related to daily living were performed while maintaining balance on an unstable surface, and the control group being administered neurodevelopmental treatment. Balance and gross motor function Assessments were conducted before intervention and after 8 weeks of intervention. Wilcoxon signed-rank test was performed to analyze changes in balance, gross motor function in the group, and the Mann–Whitney test was conducted to compare the differences between the two groups before and after intervention. The results showed that there was a statistically significant difference in both groups when balance in a sitting position and gross motor function (P<0.05). There was a statistically significant difference between the two groups in balance and gross motor function assessment (P<0.05). Based on the results of this study, it was confirmed that dual-task training improves balance, gross motor function in children with spastic diplegia. Therefore, dual-task training may be considered as an effective method of intervention method in the functional aspect of children with spastic diplegia.

The Effects of Electrical Stimulation on Gross Motor Function in Children with Spastic Cerebral Palsy: A Review Article

Cerebral Palsy (CP) is the most common childhood disability in children. The child’s motor development and functioning are affected by variety neuromuscular and musculoskeletal impairments. Both of upper and lower extremities motor function are important for many daily life activities. For example, children who has good fine motor function and who can sitting independently can manipulate the objects by using upper extremities and can realize transfer activities. Therefore, she/he can play effectively in daily life. Children who can play will be happy and independent in daily life activities. Spasticity is the most common problem in children with CP and can interfere with daily life activities. Children who have spastic CP constrained in daily life activity, participation and recreational activities. Working on gross motor skills helps to gain strength, increase postural control, to achieve motor milestones and to become independent in daily life activities. In treatment program, physical therapist used different approach, like, exercise programs (stretching, strengthening, aerobic exercise…), electrical stimulation, neurodevelopmental approaches, virtual reality, constrained induced movement therapy. Neuromuscular Electrical Stimulation, Functional Electrical Stimulation and Threshold Electrical Stimulation commonly used for this reason. There is a few evidence on positive effects of electrical stimulation applied in children with CP. This review study was planned to investigate the effects of electrical stimulation on gross motor function in children with CP.

Influence of motivated walking with partial body weight supporting on the gross motor functions in children with cerebral palsy

The aim of the work is to increase the effectiveness of physical therapy of gross motor functions impairments in children with spastic cerebral palsy by using a therapeutic exercises program with partial body weight supporting and motivated walking on the device for the rehabilitation of people with impaired functions of the musculoskeletal system. The study included 30 children 6 to 11 years old with a spastic form of cerebral palsy. All patients were divided into 2 groups: in group I, in addition to the standard complex of physical therapy, walking according to the dynamic method was prescribed, in group II – according to the static method with partial body weight supporting. The duration of the program was 6 weeks. The survey was carried out before the start, at 2, 4 and 6 weeks of therapy. We studied the spatiotemporal characteristics of walking and activity of daily living indicators. The use of the developed program with the rehabilitation device positively influenced the spatiotemporal indicators of walking in both groups. The stride length, walking speed and the length of the covered distance increased statistically significantly. A significant increase in the volume of performed activities of daily living in the I group was found. At the same time, an increase in this indicator was also observed in group II, but it did not reach statistical significance. The use of the developed program of therapeutic exercises, including walking with motivated movement and partial body weight supporting on the developed rehabilitation device positively influenced the static and dynamic characteristics of walking, which improved the performance of activities important for children with cerebral palsy, especially walking and running. The optimal time for increasing the stride length is a 4-week program, for the development of general endurance and speed – a 6-week program of therapeutic training.

Hip contractures were associated with low gross motor function in children with cerebral palsy.

The aim was to identify the prevalence of hip contractures and their association with gross motor function and pain in the lower extremities among Danish children with cerebral palsy (CP). This cross-sectional study was based on data collected during regular clinical examinations in 2018-2019 and registered in the National Danish Clinical Quality Database of children with CP. The study population was 688 children (59% boys) aged five to 12years across all Gross Motor Function Classification System (GMFCS) levels. Any associations between hip contracture and gross motor function and pain were investigated with logistic regression analysis and presented as odds ratios (OR) with 95% confidence intervals (95% CI). The prevalence of hip contracture was 22% across all five GMFCS levels, and the incidence varied across the five Danish regions. The odds ratios for hip contracture were significantly higher at GMFCS level IV (OR 1.99, 95% CI 1.10-3.62) and V (OR 5.49, 95% CI 3.33-9.07) compared with level I. Hip contractures were not significantly associated with pain in the lower extremities (OR 1.43, 95% CI 0.95-2.15). Hip contractures were frequent and associated with low gross motor function, but not lower extremity pain, in children with CP.

Critically appraised paper: A program of functional electrical stimulation cycling, goal-directed training and adapted cycling improves gross motor function in children with cerebral palsy [synopsis

Critically appraised paper: A program of functional electrical stimulation cycling, goal-directed training and adapted cycling improves gross motor function in children with cerebral palsy [synopsis

Critically appraised paper: A program of functional electrical stimulation cycling, goal-directed training and adapted cycling improves gross motor function in children with cerebral palsy [commentary

Critically appraised paper: A program of functional electrical stimulation cycling, goal-directed training and adapted cycling improves gross motor function in children with cerebral palsy [commentary

Gross Motor Function in Children with Congenital Zika Syndrome.

Little information on gross motor function of congenital Zika syndrome (CZS) children is available. To evaluate gross motor function in CZS children aged up to 3 years, and its associated factors and changes in a minimum interval of 6 months. One hundred children with CZS and cerebral palsy (36 with confirmed and 64 with presumed CZS) were evaluated with the Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM-88/GMFM-66). Forty-six were reevaluated. Wilcoxon tests, Wilcoxon tests for paired samples, percentile scores, and score changes were performed. Clinical and socioeconomic characteristics (except maternal age), GMFM scores and GMFCS classification of confirmed and probable cases, which were analyzed together, were similar. The mean age was 25.6 months (±5.5); the median GMFM-88 score was 8.0 (5.4-10.8); and the median GMFM-66 score was 20.5 (14.8-23.1); 89% were classified as GMFCS level V. Low economic class, microcephaly at birth, epilepsy, and brain parenchymal volume loss were associated with low GMFM-66 scores. The median GMFM-66 percentile score was 40 (20-55). On the second assessment, the GMFM-66 scores in two GMFCS level I children and one GMFCS level IV child improved significantly. In one GMFCS level III child, one GMFCS level IV child, and the group of GMFCS level V children, no significant changes were observed. Almost all CZS children had severe cerebral palsy; in the third year of life, most presented no improvement in gross motor function and were likely approaching their maximal gross motor function potential.

Early intervention physical therapy using “Parent Empowerment Program” for children with Down syndrome in Pakistan: A feasibility study

The aim of this study was to evaluate the feasibility and effectiveness of the Parent Empowerment Program (PEP) to help caretakers deliver a home program to promote developmental activities and gross motor function in their children with Down syndrome. Parents attended a 14-month program with training sessions 1-4 times a month. Outcomes were measured using a change in the Gross Motor Function Measure (GMFM-88) at baseline and assessment one. Forty-eight families participated in the PEP. Children's mean age was 16.2 ± 10.8 months. There were significant changes in GMFM-88 scores between baseline and assessment one; t (30) =-9.158, p< 0.001; 95% CI -14.6 - -22.9. Previous hospitalization significantly affected GMFM scores. This study describes a clinically applied research that focuses on program design, development and evaluation. Findings indicate that the PEP is effective in improving gross motor function in children with Down's syndrome in Pakistan. Parents were satisfied with the program outcomes and were able to cope with the requirements at home. The PEP had favorable outcomes and may be an effective method to support PT services in resource poor countries.

Effect of a Nutritional Support System (Diet and Supplements) for Improving Gross Motor Function in Cerebral Palsy: An Exploratory Randomized Controlled Clinical Trial.

Background: Most patients with cerebral palsy (CP) do not respond to physical therapy due to deterioration in their nutritional status, secondary to gastrointestinal disorders and the catabolic state of the disease itself. However, basic treatments only contemplate the energy requirements and do not consider supplementation with glutamine, zinc, selenium, colecalciferol, spirulina, omega 3 or even vegetal proteins. Objective: In this study, we determined the effect of using a nutritional support system (NSS): diet and supplements, on the gross motor function in children with CP with spastic diparesic and Gross Motor Function Classification System III (GMFCS III). Methods: An exploratory study was performed. Thirty patients (from 4 to 12 years old) were randomly assigned to: (1) dietary surveillance (FG), (2) deworming and WHO diet (CG), or (3) deworming and the NSS (IG). Gross motor function was evaluated using the gross motor function measure (GMFM) scale. Results: The IG-treated group presented a significant improvement in standing and walking parameters analyzed in the GMFM compared with FG and CG groups. Fifty percent of the IG-treated patients managed to walk, while in the other groups, no patients were able to walk. Conclusions: The NSS used in the present work improves gross motor function and promotes walking in patients with CP.

Basic Motor Skills of Children With Down Syndrome: Creating a Motor Growth Curve.

To create a motor growth curve based on the Test of Basic Motor Skills for Children with Down Syndrome (BMS) and estimate the age of achieving BMS milestones. A multilevel exponential model was applied to create a motor growth curve based on BMS data from 119 children with Down syndrome (DS) aged 2 months to 5 years. Logistic regression was applied to estimate the 50% probability of achieving BMS milestones. The BMS growth curve had the largest increase during infancy with smaller increases as children approached the predicted maximum score. The age at which children with DS have a 50% probability of achieving the milestone sitting was 22 months, for crawling 25 months, and for walking 38 months. The creation of a BMS growth curve provides a standardization of the gross motor development of children with DS. Physical therapists then may monitor a child's individual progress and improve clinical decisions.

Effectiveness of instrumented gait analysis in interdisciplinary interventions on parents\u2019 perception of family-centered service and on gross motor function in children with cerebral palsy: a randomized controlled trial

BackgroundChildren with cerebral palsy often exhibit an altered gait pattern; however, it is uncertain whether the use of an instrumented gait analysis in interdisciplinary interventions affects the perceived experience of family-centered service (FCS) and/or gross motor function. The aim of this study is to investigate whether individually tailored interdisciplinary interventions, based on an instrumented gait analysis report, has a superior effectiveness on perceived FCS and gross motor function in children with cerebral palsy, compared to ‘care as usual’ without the use of instrumented gait analysis. Furthermore, to investigate potential associations between perceived FCS and gross motor function improvement with the goal of improving future therapy on gross motor function.MethodThis is a sequel analysis on tertiary outcome measures from a prospective, single blind, randomized, parallel group study including two groups of 30 children aged 5–8 years with spastic cerebral palsy at Gross Motor Function Classification System levels I-II (n = 60). The intervention group underwent a three-dimensional gait analysis, from which a clinical report was written with recommendations on interdisciplinary interventions, such as physical therapy, orthopedic surgery, orthotics or spasticity management.To assess effectiveness on perceived FCS and gross motor function, at baseline, 26 weeks and 52 weeks, the five domains in the Measure of Processes of Care (MPOC-20) (Enabling and partnership, Providing general information, Providing specific information about the child, Respectful and supportive service, and Coordinated and comprehensive care) and the Gross Motor Function Measurement (GMFM-66) were used as outcome measures.ResultsNo significant differences in between-group change scores in any of the five MPOC-20 domains were observed (p = 0.40–0.97). In favor of the intervention group a significantly higher between-group change score in GMFM-66 (mean difference: 3.05 [95%CI: 1.12–4.98], p = 0.003) after 52 weeks was observed.ConclusionThe addition of an instrumented gait analysis report to ‘care as usual’ did not improve the parents’ perceptions of FCS in treatment of children with cerebral palsy. However, superior improvement in the GMFM-66 was observed in the intervention group, suggesting meaningful gross motor function improvement.Trial registrationClinical Trials, NCT02160457. Registered June 10th 2014.

The Effectiveness of Hippotherapy to Recover Gross Motor Function in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

Cerebral palsy (CP) is a permanent disorder of the posture and movement, which can result in impairments of gross motor function, among others. Hippotherapy (HPT) is an emerging intervention to promote motor recovery in patients with neurological disorders, providing a smooth, precise, rhythmic, and repetitive pattern of movement to the patient. The main objective of this systematic review and meta-analysis of randomized controlled clinical trials was to analyze the effectiveness of HPT interventions on gross motor function in subjects with CP. The following databases were searched in May 2019: PubMed, Scopus, Embase, and Web of Science. The methodological quality of the randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) scale. A total of 10 studies were analyzed in this review, involving 452 participants. Favorable effects were obtained on the gross motor function (Gross Motor Function Measure-66, standardized mean difference (SMD) = 0.81, 95% confidence interval (CI) = 0.47–1.15, Gross Motor Function Measure-88 dimension A SMD = 0.64, 95% CI = 0.30–0.97, dimension B SMD = 0.42, 95% CI = 0.09–0.75, and dimension E SMD = 0.40, 95% CI = 0.06–0.73). The results obtained in the present review show the potential benefit of HPT intervention in improving gross motor function in children with CP.

Effect of Platform Swing Walkway on Locomotor Behavior in Children With Diplegic Cerebral Palsy: Randomized Controlled Trial

Background Limited attention has been given to the effectiveness of the platform swing walkway, which is a common way to improve gait pattern through activation of sensory stimuli (visual, auditory, vestibular, and somatosensory). Objective The objective of this study was to determine the effect of a platform swing walkway on gait parameters in children with diplegic cerebral palsy (CP). Methods A total of 30 children of both sexes (aged 6-8 years) with diplegic CP were enrolled in this study. They were randomly assigned into two groups of equal number: the control group (n=15) and the study group (n=15). The control group received the conventional physical therapy plan, whereas the study group received the same conventional physical therapy program in addition to gait training on a platform swing walkway. Temporal parameters during the gait cycle were collected using gait tracker video analysis, and the Growth Motor Function Measure Scale (GMFM-88) was used to assess standing and walking (Dimensions D and E) before and after the treatment program. Results A statistically significant improvement in both groups was noted when comparing the mean values of all measured variables before and after treatment (P≤.05). There were significant differences between the control and study groups with respect to all measured variables, which favored the study group when comparing the posttreatment outcomes (P≤.05). Conclusions Results suggest that gait training on platform swing walkways can be included as an alternative therapeutic modality to enhance gait parameters and gross motor function in children with diplegic CP. Trial Registration ClinicalTrials.gov NTC04246658; https://clinicaltrials.gov/ct2/show/NTC04246658

The effects of serial casting on lower limb function for children with Cerebral Palsy: a systematic review with meta-analysis

BackgroundLower limb serial casting is commonly used therapeutically in paediatric clinical practice with some evidence to support its efficacy. This systematic review aimed to determine the effects of serial casting in isolation or combination with other therapies for the management of lower limb dysfunction in children with Cerebral Palsy (CP).MethodsA systematic literature search was conducted in February 2019 across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using key terms ‘Cerebral Palsy’ and ‘serial casting’ and associated synonyms. A meta-synthesis and meta-analysis were undertaken when sufficient results were available showing the effect of serial casting on functional outcomes including: Ankle range of motion; neurological measures of hypertonicity and spasticity, functional gait measures and; gross motor function.ResultsTwenty-five articles from 3219 possible citations were included. Serial casting was found to be effective for: Improving ankle dorsiflexion (DF) passive range of motion (PROM) in the immediate to short-term, decreasing hypertonicity measured by Modified Ashworth Scale (MAS) in the short-term and, enhancing functional gait outcomes in the mid-term. Serial casting with or without botulinum toxin type-A (BTX-A) did not significantly affect gross motor capacity measured by Gross Motor Function Measure (GMFM). Serial casting with pharmacological intervention achieved significantly more DF PROM than serial casting alone (MD − 3.19 degrees; 95% CI − 5.76 to − 0.62; P = 0.01; I2 = 0%), however the clinical importance of improving ankle DF PROM by an additional three degrees remains unclear.ConclusionsLower limb serial casting, improves several outcomes relevant to lower limb function supporting its clinical use for improving DF PROM, reducing hypertonicity and improving gait in children with CP. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes such as gross motor function in children with CP. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decision-making consultations.

Association Between Strength Fitness And Gross Motor Function In Children: A Us National Study

It was believed that children with better motor function and skills will be likely more physically active. Yet, contribution of fitness, especially muscular strength, to children’s motor function and skill has not been well understood. PURPOSE: To examine the relationship between core and upper-body strength and gross motor function in children using a US national sample. METHODS: Three data sets in the 2012 National Youth Fitness Survey (NNYFS) were merged: Test of Gross Motor Development – Second Edition (TGMD-2), modified pull-up, and plank. TGMD-2 total score (TGMD-2 TS) was calculated by adding “Local motor subtest raw score” and “Object control subtest raw score” together. Descriptive statistics and correlations of TGMD-2 TS, “# of correctly completed modified pull-ups (M-Pull-up)”, and “# of seconds planks position is held (Planks)” were computed using the 2012 NNYFS data. RESULT: A total of 6375389 of boys and 6134317 of girls who aged between 3 and 5 yr. old participated in 2012 NNYFS, and their performances (M±SD) in gross motor function and fitness, as well as their correlations (r), are summarized below: Table CONCLUSION: As children become older, core and upper-body strength seems playing a positive impact on children’s gross motor function in both boys and girls.

Analysis of orthopedic surgical procedures in children with cerebral palsy

Orthopedic surgery in children with cerebral palsy (CP) aims to improve function and prevent deformities. Each child's condition in CP is unique and many co-variables influence surgical decision-making including a patient's age and their functional level. Little is known about the frequency of different types of orthopedic surgery in children with CP who have varied functional levels, particularly in countries from Latin America. To assess the type of orthopedic surgical procedures in relation to age and gross motor function in children with CP. This retrospective study included all children with CP (n = 245) treated with elective orthopedic surgery at a Uruguayan university hospital between October 2010 and May 2016 identified from a surgical database. Eighteen children (7%) were lost to follow-up due to missing medical charts. Demographics, gross motor function classification (GMFCS), and orthopedic surgeries were obtained from the medical records of 227 children. Chi-squared tests and analysis of variance were used to assess the frequency of surgery, accounting for GMFCS levels. Mean age for soft tissue vs bone surgery was compared with the independent samples t-test. A total of 711 surgical procedures were performed between 1998 and 2016. On average, children had 3.1 surgical procedures and the mean age at first surgery was 8.0 years. There were no significant differences in age at first surgery among GMFCS levels (P = 0.47). The most common procedures were lower leg soft tissue surgery (n = 189, 27%), hip tenotomy (n = 135, 19%), and hamstring tenotomy (n = 104, 14%). For children with GMFCS level I, the mean number of surgeries per child [1.8 (range 1-9)] differed significantly at P < 0.05 in children with GMFCS levels II [3.2 (1-12)], III [3.2 (1-8)], IV [3.3 (1-13)], and V [3.6 (1-11)]. Within II, III, IV, and V, there was no significant difference in mean number of surgeries per child when comparing across the groups. The proportion of soft tissue surgery vs bone surgery was higher in GMFCS levels I-III (80%-85%) compared to levels IV (68%) and V (55%) (P < 0.05). The frequency of surgical procedures per child did not increase with higher GMFCS level after level I. However, the proportion of bone surgery was higher in GMFCS levels IV-V compared to I-III.

Transcranial direct current stimulation for improving gross motor function in children with cerebral palsy: A systematic review

Introduction The functional abilities of children with cerebral palsy are often compromised because of limited motor function. Transcranial direct current stimulation is a neuromodulation tool used as an adjunct to other therapeutic modalities to improve gross motor function. This review aimed to examine the quality of evidence and the effectiveness of transcranial direct current stimulation for improving gross motor function in children with cerebral palsy. Method A systematic review was conducted, and eligible studies were critically appraised for methodological quality. Randomised controlled trials were selected to undergo meta-analysis for assessing the effectiveness of transcranial direct current stimulation on clinical outcomes. Results Eight studies, including seven randomised controlled trials, fitted the inclusion criteria. All the randomised controlled trials were rated ‘moderate’ quality based on the grading of recommendations assessment, development and evaluation (GRADE) system. Using meta-analysis, only cadence, an outcome measure of gait variables, demonstrated efficacy of intervention, mean difference 16.57 (10.88, 22.25); I2 = 0%, P = 0.83. Other gross motor and functional outcomes had either inconsistent mean difference or high heterogeneity. Conclusion Overall, the effectiveness of transcranial direct current stimulation as a treatment in children with cerebral palsy remains unclear, and the findings should be interpreted with caution. The quality of evidence was mostly moderate, and more vigorous research incorporating functional outcomes should be conducted to guide clinical practice.

A prospective study investigating gross motor function of children with cerebral palsy and GMFCS level II after long-term Botulinum toxin type A use

BackgroundThe aim of this study is to contribute to the knowledge base on the long-term outcomes of evidence-based medical interventions used to improve gross motor function in children and adolescents with Cerebral Palsy.MethodProspective cohort study of children with Cerebral Palsy in the birth years 2000–2009 attending a tertiary level service for children with Cerebral Palsy who’s first recorded Gross Motor Function Classification System level was II.ResultsA total of 40 children were eligible for the study, of whom 28 (72.7%) enrolled. The Botulinum toxin A treatment for this cohort, (median and interquartile ranges) were: total number of lower limb Botulinum toxin A injections 11 (6.7, 5.5); total dose of Botulinum Toxin A per lower limb treatment 6.95 u/kg (4.5, 11); and dose of Botulinum Toxin u/kg/muscle 2.95 (2.2, 4). For all 28 subjects there was a median of 15 (8.5 to 22) Gross Motor Function Classification System level recordings: six of the 28 children (21.4%) improved from level II to level I, the remaining 22 children remained stable at level II (78.6%). In this highly treated population, the average 66 item Gross Motor Function Measure score for the 22 children in level II was 72.55, which is consistent with the mean of 68.5 reported in the original Ontario cohort.ConclusionThis cohort study has confirmed that children with Cerebral Palsy, Gross Motor Function level II treated at a young age with repeated doses of Botulinum Toxin A within an integrated comprehensive service, maintain or improve their functional motor level at a later age.