Limb In Children Research Articles

Age-Related Development of Bilateral Coordination of the Upper Limbs in Children and Adolescents

Bilateral coordination of the upper limbs (UL) is important for activities of daily living and physical activities. Motor coordination improves from childhood through adolescence. However, age-coordination trajectories for bilateral UL movements are not well-established, and it is unclear if bimanual coordination develops slower than unilateral coordination. In this study we examined age-related changes in UL coordination from childhood to late adolescence. Typically-developing children (N = 29, aged 7–17 years) performed unilateral and bilateral, antiphase cycling tasks with their ULs. Variations in cycling velocity and interlimb phase errors were computed as measures of coordination. Linear regression was used to examine age-coordination effects. Given the sensorimotor processing for bilateral movements and gradual development of the corpus callosum, we hypothesized different relationships between age and coordination for bilateral and unilateral movements. Results showed UL coordination was significantly related to age, where coordination was better in older compared to younger children (p < 0.001); however, there were similar significant effects for unilateral movements. Differences in unilateral and bilateral coordination were not significantly explained by biological sex, although power to detect sex differences was low. We conclude that bilateral and unilateral UL coordination are age-dependent; each improves at similar rates through childhood and adolescence.

Impact of dairy supplementation on bone acquisition in children's limbs: a 12-month cluster-randomized controlled trial and meta-analysis.

This study evaluated the impact of dairy supplementation on bone acquisition in children's limbs through a cluster-randomized controlled trial and a meta-analysis. The trial involved 315 children (4-6year) from Northwest China, randomized to receive either 390ml of milk daily (n = 215) or 20-30g of bread (n = 100) over 12months. We primarily assessed bone mineral density (BMD) and content (BMC) changes at the limbs, alongside bone-related biomarkers, measured at baseline, the 6th and 12th months. The meta-analysis aggregated BMD or BMC changes in the forearm/legs/calcaneus from published randomized trials involving children aged 3-18years supplemented with dairy foods (vs. control group). Of 278 completed the trial, intention-to-treat analysis revealed significant increases in BMD (4.05% and 7.31%) and BMC (4.69% and 7.34%) in the left forearm at the 6th and 12th months in the milk group compared to controls (P < 0.001). The calcaneus showed notable improvements in BMD (2.01%) and BMC (1.87%) at 6months but not at 12months. Additionally, milk supplementation was associated with beneficial changes in bone resorption markers, parathyroid hormone (- 12.70%), insulin-like growth factor 1 (6.69%), and the calcium-to-phosphorus ratio (2.22%) (all P < 0.05). The meta-analysis, encompassing 894 children, indicated that dairy supplementation significantly increased BMD (SMD, 0.629; 95%CI: 0.275, 0.983) and BMC (SMD, 0.616; 95%CI: 0.380, 0.851) (P < 0.05) in the arms, but not in the legs (P > 0.05). Milk supplementation significantly improves bone health in children's forearms, underscoring its potential as a strategic dietary intervention for bone development. Trial registration NCT05074836.

Effect of Botulinum Toxin Type-A on Improvement of Muscle Function of Lower Limb in Children with Spastic Cerebral Palsy

Background: Spasticity significantly contributes to the functional and postural impairments in children with cerebral palsy (CP), leading to limitations in daily independence, participation, and quality of life. Botulinum Toxin-A (BTX-A) is recognized as an effective treatment for improving outcomes related to spasticity in individuals with CP. Objectives: This study aimed to evaluate the impact of BTX-A treatment on lower limb muscle function in children with spastic CP who were unable to complete physiotherapy sessions due to muscle spasms. Methods: This cross-sectional study reviewed the medical records of 24 children with CP (14 boys, 10 girls; average age: 4.50 ± 2.70 years) who had received BTX-A injections. We recorded demographic characteristics, types of muscle dysfunction, and the number of muscles involved. BTX-A injections were administered at a dosage of 5 units/kg across multiple sites. The severity of spasticity (measured using the Ashworth scale) and motor performance (assessed by the ability to walk and stand) were evaluated 30 days after the BTX-A injection. Satisfaction levels of surgeons, physiotherapists, and parents, along with final functional outcomes, were also gathered. Data analysis was performed using SPSS. Results: The most common movement disorders observed were equinus, knee flexion, and adduction. The median score on the Ashworth scale significantly decreased (P &lt; 0.001) following BTX-A injection. There was a notable improvement in walking and standing performance (P &lt; 0.05), particularly among boys aged 3 years or younger (P &lt; 0.05). Most cases showed satisfactory outcomes 30 days after BTX-A injection. Significant enhancements in the functional outcomes of children with CP were noted after a 30-day follow-up, with no significant differences related to gender, age, or the muscles involved (P &gt; 0.05). Conclusions: The findings suggest a substantial reduction in spasticity and enhancement of functional outcomes in children with cerebral palsy after BTX-A injections. This improvement was especially evident in boys and younger children with fewer muscles involved, accompanied by notably satisfactory outcomes.

The Effect of Transcranial Direct Current Stimulation on M1 with and without Mirror Visual Feedback on Range of Motion and Hand Grip Strength of the Affected Upper Limb in Children with Spastic Hemiplegic Cerebral Palsy.

This study investigated the effects of transcranial direct current stimulation (tDCS) before and during the mirror visual feedback (MVF) on hand grip strength (HGS) and range of motion of the affected hand in children with spastic hemiplegia cerebral palsy (SHCP). Twelve children with SHCP participated in this randomized, crossover, and double-blind study. They were randomly exposed to one of four intervention conditions, including 1) a-tDCS-offline, 2) s-tDCS-offline, 3) a-tDCS-online, and 4) s-tDCS-online, with a one-week interval. Participants in the online condition received either anodal or sham tDCS during MVF, while those in the offline condition received tDCS before performing MVF. The tDCS was applied over the M1 area of the affected hemisphere for 20 minutes at 1 mA intensity. The HGS and range of motion of the wrist and elbow (ROM-W and ROM-E) of the affected limb were measured before (pre) and immediately after (post) interventions in each session. The results showed that the HGS was significantly higher under a-tDCS-offline (p=0.001), s-tDCS-offline (p=0.004), and s-tDCS-online (p=0.005) compared to the a-tDCS-online. Moreover, the ROM-W was significantly higher under a-tDCS-offline (p=0.034), s-tDCS-offline (0.011), and s-tDCS-online (p=0.027) compared to the a-tDCS-online. Eventually, the ROM-E was significantly higher under a-tDCS-offline, s-tDCS-offline, and s-tDCS-online compared to the a-tDCS-online (p ˂0.001; p ˂0.001; p=0.01, respectively). The results might have practical implications regarding the timing of the application of tDCS in conjunction with MVF in children with SHCP.

Effect of Botulinum Toxin- A injection for the Lower Limb in Children with Spastic Cerebral Palsy

Objectives: To investigate the effect of botulinum toxin-A (BoNT-A) on the age groups and gross motor function classification level in children with cerebral palsy (CP).Method: In this study, 116 children with spastic CP were investigated. BoNT-A was injected into the spastic muscles of the lower limbs of all participants. All participants received physiotherapy and functional electrical stimulation for 3 months after injection. We measured the change in spasticity using the Modified Ashworth Scale and gross motor function using the GMFM-88. Spasticity was measured before injection and at 1 and 3 months after injection. Measurement of gross motor function was performed before and after the injections. Results: The effect of BoNT-A injection in combination with physiotherapy and electrical stimulation significantly improved spasticity and gross motor function. After BoNT-A injection, younger children showed reduced spasticity and improved gross motor skills compared to older children. At the gross motor level, sitting, standing, and walking improved in children with gross motor function classification levels I-III, and posture and mobility improved in children with gross motor function classification levels IV-V.Conclusions: We conclude that BoNT-A injection is effective for improving gross motor function in patients younger than 72 months of age.

The Diagnostic Capacity of Physical Examinations in Diagnosing Musculoskeletal Disorders of the Lower Limbs in Children with Down Syndrome.

Background and Objectives: although musculoskeletal alterations are common in patients with Down syndrome (DS), studies investigating this association are scarce, and proposals for diagnostic standardization are limited. We aimed to evaluate the prevalence of musculoskeletal disorders in the lower limbs in a sample of children and adolescents with DS and to investigate the diagnostic capacity of orthopedic clinical examinations performed by orthopedists and pediatricians to diagnose these alterations. Materials and Methods: Twenty-two patients aged between three and ten years with DS were included. Patients and guardians answered a simple questionnaire regarding orthopedic complaints and underwent a systematic orthopedic physical examination, performed twice: once by an orthopedist and again by a pediatrician. Patients underwent a series of radiographs to diagnose anisomelia, hip dysplasia, epiphysiolysis, flatfoot valgus, mechanical axis varus, and mechanical axis valgus. The radiological diagnosis was considered the gold standard, and the diagnostic capacity of the physical examination performed by each physician was determined. Results: The median age was 6.50 years. Only four patients (18.2%) presented with orthopedic complaints. All patients were diagnosed with at least one musculoskeletal disorder. The only musculoskeletal disorder with a good diagnostic capacity was flatfoot valgus. Limited sensitivity values were found for hip dysplasia, mechanical axis varus, and mechanical axis valgus. The agreement between the orthopedic physical examinations performed by the two examiners was weak, poor, or indeterminate for most of the analyzed items. Conclusions: There was a high prevalence of orthopedic alterations in children with DS who did not present with musculoskeletal complaints. The diagnostic capacity of the physical examination was limited. Therefore, all children with DS should undergo a radiological evaluation of the musculoskeletal system and subsequent specialized orthopedic evaluation. Level of Evidence: Level II (Diagnostic Studies).

Profile of Common Osteo-Articular Infections in Children's Limbs at the Albert Royer Children's Hospital in Dakar (Senegal): Contribution of the Radiography- Ultrasound Couple

Profile of Common Osteo-Articular Infections in Children's Limbs at the Albert Royer Children's Hospital in Dakar (Senegal): Contribution of the Radiography- Ultrasound Couple

Development of a Clinical Framework for the Assessment of Dyskinesia and Function in the Upper Limb in Children with Cerebral Palsy

Objective Dyskinesia in cerebral palsy (CP) is a complex movement disorder that can significantly impact upper limb function. Despite a range of available tools, there is no consensus on best practice assessment of upper limb function in children with CP and dyskinesia. This study aimed to develop a clinical framework for the assessment of the impact of dyskinesia on upper limb function in children with CP. Design Modified Delphi study using expert consensus. Methods An expert panel of six highly experienced Australian therapists ranked assessment tools sourced from existing evidence-based literature using a five-point Likert scale. Tools rated as important for use “most” or “all” of the time, by 80% of respondents were accepted into the framework following two survey rounds and a third stage discussion. Results Of 21 tools, 12 were included in the framework under five categories: (i) screening for dyskinesia; (ii) measuring the severity of dyskinesia; (iii) Classifying upper limb functional ability; (iv) measuring upper limb functional ability; and (v) measuring upper limb movement. Conclusions The framework for assessing the impact of dyskinesia on upper limb function in CP aims to guide clinicians to improve assessment consistency and facilitate individualized goal-directed management. Further studies with a larger number of expert clinicians and researchers will further strengthen the utility of the framework.

Computer-Aided Surgical Simulation through Digital Dynamic 3D Skeletal Segments for Correcting Torsional Deformities of the Lower Limbs in Children with Cerebral Palsy

Torsional deformities of the lower limb are common in children with cerebral palsy (CP)-determining gait problems. The mechanisms underlying transverse plane gait deviations arise from a combination of dynamic and static factors. The dynamic elements may be due to spasticity, contractures and muscle imbalances, while the static ones may result from excessive femoral anteversion, which decreases the efficiency of the hip abductors by reducing the muscular lever arms. A therapeutic approach has been identified in multi-level functional surgery for the lower limb. Treating the malalignments of the lower limb with femoral or tibial derotation provides optimal results, especially when supported by adequate biomechanical planning. This planning requires an integrated static-dynamic approach of morphological and functional evaluation, based on radiological measurements, physical examination and gait analysis. Instrumented gait analysis has been confirmed as essential in the evaluation and surgical decision making process for children affected by CP with transverse plane deformities. Computational simulations based on musculoskeletal models that integrate patient-specific CT morphological data into gait analysis can be used for the implementation of a surgical simulation system in pre-operative planning to test the possible effects of the different surgical treatment options on the torsional defects of the lower limbs. Recently, a computer-aided simulation process has been implemented in the preoperative planning of complex osteotomies for limb deformities in children. Three-dimensional (3D) digital models were generated from Computed Tomography (CT) scans, using free open-source software. The aim of this study is to integrate the patient-specific CT musculoskeletal model with morphological data and gait analysis data, with the personalized calculation of kinematic and kinetic parameters, which allow us to generate an “avatar” of the patient for a more in-depth evaluation of the gait abnormalities. The computational simulation platform proposed provides a realistic movable musculoskeletal model in a virtual environment, with the possibility of planning and monitoring the effects of virtual three-dimensional surgical corrections.

Management of loss of tissue substance in children's limbs. What are the salient peculiarities? A proposed algorithm

Loss of tissue substance in children's limbs has the same etiologies and in many cases, the same severity as in adults' limbs, and the means placed at the disposal of a surgeon are likewise comparable. It may nonetheless prove difficult to strategically position the different treatment methods in a decision-making tree. After all, a child presents numerous peculiarities: high quality of vascularization (both microcirculation and macrocirculation), better ability to achieve nerve regeneration and durable bone consolidation and, last but not least, a pronouncedly superior overall functional prognosis. Moreover, a child's future needs to be taken into account; it is not only cicatrization per se, but also the quality of healing that should dictate therapeutic choices, which will consequently be determined in view of avoiding functional disorders during the growth process. On the basis of their experience and following a review of the literature, the authors have assessed the interest of each relevant technique and drawn up a decision-making tree.

Lipoid Proteinosis: A Rare Disease In Pediatric Dentistry.

This report describes the diagnostic process of a rare disorder in a Brazilian female child. The patient presented initially as a 7-year-old with multiple whitish submucosal nodules of a fibrous consistency in the lower lip, but with an inconclusive pathology report. When she turned 9 years of age, she presented with exacerbation of the original clinical findings, which then involved the upper lip, buccal mucosa, tongue and lingual frenulum. In addition, dermatological lesions were noted on the child's limbs and face, as well as a hoarse voice. Histopathological examination of the buccal mucosa revealed dense connective tissue with hyaline foci, which were positive with periodic acid-Schiff (PAS) staining and resistant to diastase digestion. Clinical and histopathological findings led to the diagnosis of a rare genetic disease with fewer than 300 reported cases - lipoid proteinosis. Magnetic resonance imaging revealed calcium deposits in her amygdaloid region of the brain, and nasopharyngolaryngoscopy revealed lesions in her vocal cords. The patient currently is stable and under multidisciplinary follow-up, but no treatment has been recommended to date.

Pathological Fracture of Lower Limb in Children

Background: pathological fractures in children occur from many aetiology. The physician has to develop an individual strategy for management and rehabilitation, considering the biology of bone and the biomechanics at the fracture site to detect pathology of lesion and to reach perfect bone healing. Time-efficient protection and reconstruction of the child’s musculoskeletal system is the aim of the orthopaedic surgeon’s intervention. The whole strategy must be individualized to every situation. Objective: The goals of managing a child’s pathological fracture are all based on establishing a diagnosis. Fracture management is then based on five points:(a) relief the pain; (b) achieve local control of the pathological lesion; (c) skeletal stabilization, preservation of growth, and maintain anatomical alignment; (d) fracture healing; and (e) restoration of function. Patients and Methods: Our study was done over 20 cases of pathological fracture of lower limb in children in Al-Azhar University Hospitals (Al-Hossin and Saeid Galal hospitals) from January 2016 to December 2018. Imaging and radiology reports were used to determine fracture types. Complete fractures were classified to four major types: transverse, spiral, oblique and comminuted. In our study we use the Musculoskeletal Tumor Society (MSTS) scoring system to assess functional outcome for each patient. For lower extremity function, the MSTS used a 0-5 scale for the following variables: motion, pain, stability, deformity, strength, functional activity and emotional acceptance. Results: According to our study no patients with fractures underwent amputation, affection of neurovascular structures, or tumour progression on therapy. Pathologic fracture was not an indication for any of the amputation procedures, only the tumour pathology in an indication. Two patients refused surgery. Only one patient had a local recurrence after limb salvage surgery, and underwent no further surgical intervention.

Pathological Fracture of Lower Limb in Children

Background: pathological fractures in children occur from many aetiology. The physician has to develop an individual strategy for management and rehabilitation, considering the biology of bone and the biomechanics at the fracture site to detect pathology of lesion and to reach perfect bone healing. Time-efficient protection and reconstruction of the child’s musculoskeletal system is the aim of the orthopaedic surgeon’s intervention. The whole strategy must be individualized to every situation. Objective: The goals of managing a child’s pathological fracture are all based on establishing a diagnosis. Fracture management is then based on five points:(a) relief the pain; (b) achieve local control of the pathological lesion; (c) skeletal stabilization, preservation of growth, and maintain anatomical alignment; (d) fracture healing; and (e) restoration of function. Patients and Methods: Our study was done over 20 cases of pathological fracture of lower limb in children in Al-Azhar University Hospitals (Al-Hossin and Saeid Galal hospitals) from January 2016 to December 2018. Imaging and radiology reports were used to determine fracture types. Complete fractures were classified to four major types: transverse, spiral, oblique and comminuted. In our study we use the Musculoskeletal Tumor Society (MSTS) scoring system to assess functional outcome for each patient. For lower extremity function, the MSTS used a 0-5 scale for the following variables: motion, pain, stability, deformity, strength, functional activity and emotional acceptance. Results: According to our study no patients with fractures underwent amputation, affection of neurovascular structures, or tumour progression on therapy. Pathologic fracture was not an indication for any of the amputation procedures, only the tumour pathology in an indication. Two patients refused surgery. Only one patient had a local recurrence after limb salvage surgery, and underwent no further surgical intervention.

Prospective Study on Physiological Intorsion of Lower Limbs in Children

Background: Rotational profiles vary widely among healthy children. Rotation of the long bones refers to the twist of the bone about its long axis. Rotational deformity of the lower limb in the transverse plane is associated with many clinical settings ranging from harmless to excessive intoeing in children. Materials and Methods: This study was conducted at the Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi. Children presenting to the outpatient department during the period of April to September 2013 were followed up. It is a prospective study conducted over 14 months. A total of 27 children (54 lower limbs) were included and followed up. Results: Twenty-seven children were selected as per the inclusion criteria and assessed for the thigh-transmalleolar axis, thigh-foot angle, femoral anteversion (FA), foot progression angles (FPA), and hip rotations at 4-month interval for 2 follow-ups. There were very few studies of such type which have been conducted in India. Conclusions: In our study, there was a definite and significant decrease in FPA and internal tibial torsion with increasing age. The values of clinical anteversion also decreased with age along with a gradual decrease of internal rotation and an increase of external rotation (ER). The decrease of FA with age correlated better with increase of hip ER. FPA was a significant clinical parameter which gave us an objective picture of the change in both femoral and tibial torsions with age.

Action-selection perseveration in young children: Advances of a dynamic model.

This study presents an empirical test and dynamic model of perseverative limb selection in children of 14‐, 24‐, and 36‐months old (N = 66 in total). In the experiment, children repeatedly grasped a spoon with a single hand. In two separate conditions, the spoon was presented either four times on their right side or four times on their left side. In both conditions, following this training, the spoon was presented on midline for two more trials. This setup enabled us to determine whether children's limb selection was influenced by their prior choices in the task (i.e., perseveration). Individual children's handedness was determined in a third condition consisting of nine object presentations (laterally or on midline). A dynamic model for limb selection is presented combining external input, motor memory, and preferences. The model was used to simulate the experiment and reproduced the results, including the age‐related changes.

Osmičkové dlahy - nové možnosti v managementu řešení osových a délkových diskrepancí dolních končetin u dětí. Naše první zkušenosti

Osmičkové dlahy - nové možnosti v managementu řešení osových a délkových diskrepancí dolních končetin u dětí. Naše první zkušenosti

Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children

Epinephrine autoinjector use for anaphylaxis is increasing. There are reports of digit injections because of incorrect autoinjector use, but no previous reports of lacerations, to our knowledge. We report complications of epinephrine autoinjector use in children and discuss features of these devices, and their instructions for use, and how these may contribute to injuries. We queried emergency medicine e-mail discussion lists and social media allergy groups to identify epinephrine autoinjector injuries involving children. Twenty-two cases of epinephrine autoinjector-related injuries are described. Twenty-one occurred during intentional use for the child's allergic reaction. Seventeen children experienced lacerations. In 4 cases, the needle stuck in the child's limb. In 1 case, the device lacerated a nurse's finger. The device associated with the injury was operated by health care providers (6 cases), the patient's parent (12 cases, including 2 nurses), educators (3 cases), and the patient (1 case). Of the 3 epinephrine autoinjectors currently available in North America, none include instructions to immobilize the child's leg. Only 1 has a needle that self-retracts; the others have needles that remain in the thigh during the 10 seconds that the user is instructed to hold the device against the leg. Instructions do not caution against reinjection if the needle is dislodged during these 10 seconds. Epinephrine autoinjectors are lifesaving devices in the management of anaphylaxis. However, some have caused lacerations and other injuries in children. Minimizing needle injection time, improving device design, and providing instructions to immobilize the leg before use may decrease the risk of these injuries.

A Study of Effects of Intervention of Botulinum Toxin- A on Lower Limb in Children with Spastic Cerebral Palsy

Abstract Objective Analysis of clinical gait pattern, change in spasticity and range of motion (ROM) in cerebral palsy patient (CP) with spastic lower limb muscle after injecting botulinum toxin- A. Study Design Prospective study Methods 28 children (18 male and 10 female) with spastic CP had problems in normal walking, aged 2–9 years (mean age 4.65 years), consecutively treated in the PMR department over a 2-year period, were prospectively followed-up and clinically assessed pre- and post-treatment (at 2 weeks and 2 months) both objectively and subjectively. Objective assessment included gait parameters -- stride length, cadence, velocity, step length, base of support; active and passive range of motion (ROM), (measured by goniometry) and spasticity on modified Ashworth scale. Subjective assessment was done by asking questionnaire in terms of comfort, ease of care, perineal hygiene, walking. Injections were given using clinical palpatory method on OPD basis. All patients received botulinum toxin-A injections, followed with exercises and activities and orthosis as needed. Results Significant improvement was achieved for spasticity reduction in gastrocnemius (p&lt; 0.001), hamstring and adductor (p=0.050), ankle AROM &amp; PROM (p&lt; 0.001), active knee extension (p=0.009), popliteal angle (p=0.015) and percentage left and right foot contact (p&lt; 0.001), whereas non-significant change was observed in step length, cadence, velocity, stride length, and base of support. Parents felt subjective improvement in most of the cases (&gt;90%). Conclusions Botulinum toxin- A injection is effective in the treatment of spastic lower limb muscles for equinus/ crouching/scissoring gait in cerebral palsy children. The treatment was feasible and easily implemented. Botulinum toxin- A injections were well tolerated, yielded no serious treatment-related adverse events.

Responsiveness of Edinburgh Visual Gait Score to Orthopedic Surgical Intervention of the Lower Limbs in Children with Cerebral Palsy

The aim of this study was to report the responsiveness and minimal clinically important difference of the Edinburgh Visual Gait Score (EVGS), used to measure gait deviations in children with cerebral palsy. Fifty ambulant children with spastic diplegia (Gross Motor Function Classification System levels II and III) aged between 6 and 19 yrs were recruited for this longitudinal study. The participants were evaluated before surgery and at 6 and 12 mos after surgery. The change in EVGS at these time points was used to calculate effect sizes and minimal clinically important differences. Friedman analysis of variance showed a significant difference (χ2 = 60.69, P = 0.000) in the EVGS scores at 6 and 12 mos when compared with baseline. Effect sizes at 6 and 12 mos were large (1.19 and 1.22, respectively), indicating a visible difference in gait .The minimal clinically important differences of EVGS at 6 and 12 mos were 11 and 15, respectively. The EVGS is an outcome measure that can be used to evaluate the effect of orthopedic surgical intervention in children with cerebral palsy. Differences of 11 and 15 points on the EVGS are required to suggest that changes in gait are attributable to intervention when group means are considered.

Botulinum Toxin A Injections to the Upper Limbs in Children With Cerebral Palsy: Duration of Effect

We report our experience on the duration of effectiveness of botulinum toxin A injections to the upper extremities of children with cerebral palsy. A retrospective chart review was conducted on 30 consecutive patients (mean age, 9.9 ± 5.0 years) with spastic hemiparesis and quadriparesis. They received 1 to 5 treatments, totaling 56 treatments for the entire cohort. The injected muscles were the pronator teres (50/56), flexor carpi radialis (39/56), biceps (38/56), flexor carpi ulnaris (35/56), opponens (21/56), and adductor pollicis (17/56). Children were assessed for muscle tone and classified according to the Manual Ability Classification System before and after treatment. Functional improvement was apparent after 42 of 56 treatments, and muscle tone decreased significantly (P < .001). The mean duration of the effect was 7.0 ± 3.0 months. We conclude that the effect of botulinum toxin A to the upper limbs is retained for longer periods of time than those reported for lower limbs.