A comparison of goal attainment scaling and the Canadian Occupational Performance Measure for paediatric rehabilitation research

Modified constraint-induced movement therapy or bimanual occupational therapy following injection of Botulinum toxin-A to improve bimanual performance in young children with hemiplegic cerebral palsy: a randomised controlled trial methods paper

Background

Use of Botulinum toxin-A (BoNT-A) for treatment of upper limb spasticity in children with cerebral palsy has become routine clinical practice in many paediatric treatment centres worldwide. There is now high-level evidence that upper limb BoNT-A injection, in combination with occupational therapy, improves outcomes in children with cerebral palsy at both the body function/structure and activity level domains of the International Classification of Functioning, Disability and Health. Investigation is now required to establish what amount and specific type of occupational therapy will further enhance functional outcomes and prolong the beneficial effects of BoNT-A.

Methods/Design

A randomised, controlled, evaluator blinded, prospective parallel-group trial. Eligible participants were children aged 18 months to 6 years, diagnosed with spastic hemiplegic cerebral palsy and who were able to demonstrate selective motor control of the affected upper limb. Both groups received upper limb injections of BoNT-A. Children were randomised to either the modified constraint-induced movement therapy group (experimental) or bimanual occupational therapy group (control). Outcome assessments were undertaken at pre-injection and 1, 3 and 6 months following injection of BoNT-A. The primary outcome measure was the Assisting Hand Assessment. Secondary outcomes included: the Quality of Upper Extremity Skills Test; Pediatric Evaluation of Disability Inventory; Canadian Occupational Performance Measure; Goal Attainment Scaling; Pediatric Motor Activity Log; modified Ashworth Scale and; the modified Tardieu Scale.

Discussion

The aim of this paper is to describe the methodology of a randomised controlled trial comparing the effects of modified constraint-induced movement therapy (a uni-manual therapy) versus bimanual occupational therapy (a bimanual therapy) on improving bimanual upper limb performance of children with hemiplegic cerebral palsy following upper limb injection of BoNT-A. The paper outlines the background to the study, the study hypotheses, outcome measures and trial methodology. It also provides a comprehensive description of the interventions provided.

Trial Registration

ACTRN12605000002684

Goal-setting in paediatric rehabilitation: perceptions of parents and professional

BACKGROUND

In paediatric rehabilitation, there is a belief in goal-setting as a fundamental component of decision-making that encourages collaboration and motivation, and improves outcomes. This study aimed to explore parents' and professionals' perceptions of setting and implementing goals within a family centred rehabilitation programme for preschoolers with cerebral palsy (CP).

METHODS

Parents and service providers of 13 preschoolers with CP, classified in Gross Motor Function Classification System level I-III, participated in two-step focus group interviews.

RESULTS

Three major themes emerged, each with two subthemes: (1) 'Goals enhance competence' with the subthemes 'parents as drivers', and 'awareness through observation'; (2) 'Goals direct attention' with the subthemes 'goals as valuable means' and 'collaboration through participation', and (3) 'Goals enter everyday life' with the subthemes 'goals as activities' and 'training vs. everyday practise'. A fourth theme 'child perspective' with the subthemes 'follow-up initiative', 'capture mastery', and 'create learning opportunities' was both an exclusive theme and integrated in the other three main themes.

CONCLUSIONS

Active involvement of parents throughout the process of setting and implementing goals seemed to increase their feeling of competency and partnership with professionals. Concrete goals based on families' preferences and concerns, participatory observation, and discussions with professionals, came out as valuable means for practice of functional tasks within home environments.

Effects of botulinum toxin A on calf muscles in children with cerebral palsy: a systematic review

OBJECTIVE

To assess the efficacy of botulinum toxin A injection for the management of spastic calf muscles in children with cerebral palsy.

DATA SOURCES

We reviewed all relevant literature indexed in MEDLINE, CINAHL, EMBASE, PEDro and the Cochrane Registered Trials, and also hand reviewed abstracts.

METHODS

Eligible studies were randomized controlled trials that compared botulinum toxin A injection with any type of treatment or no treatment with identical conditions. We extracted data on calf muscle tone, passive ankle range of motion, gait speed, ankle kinematics and Gross Motor Function Measure, and assessed methodological qualities.

RESULTS

Fifteen studies met our inclusion criteria. When botulinum injection was compared with a non-sham control, it was found to be effective at improving calf muscle tone (one month: -2.73 (confidence interval (CI) -3.42 to -2.04), three months: -1.72 (-2.68 to -0.76)), passive ankle range of motion (one month: 3.29 (CI 2.52 to 4.05), three months: 1.00 (CI 0.44 to 1.56)) and gait speed (one month: 0.91 (CI 0.29 to 1.53), three months: 0.61 (CI 0.01 to 1.21)) for four months, as well as Gross Motor Function Measure (2.02 (CI 1.30 to 2.75)) for two months. When compared with sham injection, botulinum injection was only effective on Gross Motor Function Measure (0.98 (CI 0.28 to 1.69)) after four months.

CONCLUSIONS

Although we found evidence supporting the efficacy of botulinum toxin A in studies comparing botulinum injection with non-sham controls, we did not find clear evidence of support in studies comparing botulinum injection with sham injection.

Outcome measures used in studies of botulinum toxin in childhood cerebral palsy: a systematic review

This literature review uses the International Classification of Functioning, Disability and Health to describe the quality and variety of the studies of botulinum toxin in children with cerebral palsy since 2001. Articles were identified via electronic query and then reviewed for strength of evidence and classification of outcome measures. The distribution of levels of evidence for the 63 articles was I (n = 8), II (n = 12), III (n = 21), and IV (n = 22). One or more measurements were used in the International Classification of Functioning, Disability and Health domains of body structure and function (47 papers), activity (47 papers), participation (12 papers), and environmental/personal factors (10 papers). A total of 67% of all outcomes demonstrated a significant difference (I 49%, II 39%, III 74%, IV 88%). This review illustrates that few studies provide a high level of evidence and that outcomes focus on arenas such as spasticity or range of motion rather than activity or participation domains such as walking.

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE)

BACKGROUND

Cerebral palsy (CP) is "a group of permanent disorders of the development of movement and posture causing activity limitation(s) that are attributed to non-progressive disturbance that occurred in the developing fetal or infant brain" (Rosenbaum 2007, p.9). The spastic motor type is the most common form of CP. Therapeutic management may include splinting/casting, passive stretching, facilitation of posture/movement, spasticity-reducing medication and surgery. Botulinum toxin-A (BoNT-A) is now used as an adjunct to these techniques in an attempt to reduce spasticity, improve range of movement and function.

OBJECTIVES

To assess the effectiveness of injections of BoNT-A or BoNT-A and occupational therapy in the treatment of the upper limb in children with CP.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register/CENTRAL (The Cochrane Library, Issue 3, 2008), MEDLINE (1966 to August Week 1 2008), EMBASE (1980 to 2008 Week 28) and CINAHL (1982 to August Week 1 2008).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing BoNT-A injection or BoNT-A injection and occupational therapy in the upper limb(s) with other types of treatment (including no treatment or placebo) in children with CP.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity and rated for quality using the PEDro scale. Data were extracted and entered into RevMan 5.0.15.

MAIN RESULTS

Ten trials met the inclusion criteria. PEDro quality ratings ranged from 6/10 to 10/10. Concentration of BoNT-A ranged from 50U/1.0ml to 200U/1.0ml saline with doses of 0.5U to 16U/kg body weight and total doses of 220 to 410 Units (Botox(R)).A combination of BoNT-A and occupational therapy is more effective than occupational therapy alone in reducing impairment, improving activity level outcomes and goal achievement, but not for improving quality of life or perceived self-competence. When compared with placebo or no treatment, there is moderate evidence that BoNT-A alone is not effective.

AUTHORS' CONCLUSIONS

This systematic review found high level evidence supporting the use of BoNT-A as an adjunct to managing the upper limb in children with spastic CP. BoNT-A should not be used in isolation but should be accompanied by planned occupational therapy.Further research is essential to identify children most likely to respond to BoNT-A injections, monitor longitudinal outcomes, determine timing and effect of repeated injections and the most effective dosage, dilution and volume schedules. The most effective adjunct therapies including frequency and intensity of delivery also requires investigation.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

Goal attainment scaling: a direct comparison of alternative rating methods

Purpose: To compare two alternative rating systems for goal attainment scaling (GAS) intended to improve capture of goal underachievement.

Setting: A tertiary inpatient neurorehabilitation unit.

Design: Secondary comparative analysis of prospective cohort data.

Participants: A total of 243 patients were included, with 977 goals between them; M:F ratio 146:97, mean age 44.8 (SD 14.2) years. Diagnosis: 200 (82%) acquired brain injury, 21 (9%) spinal cord injury, 22 (9%) other neurological conditions.

Methods: Goal attainment scaling-rated achievement of 1—6 patient-selected goals was collected using the standard 5-point scale (—2 to +2) and formula to derive aggregated T-scores, as recommended by its originators. Two alternative 6-point rating systems were applied retrospectively. Version 1 set all baseline scores at ‘—2’ and added ‘—3’ to denote ‘worsening’. Version 2 added a ‘—0.5’ score to denote ‘partial achievement’ for goals starting at ‘—1’, without change to range or baseline scores.

Results: Baseline scores were identical for standard rating and version 2 (median 34.9, interquartile range (IQR) 31.9—35.5), but lower for version 1 (median 21.0, IQR 19.8—22.6), which was reflected in the change scores. While median achieved T-scores were 50.0 for all three methods, version 2 marginally overestimated goal attainment (Wilcoxon z —6.8, P<0.001), while version 1 underestimated it (Wilcoxon z —7.2, P<0.001), in comparison with standard goal rating.

Conclusion: Different goal rating methods may have significant impact on goal attainment scaling results. Version 2 provided the closest match to standard rating, supporting documentation of partial goal achievement without affecting score range. For analysis and reporting, ‘0.5’ scores should be converted to ‘—1’, to maintain parity with standard rating systems.

Occupational therapy home programs for cerebral palsy: double-blind, randomized, controlled trial

OBJECTIVE

The goal was to assess the effectiveness of an occupational therapy home program (OTHP), compared with no OTHP, with respect to function and parent satisfaction with child function, participation, goal attainment, and quality of upper limb skill in school-aged children with cerebral palsy.

METHODS

Thirty-six children with cerebral palsy (mean age: 7.7 years; male: 69%; Gross Motor Function Classification System: level I, 47%; level II, 14%; level III, 16%; level IV, 7%; level V, 16%; spasticity, 85%; dyskinesia, 14%; ataxia, 3%) were randomly and equally assigned to OTHPs for 8 or 4 weeks or to no OTHP. The primary end point was Canadian Occupational Performance Measure scores 8 weeks after baseline. Secondary measures were recorded at 4 and 8 weeks.

RESULTS

Eight weeks of OTHP produced statistically significant differences in function and parent satisfaction with function, compared with no OTHP. Parents in the 4-week OTHP group did not discontinue use at 4 weeks, as instructed, and continued for 8 weeks; results demonstrated statistically significant differences, compared with no OTHP. There was no difference in primary or secondary end point measures between intervention groups.

CONCLUSION

Pediatricians can advise families that OTHPs developed with a collaborative, evidence-based approach and implemented by parents at home were clinically effective if implemented 17.5 times per month for an average of 16.5 minutes per session.

Goal-oriented cognitive rehabilitation for an individual with Mild Cognitive Impairment: behavioural and neuroimaging outcomes

An individual, goal-oriented cognitive rehabilitation intervention was conducted with AB, a 77-year-old woman with MCI. Outcomes were evaluated using a client-centred measure of goal achievement and an experimental associative learning task testing a skill practised in the intervention. Pre- and post-intervention fMRI scans were compared to examine changes in brain activation. Following intervention, AB showed improved performance on rehabilitation goals and on the associative learning task. There were significant decreases in brain activation in sensory areas and significant increases in memory-related areas. Both client-centred measures and fMRI may assist in detecting clinically-meaningful changes resulting from cognitive rehabilitation interventions.

Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial

BACKGROUND

The Canadian Occupational Performance Measure (COPM) is a commonly used outcome measure in rehabilitation. In this study it was adapted for very young children by deleting paid/unpaid work and household management categories and having parents act as proxies to rate child performance and their own satisfaction.

PURPOSE

To assess the internal consistency reliability, content and construct validity, responsiveness, and impact of half scores (20 not 10-point scale) of the adapted COPM.

METHOD

Parent proxies of subjects aged 2 - 8 (mean 3.9) years with spastic hemiplegic cerebral palsy (n = 41) participating in a clinical trial. There was a total of 214 occupational performance problems for analysis and an additional 56 which had used half score ratings. Internal consistency reliability and construct validity were evaluated using Cronbach alpha statistic. Proxy views explored content validity. Responsiveness was evaluated using pre-post intervention scores and a comparison with Goal Attainment Scaling scores which were assumed to be a suitable benchmark measure. The effect of half scores was assessed by two-sample t-tests.

RESULTS

The COPM adaptations did not have a negative impact on internal consistency reliability as this was acceptable for performance (0.73) and satisfaction (0.83). The high Cronbach alpha scores indicated good construct validity. Content of occupations and rating approach was considered valid by proxies. Use of half scores did not result in significantly different performance ratings, but mean satisfaction ratings were significantly higher when half scores were used (p = 0.0001). This suggests that half scores may provide more precise proxy satisfaction ratings, but at the cost of rigour as internal consistency with satisfaction half scores was lower (0.63 vs. 0.82). Responsiveness to change in clinical status was demonstrated by significant pre-post scores and moderate correlations with goal attainment scores.

CONCLUSION

The adapted COPM is a psychometrically robust tool and the use of half scores is not recommended.

Goal attainment scaling (GAS) in rehabilitation: a practical guide

Goal attainment scaling is a mathematical technique for quantifying the achievement (or otherwise) of goals set, and it can be used in rehabilitation. Because several different approaches are described in the literature, this article presents a simple practical approach to encourage uniformity in its application. It outlines the process of setting goals appropriately, so that the achievement of each goal can be measured on a 5-point scale ranging from -2 to +2, and then explains a method for quantifying the outcome in a single aggregated goal attainment score. This method gives a numerical T-score which is normally distributed about a mean of 50 (if the goals are achieved precisely) with a standard deviation of around this mean of 10 (if the goals are overachieved or underachieved). If desired, the approach encompasses weighting of goals to reflect the opinion of the patient on the personal importance of the goal and the opinion of the therapist or team on the difficulty of achieving the goal. Some practical tips are offered, as well as a simple spreadsheet (in Microsoft Excel) allowing easy calculation of the T-scores.

Effect of sensorimotor groups on gross motor acquisition for young children with Down syndrome

PURPOSE

To examine whether participation in sensorimotor groups and individual intervention resulted in greater improvements in motor skill acquisition than solely individual intervention for young children with Down syndrome.

METHODS

Ten children with Down syndrome, 13 to 29 months of age, participated. Children in both groups received individual intervention, and children in the intervention group participated in 10 weekly sensorimotor groups. All children were assessed at 3 points using the Gross Motor Function Measure and Goal Attainment Scaling.

RESULTS

Children in the intervention group demonstrated significant improvement compared with children in the control group at the p < 0.10 level in lying and rolling, crawling and kneeling, and total score domains of the Gross Motor Function Measure and in Goal Attainment Scaling.

CONCLUSIONS

Participation in sensorimotor groups and individual intervention resulted in greater improvement in motor skill acquisition than solely individual intervention for young children with Down syndrome. Additional research to support these exploratory findings is needed.

Goal-oriented rehabilitation of preschoolers with cerebral palsy--a multi-case study of combined use of the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scaling (GAS)

PURPOSE

To explore setting and implementing goals as an ongoing process, using the COPM and the GAS in combination.

METHODS

Multi-case study of a goal-setting approach, involving parents and service providers of 13 children (aged 23-50 months) with mild-to-moderate CP enrolled in a 9-month rehabilitation programme consisting of two blocks of setting and implementing goals. The children's COPM reports and GAS goals and information from a questionnaire about implementation were analysed.

RESULTS

In the initial assessment, most problems prioritized by the parents in the COPM were phrased in terms of activities. The priorities for intervention changed during the process of setting and implementing goals. GAS goals were frequently integrated in everyday activities both at home and in kindergarten based on decisions on how to implement the goals. Changes in the children's performance were recognized by a high proportion of goal attainment and a small, but clear change in the parents' perception of performance. Parents and service providers reported many gains working towards concrete and measurable goals, but also some challenges.

CONCLUSION

By using the COPM and GAS in combination, a dynamic and interactive process of setting and implementing goals in the context of everyday activities emerged.

Paediatric Application of Individualised Client-Centred Outcome Measures: A Literature Review

A literature review was conducted to identify and compare the clinical utility of client-centred, individualised outcome measures for paediatric rehabilitation. Five measures were identified: the Canadian Occupational Performance Measure (COPM) (28 studies); Goal Attainment Scaling (GAS) (34 studies); Perceived Efficacy and Goal Setting System (PEGS) (2 studies); Target Complaints (TC) (1 study); and the Paediatric Activity Card Sort (PACS) (instruction manual only). The COPM and GAS have been used with children across a wide age range and variety of clinical settings. The PEGS and PACS provided young children direct involvement in the goal-setting process. Little evidence supports the use of TC in paediatrics.

Clinicians need to use individualised measures in a way that facilitates the maximal participation of children and families in goal setting and outcome evaluation. Clinicians should document their own role in goal setting. The use of individualised and client-centred measures can motivate children and families and focus their attention on therapy goals.

Goal Attainment Scaling in paediatric rehabilitation: a report on the clinical training of an interdisciplinary team

BACKGROUND

Goal Attainment Scaling (GAS) is a responsive method for individual goal setting and treatment evaluation. However, current knowledge about its reliability when used in paediatric rehabilitation treatment is insufficient and depends highly on standardization of the GAS method. A training programme was developed to introduce GAS to a team of 27 professionals from five disciplines. The purpose of the paper is to share the experiences of professionals and parents during this training.

METHODS

The training consisted of three 2-h general discussion sessions and intensive individual feedback from the study leader (i.e. the first author). Feedback was given until the GAS scales met predetermined criteria of ordinality, described specific, measurable, acceptable, realistic abilities and activities in a single dimension, used the 'can-do' principle and could be scored within 10 min. Therapists and parents were asked to give their opinion by completing a questionnaire.

RESULTS

One hundred and fifteen GAS scales were developed and scored by professionals. The development of a GAS scale remained a time-consuming procedure, despite the training: 45 (SD = 27) minutes per scale. The content criteria of GAS were found to be useful by all participants. Common issues requiring revision of the initial scales were equal scale intervals, specificity, measurability and selection of a single variable. After the training, 70% of the therapists and 60% of the parents regarded GAS as a suitable tool to improve the quality of rehabilitation treatment. Examples of GAS scales developed by the various disciplines are presented and discussed.

CONCLUSIONS

The experiences reported in this paper support the further development of training procedures for GAS before it can be used as an outcome measure in effect studies. The findings may be helpful in introducing GAS in the field of childhood disability.

Visual Analogue Scale to score the effects of Botulinum Toxin A treatment in children with cerebral palsy in daily clinical practice

OBJECTIVE

This study examined the reliability and efficiacy of the Visual Analogue Scale (VAS) in evaluating spasticity treatment in an outpatient setting.

PATIENTS AND METHODS

We used a parent-reported VAS device for evaluating the effects of Botulinum Toxin A (BTX-A). Data were collected on 55 children with cerebral palsy. Individual goals of treatment were formulated in close consultation with the caregivers. The categories of treatment options were improvement of pain, problems with nursing, sitting position, standing and walking.

RESULTS

Seventy-four interventions were performed in 55 children. A statistically significant effect was found for improvement of nursing, standing and walking. No statistically significant effect for pain was found, probably because of small numbers. In seven children there was no effect at all. Side effects were observed in five children.

CONCLUSION

In using a VAS instrument, beneficial effects were found for nursing, standing and walking after BTX-A treatment. A positive (not significant) correlation was found between the VAS and the Modified Tardieu for those children who also underwent a gait analysis. Evaluating spasticity treatment with the use of the VAS has an important advantage because it is a quick and easy method for evaluating individually defined treatment goals in an outpatient setting, in which time-consuming evaluations are not an option.

Goal attainment scaling in paediatric rehabilitation: a critical review of the literature

The aim of the study was to review the psychometric properties and use of goal attainment scaling (GAS) in paediatric rehabilitation research. We performed a critical literature review searching: (1) all studies whose main focus was to assess the psychometric properties of GAS in paediatric rehabilitation; and (2) all effect studies in paediatric rehabilitation that used GAS as one of the outcome measures. Three articles in the first group and six in the second group met the inclusion criteria. None of the studies had investigated the content reliability of the scales. Interrater reliability had been investigated in one study and had been found to be good. Only one trial had assessed the content validity of the developed scales, which was found to be acceptable. Comparisons showed that GAS, because of its idiosyncratic nature, measures different constructs from those measured by some related instruments. Low concurrent validity was found. All included studies reported good sensitivity to change. We conclude that the literature supports promising qualities of GAS in paediatric rehabilitation. GAS is a responsive method for individual goal setting and for treatment evaluation. However, current knowledge about its reliability when used with children is insufficient. There is a need for further development of GAS and its application for children of different ages and disabilities, across therapists of different disciplines.

Clinimetric properties of participation measures for 5- to 13-year-old children with cerebral palsy: a systematic review

This study systematically reviewed the validity, reliability, sensitivity to change, and clinical utility of measurements of participation for children with cerebral palsy. Sixteen measures were identified and seven met the inclusion criteria of having 30% content measuring participation, for use with children aged 5 to 13 years with physical disability, and were condition specific. The Children's Assessment of Participation and Enjoyment (CAPE) assessed participation in leisure and recreation, while the School Function Assessment (SFA) and School Outcome Measure addressed participation in the school environment. The Assessment of Life Habits for Children (LIFE-H) measured participation in home, school, and community life, and the Children Helping Out: Responsibilities and Expectations assessed children's participation in household duties. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were individualized tools used to evaluate goal achievement. Results showed most instruments had adequate reliability and validity. The COPM and GAS were the only measures that reported adequate responsiveness to detect clinically significant change. Limited data are currently available to determine the responsiveness of the CAPE, LIFE-H, and SFA. A combination of assessments is required to capture participation of children in home, school, and community environments.

A pilot study of the Video Observations Aarts and Aarts (VOAA): a new software program to measure motor behaviour in children with cerebral palsy

A new computer software program to score video observations, Video Observations Aarts and Aarts (VOAA) was developed to evaluate paediatric occupational therapy interventions. The VOAA is an observation tool that assesses the frequency, duration and quality of arm/hand use in children, in particular those with cerebral palsy. Reliability studies show that the first module, designed to evaluate a forced-use programme, has an excellent content validity index (0.93) and good intra- and inter-observer reliability (Cohen's kappas ranging from 0.62 to 0.85 for the three activities tested). With the built-in statistical package, paediatric occupational therapy departments can conduct therapeutic evaluations with children with impairments in the upper extremities. Further research is recommended to apply the VOAA in clinical studies in paediatric occupational therapy.

European consensus table 2006 on botulinum toxin for children with cerebral palsy

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.