During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.

Objective: To identify and appraise the existing clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of adult and paediatric focal spasticity to generate a single synthesized guideline. Methods: Systematic review of 12 electronic databases. Clinical practice guidelines, consensus statements and Cochrane systematic reviews for focal spasticity in adults and children. Included studies were appraised according to the AGREE II criteria. Results: A total of 25 papers were included in this review, comprising 12 clinical practice guidelines, nine consensus statements and four Cochrane systematic reviews. The areas most strongly endorsed were: (1) management to be provided by a multi-disciplinary team, (2) therapy should be goal-directed, (3) goals to be developed in conjunction with the patient and family, and (4) importance of follow-up evaluations. There was a greater focus on activity outcomes and classification in the paediatric papers. The guidelines varied considerably in their quality, with AGREE II scores ranging from 52.8 to 97.1%. Conclusions: This systematic review has synthesized the key elements regarding principles of focal spasticity management, outcome measures, physical interventions and educational recommendations into a single, readily applied guideline available for clinical use. Despite considerable variability in the quality of the guidelines, several strong themes emerged.

Authentic, situated learning experiences which mirror the collaborative nature of healthcare practice are essential in preparing students for their future professions. Feedback literacy may be thought of as the understanding, capacity, and disposition needed to make sense of information and use it to enhance work or learning strategies. This study explored how feedback literacy can be developed through situated, interprofessional peer-to-peer feedback within a community-based paediatric health screening programme. Using an exploratory Action Research qualitative design, the planning activities stage explored current practice, gathering student insights via interviews, reflections, and a workshop to co-design an Interprofessional Feedback Conversation Guide (IPFCG). The IPFCG was piloted, integrating structured feedback tools and protected time for peer exchange, within the community screening activity. Feedback regarding use of the IPFCG contributed to the gathering data stage, which was followed by the evaluation and reflection stage. Evaluation revealed four key themes: value, engagement, optimising relationships, and structuring conversations. Students valued receiving feedback from peers outside their discipline, actively engaged with the process, emphasised the importance of building rapport, and utilised structured dialogue. These findings highlight how authentic, field-based learning can foster feedback literacy, enhancing the development of professional identity. The interprofessional nature of the program reflects the complexity of modern healthcare and demonstrates how curriculum-integrated models of authentic learning can enhance student engagement and workplace readiness. This study contributes to the evolving conversation about embedding authenticity in higher education and offers a practical model for building collaborative communication within situated learning experiences at scale.

This commentary is on the original article by Li et al. on pages 86‐93 of this issue.