Gait of children and adolescents with cerebral palsy (CP) is often reported to be more asymmetric and variable than gait of typically developing (TD) peers. As this may lead to less stable and less efficient gait, a relevant clinical question is how asymmetry may be improved and variability reduced in this population. The main objective of the current study was to investigate whether higher walking speed would affect gait symmetry and gait variability in children and adolescents with CP. Data from clinical gait analyses of 43 children and adolescents (29 males and 14 females) with unilateral (n = 28) or bilateral (n = 15) CP were included. Mean age was 11.3 ± 3.4 years, with level I (n = 26) or level II (n = 17) according to the Gross Motor Function Classification System (GMFCS). Corresponding data from 20 TD peers, matched in age and gender, were included as reference. Step time, step length, single support, and stance phase were studied at two different gait speeds: preferred and fast walking speed. Symmetry index and coefficient of variation were used as measures of asymmetry and variability, respectively. Results indicated that all participants managed to increase gait speed when instructed to do so. Overall, increased speed did not result in a more asymmetrical or variable gait, except for an increase in step length asymmetry and a difference in response between GMFCS levels I and II in variability. This implies that manipulation of gait speed may be useful clinically without necessarily making gait more unstable. However, some increase in step length asymmetry may be inevitable when gait speed is increased in people with CP.

Intramuscular injections of botulinum toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last 20 years. In Norway, the treatment is now offered to two out of three children with spastic cerebral palsy (CP). However, despite its common use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A in the calf muscles will reduce energy cost during walking, improve walking capacity, increase habitual physical activity, reduce pain and improve self-perceived performance and satisfaction. This randomized, double-blinded, placebo-controlled, multicenter trial is conducted in a clinical setting involving three health regions in Norway. Ninety-six children with spastic CP, referred for single-level injections with BoNT-A in the calf muscles, will be invited to participate. Those who are enrolled will be randomized to receive either injections with BoNT-A (Botox®) or 0.9% saline in the calf muscles. Stratification according to age and study center will be made. The allocation ratio will be 1:1. Main inclusion criteria are (1) age 4 − 17.5 years, (2) Gross Motor Function Classification System levels I and II, (3) no BoNT-A injections in the lower limbs during the past 6 months and (4) no orthopedic surgery to the lower limbs during the past 2 years. The outcome measures will be made at baseline and 4, 12 (primary endpoint) and 24 weeks after injections. Primary outcome is change in energy cost during walking. Secondary outcomes are change in walking capacity, change in activity, perceived change in performance and satisfaction in mobility tasks, and pain. The primary analysis will use a linear mixed model to test for difference in change in the outcome measures between the groups. The study is approved by the Regional Ethical Committee and The Norwegian Medicines Agency. Recruitment started in September 2015. The evaluation of effect is comprehensive and includes objective standardized tests and measures on both impairment and activity level. Results are to be expected by spring 2019. ClinicalTrials.gov, NCT02546999 . Registered on 9 September 2015.

Background: Impaired postural control is a key feature of cerebral palsy that affects daily living. Measures of trunk movement and acceleration have been used to assess dynamic postural control previously. In many children with cerebral palsy, ankle-foot orthoses are used to provide a stable base of support, but their effect on postural control is not yet understood. Objectives: The objectives of the current study were to investigate the effects of ankle-foot orthoses on postural control and energy cost of walking in children with cerebral palsy. Study design: Clinical study with controls. Methods: Trunk accelerometry (amplitude and structure) and energy cost of walking (J/kg/m) were recorded from five-minute walking trials with and without ankle-foot orthoses for children with cerebral palsy and without orthoses for the reference group. Results: Nineteen children with unilateral spastic cerebral palsy and fourteen typically developed children participated. The use of ankle-foot orthoses increased structure complexity of trunk acceleration in mediolateral and anterior–posterior directions. The use of ankle-foot orthoses changed mediolateral-structure toward values found in typically developed children. This change was not associated with a change in energy cost during walking. Conclusions: The use of ankle-foot orthoses does affect trunk acceleration that may indicate a beneficial effect on postural control. Using measures of trunk acceleration may contribute to clinical understanding on how the use of orthoses affect postural control.

Aim: To assess the effect of single botulinum neurotoxin A (BoNT‐A) injections into the calf muscles on the gross energy cost of walking in children with cerebral palsy (CP) and to evaluate the effect of BoNT‐A on walking capacity, physical activity, perceived changes in mobility, and pain.Method: This was an industry‐independent, randomized, quadruple‐blind, placebo‐controlled, multicentre trial (ClinicalTrials.gov registration: NCT02546999). Sixty‐one children (33 male, median age [range] = 8 years [4–16 years]) with spastic CP and classified in Gross Motor Function Classification System (GMFCS) levels I and II allocated to single injections of either BoNT‐A or 0.9% saline into the calf muscles. The main outcome was gross energy cost (J/kg/m); secondary outcomes were walking capacity, habitual physical activity, perceived change in mobility tasks, and calf pain at baseline, 4 weeks (P1), 12 weeks (P2), and 24 weeks (P3) after the injection.Results: The mean change in energy cost did not differ significantly between groups at the primary time point P2 (−0.27 J/kg/m, 95% confidence interval − 0.91 to 0.36, p = 0.404), nor at P1 or P3. Regarding the secondary outcomes, there was some evidence of a larger reduction in pain intensity in the group given BoNT‐A (p = 0.043).Interpretation: One treatment with BoNT‐A was not superior to placebo in making walking easier in children with CP classified in GMFCS levels I and II, at least in the short term. BoNT‐A may have a pain‐reducing effect.

(1) Background: Our study explores the relationship between expected, perceived, and measured effects of botulinum toxin A (BoNT-A) treatment and saline (placebo) in children and adolescents with cerebral palsy (CP) in the calf muscles of 20 children and adolescents with cerebral palsy (CP), aged 4–15 years, using the Gross Motor Function Classification System (GMFCS) I–II. (2) Methods: A mixed methods parallel database design was used. Quantitative and qualitative data were collected at baseline and four weeks after treatment. The primary quantitative measure was gross energy cost (EC) during walking, obtained from a 5-Minute Walk Test (5MWT), while qualitative semi-structured interviews were performed with each parent and child/adolescent individually. (3) Results: Four weeks after treatment, we did not find any correspondence between expected, measured, and perceived effects. Interestingly, parental perceptions of treatment effects were more consistent than the measured outcomes. We also observed a connection between parental treatment expectations and perceived effects, often related to reduced energy expenditure. Children tended to view their parents as treatment experts and had fewer expectations and perceptions themselves. (4) Conclusions: These findings support the importance of child-centered care, which entails actively listening to children’s expectations and perceptions during the treatment process.