***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Despite the lack of consensus of the role of spasticity in the observed motor disability in cerebral palsy ( CP ) , alleviation of spasticity remains a primary focus in the clinical management of these patients . The purpose s of this study were to : ( 1 ) quantify voluntary torque and passive resistance across speeds in the hamstrings and quadriceps muscle groups with respect to the presence of stretch responses and /or passive muscle stiffness in patients with CP compared to age-related children without disability , and ( 2 ) relate these parameters to each other and to functional performance , as measured by the Gross Motor Function Measure ( GMFM ) , in CP . Included were 23 subjects with CP , sub-grouped by the presence or absence of stretch responses as determined by electromyography , and 9 subjects without CP .  Results indicated that peak torque was considerably greater in the comparison group than for each of the CP groups and resistance was greater in the CP group with spasticity compared to the nonspastic CP group in both muscles at all speeds . Stiffness differed between the spastic CP group and the comparison group only for the quadriceps at the fastest speed . Higher passive resistance torque and stiffness were correlated with decreased voluntary torque , particularly for the antagonists , and with lower GMFM scores . In conclusion , strength and motor function are related to the magnitude of resistance torque and stiffness in CP , although the small amount of variance explained reinforces the multidimensional nature of this disorder , and the challenges inherent in managing it Authors report the preliminary results of an open-label , prospect i ve study to evaluate a functional benefit of botulinum toxin type A injections in diparetic cerebral palsy patients , using gross motor function measure ( GMFM ) score . In a group of 14 children ( mean age 3.9 years , range 2 - 6 ) treated with Dysport 30 IU/kg , a statistically significant improvement ( P < 0.05 ) was noticed in both simple measurements ( Modified Ashworth Scale , Selective Motor Control , Passive Range of Movements , Physician Rating Scale and parental Clinical Global Impression ) and complex functions ( GMFM dimensions D and E ) after 1 and 3 months . However , the simple measurement scores decreased ( but not to the baseline ) after 3 months ; surprisingly , GMFM scores were still increasing ( 7.7 % change after 3 months and 11.3 % change after 6 months in nine patients ) . These results are in concordance with a few other data published to date . The study may support the concept of persistent functional gain in long-term treatment of spasticity caused by cerebral palsy with botulinum toxin type Botulinum neurotoxin type-A ( BoNT-A ) has been used in association with other interventions in the management of  spasticity in children with cerebral palsy ( CP ) for almost two decades . This consensus statement is based on an extensive review of the literature by an invited international committee . The use of BoNT-A in the lower limbs of children with spasticity caused by CP is reported using the American Academy of Neurology Classification of Evidence for therapeutic intervention . R and omized clinical trials have been grouped into five areas of management , and the outcomes are presented as treatment recommendations . The assessment of children with CP and evaluation of outcomes following injection of BoNT-A are complex , and therefore , a range of measures and the involvement of a multidisciplinary team is recommended . The committee concludes that injection of BoNT-A in children with CP is generally safe although systemic adverse events may occur , especially in children with more physical limitations ( GMFCS V ) . The recommended dose levels are intermediate between previous consensus statements . The committee further concludes that injection of BoNT-A is effective in the management of lower limb spasticity in children with CP , and when combined with physiotherapy and the use of orthoses , these interventions may improve gait and goal attainment OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity OBJECTIVES . The purpose of this work was to assess the effect of botulinum toxin A and occupational therapy compared with occupational therapy alone on body structure , activities participation , and self-perception in a sample of children ( aged 3–16 years ) with hemiplegic cerebral palsy recruited from a statewide register . PATIENTS AND METHODS . Participants of this single-blind , r and omized , controlled trial identified from a population -based cerebral palsy register received either an individually prescribed and localized injection of botulinum toxin A with 4 sessions of occupational therapy over 4 weeks ( intervention ) or occupational therapy alone ( control ) . Outcomes were assessed from 2 domains of the World Health Organization International Classification of Functioning , Disability , and Health : body structure ( Modified Ashworth Scale and Tardieu Scale ) and activities participation ( Assessment of Motor and Process Skills , Goal Attainment Scale , Pediatric Evaluation of Disability Inventory , and Pediatric Quality of Life Inventory ) . Self-perception was also measured . RESULTS . All of the participants ( intervention : n = 21 ; control : n = 22 ) provided data at baseline and 3 and 6 months . Mean age was 8.6 years ; 23 were boys and 20 were girls . At 3 months , children allocated to receive the intervention performed significantly better in terms of body structure and activities participation . They reported improvements in self-perception for the global self-worth domain . At 6 months , the differences between the intervention and control groups persisted for the measures of body structure but not for activities participation or self-perception . CONCLUSION . Botulinum toxin A injection combined with a low-intensity occupational therapy program achieves significant improvements in body structure , activity participation , and self-perception The purpose of this study was to compare the cumulative efficacy ( three treatment sessions ) of botulinum toxin A ( BTX-A ) alone , casting alone , and the combination of BTX-A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy ( CP ) . Thirty-nine children with spastic CP ( mean age 5y 10mo , range 3 to 9y ) were enrolled in the study . A multicenter , r and omized , double blind , placebo-controlled prospect i ve study was used . Children were r and omly assigned to one of three treatment groups : BTX-A only ( B ) , placebo injection plus casting ( C ) , or BTX-A plus casting ( B+C ) . The dosage for the BTX-A injections was 4U/kg per extremity . Assessment s were performed at baseline , 3 , 6 , 7.5 , and 12 months with a total of three treatments administered after the evaluations at baseline , 3 , and 6 months . Primary outcome measures were ankle kinematics , velocity , and stride length . Secondary outcome measures were ankle spasticity , strength , range of motion , and ankle kinetics . Group B made no significant change in any variable at any time . Groups C and B+C demonstrated significant improvements in ankle kinematics , spasticity , passive range of motion , and dorsiflexor strength . Results of this 1-year study indicate that BTX-A alone provided no improvement in the parameters measured in this study , while casting and BTX-A/casting were effective in the short- and long-term management of dynamic equinus in children with spastic CP OBJECTIVE To evaluate the changes in cortical somatosensory-evoked potentials ( SEPs ) after botulinum toxin type A injection to determine what effect spasticity has on cortical SEPs . DESIGN Intervention study and before-after trial . SETTING University-affiliated hospital in Korea . PARTICIPANTS Twelve children with spastic hemiplegic cerebral palsy ( CP ) , 7 children with spastic diplegic CP , and 8 patients with traumatic brain injury . INTERVENTION All participants had botulinum toxin type A injected into the muscles of the spastic limb . MAIN OUTCOME MEASURES SEPs were recorded before and 7 days after the botulinum toxin type A injection .  Spasticity of the affected spastic limb was also measured . The short latency and amplitude of waves in SEPs were measured . The SEP results were divided into 3 groups : flat ( no evoked potential ) , abnormal ( evoked but delayed in latency ) , and normal ( clear waveform with normal latency ) . RESULTS The normal response of cortical SEP increased after injection . The SEPs exhibited more frequent improvement in the limbs , with greater improvement of spasticity in grade ( > 1.0 grade ) and in patients of younger age ( < 3y ) after injection ( P<.05 ) . CONCLUSION The observed improvement of cortical SEPs with associated reduction of spasticity that occurred after the botulinum toxin type A injection indicates that spasticity itself can be considered a factor affecting cortical SEPs Aim Stiffness and shortening of the calf muscle due to neural or mechanical factors can profoundly affect motor function . The aim of this study was to investigate non‐neurally mediated calf‐muscle tightness in children with cerebral palsy ( CP ) before and after botulinum toxin type A ( BoNT‐A ) injection Resistance training of the lower limbs is now commonly used in clinical practice in children and adolescents with spastic cerebral palsy ( CP ) . However , the effectiveness of this type of training is still disputed . The most recently published systematic review with meta- analysis included interventions such as electrical stimulation and resistance training and found insufficient evidence to support or refute the efficacy of these exercises in children with CP . Thus , the aim of this article is to evaluate the extent to which training protocol s from the most recent r and omized controlled trials are in keeping with the evidence for effective resistance  training in children who are developing typically , as reflected in the training guidelines of the National Strength and Conditioning Association . Recommendations for resistance training protocol s , based on this evidence and appropriate to children with CP , are provided to help guide both future research and clinical practice for resistance training in children with CP It has been demonstrated that botulinum toxin type A ( BTX‐A ) injections reduce spasticity and improve muscle growth in children with spasticity . It has been postulated that BTX‐A allows the learning of more normal movement patterns . The aim of this study was to measure the effect of this treatment on functional ability , as measured by the Gross Motor Function Measure ( GMFM ) , in children with spastic hemiplegic cerebral palsy . Children of 3–13 years and meeting the selection criteria were r and omly allocated to the control or injection group using a matched pair design . A match constituted a child within 6 months of age with the same Modified Ashworth Score ( MAS ) for the gastroc‐soleus and within 10 % of the same goal scores on the Gross Motor Function Measure . Twelve matched pairs were enrolled . Outcomes were measured on enrolment and at 1 , 3 and 6 months post injection . The time course of the response to BTX‐A was assessed with measurements of the MAS , dynamic range of motion ( R1 ) and static muscle length ( R2 ) . Motor function was assessed using the 88‐item GMFM and parental satisfaction with a 10‐point visual analogue scale . Within pair comparisons of the GMFM using the Wilcoxon signed rank test indicated that the treatment group made significantly greater gains than controls at 3 months ( P=0.02 ) with even greater differences seen at 6 months ( P=0.004 ) . Using parametric statistics , the intrapair difference in proportional change of GMFM increased from 35 % ( 4 to 65 ) at 3 months to 52 % ( 17–87 ) at 6 months . Response to injection was confirmed by a decrease in MAS in the treatment group and very little change in controls . This difference was significant ( P=0.002 ) at 3 months and was attenuated but still significant ( P=0.016 ) at 6 months ; the difference in proportional change decreased from 44 % at 3 months to 22 % at 6 months . 
    Output:
    
BTX-A application demonstrated no changes in the passive stiffness of spastic muscle .
In relation to functional level , the evidence of BTX-A effect was controversial .