Cerebral palsy (CP) is a nonprogressive neurological disorder presenting with multiple impairments including spasticity, weakness, and impaired motor control. botulinum toxin A (Botox) is a recently well-documented, safe, and noninvasive adjunct to the management of children with CP.1,2 Botox provides an effective, short-term intervention to reduce spasticity, prevent or delay orthopedic surgery, and improve function and gait when used as an adjunct to other interventions including physiotherapy and casting.3–9 Local injection of Botox into muscles with spasticity results in reversible disruption of acetylcholine release from the nerve endings into the muscle,10 enabling increased function to be achieved over the time effect of the Botox.11
Although current research on the efficacy of Botox in children with CP has focused on function and impairment outcomes, other therapy-related aspects such as service coordination, communication between those involved with the child’s care and therapy, and patient instruction for therapy after Botox are also important following Botox.12 Dumas et al13 discovered in their study of six physiotherapists who were primary therapists for children with CP who received lower limb Botox injection that a number of strategies are implemented by therapists in their management of these children. These strategies included strengthening techniques, gait training, balance training, stretching, and the use of orthotics. A search of databases, Embase, MEDLINE, AHMED, and CINAHL found no case studies that closely examined and documented the strategies used by physiotherapists (such as patient instruction, specific physical treatment, and communication within the team delivering the care) following Botox injection in children with CP. Although it is probably not possible to apply one prescription of intervention that will be suitable for every child after Botox injection (because each child will have differing functional ability, cognitive level, and personal goals), a case study offers the opportunity to document practice in detail, so that readers can reflect on the outcomes of this practice, compare it to their own practice, and raise questions for further research. The purpose of this case report is to document and evaluate the physiotherapy assessment and management of a child with CP who received lower limb Botox injections and to examine the context in which this management was delivered.
A variety of examination tools, both function and impairment based, have been used to determine the efficacy of Botox in children with CP. The Gross Motor Function Measure (GMFM) and Goal Attainment Scaling have been used in studies that examine change in function.4,6,8,11 The GMFM is a standardized quantitative assessment scale of gross motor function, with good intra- (0.92–0.99) and interrater (0.87–0.99) reliability14 that has been shown to have good validity (0.66–0.79) to demonstrate change in function over time,15 although it has ceiling and floor effects in very high or very low functioning children.14 It consists of five dimensions, ranging from functional abilities such as rolling and sitting to running and jumping. Specific dimensions can be scored separately (as a goal score for a particular child) or together as a total score. Goal Attainment Scaling is a method of identifying personal goals for the child and his or her family and setting this as a measure of efficacy of treatment.16 In addition, video gait analysis has been frequently used to show changes in gait after Botox treatment.4,8,11
Impairment outcomes used in such studies4,6,8,11,17,18 have included measures of passive range of motion, dynamic range of motion, selective motor control (the ability to select muscle activity in order to move joints individually, eg, the ability to flex the ankle without also having to flex the knee), muscle tone, and scoring of elements of the gait cycle such as the ability to achieve correct foot strike. Scoring of elements of the gait cycle has been performed using the Physicians Rating Scale,19 which gives a grade score for each of seven observations during gait (Appendix 1). A higher score indicates a more typical gait pattern with a total possible score of 15 per limb. This measure was reported to have limits in interrater reliability3 and so has more recently been adapted and named the Observational Gait Scale.17 Its reliability and validity have been investigated by Mackay et al,20 and although some of the sections have acceptable interrater and intrarater reliability (eg, ranging from 0.53 to 0.91); further work on sections of this scale is recommended by the authors before it is used as an outcome measure for ambulant children with CP.
Graham et al21 recommended the following for baseline measures prior to Botox injections in the lower limbs of children with CP: passive range of motion, dynamic range of motion (Tardieu Scales), muscle strength, selective motor control, and muscle spasticity.
LA, born at 34 weeks’ gestation, was diagnosed with spastic diplegic CP at approximately eight months of age, when a delay in developmental milestones was noted. LA had received weekly home-based physiotherapy from the age of two years. Prior to that, LA had received physiotherapy on a less regular basis due to living in a rural area. LA had a classification of level II on the Gross Motor Function Classification System (GMFCS),22 being independently mobile with a posterior walking frame and bilateral ground reaction ankle foot orthoses (GRAFOs). LA was unable to stand independently without support and, even with support, stood on tiptoe. At the age of 3.5 years, LA received Botox injections to his medial hamstrings and gastrocnemius muscles (70 units to the hamstrings and 30 units into the calf muscles bilaterally). Written informed consent for this child to be the subject of a case report was obtained from the child’s mother.
An initial physiotherapy assessment was completed prior to the Botox injections with a second assessment at the completion of 10 weeks of therapy. The initial examination consisted of the following outcome measures: the GMFM,14,23 gait speed, Goal Attainment Scaling,16 dynamic21 and passive range of movement, Selective Muscle Control,17 and the Physicians Rating Scale of Gait19 (by video analysis).
The initial examination was completed at the clinic setting of the child’s usual physiotherapist. The second examination was completed at the home of the child. All measurements were taken and recorded by LA’s usual physiotherapist (EW).
Two-dimensional video data were collected for gait in both sagittal and coronal planes, for the initial examination with and without orthoses while using a walker, and for the second examination with an additional condition of using quad sticks with orthoses. LA walked at both a self-selected speed and, when directed, did “best” walking (which was slower than the self-selected speed because one foot was placed on the ground before the other foot was moved from the ground, enabling a more normal gait pattern and using the available ranges of movement in the lower limbs). The Physicians Rating Scale of Gait was scored from the video of this best walking. Gait speed was calculated from the video of self-selected walking (by timing the walk over the middle five meters of a 15-m walkway).
Both dynamic and passive ranges of movement were measured using a standard protocol for goniometry.24 The dynamic range of motion measures the muscle response, as a catch, to increased velocity of passive movement of a joint and is a clinical estimate of the threshold of the angle of spasticity.21 It is recorded in this case study as R1, with passive range of movement measures presented as R2.
The Selective Muscle Control Test (dorsiflexion) is a recently developed measure of recording how accurately a child with CP can isolate the selection of a particular muscle group, without contracting other muscle groups17 (eg, in this case, being able to dorsiflex the foot at the ankle using the tibialis anterior compared to achieving dorsiflexion by combining this with hip and knee flexion). Although it is essentially a subjective measure, it is well described and detailed by Boyd,17 who reports the measure to have correlation with foot function in gait and with a higher score, predicting better foot clearance in swing (Appendix 2).
Goal Attainment Scaling was used for measuring progress by setting goals that related to LA’s particular functional needs. The physiotherapy goals for LA following Botox injections were to (1) gain independent standing and then increase independent standing time, (2) walk with a reciprocal pattern of gait when using the walking frame, and (3) ascend and descend steps with or without ankle-foot orthoses (AFOs) by walking, using the handrail for support rather than by crawling on hands and knees.
For the 18 months prior to receiving Botox, LA had received a weekly physiotherapy home visit or a very occasional preschool or clinic visit. After Botox injections, LA received a more intensive five-week block of intervention with two sessions a week, followed by another five weeks of physiotherapy received once a week. LA’s physiotherapy program was play based25 and was performed in the familiar settings of home, preschool, and the usual clinic setting.
Activities in all sessions involved part and whole practice of functional activities using concentric and eccentric muscle action in both open and closed chain exercises. Antigravity extensors of the lower limb, particularly hip and knee extensors and ankle plantarflexors, were targeted in activities designed to work the muscles throughout their range, such as ascending or descending stairs. LA practiced ascending and descending a single step with one leg leading (closed chain, concentric and eccentric muscle activity, of mid to inner range hip and knee extension and mid to outer range plantarflexion), followed by practice with the other leg. This activity was alternated with ascending and descending a single step leading with alternating legs and ascending and descending a set of steps leading with one leg or alternating legs. LA also practiced ascending and descending steps backward and sideways and climbed up and down vertical climbing bars.
Muscle lengthening activities were practiced as part of the physiotherapy intervention. For example, LA played in long sitting that was progressed by using long leg splints (applied with bandages) to assist with the maintenance of knee extension. It was further progressed by LA reaching toward the toes to retrieve toys placed strategically at increasing distances along the legs and finally by placing LA’s feet and lower calves up a wedge from its thin end for this reaching task (thus increasing the length of hamstring muscles required to be able to reach forward to retrieve the toy). In this manner, muscle lengthening involved dynamic stretching with LA activating muscles at a length suitable for the task.
The goals established by Goal Attainment Scaling were practiced individually during therapy sessions. Initially, LA required support in standing but was then able to stand (after the injections) with feet flat on the floor. LA was then encouraged to let go of the support, at first momentarily, but with practice, for an increasing amount of time. Standing balance was encouraged by timing this activity (and by counting aloud with LA). Walking up and down a single step was practiced as well as ascending and descending stairs (using a handrail for support). Being able to stand with feet flat on the floor allowed practice of the step and stairs. Before injection, LA could not stand with feet flat on the floor (even with support), so was unwilling to attempt steps or stairs except by crawling. LA was encouraged to practice best walking with the walker by slowing down the walking speed and putting feet forward reciprocally with equal step lengths. Other specific activities included in the physiotherapy programme are listed in Table 1.
Activities were practiced three to five times each, depending on their level of challenge for LA and were repeated in different combinations, over a single session of up to one hour. Orthoses were removed as a progression of activities. Progression of all activities occurred as LA’s ability improved, for example, by reducing hand support, increasing the distance reached or stepped, and increasing the time to independently maintain a position.
Clinic sessions enabled specific equipment such as parallel bars, climbing bars, and a height-adjustable ramp to be used. These sessions allowed more isolated practice of LA’s current ability and provided additional opportunities for specific challenges as LA progressed. Targeting practice was not as easily achieved in other public environments such as the preschool or local public park where equipment such as rails and ramps were required to meet regulatory laws, so could not be adjusted for the various progressions required for LA.
Home visits were one hour in duration involving whole and part practice of skills. The focus was to train LA’s family how to best challenge and develop LA’s strength and balance. Therefore, there was more whole practice of activities as this is what LA and his family encountered in their home and community. For example, there are two steps at the entrance to LA’s home and these were practiced with support from a family member. The home program included the use of AFO-type night splints and long-leg splints to maintain knee extension, both at night and when long sitting during the day. In addition, LA practiced two or three specific activities with the family each day, eg, climbing up the face of the slide at the local park or sitting to standing from a small chair without using hands for support.
Therapy sessions at preschool varied in length from 30 to 60 minutes. Sessions involved discussion and demonstration with the staff and the Education Support Worker to determine LA’s progress and then to recommend methods and timing of skill progression. Ideas on how to modify activities and equipment to better facilitate skill progression were given to staff. The preschool program was designed to challenge LA’s skills using the equipment and environment available at the preschool and was developed in conjunction with the Education Support Worker (eg, long sitting at mat time, practicing steps and stairs when moving into the outdoor area, climbing on the climbing frames).
As the intervention progressed, it became apparent that although LA’s strength and balance were increasing, there was minimal carryover to gait when using the posterior walker. LA’s gait pattern deteriorated when LA was intent on keeping up with peers. This meant sacrifice of best walking for speed and efficiency. To try to dissuade speed during gait, quad sticks were introduced. Initially, the quad sticks were used at home and during clinic sessions to improve LA’s ability and safety when using them and also to ensure LA was able to continue to socialize and play with peers at preschool using the walker. As ability with the quad sticks improved, they were introduced in the indoor area at preschool and then as competence increased and gait pattern improved, the walker was left at home to be used only over long distances on family outings.
Prior to having Botox injections, LA was using GRAFOs to facilitate knee extension for foot strike and at mid-stance. As LA’s ability to walk with less crouch improved, these were inhibiting the newly acquired ability to extend the knee independently in mid-stance. LA had several unsuccessful orthoses that either inhibited newly gained ability (leaf spring AFOs) or failed to provide sufficient support to give correct biomechanical alignment (University of California Biomechanics Laboratory [UCBL] heel cups). Supramalleolar type AFOs were found to be successful at providing correct biomechanical alignment of the hindfoot when walking and allowed some independent movement into dorsiflexion and knee extension as lower limb strength increased.
Gross motor function.
LA scored 98% for dimension A (lying and rolling) and 97% for dimension B (sitting) at both examinations. LA made progress, particularly with progression from using a posterior walker for mobility to being able to use quad sticks for all indoor mobility and for outdoor mobility within the preschool environment. These obvious advances were confirmed by increased function as measured on the GMFM, particularly in dimension D (Table 2).
Dimension C was not a goal area as LA scored highly (86%) at the initial examination. However, at second examination, LA showed an improvement in the ability to maintain a half-kneeling position without hand support for 3–4 seconds. Previously, this was a position LA could only maintain if using hand support.
Dimensions D and E were goal areas for LA as they were the areas where the most change was expected following Botox treatment. These dimensions involve standing, walking, running, and jumping. They were also the areas where LA scored lowest at initial examination. LA’s score in dimension D improved by 8%. LA increased independent standing time from not being able to achieve this to over two minutes and was able to initiate lifting either foot from the ground without hand support. LA made a 4% improvement in dimension E, as demonstrated by being able to walk forward up to two steps independently and ascend a set of four steps using one hand rail and inconsistently alternating feet.
Self-selected gait speed did not change when using the posterior walker in bare feet before or after Botox. LA’s speed decreased slightly when walking with orthoses and the posterior walker and decreased more when walking using quad sticks post-Botox and doing best walking (Table 3).
Before Botox, LA was able to ascend and descend a flight of steps only by crawling. LA took an average of 18.5 seconds (over two attempts) to ascend five steps, and 49.5 seconds to descend. Untimed observation of LA in the preschool environment after Botox and physiotherapy intervention indicated the ability to ascend a flight of three steps by walking, using a single hand rail and descend using both handrails, usually with both feet on each step. There was a remarkable improvement from crawling up and down stairs to being able to walk up and down using a rail for support and a step-to pattern.
Physicians Rating Scale of Gait (PRS).
LA’s gait pattern improved following Botox with a corresponding increase in score on the PRS (Table 4). LA had a moderate crouch (5–20 degrees hip, knee, ankle) prior to Botox which improved to mild (<5 degrees hip, knee, ankle) when using the walker either with orthoses or bare feet. There was no discernible crouch when using quad sticks. Equinus foot also improved when wearing orthoses both with the walker and with quad sticks, with occasional heel contact being noted. There was no change in his equinus foot posture when walking in bare feet after Botox.
LA maintained the ability to vary speed when using the posterior walker. However, there was a constant slower speed when using the quad sticks. Gait changed from toe-toe to toe-heel when using both quad sticks and when best walking with the walker, although this does not produce a change in score between pre- and post-Botox on the PRS (which requires a change from toe-toe to occasional heel-toe for a change in score). There was an improvement in LA’s gait when using orthoses, boots, and walker and especially when using quad sticks.
Passive and dynamic range of movement.
Overall there was no consistent improvement in range of movement either in injected or other lower limb muscles. Some movements showed an increase in both dynamic and passive range of movement (such as hip flexion and adduction). Others showed an increase in either passive or dynamic range of movement (such as ankle dorsiflexion) and yet others showed a decrease (such as hip abduction in hip flexion). There were some movements that showed no change in measurement (for example popliteal angle) (Table 5).
Selective muscle control.
Before Botox, LA could partially dorsiflex using mainly toe extensors with some movement of the hip and knee (this was scored a one for both left and right legs on the SMC test (see Appendix 2 for method of scoring). LA improved the ability to isolate dorsiflexion using some tibialis anterior movement following Botox and intervention (this was scored a 2). Further increases in score (scored up to 4) would reflect increasing control and activation of tibialis anterior without hip and knee flexion.
Goal Attainment Scaling.
LA met all of the goals established in conjunction with family at the beginning of intervention as noted in Table 6.
This child was a most suitable candidate for lower limb Botox injections21 as LA was younger than four years old, self-motivated, cognitively able, and mobile.6,21 In addition, LA’s family was motivated, ensuring excellent adherence with the home program. Previous research in which the relationship between the GMFCS22 and outcomes following Botox was examined (eg, the study by Fragala et al18) indicated that children with a GMFCS of levels I and II (children between the ages of two and four years who walk without restriction or who walk using an assistive mobility device22) have improved outcomes and are better candidates for Botox. LA, at level II on the GMFCS, was a good candidate for Botox injection. In addition, LA’s equinus deformity was predominantly dynamic in nature. Evidence suggests that Botox and physiotherapy with/without orthoses are the first choice in management of a child of this age.3,26
Increased intensity to twice-weekly physiotherapy intervention enhanced carryover and implementation of activities and exercises in all settings such as at home, at preschool, and at the therapist’s clinic. In addition, more frequent contact with the family and preschool staff facilitated better communication about the goals and progression of treatment, so that LA was practicing functional, therapeutic exercises every day. The decision was made to increase the frequency of LA’s usual physiotherapy intervention after receiving Botox so as not to waste the opportunity to improve function afforded by Botox injection. In our experience, pediatric services are reluctant to increase intervention frequency because of the extra time required from therapy staff. Prior to Botox intervention, this child had received little physiotherapy intervention. Following Botox, intervention time increased dramatically. It could be argued that the functional changes could be due solely to the increase in practice afforded by the increased adherence to intervention. However, practice in an upright position was facilitated by LA being able to stand with both feet flat on the floor after receiving Botox injections.
The selected functional assessment tools were valid in that they demonstrated clinically relevant changes in function after Botox injection and intervention. They were easy to implement in a variety of settings with the family and child and did not require any specialized or expensive equipment. Parents and caregivers could easily identify the measurable changes and were aware of what to look for based on specific areas of the assessment.
LA demonstrated a clinically important change in gross motor function. The change in dimension E of the GMFM did not reflect LA’s increased balance and walking ability with quad sticks because the examination in this case was scored without orthoses and assistive walking devices. In retrospect, we should have used the adapted scoring for both dimensions D and E, where the child would have used his orthoses and walking aid. In addition, all three dimensions (C, D, and E) could have been used as specific goal areas as there was significant improvement in score available in all these areas.
In an attempt to standardize examination of gait speed, LA wore his GRAFOs for the first and second examinations. We found, however, that the GRAFOs limited LA’s newly acquired ability to extend the knee independently in mid-stance and it may have been this that slowed him down, resulting in a slower speed at the second examination. This measure was therefore not suitably used in this case report. LA’s quality of gait was observed to be more reciprocal and with longer more equal step lengths when moving more slowly and when using quad sticks. As balance was challenged more with quad sticks than the walker, it necessitated slower walking and resulted in practice of improved positioning of the whole lower limb, in particular hip and knee extension and some heel contact. LA was only able to use short bursts of activity when walking with the walker, and he required rests between the short distances walked. On the other hand, LA could continue walking at a slower consistent speed for longer distances when using quad sticks. Timed measures of distance walked, for example, the Timed Up and Go Test27 and the 6-minute walk test28 would, in retrospect, have been very appropriate measures of walking ability and endurance before and after therapy following Botox injections.
LA showed marked improvement in stair-climbing ability over the course of the study, in being able to ascend and descend stairs in an upright position as compared to crawling up and down stairs. This functional measure demonstrated sensitivity to change, and the improvement was easily observed by all those involved in LA’s day-to-day activities. Although the first examination was performed in the clinic setting, the second was done at the child’s home because of transport issues for the family. There were no steps at LA’s home, so the stair climbing section of the second examination was performed at the child’s preschool. Unfortunately, this was not timed. The measure could have been made more accurate by using the same set of steps and timing both examinations rather than just the first, giving a more quantitative determination of actual improvement in stair climbing.
The PRS, although not a measure of function, identifies specific areas of deficit when walking and was able to be used to isolate improvements in LA’s gait following Botox and intervention. LA’s family and caregivers were also able to identify some of the same areas of improvement, including decreased crouch (which they identified as walking more upright) and improved ability to make heel contact.
Passive range of movement did not improve consistently. There are several possible explanations for this. Passive range of movement measures were completed before videoing at the first examination and after videoing at the second. LA was noticeably tired and irritable after the second video and was unwilling to participate in the measurement of passive range of motion. This may have influenced the results, and a more accurate measure of range may have been obtained by completing these prior to the second video. In addition, using goniometry in the clinical setting, particularly with young children, has been reported to have difficulties in reliability.24 Furthermore, we did not calculate reliability of any of our outcome measures for this study, although all the measures were taken and recorded by the same person, who was the child’s usual therapist. More reliable measures of passive range of movement would have to be implemented in a laboratory setting to accurately record change in range of motion. An alternative explanation for the lack of change expected in passive range of movement after Botox is that the length of time for which Botox is effective varies between children6 and therefore may have worn off by the time of the second examination. To assist in determining the length of effectiveness for LA, it would have been beneficial to have included additional range of movement measures throughout the Botox course. A further explanation is provided by Ubhi et al11 in their study of the effect of Botox on walking in CP. They found no significant difference in ankle dorsiflexion measures, suggesting that this may be due to the Botox having an effect on the dynamic spastic component of the muscle and that it had limited effect on resistance produced by muscle or joint connective tissue measured using goniometry.
Assessments of function and impairment were completed prior to LA’s Botox injections and at the completion of both the increased intensity and weekly physiotherapy intervention. To better assess the specific impact of increased intensity of physiotherapy intervention, a third examination at the completion of the five-week block of increased intervention would have been beneficial. This would have given two sets of post-Botox examination findings and would have identified whether LA was showing continued improvement in function, maintaining an increase in function, or had decreased function when reverting to weekly physiotherapy intervention. In addition, even though we had intended to reassess for a third time after a six-month period of the child’s usual (once a week) intervention, we were unable to undertake this arm of an ABA study design as the child was hospitalized for a lengthy period because of accidental trauma.
Physiotherapy management was designed to give LA the opportunities to practice components of functional activities occurring in every day life during physiotherapy sessions so that these activities could be achieved independently in natural settings. The effects of Botox allowed LA to practice the quality of the movement and achieve functional carryover. This became self-motivating, as once able to achieve an activity or position independently, LA continued to practice it because it enabled play with peers in a more natural way.8 Prior to Botox, we suggest the increased muscle tone and decreased strength in lower limb muscles inhibited the ability to learn the appropriate patterns of movement as LA could not even attempt to attain or maintain certain positions such as free standing, long sitting, or half kneeling.
Traditionally, treatment for children with CP has included passive muscle stretching techniques. A child of 3.5 years is not particularly compliant with passive stretching techniques. We therefore implemented the concept of activating and controlling movement at the length of muscle required for a particular task. LA practiced dynamic muscle stretching/lengthening by activating muscles at a length suitable for given functional tasks such as long sitting and ramp and stair climbing.
Children learn through play. Physiotherapy intervention for LA used a play-based approach to develop strength and balance. In this way, the play activities, which are intrinsically motivating and pleasurable,25 could be incorporated into any setting. LA was able to challenge strength and balance, particularly at preschool, where it enabled access to more challenging and fun equipment while participating with peers. As no additional equipment, other than LA’s walking devices, was required to enable practice and participation in activities, LA was easily included in regular preschool and home activities.
Dumas et al12 identified clear communication as an important aspect of successful intervention following Botox injection. LA’s physiotherapist ensured there was frequent and clear communication about specific activities to be implemented by family at home and support persons at preschool through personal meetings with the relevant people and by providing written instructions at these meetings. These strategies appeared successful in achieving adherence to a program and allowed LA to practice and achieve improvements in function in all settings.
LA met all of the three specific goals established with the family. LA was able to stand independently for a useful time and ascend and descend stairs by walking with handholds. Although LA could walk with a reciprocal walking pattern when using the posterior walker if directed, this slow pattern was usually sacrificed for speed to keep up with peers. Improved strength and balance allowed use of quad sticks with a reciprocal gait pattern. In retrospect, it is apparent that the goals that were established with the family were too broad. It would have been appropriate to make more specific goals to include time and activity to be achieved. For example, LA dramatically increased independent standing ability to over two minutes. In addition, LA was able to increase the complexity of hand activity while standing, from being able to concentrate only on standing to being able to thread beads while standing. The goal of increasing independent standing time was therefore not sufficiently specific. Timed goals that measure a specific activity would more readily give quantitative information about progress.
Orthotic management is recommended as part of management following Botox,21 and LA had two changes of ankle foot orthoses, both of which proved unsuitable because they provided either too much (leaf spring AFOs) or too little (UCBL heel cups) support. Supramalleolar types were later implemented successfully. As Botox effectiveness is time dependent, it is very important to maximize the ability to improve function through correct biomechanical alignment aided by appropriate orthoses. Better targeted prescription of suitable orthoses would have perhaps maximized the functional gains allowed by the administration of Botox.
LA appeared to be a most suitable candidate for Botox intervention. An increased level of physiotherapy was easily implemented by those directly involved in LA’s everyday activities and contributed to successful outcomes for LA. Appropriate outcome measures examining function were used. These outcomes demonstrated important changes that were identified by the family. Adherence to the program was assisted by clear verbal and written communication of roles and responsibilities, the inclusion of intervention in all of LA’s usual settings and the practice of functional activities. The chosen impairment level measures were not as suitable to demonstrate change following Botox and physiotherapy intervention. Other functional measures that could be useful in determining change following Botox include the six-minute walk test or the Timed Up and Go Test. Limitations in this study and changes suggested for future studies include the need to establish intrarater reliability information for outcome measures chosen, the need to be more specific when using Goal Attainment Scaling, the use and implementation of appropriate orthoses that are able to be modified as function improves, and longitudinal assessment to determine length of effectiveness of Botox injection as well as the effectiveness of the physiotherapy intervention.