Three-year outcomes of repeated botulinum neurotoxin A injections to the lower extremities in young children with spastic cerebral palsy in GMFCS levels I to III.

The study was observational rather than randomised, which limits the certainty of the evidence and means groups may not have been perfectly comparable despite baseline adjustments. There was a large baseline difference in daily step counts favouring the comparison group, which limits the interpretation of mobility outcomes even after statistical adjustment. The minimally important difference for the primary outcome was derived from an older cohort of children, which may not be fully applicable to this younger group. Information on the use of serial casting was not collected, which may have influenced range of motion outcomes. There was a high percentage of missing data for physiotherapy time, requiring caution in interpreting the difference in therapy hours between groups.

Funding was provided by the Canadian Institutes of Health Research, the Ontario Neurodegenerative Disease Research Initiative, and the Manitoba Health Research Council. The authors declared no conflicts of interest.

Do not conclude that botulinum toxin injections are ineffective for all goals. This study specifically examined gross motor function and range of motion in young children. It does not rule out benefits for other outcomes such as pain reduction or specific gait parameters not measured here, nor does it apply to older children or those at higher GMFCS levels.