An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

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Study design: Prospective comparative study. Objective: To determine whether control of upper limb joint synergy during unrestrained arm raising involving shoulder and elbow flexion is modified by deltoid-to-triceps transfer. Setting: Rehabilitation unit for spinal cord injury patients, France. Methods: Five C6 subjects with C5-C6 tetraplegia sustained posterior deltoid-to-triceps transfer and were compared to a control group of 11 subjects. Kinematics of shoulder and elbow joints before, 6 month and 1 year after surgery, during straight-arm raising (SAR) in the plane of the scapula and hand-to-nape-of-neck movements (HNNMs) were explored. Motion was recorded with a six-camera Vicon motion analysis system and the data used to assess the coupling of elbow and shoulder flexion velocities (EFVs and SFVs) and extension velocities. Results: All subjects were initially assessed at 6.9 months (mean) postsurgery. Three of the upper limbs were assessed a second time (mean 17.9 months). The first assessment showed an increase in shoulder flexion amplitudes in tetraplegic subjects with presurgery shoulder flexion deficits. Peak SFVs and EFVs and extension velocities were slightly modified at the first postsurgery assessment and dramatically improved at the second assessment during both SAR and HNNM. Despite these increased velocities, joint coordination was only partially restored. Conclusion: A restored elbow active extension improves the speed of elbow flexion. The additional improvement of shoulder motion emphasises the relation between joints in the control of arm movement.

Backgound: Metrics for movement smoothness include the number of zero-crossings on the acceleration profile (N0C), the log dimensionless jerk (LDLJ), the normalized averaged rectified jerk (NARJ) and the spectral arc length (SPARC). Sensitivity to the handedness and movement type of these four metrics was compared and correlations with other kinematic parameters were explored in healthy subjects. Methods: Thirty-two healthy participants underwent 3D upper limb motion analysis during two sets of pointing movements on each side. They performed forward- and backward-pointing movements at a self-selected speed to a target located ahead at shoulder height and at 90% arm length, with and without a three-second pause between forward and backward movements. Kinematics were collected, and smoothness metrics were computed. Results: LDLJ, NARJ and N0C found backward movements to be smoother, while SPARC found the opposite. Inter- and intra-subject coefficients of variation were lowest for SPARC. LDLJ, NARJ and N0C were correlated with each other and with movement time, unlike SPARC. Conclusion: There are major differences between smoothness metrics measured in the temporal domain (N0C, LDLJ, NARJ), which depend on movement time, and those measured in the frequency domain, the SPARC, which gave results opposite to the other metrics when comparing backward and forward movements.