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Spasticity is highly prevalent in neurological conditions involving upper motor neuron lesions (UMNL). Lower limb spasticity is known to impair gait and limit participation in physical activity. Multimodal interventions including botulinum toxin A, orthoses, and physiotherapy have shown longer lasting improvements compared to unimodal interventions. Studies to date, however, have not examined the long term efficacy of this multimodal intervention nor have they examined the impact across a breadth of domains necessary to comprehensively and fully understand its impact. The aim of this study was to investigate the efficacy of a multimodal intervention to treat lower limb spasticity in adults using a longitudinal mixed-methods approach, including a comprehensive set of outcome measures spanning the domains of the International Classification of Functioning, Disability and Health (ICF) model. Seven-teen participants with chronic UMNL were included in the analysis as per inclusion criteria and showed improvements at 6 and 12 months, compared to baseline, within all domains of the ICF model. / Graduate / 0571 / 0382 / 0384 / jazkim@uvic.ca

Spasticity is highly prevalent in neurological conditions involving upper motor neuron lesions (UMNL). Lower limb spasticity is known to impair gait and limit participation in physical activity. Multimodal interventions including botulinum toxin A, orthoses, and physiotherapy have shown longer lasting improvements compared to unimodal interventions. Studies to date, however, have not examined the long term efficacy of this multimodal intervention nor have they examined the impact across a breadth of domains necessary to comprehensively and fully understand its impact. The aim of this study was to investigate the efficacy of a multimodal intervention to treat lower limb spasticity in adults using a longitudinal mixed-methods approach, including a comprehensive set of outcome measures spanning the domains of the International Classification of Functioning, Disability and Health (ICF) model. Seven-teen participants with chronic UMNL were included in the analysis as per inclusion criteria and showed improvements at 6 and 12 months, compared to baseline, within all domains of the ICF model. / Graduate / 2015-04-24 / 0571 / 0382 / 0384 / jazkim@uvic.ca

Made available in DSpace on 2016-12-06T17:07:28Z (GMT). No. of bitstreams: 1 Elaine.pdf: 2067040 bytes, checksum: d5560a36175f4da115aaff3b8b700e40 (MD5) Previous issue date: 2010-03-26 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The posture and movement disorders typical of spastic cerebral palsy are often associated with several factors related to injury in the central nervous system, including muscle spasticity. The use of botulinum toxin type A in the lower limbs to reduce the muscle tone in children with spastic cerebral palsy, associated with different therapeutic approaches, including physiotherapy, is intended to assist in the normalization of gait through the improvement in proprioception, selective motor control and strength. Few studies discuss the effects of the botulinum toxin in the functional and biomechanical aspects of the gait cycle. This study aimed to investigate the effects of botulinum toxin type A on gait in children with spastic cerebral palsy. Participated 22 subjects with spastic cerebral palsy, divided into experimental group with 10 children (11±2 years) that received botulinum toxin type A in the lower limbs and the control group with 12 children (10±2 years) who have not received the toxin. The variables analyzed were resistance degree to passive movements of lower limbs (Ashworth Spasticity Modified Scale), gross motor function on dimensions D and E (GMFM), functional abilities in self-care, mobility and social function areas (PEDI), coactivation index of the rectus femoris and semitendinosus muscles, angular and spatiotemporal kinematic variables of the hip and knee in the sagittal plane. All procedures for data collection were performed twice in both groups with a range of 30 to 45 days between the 1st and 2nd assessment (for the experimental group before and between 30-45 days after botulinum toxin type A). The Analysis of Variance and the nonparametric Kruskal-Wallis test were used for data analysis and in case of significant effects they were carried out multiple comparisons. The Spearman correlation coefficient was used to examine the relationship between the variables and time of physical therapy during the study period. The level of significance was p<0,05. Regarding the effect of botulinum toxin type A in the variables analyzed, there were not observed statistically significant differences in any of the variables between the 1st and 2nd evaluation. It was found as longer the duration of physical therapy performed by the child, greater the stride length normalized by the height and lower the level of muscle coactivation and the level of gross motor function in the dimensions D and E of the GMFM. It can be concluded that the application of botulinum toxin type A does not show effect on gait in children with spastic cerebral palsy classified in stages I and II of the GMFCS. / As desordens da postura e do movimento características à paralisia cerebral espástica são freqüentemente associadas a diversos fatores ligados à lesão no sistema nervoso central, entre eles a espasticidade muscular. A utilização da toxina botulínica tipo A nos membros inferiores para redução do tônus muscular em crianças com paralisia cerebral espástica, associada a diferentes abordagens terapêuticas, inclusive a fisioterapia, tem a finalidade de auxiliar na regularização da marcha por meio da melhora na propriocepção, controle motor seletivo e a força. Poucos estudos discutem sobre os efeitos da toxina botulínica nos aspectos funcionais e biomecânicos durante o ciclo de marcha. Este estudo objetivou investigar os efeitos da toxina botulínica tipo A na marcha de crianças com paralisia cerebral espástica. Participaram 22 sujeitos de ambos os sexos com paralisia cerebral espástica divididos em grupo experimental com 10 crianças (11±2 anos) que receberam toxina botulínica tipo A nos membros inferiores e grupo controle com 12 crianças (10±2 anos) que não receberam a toxina. As variáveis analisadas foram grau de resistência para movimentos passivos dos membros inferiores (Escala de Espasticidade Ashworth Modificada), função motora ampla nas dimensões D e E (GMFM), habilidades funcionais nas áreas de auto-cuidado, mobilidade e função social (PEDI), índice de coativação dos músculos reto femoral e semitendíneo e variáveis cinemáticas angulares e espaço-temporais do quadril e joelho no plano sagital. Todos os procedimentos de coleta de dados foram realizados duas vezes em ambos os grupos, com intervalo de 30 a 45 dias entre a 1ª e 2ª avaliação (para o grupo experimental, antes e entre 30-45 dias após a aplicação da toxina botulínica tipo A). Os dados foram analisados por meio da Análise de Variância Univariada e o teste não paramétrico de Kruskal-Wallis e em caso de efeitos significativos procederam-se comparações múltiplas. O coeficiente de correlação de Spearmann foi usado para examinar a relação entre as variáveis e o tempo de atendimento fisioterapêutico no período do estudo. O nível de significância foi p<0,05. Com relação ao efeito da toxina botulínica tipo A nas variáveis analisadas, não foram observadas diferenças estatisticamente significativas em nenhuma das variáveis entre a 1ª e a 2ª avaliação. Constatou-se que quanto maior o tempo de atendimento fisioterapêutico realizado pela criança, maior comprimento da passada normalizado pela estatura e menor o índice de coativação muscular e o nível de função motora ampla nas dimensões D e E do GMFM. Pode ser concluído que a aplicação de toxina botulínica tipo A não demonstra efeito na marcha de crianças com paralisia cerebral espástica classificadas nos níveis I e II do GMFCS.

Le travail de cette thèse a permis de comparer les adaptations mises en place par le système nerveux après différentes méthodes d’altération et de récupération. Nos deux premières études portaient sur l’altérations de la réponse des afférences musculaires suite à une injection de toxine botulique. La troisième étude analysait la relation entre le phénotype musculaire et la réponse des afférences métabosensibles. Les deux dernières études analysaient si le vieillissement et l’activité physique altéraient la boucle sensori-motrice et la réponse des afférences métabosensibles. Les résultats de ce travail de thèse indiquent que la réponse des afférences mécano- et métabosensibles ont des profils de récupération qui diffèrent et que la réponse des afférences métabosensibles est dépendante en partie du phénotype musculaire. Enfin, le vieillissement induit une altération la boucle sensori-motrice, et l’entrainement permet de récupérer selon les muscles. L’activité des afférences métabosensibles est aussi altéré par les vieillissement mais l’entrainement ne permet pas de récupération. / This thesis work compared nervous system adaptations after different methods of alteration and recovery. The two first studies were about muscle afferents response alterations following botulinum toxin injections. The third study analyzed the relation between muscle phenotype and metabosensitive response. The two last studies analyzed whether aging and physical activity could alter the metabosensitive response and the sensory-motor loop. Results indicate that mechano- and metabosensitive afferents response have different recovery pattern and that metabosensitive afferents response is in part dependent on the muscle phenotype. Aging results indicate an alteration of the sensory-motor loop and depending on the muscle, training allows a recovery. Metabosensitive afferents response is also altered but training does not induce a recovery.

Submitted by Liliane Ferreira (ljuvencia30@gmail.com) on 2018-09-04T13:15:30Z No. of bitstreams: 2 Dissertação - Michelle Jayme Borges - 2018.pdf: 2628386 bytes, checksum: c8c34ff80b97c3389e1af61f6839baff (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2018-09-05T11:04:12Z (GMT) No. of bitstreams: 2 Dissertação - Michelle Jayme Borges - 2018.pdf: 2628386 bytes, checksum: c8c34ff80b97c3389e1af61f6839baff (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2018-09-05T11:04:12Z (GMT). No. of bitstreams: 2 Dissertação - Michelle Jayme Borges - 2018.pdf: 2628386 bytes, checksum: c8c34ff80b97c3389e1af61f6839baff (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2018-08-20 / Stroke continues to be a major concern today. It is a disease closely related to the decline of functional capacity and quality of life, and the clinical picture is varied, presenting as one of the sequelae, hemiparesis or spastic hemiplegia. Botulinum toxin type A acts by blocking neuromuscular transmission via inhibition of acetylcholine release and is a well-established treatment for post-stroke spasticity. In the literature there are no unified results for the use of Botulinum Toxin Type A with formulations such as BOTOX / DYSPORT / XEOMIN, which justifies the gathering of results of studies already produced, with a view to the construction of updated knowledge, due to the heterogeneity of the studies to the applicability of the toxin. Through a systematic review of the literature followed by meta-analysis, we aimed to present evidence from clinical trials on the effects of Botulinum Toxin Type A (BOTOX / DYSPORT / XEOMIN) on upper and lower limb spasticity and its influence on the functionality in patients sequelae of stroke. This is a documentary research, in three stages: titles, abstracts and full text, for which electronic databases were searched in the English, Spanish and Portuguese languages, using the Ashworth Modified Scale and Disability Assessment Scale ( DAS), restricting data from the last 10 years. Eligible articles fulfilled inclusion and exclusion criteria. Thus, 18 studies were included, with a total of 2573 patients (Subjected to toxin: n = 2112; Not submitted to toxin, n = 460). The quality of the studies was assessed using the Newcastle-Ottawa Scale. The existence of publication bias by the funnel plot was analyzed. The data of interest were extracted and directed to a table for the calculation of the frequency ratio and odds ratio of the results. For the execution of the meta-analysis, the software STATA IC / 64 version 16.1 was used. The overall estimate of the frequency of the effect of botulinum toxin type A on spasticity was 93% (95% CI 0.90 to 0.95, p = 0.00) and functionality resulted in 64% (95% CI, : 0.40 to 0.89, p = 0.00) for the dressing domain; with 69% (95% CI: 0.42 to 0.96, p = 0.00) for hygiene; 69% (95% CI 0.46 to 0.92, p = 0.00) for upper limb position and 79% higher (95% CI 0.68 to 0.90, p = 0, The results showed a high heterogenicity between the studies, probable publication bias for the funnel plot (t = 2, 95% CI = 0.4-8, p = 0.05) and the results suggest a positive association between the effect of botulinum toxin type A on spasticity in MMSS and MMII post-stroke, highlighting the Dysport formulation, followed by Botox and finally Xeomin, besides the improvement in functionality with emphasis on the pain domain, after hygiene and positioning of the upper limb. / O Acidente Vascular Cerebral (AVC) continua sendo uma das grandes preocupações da atualidade. É uma doença intimamente relacionada ao declínio da capacidade funcional e qualidade de vida, e o quadro clínico é variado, apresentando como uma das sequelas, hemiparesia ou hemiplegia espástica. A toxina botulínica tipo A, age através do bloqueio da transmissão neuromuscular via inibição da liberação de acetilcolina e é um tratamento bem estabelecido para espasticidade pós-AVC. Na literatura não há resultados unificados, para o uso da Toxina Botulínica Tipo A com formulações, como BOTOX/DYSPORT/XEOMIN, o que justifica a reunião de resultados de estudos já produzidos, com vista à construção de conhecimento atualizado, pela heterogenicidade dos estudos quanto à aplicabilidade da toxina. Através de uma revisão sistemática da literatura seguida de metanálise, objetivou-se apresentar evidências a partir de ensaios clínicos sobre os efeitos da Toxina Botulínica Tipo A (BOTOX/DYSPORT/XEOMIN) na espasticidade de membros superiores e inferiores e sua influência na funcionalidade em pacientes sequelados de AVC. Trata-se de pesquisa documental, em três etapas: títulos, resumos e texto completo, para a qual foi realizada busca em bases de dados eletrônicos, nos idiomas em inglês, espanhol e português, utlizando a Escala Modificada de Ashworth e Disability Assessment Scale (DAS), restringindo dados dos últimos 10 anos. Os artigos elegíveis preeencheram critérios de inclusão e exclusão. Sendo assim, inclui-se 18 estudos, com um total de 2573 pacientes (Submetidos à toxina: n= 2112; Não submetido à toxina, n= 460). A qualidade dos estudos foi avaliada por meio da Escala de Newcastle-Ottawa. Analisou-se a existência de viés de publiação pelo funnel plot. Os dados de interesse foram extraídos e direcionados a uma tabela para o cálculo da razão de frequência e odds ratio dos resultados. Para a execução da meta-análise foi utlizado o software STATA IC/64 versão 16.1. A estimativa global da freqüência do efeito da toxina botulínica tipo A na espasticidade foi de 93% (IC a 95%: 0,90 a 0,95; p= 0,00) e da funcionalidade resultou em 64% (IC a 95%: 0,40 a 0,89; p=0,00) para o domínio vestir; com 69% (IC a 95%: 0,42 a 0,96; p=0,00) para higiene; 69% (IC a 95%: 0,46 a 0,92; p=0,00) para posição do membro superior e a maior 79% (IC a 95%: 0,68 a 0,90; p=0,06) relacionado a dor.As conclusões mostraram alta heterogenicidade entre os estudos, provável viiés de publicação pelo funnel plot (t=2; IC 95%=0,4-8; p=0,05) e os resultados sugerem associação positiva entre o efeito a toxina botulínica tipo A na espasticidade em MMSS e MMII pós- AVC, destacando a formulação Dysport, seguida de Botox e por fim Xeomin, além da melhora na funcionalidade com ênfase no domínio dor, depois higiene e posicionamento do membro superior.

INTRODUÇÃO: A paralisia facial de longa duração cursa com déficit funcional e estético, responsáveis por distúrbios psicológicos e prejuízo na qualidade de vida. Mesmo técnicas cirúrgicas modernas de reanimação conseguem restabelecer apenas parcialmente a movimentação emocional e a simetria entre as hemifaces. A toxina botulínica tipo A provoca paralisia muscular flácida reversível, corrigindo desequilíbrios entre músculos agonistas hipoativos e antagonistas relativamente hiperativos. Não há na literatura séries padronizadas com mais de 10 pacientes com paralisia facial tratados por meio da aplicação de toxina botulínica no lado são a fim de obter maior simetria na dinâmica facial na região da boca. MÉTODOS: Este estudo prospectivo teve como objetivo avaliar o efeito do tratamento adjuvante com toxina botulínica no lado são de 25 pacientes com paralisia facial de longa duração, previamente tratados cirurgicamente. O tempo de seguimento foi de 6 meses. Foram métodos de avaliação escala clínica padronizada, grau de satisfação do paciente, Índices de Função Física (IFF) e de Bem-Estar Social (IBES) e eletromiografia de superfície. A dose total de toxina botulínica variou de 15 a 69 U, média 37,9 ± 5,4 U. Dezesseis pacientes apresentaram efeitos adversos com duração média de 14,1 ± 7,3 dias, incluindo dificuldade para articular palavras, beber, mastigar e se adaptar à redução do sorriso. RESULTADOS: 1) Houve redução significante da assimetria entre as hemifaces, de 48,4% após 1 mês e 16,8% aos 6 meses. O ganho de simetria após 1 mês ocorreu em decorrência da diminuição do movimento do lado são, combinada à melhora da avaliação do lado paralisado. Aos 6 meses, com a perda do efeito clínico da toxina botulínica, a nota do lado são voltou a ser semelhante à do pré-tratamento. A redução de assimetria nessa fase ocorreu devido à melhora significante do lado paralisado em relação ao pré-tratamento. 2) A avaliação subjetiva do paciente em relação à simetria apresentou aumento significante, 1 mês e 6 meses em relação ao pré-tratamento. 3) Houve aumento do IFF ao longo do tempo, porém não significante. O IBES apresentou aumento significante aos 6 meses, comparado ao pré-tratamento. 4) Um mês após a aplicação, o efeito da toxina botulínica levou à diminuição significante do potencial de ação do lado não-paralisado. Após 6 meses, o valor voltou a ser semelhante ao do pré-tratamento. CONCLUSÕES: O tratamento proposto permitiu, com técnica minimamente invasiva, obter melhor simetria facial estática, evidenciada pela posição do ângulo da boca, do filtro labial, dos sulcos nasogenianos, do nariz e do supercílio, e melhor simetria dinâmica, principalmente ao sorrir, falar, na exposição dos dentes e na movimentação facial como um todo. Mesmo após a perda do efeito clínico da droga aos 6 meses, houve 18% de melhora da avaliação clínica do lado paralisado em relação ao pré-tratamento, e melhora dos índices de satisfação e qualidade de vida dos pacientes. / INTRODUCTION: Long-standing facial paralysis presents with functional and aesthetic deficits, which are responsible for psychological disturbances and life quality impairment. Even after modern facial reanimation surgical techniques, the emotional movement and the symmetry of the hemifaces is only partially restablished. Botulinum toxin type A causes reversible flacid muscle paralysis, thus correcting imbalances among hypoactive agonists and relatively hyperactive antagonists. There are no standardized series in the literature with more than 10 facial paralysis patients treated with botulinum toxin injection in the non-paralysed side in the mouth area, with the objective of obtaining better dynamic facial symmetry. METHODS: This prospective study had the objective of evaluate, with 6 months follow-up, the effects of the adjuvant treatment using botulinum toxin in the healthy hemiface of 25 patients with long-standing facial paralysis, previously treated surgically. The methods of evaluation were a standardized clinical scale, the patients degree of satisfaction, the Physical Function and Social/well-being Function subscales of the Facial Disability Index and surface electromyography. Total botulinum toxin dose varied from 15 to 69 U, mean 37,9 ± 5,4 U. Sixteen patients presented adverse effects with mean duration time 14,1 ± 7,3 days, including difficulty in speaking, drinking, eating and adapting to the reduced smile. RESULTS: 1) There was significant reduction of facial asymmetry, of 48,4% at 1 month and of 16,8% at 6 months post-treatment. The better symmetry 1 month post-treatment was consequent to reduced movement on the non-paralysed side combined to better evaluation on the paralysed side. At 6 months, the non-paralysed side had similar grading than that of pre-treatment, showing absence of clinical effect of the toxin. At this time, the asymmetry reduction was due to significant increase in the evaluation of the paralysed side in relation to the pre-treatment. 2) Patients satisfaction with facial symmetry showed significant increase, 1 month and 6 months post-treatment. 3) The Physical Function Index increased, but not significantly. The Social/well-being Function Index showed significant increase at 6 months compared to pre-treatment. 4) There was significant decrease in the action potential of the non-paralysed side one month post-injection of the botulinum toxin. After 6 months, the value returned to baseline. CONCLUSIONS: The proposed treatment allowed, with minimally invasive technique, better facial symmetry at rest, evidenced by better mouth, nose and brow position, and on facial movement as a whole, especially when smiling, speaking or exposing teeth. Even after the loss of the clinical effect of the drug at 6 months, there was an 18% increase in the clinical evaluation of the paralysed side in relation to pre-treatment, and increase in the satisfaction and quality of life indexes.

Hintergrund:Allergische Rhinitis führt zu nasaler Hyperreagibilität mit den Symptomen Obstruktion, Sekretion und Niesreiz. Diese wiederkehrenden Symptome haben einen störenden Einfluss auf die Lebensqualität der Betroffenden mit negativen Auswirkungen auf ihre Leistungsfähigkeit, Arbeitsproduktivität und ihr Sozialleben. Zudem kommt es dadurch zu hohen Kosten im Gesundheitswesen.Ziel dieser monozentrischen, randomisierten, doppelblinden, Placebo-kontrollierten, dreiarmigen Studie der Phase II, die an 33 Personen mit allergischer oder intrinsischer Rhinitis durchgeführt wurde, war die Bestimmung der therapeutischen Wirksamkeit von nasal mit einem Merocel®-Schwämmchen appliziertem Xeomin® (BoNTA) auf die nasale Hypersekretion der Patienten. Methode:Es wurde nach drei Gruppen unterteilt: Die erste Gruppe erhielt 80 Einheiten BoNTA pro Nasenloch in einen Schwamm in der Nase. Die zweite die Hälfte der Dosis und die dritte nur Placebo (Kochsalzlösung). Während eines sich anschließenden sechsmonatigen Beobachtungszeitraums wurden die Patienten regelmäßig untersucht.Als primäre Zielgröße wurde die Menge des nasalen Sekretflusses nach BoNTA- oder Placebo-Gabe definiert. Diese wurde durch das Zählen des vom Patienten im Nasentagebuch dokumentierten Papiertaschentücherverbrauchs bestimmt. Die Patienten benutzten hierzu jedes Taschentuch nur einmalig. Eine sekundäre Zielgröße war die Gewichtsveränderung der Sekretmenge in den Taschentüchern, die am Tag vor der Kontrollvisite in einer verschließbaren Plastiktüte gesammelt wurden.Als weitere Zielgrößen wurden die Veränderung der Nasenatmungsbehinderung, des nasalen Juckreizes, des Niesreizes, des Geruchssinnes und unerwünschte Nebenwirkungen wie Trockenheit der Nasenschleimhaut oder Epistaxis dokumentiert. Auch wurde eine Rhinomanometrie und Olfaktometrie bei den Kontrollvisiten durchgeführt.Ergebnis:Die Analysen der Daten des Taschentuchzählens (primäre Zielgröße) ergab im Vergleich zwischen der höheren und niedrigeren Xeomin®-Dosisgruppe und der Placebo-Gruppe keinen signifikanten Unterschied (p=0,2203/ p=0,8469). Der Verlauf der Änderung des Sekretflusses unter Xeomin® im Vergleich zum Placebo war über die Zeit nicht unterschiedlich. Es zeigte sich lediglich, dass eine Tendenz der Verminderung des Taschentuchverbrauchs in allen Gruppen bestand. Das bedeutet, dass keine eindeutige Wirkung auf die nasale Schleimhaut durch Xeomin® feststellbar war.Demgegenüber stehen die Ergebnisse aus der Analyse des Auswiegens der Taschentücher (sekundäre Zielgröße). Entgegen dem Kriterium „Veränderung der Anzahl der verbrauchten Taschentücher“ ergab sich über das Auswiegen der nasalen Sekretmenge, dass im Vergleich zwischen der Gruppe mit der höheren Xeomin®-Dosis und der mit Placebo behandelten ein signifikanter Unterschied bezüglich der Sekretmenge (p=0,0064) bestand.Es scheint die objektivere Messung des Gewichtes für zukünftige Untersuchungen geeigneter zu sein.Die Vergleiche zwischen den Gruppen erbrachten keine deutlichen Hinweise auf einen Behandlungseffekt durch BoNTA bezüglich der Nasenatmungsbehinderung, des nasalen Juckreizes, des Niesreizes und des Geruchssinnes.Aufgrund der nur sehr geringen Nebenwirkungen handelt es sich um eine risikoarme Behandlungsmethode. Die Verlaufsdaten zur Rhinomanometrie und Olfaktometrie blieben in allen Gruppen auf einem vergleichbaren Niveau, sodass sich hieraus keine Unterschiede zwischen den Gruppen ergaben.

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La paralysie cérébrale, cause la plus fréquente des déficiences motrices de l’enfant, affecte entre 2,08 et 3,60 enfants/1000 naissances en Europe et aux Etats Unis. La lésion initiale du cerveau immature sur un squelette en croissance est responsable, selon la CIF, d’altération des structures anatomiques et fonctionnelles avec une limitation des activités et de la participation. La toxine botulinique est aujourd’hui le traitement de référence de la spasticité focale chez l’enfant PC car elle est sélective, réversible, sûre et dose dépendante. Toutefois s’il est clair que les injections de TB diminuent les troubles du tonus, la question des indications et des bénéfices fonctionnels mérite encore d’être investiguée. La mise en œuvre de ce traitement se heurte à la difficulté de l’évaluation pour déterminer les indications et les bénéfices, du fait des présentations cliniques très hétérogènes et du contexte de maturation neurologique et de croissance osseuse, et à la dynamique environnementale particulière entre l’enfant et ses parents. Avec pour objectif d’aborder l’évaluation du traitement par TB de manière multidimensionnelle, nous apportons dans ce travail diverses études permettant d’appréhender une approche globale. Cela prend en compte la déficience du MS, du MI, du complexe spino-pelvien, des capacités et de la performance fonctionnelle, et du comportement. Ceci permet d’appréhender in fine la participation et de proposer par des outils standardisés une analyse personnalisée , des conséquences à moyen et long terme des traitements chez un sujet en croissance et en développement. / Cerebral palsy is the most common cause of motor impairment in children, affecting 2.08 to 3.60 children/1000 births in Europe and the United States. Initial injury on an immature brain and a growing skeleton is responsible of altering body functions and structures with a limitation of activities and an impact on participation, according to the ICF. Botulinum toxin has become the standard treatment for focal spasticity in children with CP, as it is selective, reversible, safe and dose dependent. However, while it is clear that BT injections decrease tone disorders, the question of indications and benefits in terms of functional improvement still needs to be investigated. Indeed, the implementation of this treatment meets different issues, including the difficulty of the evaluation to determine the indications and benefits, because of very heterogeneous clinical presentations and the context of neurological maturation and bone growth, but also the difficulty to take into account the particular environmental dynamics between the child and his parents.In order to approach the evaluation of BT treatment in a multidimensional way, we bring with this thesis several studies contributing to a global approach to understand the different aspects of disability in UL, LL or spine, but also to understand the field of activity for the UL in terms of capacities and functional performance, and finally on the level of behavior to better understand ultimately participation. In this context, the main aim of this work is to propose a personalized analysis, using standardized tools, of the medium- and long-term consequences of treatment for a subject in growth and development.