Cerebral palsy is a non-progressive, lifelong condition resulting from damage to the developing brain and it’s the most common cause of physical disabilities in children in high-income countries. 
Spasticity is the most prevalent motor impairment in patients with cerebral palsy. Its treatments include physiotherapy, oral antispastic drugs, casts, splints, orthopaedic surgery, and botulinum toxin A (BoNT-A), that is considered the first-line treatment for focal spasticity in these patients.
The aim of this Cochrane systematic review was to evaluate the effectiveness and safety of BoNT-A compared to other treatments used in the management of lower limb spasticity in children with cerebral palsy.
Thirty-one randomised controlled trials, with 1508 participants (mean age 3-7 years) treated with BoNT-A injections in the lower limb muscles compared to other interventions, were included.
Primary outcomes were gait analysis and function. Secondary outcomes were joint range of motion, quality of life, satisfaction, spasticity, and adverse events.
Fourteen studies compared BoNT-A in the lower limb muscles to usual care or physiotherapy, 12 compared it with placebo or sham therapy, 4 with serial casting, and 1 with orthoses.
The quality of the evidence was overall low to very low for most of the outcomes analysed.
There was limited evidence that BoNT-A is more effective than placebo or a non-placebo control in improving gait, joint range of motion, satisfaction, and lower limb spasticity in children with cerebral palsy, whereas the results for other functions were contradictory. BoNT-A is not more effective than ankle serial casting to treat ankle contracture for any of the assessed outcomes, but it is more effective than orthotics at improving range of motion and spasticity.
Considering that for the management of spasticity in children with cerebral palsy, a multimodal approach should be always recommended, authors believe that future studies should aim to determine the most effective treatment combination.

Comment by Francesco Agostini