{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T09:01:31Z","timestamp":1785229291949,"version":"3.55.0"},"reference-count":30,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T00:00:00Z","timestamp":1785196800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxins"],"abstract":"<jats:p>Cerebral palsy is a leading cause of childhood motor disability, and ambulatory children with spastic hemiplegia commonly present with dynamic equinus, calf muscle overactivity, and gait impairment. Evidence on focal vibration after botulinum toxin type A injection remains limited. This exploratory proof-of-concept pilot study assessed short-term changes following a four-week multimodal rehabilitation program incorporating focal vibration. In this uncontrolled single-group pre\u2013post study, nine ambulatory children (mean age, 12.1 years), all classified as level II on the Gross Motor Function Classification System, received onabotulinumtoxinA injections into the affected gastrocnemius muscles, followed by twelve outpatient sessions combining focal vibration, conventional physiotherapy, and robotic gait training. Passive ankle dorsiflexion increased, calf muscle spasticity decreased, and selected gait parameters improved. Walking speed increased from 0.79 to 0.90 m per second, an absolute change of 0.11 m per second, comparable in magnitude to published estimates of clinically important change in ambulatory children with cerebral palsy. After Bonferroni correction, only walking speed and affected-limb stride length remained significant. No adverse events occurred. These findings describe outcomes associated with the combined program but do not establish the efficacy or independent contribution of focal vibration.<\/jats:p>","DOI":"10.3390\/toxins18080327","type":"journal-article","created":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T07:55:41Z","timestamp":1785225341000},"page":"327","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Multimodal Rehabilitation with Focal Vibration After Botulinum Toxin Injection in Ambulatory Children with Cerebral Palsy: A Proof-of-Concept Pilot Study"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3558-8276","authenticated-orcid":false,"given":"Alessandro","family":"Picelli","sequence":"first","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"},{"name":"Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rita","family":"Di Censo","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-2576-963X","authenticated-orcid":false,"given":"Ilaria","family":"Di Maria","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonella","family":"Vangelista","sequence":"additional","affiliation":[{"name":"Poliambulanza Foundation, 25124 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Vittoria","family":"Benetti","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7630-1887","authenticated-orcid":false,"given":"Nicola","family":"Smania","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4242-8497","authenticated-orcid":false,"given":"Valentina","family":"Varalta","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Department of Neurosciences, University Hospital of Verona, 37126 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5930-5974","authenticated-orcid":false,"given":"Mirko","family":"Filippetti","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy"},{"name":"Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.cpm.2021.09.001","article-title":"Surgical management of foot and ankle deformities in cerebral palsy","volume":"39","author":"Bloom","year":"2022","journal-title":"Clin. Podiatr. Med. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.gaitpost.2022.10.009","article-title":"Selective motor control correlates with gross motor ability, functional balance and gait performance in ambulant children with bilateral spastic cerebral palsy","volume":"99","author":"Yun","year":"2023","journal-title":"Gait Posture"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1007\/s40272-019-00344-8","article-title":"Botulinum toxin in the management of children with cerebral palsy","volume":"21","author":"Multani","year":"2019","journal-title":"Paediatr. Drugs"},{"key":"ref_4","first-page":"CD001408","article-title":"Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy","volume":"10","author":"Blumetti","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"496","DOI":"10.3349\/ymj.2016.57.2.496","article-title":"Botulinum toxin type A injection for spastic equinovarus foot in children with spastic cerebral palsy: Effects on gait and foot pressure distribution","volume":"57","author":"Choi","year":"2016","journal-title":"Yonsei Med. J."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"S\u0103ndulescu, M.I., Cintez\u0103, D., Poenaru, D., Potcovaru, C.G., P\u0103unescu, H., and Coman, O.A. (2024). The complex role of botulinum toxin in enhancing goal achievement for post-stroke patients. Toxins, 16.","DOI":"10.3390\/toxins16040172"},{"key":"ref_7","first-page":"757","article-title":"Effect of physiotherapeutic intervention on the gait after the application of botulinum toxin in children with cerebral palsy: Systematic review","volume":"54","author":"Galli","year":"2018","journal-title":"Eur. J. Phys. Rehabil. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1080\/01616412.2024.2359260","article-title":"Effect of botulinum toxin type A combined with physical therapy on functional capacity in children with spastic cerebral palsy: A randomized controlled clinical trial","volume":"46","author":"Politti","year":"2024","journal-title":"Neurol. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1016\/j.rehab.2018.08.004","article-title":"Adjuvant treatments associated with botulinum toxin injection for managing spasticity: An overview of the literature","volume":"62","author":"Picelli","year":"2019","journal-title":"Ann. Phys. Rehabil. Med."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Hoare, B.J., Imms, C., Rawicki, H.B., and Carey, L. (2010). Modified constraint-induced movement therapy or bimanual occupational therapy following injection of Botulinum toxin-A to improve bimanual performance in young children with hemiplegic cerebral palsy: A randomised controlled trial methods paper. BMC Neurol., 10.","DOI":"10.1186\/1471-2377-10-58"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Fattorini, L., Pettorossi, V.E., Marchetti, E., Rodio, A., and Filippi, G.M. (2025). A review about muscle focal vibration contribution on spasticity recovery. Front. Neurol., 16.","DOI":"10.3389\/fneur.2025.1579118"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"44","DOI":"10.23736\/S1973-9087.20.06390-X","article-title":"Localized muscle vibration in the treatment of motor impairment and spasticity in post-stroke patients: A systematic review","volume":"57","author":"Avvantaggiato","year":"2021","journal-title":"Eur. J. Phys. Rehabil. Med."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Giorgi, F., Donati, D., Platano, D., and Tedeschi, R. (2024). Focal vibration therapy for motor deficits and spasticity management in post-stroke rehabilitation. Brain Sci., 14.","DOI":"10.3390\/brainsci14111060"},{"key":"ref_14","first-page":"e125","article-title":"Preliminary evidence of focal muscle vibration effects on spasticity due to cerebral palsy in a small sample of Italian children","volume":"162","author":"Celletti","year":"2011","journal-title":"Clin. Ter."},{"key":"ref_15","first-page":"193","article-title":"An overview of the effects of whole-body vibration on individuals with cerebral palsy","volume":"15","author":"Ruhde","year":"2022","journal-title":"J. Pediatr. Rehabil. Med."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Krause, A., Sch\u00f6nau, E., Gollhofer, A., Duran, I., Ferrari-Malik, A., Freyler, K., and Ritzmann, R. (2017). Alleviation of motor impairments in patients with cerebral palsy: Acute effects of whole-body vibration on stretch reflex response, voluntary muscle activation and mobility. Front. Neurol., 8.","DOI":"10.3389\/fneur.2017.00416"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Peungsuwan, P., Chatchawan, U., Donpunha, W., Malila, P., and Sriboonreung, T. (2023). Different protocols for low whole-body vibration frequency for spasticity and physical performance in children with spastic cerebral palsy. Children, 10.","DOI":"10.3390\/children10030458"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1016\/j.jmpt.2023.04.011","article-title":"Effect of whole-body vibration exercise on hamstrings-to-quadriceps ratio, walking performance, and postural control in children with hemiparetic cerebral palsy: A randomized controlled trial","volume":"45","author":"Hegazy","year":"2022","journal-title":"J. Manip. Physiol. Ther."},{"key":"ref_19","first-page":"259","article-title":"Effect of a rehabilitation program including home-based vibration-assisted therapy on gait parameters in children with cerebral palsy","volume":"24","author":"Steven","year":"2024","journal-title":"J. Musculoskelet. Neuronal Interact."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/j.pmr.2026.01.002","article-title":"Do physical modalities have a role in spasticity management?","volume":"37","author":"Picelli","year":"2026","journal-title":"Phys. Med. Rehabil. Clin. N. Am."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Boulay, C., Coq, J.O., Sangeux, M., Authier, G., Ulian, A., Pradines, M., Baude, M., Desnous, B., Jouve, J.L., and Parratte, B. (2025). Case report: Combination of focal vibration therapy and botulinum toxin injections to treat equinus gait in a child with unilateral spastic cerebral palsy. Front. Rehabil. Sci., 6.","DOI":"10.3389\/fresc.2025.1454109"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1251","DOI":"10.1111\/dmcn.14910","article-title":"Measurement properties of the Gross Motor Function Classification System, Gross Motor Function Classification System-Expanded & Revised, Manual Ability Classification System, and Communication Function Classification System in cerebral palsy: A systematic review with meta-analysis","volume":"63","author":"Piscitelli","year":"2021","journal-title":"Dev. Med. Child. Neurol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1186\/s13018-024-04894-7","article-title":"Methods of muscle spasticity assessment in children with cerebral palsy: A scoping review","volume":"19","author":"Nourizadeh","year":"2024","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"665","DOI":"10.3233\/NRE-220036","article-title":"Robot-assisted rehabilitation for children with neurological disabilities: Results of the Italian consensus conference CICERONE","volume":"51","author":"Castelli","year":"2022","journal-title":"NeuroRehabilitation"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1111\/j.1469-8749.2008.03150.x","article-title":"Outcome tools used for ambulatory children with cerebral palsy: Responsiveness and minimum clinically important differences","volume":"50","author":"Oeffinger","year":"2008","journal-title":"Dev. Med. Child. Neurol."},{"key":"ref_26","unstructured":"Agenzia Italiana del Farmaco (2026, July 22). BOTOX 100 Unit\u00e0, Polvere Per Soluzione Iniettabile: Riassunto delle Caratteristiche del Prodotto, Available online: https:\/\/api.aifa.gov.it\/aifa-bdf-eif-be\/1.0.0\/organizzazione\/3732\/farmaci\/34883\/stampati?ts=RCP."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"486","DOI":"10.23736\/S1973-9087.17.04667-6","article-title":"Sonographic guide for botulinum toxin injections of the lower limb: EUROMUSCULUS\/USPRM spasticity approach","volume":"54","author":"Kaymak","year":"2018","journal-title":"Eur. J. Phys. Rehabil. Med."},{"key":"ref_28","first-page":"100299","article-title":"Ultrasound image guided injection of botulinum toxin for the management of spasticity: A Delphi study to develop recommendations for a scope of practice, competency, and governance framework","volume":"5","author":"Ashford","year":"2023","journal-title":"Arch. Rehabil. Res. Clin. Transl."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"108287","DOI":"10.1016\/j.toxicon.2025.108287","article-title":"A practical booklet for ultrasound-guided botulinum toxin injections","volume":"256","author":"Carda","year":"2025","journal-title":"Toxicon"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.gaitpost.2007.01.001","article-title":"Test\u2013retest reliability of spatial and temporal gait parameters in children with cerebral palsy as measured by an electronic walkway","volume":"27","author":"Sorsdahl","year":"2008","journal-title":"Gait Posture"}],"container-title":["Toxins"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6651\/18\/8\/327\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T08:09:28Z","timestamp":1785226168000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6651\/18\/8\/327"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,28]]},"references-count":30,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["toxins18080327"],"URL":"https:\/\/doi.org\/10.3390\/toxins18080327","relation":{},"ISSN":["2072-6651"],"issn-type":[{"value":"2072-6651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,28]]}}}