Investigate the combination effects of strength training and Botulinum Toxin type-A (BoNT-A) on muscle strength and morphology in children with Cerebral Palsy (CP). Fifteen children receiving BoNT-A, classified as Spastic Diplegic CP, GMFCS I to II, and aged 5 to 12 years were recruited for this study. Randomly allocated to 10 weeks of strength training either before or after BoNT-A, children were assessed over 6 months. Eight of the 15 children also completed a control period. The Modified Ashworth Scale measured spasticity. The Goal Attainment Scale (GAS) assessed achievement of functional goals. Magnetic Resonance Imaging assessed muscle volume (MV). Instrumented dynamometry assessed strength. Spasticity was significantly reduced following BoNT-A injection (p = 0.033). Children made significant isokinetic strength gains (mean p = 0.022, ES 0.57) in the intervention period compared to the control period (mean p = 0.15, ES 0.56). Irrespective of timing, significant strength improvements were seen immediately (10 weeks) and over 6 months for all children. This was also the case for improvements in the GAS (immediately: mean p = 0.007, ES 4.17, 6 months: mean p = 0.029, ES 0.99), and improvements in MV in all assessed muscles. The simultaneous use of BoNT-A and strength training was successful in spasticity reduction, improving strength and achieving functional goals, over and above treatment with BoNT-A alone. Muscles targeted for BoNT-A injection should be included in strength training.

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