Abstract Committee Review

Strengths of the Revision

• Clearer framing: The abstract now convincingly positions ESWT as an adjunctive therapy addressing both neurogenic and non-neurogenic components of spasticity. This provides a strong and clinically relevant rationale.
• Design transparency: Explicitly describing the work as a “pilot randomized controlled trial” is appropriate and enhances scientific accuracy given the limited sample size.
• Balanced reporting: The results section is clearer, distinguishing outcomes between groups and highlighting the persistence of MAS reduction, as well as the additional improvements in MTS, pain, and mobility in the ESWT group.
• Acknowledgment of limitations: The revised conclusion appropriately notes the absence of a placebo group, the relatively short follow-up period, and the small sample size. This strengthens the credibility of the study and aligns with good reporting standards.
• Concise and logical flow: The abstract follows a logical structure (Introduction–Methods–Results–Conclusions) and communicates the study clearly and efficiently.

Areas for Further Improvement

1. Statistical reporting
   • The abstract currently presents multiple p-values without effect sizes or confidence intervals. Including at least one measure of effect (e.g., Cohen’s d or mean difference with CI) would enhance interpretability and transparency, even in an abstract format.
2. Follow-up duration wording
   • The current phrasing, “effects over a longer period were not observed,” could be misunderstood. A clearer and more precise formulation would be: “The evaluation period was limited to three months; therefore, long-term durability could not be assessed.”
3. Grammar and word choice
   • “The significant reduction in MAS scores of the most spastic muscles” → “The reduction in MAS scores of the most spastic muscles remained significant for three months…”
   • “was found enough by power analysis” → “was deemed sufficient by power analysis.”
4. Conclusion refinement
   • A cautious and academically rigorous conclusion is recommended:

Conclusions:
This pilot study indicates that ESWT may be a useful adjunct to BoNT-A, providing longer-lasting reductions in spasticity and additional improvements in functional mobility and pain management in children with CP. Nevertheless, the absence of a placebo group, the limited three-month follow-up, and the small sample size (n=20), although supported by power analysis, restrict the generalizability of the findings. Larger, multicenter randomized controlled trials with extended follow-up are required to confirm these preliminary results.

Conclusion of Review
The revised abstract is substantially improved. It now frames the study appropriately as a pilot RCT, presents the main findings with clarity, and acknowledges the key limitations responsibly. With minor language refinements and, if feasible, the addition of effect size data, the abstract will be well-positioned for acceptance and will contribute meaningfully to the emerging evidence base on multimodal spasticity management in cerebral palsy.

Dear Authors,

Your abstract addresses a clinically important and timely question in pediatric rehabilitation: whether extracorporeal shockwave therapy (ESWT) can enhance and prolong the effects of botulinum toxin type A (BoNT-A) in reducing spasticity among children with cerebral palsy. The work is highly relevant, as both interventions are increasingly applied in practice, yet their combined efficacy has not been sufficiently studied in randomized trials.

Strengths

1. Clear rationale: The introduction successfully highlights the limitations of BoNT-A monotherapy and positions ESWT as a logical adjunctive treatment.
2. Appropriate design: The randomized controlled trial methodology and inclusion of widely accepted outcome measures (MAS, MTS, MTUG, FPS-R, ROM) strengthen the validity of the findings.
3. Clinical value: The results are directly applicable to practice, suggesting meaningful improvements in spasticity, functional mobility, and pain when ESWT is added to BoNT-A.
4. Concise structure: The abstract is logically organized and includes sufficient detail to inform readers of the intervention, outcomes, and main findings.

Areas for Improvement

1. Sample size: With only 20 participants, the trial should be presented as exploratory or pilot in nature. Acknowledging this limitation in the conclusion would strengthen credibility.
2. Statistical reporting: The multiple p-values may distract the reader. Consider summarizing trends (e.g., persistence of effect in the combined group vs. decline in the BoNT-A group) and, if possible, include effect sizes or confidence intervals.
3. Follow-up: Three months is useful for short-term assessment but insufficient to evaluate long-term durability. Noting this as a limitation would be appropriate.
4. Language: Minor grammatical refinements could enhance clarity (e.g., “may lead complications” → “may lead to complications”).

Conclusion of Review
Overall, this is a promising and clinically relevant study that contributes to the growing body of evidence supporting multimodal spasticity management in children with CP. The findings suggest that ESWT is a valuable adjunct to BoNT-A, providing longer-lasting spasticity reduction and additional functional benefits. To increase the impact of this work, future studies with larger sample sizes, multicenter collaboration, and extended follow-up are recommended.

I commend the authors for addressing this important topic with a rigorous design and meaningful clinical application.