title: Efficacy of botulinum toxin A in children with cerebral palsy in Gross Motor Function Classification System levels IV and V: a systematic review.
abstract: OBJECTIVE
  Previous studies have shown the efficacy of botulinum toxin type A (BoNT-A) in the management of ambulant individuals with cerebral palsy (CP). There is little evidence on its use in non-ambulant children with CP. This review aimed to investigate indications and efficacy for BoNT-A use in managing pain, care, and comfort, and improving function in children with CP in Gross Motor Function Classification System (GMFCS) levels IV and V.
  
  
  METHODS
  Electronic databases were searched from the earliest available date to June 2012 using a combination of subject headings and free text. Inclusion criteria consisted of studies with (1) participants aged 18 or under, (2) participants with CP in GMFCS levels IV and V, (3) participants receiving BoNT-A treatment, and (4) studies published in English-language peer-reviewed journals.
  
  
  RESULTS
  The search resulted in a total of 814 studies, of which 19 met the inclusion criteria. Eighteen studies provided level IV or V evidence and one level I evidence according to the American Academy for Cerebral Palsy and Developmental Medicine guidelines for the development of systematic reviews. Most of the studies were of weak to moderate methodological quality.
  
  
  CONCLUSIONS
  The evidence that BoNT-A is effective in reducing postoperative pain in children with CP in GMCFS levels IV and V is limited, with only one level I study identified. Remaining indications were general pain reduction, maintaining hip integrity, achieving functional changes, and goal attainment. A high percentage of participants in the studies showed positive changes in these areas. With the poor level of evidence of the included studies, no definite conclusion could be drawn on the indications for BoNT-A use in children with CP in GMCFS levels IV and V. Further investigation by rigorous studies is required.
authors.affiliation: Kids Rehab Department, The Children's Hospital at Westmead, Westmead, NSW, Australia. tamispin@hotmail.com
authors.forename: Tamis W
authors.initials: TW
authors.lastname: Pin
authors.forename: Jessica
authors.initials: J
authors.lastname: Elmasry
authors.forename: Jenny
authors.initials: J
authors.lastname: Lewis
mesh_terms: D000293:Adolescent; D001259:Ataxia / Q000209:etiology; D019274:Botulinum Toxins, Type A / Q000494:pharmacology / Q000627:therapeutic use*; D002547:Cerebral Palsy / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology*; D002648:Child; D002675:Child, Preschool; D015986:Confounding Factors, Epidemiologic; D020820:Dyskinesias / Q000209:etiology; D004421:Dystonia / Q000209:etiology; D019317:Evidence-Based Medicine; D006621:Hip Joint / Q000187:drug effects / Q000503:physiopathology; D006801:Humans; D007223:Infant; D009128:Muscle Spasticity / Q000209:etiology; D010146:Pain / Q000209:etiology / Q000517:prevention & control; D011187:Posture; D011597:Psychomotor Performance; D012107:Research Design; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D019274:Botulinum Toxins, Type A