title: The efficacy of Botulinum Toxin A for spasticity and pain in adults: a systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation approach.
abstract: OBJECTIVE
  A systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to evaluate Botulinum Toxin Type A efficacy on spasticity and pain in the upper/lower limb in adults.
  
  
  METHODS
  Pubmed, Cinahl, Amed, Embase and Cochrane Databases. English language. 1989 to April 2013.
  
  
  METHODS
  All randomized controlled trials on adults with spasticity of any origin in the upper or lower limb, treated with a single dose of Botulinum Toxin A, with outcome measures for pain or spasticity. Quality was assessed by GRADE, which uses a transparent, structured process for developing and presenting summaries of evidence, including its quality, for systematic reviews.
  
  
  RESULTS
  A total of 37 studies were reviewed. A meta-analysis was carried out on 10 for pain and 21 for spasticity. Evidence quality was low/very low for pain. No significant effect was found in the upper limb (standardised mean difference (SMD) = 0.44, confidence interval (CI) -0.02 to 0.90, Z = 1.88, P=0.06), and no effect was found in the lower limb (risk ratio (RR) = 1.01 CI 0.19 to 5.36, Z = 0.02, P=0.99). Evidence quality for spasticity was moderate. Significant effects were found for Botulinum Toxin in the upper limb (weighted mean difference (WMD) = 0.88, CI 0.63 to 1.14, Z = 6.86, P<0.00001), and the lower limb (RR=2.42, CI 1.60 to 3.65, Z=4.18, P<0.0001).
  
  
  CONCLUSIONS
  The use of Botulinum Toxin A is supported for upper and lower limb spasticity. Further evidence is needed for spasticity-related pain. Evidence quality is reduced by inadequate study design.
authors.affiliation: 1Physiotherapy Department, Poole Hospital NHS Foundation Trust, Poole, UK.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Baker
authors.forename: Gavin
authors.initials: G
authors.lastname: Pereira
mesh_terms: D000328:Adult; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D016206:Databases, Bibliographic; D005121:Extremities / Q000503:physiopathology; D006801:Humans; D009128:Muscle Spasticity / Q000150:complications / Q000188:drug therapy*; D009498:Neurotoxins / Q000008:administration & dosage / Q000627:therapeutic use; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D016032:Randomized Controlled Trials as Topic
chemical_list: D009498:Neurotoxins; D019274:Botulinum Toxins, Type A
keywords: Botulinum toxin; GRADE; systematic review