Treatment With Botulinum Toxin Improves Upper-Extremity Function Post Stroke: A Systematic Review and Meta-Analysis

Objective: To examine whether treatment with botulinum toxin type A (BTX-A) is associated with improvements in activity capacity or performance associated with poststroke spasticity in the upper extremity. Data Sources: MEDLINE, EMBASE, Scopus, and ISI Web of Science databases were searched from 1985 to November 2011. Data Selection: Studies were included if (1) the study design was a randomized controlled trial comparing injection of BTX-A with placebo or a nonpharmacologic treatment condition; (2) at least 60% of the sample was composed of adult subjects recovering from either first or subsequent stroke; (3) subjects presented with moderate to severe upper-extremity spasticity of the wrist, finger, or shoulder; and (4) activity was assessed as an outcome. Studies were limited to those published in the English language. Data Extraction: Data pertaining to participant characteristics, treatment contrasts, and outcomes assessing activity limitations were extracted from each trial. The World Health Organization's International Classification of Functioning, Disability and Health was used to identify outcomes that captured the domain of activity used within each of the included studies. Where possible, a treatment effect size was calculated for each study using the standardized mean difference +/- standard error (95% confidence interval) and the results pooled. Data Synthesis: Sixteen randomized controlled trials were identified, 10 of which reported sufficient data for inclusion in the pooled analysis (n=1000). Six different outcomes that assessed activity limitations had been used, including the Disability Assessment Scale, the Action Research Arm Test, and the Barthel Index. Overall, BTX-A was associated with a moderate treatment effect (standardized mean difference=.536 +/-.094, 95% confidence interval -=.352-.721, P<.0001). Conclusions: The use of BTX-A was associated with moderate improvement in upper-extremity activity capacity or performance after stroke. Archives of Physical Medicine and Rehabilitation 2013;94:977-89 (C) 2013 by the American Congress of Rehabilitation Medicine