Summary of findings for the main comparison. BoNT‐A compared to usual care or physiotherapy in the treatment of lower limb spasticity in children with cerebral palsy: short‐term results.

BoNT‐A compared to usual care or physiotherapy in the treatment of lower limb spasticity in children with cerebral palsy: short‐term results
Patient or population: children with CP Setting: short‐term follow‐up (2 to 8 weeks) Intervention: BoNT‐A injections into the lower limb muscles Comparison: usual care or physiotherapy
Outcomes	Anticipated absolute effects* (95% CI)		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with usual care or physiotherapy	Risk with BoNT‐A
Instrumented gait analysis (kinematics) (not measured)	‐	‐	‐	‐	‐	Not measured in any trial
Observational gait analysis (not measured)	‐	‐	‐	‐	‐	Not measured in any trial
Function Assessed with: various scales (GMFM total scores and GMFM goal scores) Follow‐up: range 2 to 8 weeks	‐	The SMD in the intervention group was 0.59 SD higher (0.23 higher to 0.95 higher).	‐	123 (2 RCTs)	⊕⊝⊝⊝ Very lowa	Favours BoNT‐A group (higher functional scores in BoNT‐A group). Rule of thumb to interpret the magnitude of effect for the SMD: 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988).
Range of motion (passive ankle dorsiflexion) Assessed with: goniometry (degrees) Follow‐up: range 2 to 8 weeks	The mean passive ankle dorsiflexion in the control group ranged from −0.30 to 13.40 degrees.	The mean passive ankle dorsiflexion in the intervention group was 8.34 degrees higher (1.19 higher to 15.50 higher).	‐	186 (2 RCTs**)	⊕⊝⊝⊝ Very lowb	**1 study reported on this outcome per lower limb. Favours BoNT‐A group (higher passive ankle dorsiflexion in BoNT‐A group). High statistical heterogeneity
Satisfaction (not measured)	‐	‐	‐	‐	‐	Not measured in any trial
Spasticity (ankle plantarflexors) Assessed with: various scales Follow‐up: range 2 to 8 weeks	‐	The SMD in the intervention group was 1.19 SD lower (2.62 lower to 0.24 higher).	‐	186 (2 RCTs***)	⊕⊝⊝⊝ Very lowb	***1 study reported on this outcome per lower limb. No difference between groups. High statistical heterogeneity. Rule of thumb to interpret the magnitude of effect for the SMD: 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect (Cohen 1988).
Adverse events	Study population		0.37 proportion of AE in the BoNT‐A group (0.08 to 0.66)	206 (5 RCTs)	⊕⊝⊝⊝ Very lowc	AE for all studies (multiple follow‐up times). Favours control group (higher number of AE in BoNT‐A group)
	0 per 1000	Not estimable due to the lack of events in the control group
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). AE: adverse events; BoNT‐A: botulinum toxin type A; CP: cerebral palsy; CI: confidence interval; GMFM: Gross Motor Function Measure; RCT: randomised controlled trial; SD: standard deviation; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

^aDowngraded two levels for several potential sources of bias and one level for imprecision due to the small sample size.
 ^bDowngraded two levels for several potential sources of bias and one level due to high statistical heterogeneity and imprecision due to the small sample size.
 ^cDowngraded two levels for several potential sources of bias and high statistical heterogeneity and one level for imprecision, since most studies in this comparison did not report on adverse events.