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Previous reviews lacked an assessment of the certainty of evidence and focused solely on clinician\u2010reported outcomes. Additionally, studies have demonstrated interindividual variability in BoNT efficacy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>The aim of the study was to assess the efficacy and safety of BoNT injections for ET and DTS of the upper limbs, and to identify factors associated with BoNT efficacy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We systematically searched Pubmed, Embase, Cochrane Library, and Web of Science databases for studies on BoNT injections in ET and DTS of the upper limbs. The certainty of evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Outcomes from randomized controlled trials (RCTs) were pooled as standardized mean differences (SMDs).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We identified 5 RCTs, 6 open\u2010label trials, and 6 retrospective cohort studies. Meta\u2010analysis of post\u2010intervention scores showed a moderate effect on patient\u2010reported change (SMD: 0.58 [95% confidence interval [CI]: 0.39, 0.78]), no effect on clinically rated tremor severity (SMD: 1.69 [95% CI: \u22123.80, 0.42]), and no effect on grip strength (SMD: \u22120.63 [95% CI: \u22121.37, 0.10]). In contrast, meta\u2010analysis using change\u2010from\u2010baseline scores showed an improvement of clinically rated tremor severity (SMD: \u22121.12 [95% CI: \u22121.70, \u22120.54]). Certainty of evidence ranged from low to very low. No clear associations between BoNT efficacy and tremor phenotypes or injection strategies were identified.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Patient\u2010tailored BoNT injections may be effective and safe for ET and DTS. More trials are needed to confirm efficacy and safety, identify which tremor phenotypes benefit the most, and optimize injection strategies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/mdc3.70307","type":"journal-article","created":{"date-parts":[[2025,8,29]],"date-time":"2025-08-29T06:45:02Z","timestamp":1756449902000},"page":"369-378","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Botulinum Toxin Efficacy in Upper Limb Tremor: A Systematic Review and Meta\u2010Analysis"],"prefix":"10.1002","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2358-1795","authenticated-orcid":false,"given":"Iris M.","family":"Visser","sequence":"first","affiliation":[{"name":"Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behaviour Radboud University Medical Center  Nijmegen The Netherlands"},{"name":"Centre for Cognitive Neuroimaging, Donders Institute for Brain, Cognition and Behaviour Radboud University  Nijmegen The Netherlands"},{"name":"Department of Neurology, Canisius Wilhelmina Hospital  Nijmegen The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuvadee","family":"Pitakpatapee","sequence":"additional","affiliation":[{"name":"Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Donders Institute for Brain, Cognition and Behaviour Radboud University Medical Center  Nijmegen The Netherlands"},{"name":"Centre for Cognitive Neuroimaging, Donders Institute for Brain, Cognition and Behaviour Radboud University  Nijmegen The Netherlands"},{"name":"Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital Mahidol University  Bangkok Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bart","family":"van de Warrenburg","sequence":"additional","affiliation":[{"name":"Department of Neurology, Center 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