Botulinum toxin type A has been widely used in focal dystonias for more than 10 years, but it is also undoubtedly of benefit in the relief of spasticity,1 a far commoner cause of motor impairment and neurological disability. The injection technique, by contrast with more traditional peripheral nerve blocks, requires little special equipment and can be learnt relatively easily. Thus it seems likely that botulinum toxin is destined to become much more widely used for this indication, although good evidence on which to base management decisions for busy clinicians is lacking.

There is uncertainty about the best delivery …