Letter by Munin et al Regarding Article, “Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial: Effect on Impairment, Activity Limitation, and Pain”

To the Editor:We read the article by Shaw et al1 with great interest. Their trial examined whether abobotulinumtoxinA and task practice therapy could improve upper limb function after spastic hemiparesis more than therapy alone in controls based on changes in the Action Research Arm Test (ARAT).1 There are several points that may explain why the investigators saw only improvements in patient-rated basic upper limb functional activities rather than observed ARAT scores in treated subjects.When injecting botulinum toxin, the clinicians used surface localization to identify forearm muscles instead of more accurate guidance from ultrasound with electromyography or nerve stimulation. We demonstrated that ultrasound guidance during botulinum toxin injections is more accurate than surface localization when targeting forearm muscles that have a complex pattern of overlapping anatomy with superficial and deep layers.2 Using ultrasound guidance, muscles with several bellies (eg, …