In reply: We thank Graham et al for their response to our article.1

It is important to understand that the clinician who posed the question regarding botulinum toxin A injection wished to find the "best available medical evidence". We were not asked to take account of the historical context of previously published articles, nor were we asked to exclude specific types of RCTs. If we were to exclude specific RCTs based on the preference of an author, then the strong methodological principles that surround the evidence-based practice movement would be open to extreme forms of bias.

We also disagree that our conclusions were incorrect. Our reading of the article by Corry et al2 differed from that of Graham et al. We do not consider that their study showed that botulinum toxin injection significantly improved the function of the hemiplegic upper limb. Together with the results of the study by Fehlings et al,3 indicating a significant improvement in weight-bearing at four weeks (part of the QUEST assessment), our conclusion — that we could not support or refute the efficacy of botulinum toxin injections for improving upper-limb function in cerebral palsy because of differing opinions — remains unchanged.