Factors Influencing the Selection of Botulinum Toxin Preparations for the Management of Spasticity

To identify and prioritize key factors influencing clinicians' selection of BoNT formulations for chronic spasticity treatment to inform future guidelines and standardize decision-making.

Modified two-round Delphi study with international spasticity management experts.

International survey involving clinicians from various practice settings.

Round 1: 108 clinicians rating decision factors; Round 2: 55 respondents ranking factors. Convenience sampling of international spasticity experts.

Importance ratings of seven decision-making categories using 5-point Likert scales (Round 1) and factor ranking (Round 2). Inter-rater agreement assessed using Kendall's coefficient of concordance.

Respondents primarily used onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA. Round 1 identified economic factors as most important (mean 3.74 points), followed by hospital/system factors (3.53 points) and toxin-specific factors (3.27 points). Round 2 revealed disease-specific factors as highest priority (14 first-place votes, mean rank 3.42 points), followed by injector expertise and toxin characteristics. Kendall's coefficient was 0.35, indicating moderate agreement.

BoNT formulation selection involves multiple factors with significant practice variability. While economic and institutional considerations influence decisions, clinicians prioritize disease characteristics, clinical expertise, and toxin properties when ranking options. Evidence-based guidelines are needed to reduce practice variation and improve BoNT-based spasticity management.