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

Objectives: To identify and prioritize key factors influencing clinicians' selection of BoNT formulations for chronic spasticity treatment to inform future guidelines and standardize decision-making. Design: Modified two-round Delphi study with international spasticity management experts. Setting: International survey involving clinicians from various practice settings. Participants: Round 1: 108 clinicians rating decision factors; Round 2: 55 respondents ranking factors. Convenience sampling of international spasticity experts. Main Outcome Measures: 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. Results: 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. Conclusions: 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.