# Good Clinical Practices for the Management of Cervical Dystonia with BoNT-A: A Delphi-Based Approach from the Italian Expert Group

## TL;DR

This paper presents expert-based clinical guidelines for managing cervical dystonia in Italy, aiming to standardize care and improve patient outcomes.

## Contribution

The paper introduces structured good clinical practice recommendations for cervical dystonia management based on a Delphi process involving Italian experts.

## Key findings

- A Delphi process involving 56 Italian experts achieved consensus on 52 clinical statements for cervical dystonia management.
- Recommendations include comprehensive patient assessment, individualized BoNT-A dosing, and integration of physiotherapy and psychological support.
- The guidelines aim to standardize care and optimize treatment for cervical dystonia patients.

## Abstract

Cervical dystonia (CD) is the most common adult-onset focal dystonia, with heterogeneous clinical presentation and significant functional impairment. Currently, no structured Italian good clinical practice documents specifically addressing CD have been published. Optimizing CD management requires expert-based recommendations to guide diagnosis, treatment, and follow-up. A two-round Delphi process was conducted, involving a scientific board of six neurologists with expertise in CD management and an external panel of 56 Italian experts (neurologists and physiatrists managing CD patients). Fifty-two statements were developed, discussed, and voted using a 5-point Likert scale, with consensus defined as ≥75% agreement (‘strongly agree’ or ‘somewhat agree’). In Round 1, 48 of 52 statements (92.4%) reached consensus; the four remaining statements were revised, and two were re-voted in Round 2, both achieving consensus. Final recommendations emphasize comprehensive patient assessment in multiple postural conditions; individualized botulinum neurotoxin type A (BoNT-A) dosing taking into account tonic and phasic components, pain, and dysphagia; the use of instrumental guidance; standardized outcome measures; and integration of physiotherapy and psychological support. This article provides structured good clinical practice recommendations for CD management and offers clinicians, especially those with limited experience, a practical framework to standardize care, optimize treatment, and improve patient outcomes.