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Post-stroke flexed elbow deformity management: consensus opinion from an international Delphi expert panel
Marjorie Salga1, Vincent T Carpentier1, Laure Gatin2
1Department of Physical Medicine and Rehabilitation, Perioperative Disability Unit, Raymond-Poincaré Hospital, AP-HP, Paris Saclay University, Boulevard Raymond-Poincaré 104, 92380 Garches, France; UR 20262 Handistart, UFR Simone Veil Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Ave de la Source de la Bièvre 4, 78180 Montigny le Bretonneux, France.
Background:
Poststroke flexed elbow deformity is a frequent and disabling abnormal joint posture that impairs function, hygiene, and quality of life. Despite its clinical impact, assessment strategies and treatment sequencing remain heterogeneous, fragmented across disciplines, and poorly standardized.
Objectives:
To establish an international, interdisciplinary expert consensus on the assessment and management of poststroke flexed elbow deformity using a hypothesis-driven Delphi methodology.
Methods:
An international Delphi process was conducted involving 28 experts in physical and rehabilitation medicine, orthopedic surgery, and neurosurgery from 12 countries. Three sequential, anonymous rounds of structured online questionnaires were administered. Statements addressed diagnosis, clinical and instrumental assessment, treatment selection, and surgical indications. Experts rated their agreement with each statement. Consensus was predefined as ≥80% agreement among respondents for a given item.
Results:
Across 3 Delphi rounds, 164 statements were evaluated, of which 61 (38%) reached consensus. Experts, including physical and rehabilitation medicine physicians (n = 13), orthopedic surgeons (n = 10), and neurosurgeons (n = 1) agreed that functional impact assessment must precede treatment decisions and that differentiation between muscle overactivity and soft-tissue contracture is essential. Diagnostic motor nerve blocks and radiological imaging were endorsed as complementary tools in selected cases. Botulinum toxin injections combined with rehabilitation were supported as first-line treatment for correctable deformities, whereas surgical intervention was considered appropriate for partially or non-correctable deformities. Preoperative interdisciplinary consultation and formal goal setting were deemed mandatory before intervention.
Conclusions:
This Delphi-based international consensus provides structured, interdisciplinary guidance for the evaluation and management of poststroke flexed elbow deformity. By clarifying assessment principles, treatment sequencing, and indications for referral and surgery, this consensus aims to standardize care pathways and improve patient-centered outcomes.
Registration:
Not applicable. This study used a Delphi methodology involving expert opinion only, without human participant intervention.
