Post-stroke flexed elbow deformity management: consensus opinion from an international Delphi expert panel - 02/05/26

Doi : 10.1016/j.rehab.2026.102136

Marjorie Salga ^1,^2,^⁎ , Vincent T. Carpentier ^1,², Laure Gatin ^1,^2,³, Thierry Deltombe ^4,⁹, Thierry Gustin ⁵, Stefano Carda ⁶, Philippe Marque ^7,²⁹, Paul Winston ^8,⁹, Rajiv Reebye ^9,¹⁰, Theodore Wein ¹¹, Alberto Esquenazi ¹², Mary-Ann Keenan ¹³, Franco Molteni ¹⁴, Paolo Zerbinati ^15,¹⁶, Alessandro Picelli ¹⁷, Flavia Coroian ¹⁸, Bertrand Coulet ¹⁹, Nadine Sturbois-Nachef ^9,²⁰, Christian Fontaine ²⁰, Alain Yelnik ²¹, Bernard Parratte ²², Prakash Henry ²³, Srikant Venkatakrishnan MD ²⁴, Philippe Rigoard ²⁵, Romain David ²⁶, Philippe Denormandie ^1,³, Alexis Schnitzler ²⁷, Etienne Allart ²⁸, François Genet ^1,²

¹ Department of Physical Medicine and Rehabilitation, Perioperative Disability Unit, Raymond-Poincaré Hospital, AP-HP. Paris Saclay University, Boulevard Raymond-Poincaré 104, 92380 Garches, France

² 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

³ Department of Orthopedic Surgery, Raymond-Poincaré Hospital, AP-HP. Paris Saclay University, Boulevard Raymond-Poincaré 104, 92380 Garches, France

⁴ Department of Physical Medicine and Rehabilitation, CHU UCL Namur site Godinne, Ave Docteur G. Thérasse 1, 5530 Yvoir, Belgium

⁵ Department of Neurosurgery, CHU UCL Namur site Godinne, Ave Docteur G. Thérasse 1, 5530 Yvoir, Belgium

⁶ Service of Neuropsychology and Neurorehabilitation, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011 Lausanne, Switzerland

⁷ ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, Place du Dr Joseph Baylac, 31024 Cedex 3 Toulouse, UPS, France

⁸ University of British Columbia. Division of Physical Medicine and Rehabilitation, Bay St, Victoria 1952, British Columbia, V8R 1J8 Victoria, Canada

⁹ Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), 4 Cataraqui St, Suite 310, Kingston, ON K7K 1Z7, Canada

¹⁰ Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, G.F. Strong Rehabilitation Center, Laurel St 4255, V5Z 2G9 Vancouver, British Columbia, Canada

¹¹ Department of Neurology and Neurosurgery, McGill University, Rue University 3801, Montreal, H3A 0G4 Quebec, Canada

¹² Jefferson Moss-Magee Rehabilitation, Township Line Rd 60, Elkins Park, 19027 PA, United States

¹³ Penn Neuro-Orthopedics Service, University of Pennsylvania, South Pavilion, 3400 Civic Center Blvd, 2nd Floor, Philadelphia, PA 19104, USA

¹⁴ Villa Beretta Rehabilitation Center, Valduce Hospital, N. Sauro 17, 23845 Costa Masnaga, Lecco, Italy

¹⁵ Neuro-Orthopedics Unit, Sol et Salus Hospital, Viale San Salvador 204, 47922 Torre Pedrera Rimini, Italy

¹⁶ U.O. Neuro-ortopedia, Ospedale Santa Maria Multimedica Castellanza, Viale Piemonte 70, 21053 Castellanza Varese, Italy

¹⁷ Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37124 Verona, Italy

¹⁸ Physical and Rehabilitation Medicine Department, Montpellier University Hospital, Euromov, Ave du Doyen Gaston Giraud 371, 34090 Montpellier, France

¹⁹ Hand and Upper Limb Surgery Department, CHRU Lapeyronie, Ave du Doyen Gaston Giraud 371, 34090 Montpellier, France

²⁰ Department of Orthopedic Surgery, Lille University Medical Center, 2 Ave Oscar Lambret, 59000 Lille, France

²¹ Department of Physical and Rehabilitation Medicine, AP-HP Hospital Fernand Widal, Université de Paris, Rue du Faubourg Saint-Denis 200, 75010 Paris, France

²² Department of Physical and Rehabilitation Medicine, CHRU Jean Minjoz, Boulevard Alexandre Fleming 3, 25030 Besançon Cedex, France

²³ Department of Neurological Rehabilitation, Christian Medical College, Ida Scudder Road, Vellore, 632004 Tamil Nadu, India

²⁴ Department of Neurological Rehabilitation, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 5600029 Karnataka, India

²⁵ Institut Pprime UPR 3346, CNRS - Université de Poitiers - ISAE-ENSMA, France; Spine & Neuromodulation Functional Unit, Department of Neurosurgery, CHU Poitiers, PRISMATICS Lab, Rue de la Miletrie 2, 86000 Poitiers, France

²⁶ Department of Physical and Rehabilitation Medicine, University Hospital Center of Poitiers, PRISMATICS Lab, Rue de la Miletrie 2, 86000 Poitiers, France

²⁷ Department of Physical and Rehabilitation Medicine, CIC 1429, Raymond-Poincaré Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), Garches, France

²⁸ University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Neurorehabilitation Unit, Rue André Verhaegue, 59000 Lille, France

²⁹ Department of Neurological Rehabilitation, University Hospital of Toulouse, Hôpital de Rangueil, Ave du Professeur Jean Poulhès 1, 31400 Toulouse, France

^⁎ Corresponding author: Hôpital Raymond-Poincaré, Unité péri-opératoire du handicap, Pavillon Letulle, 104 Bd Raymond-Poincaré, 92380 Garches, France, 01.47.10.70.68, +33.6.12.53.17.96 Hôpital Raymond-Poincaré Unité péri-opératoire du handicap Pavillon Letulle 104 Bd Raymond-Poincaré Garches 92380 France

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Highlights

•	First international expert consensus on poststroke flexed elbow deformity (FED)
•	Functional impact assessment drives treatment decisions on poststroke FED
•	Distinguishing overactivity from contracture is key in poststroke FED treatment
•	Botulinum toxin with rehabilitation is first-line for correctable poststroke FED
•	Surgery is recommended for partially or non-correctable poststroke FED

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Abstract

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.