Stroke: arm recovery (FS-23)

Best practice for arm recovery post stroke: an international application

Steven Wolf (United States of America), Gert Kwakkel (Netherlands), Mark Bayley (Canada), Michelle McDonnell (Australia)

Focused symposium

Sunday 3 May 2015, 16:00-17:30, Hall 404

Best practice for arm recovery post stroke: an international application

Wolf S. 1, Kwakkel G. 2, Bayley M. 3, McDonnell M. 4

1Emory University School of Medicine, Rehabilitation Medicine, Division of Physical Therapy, Atlanta, United States of America, 2VU University Medical Center, Dept. Rehabilitation Medicine, Amsterdam, Netherlands, 3UHN-Toronto Rehabilitation Institute, Brain and Spinal Cord Rehabilitation Program and University of Toronto, Toronto, Canada, 4University of South Australia, School of Health Sciences, Adelaide, Australia

Learning objectives

  1. Increase awareness amongst clinicians of evidence-based approaches to upper limb rehabilitation following stroke
  2. Understand how a decision making pathway with clearly defined assessment and treatment criteria can be used to incorporate best practice guidelines into rehabilitation
  3. Challenge physiotherapists to consider their own barriers to implementation of best evidence and how this approach could apply to other areas of physiotherapy practice.


9am, Mangalore, India. You arrive at work to discover that your first outpatient had a stroke 6 weeks ago. This isn't your area of expertise….they have come to you because they can't return to work until they can type on a keyboard, and they have weakness of their right arm and hand. What do you do? Get out your phone and check the app!

Approaching the mammoth task of rehabilitating the upper limb can be daunting, whether your patient is in pain, has restricted movement or severe weakness. Often, clinicians wonder where to start - what is appropriate for my patient at this time with this degree of impairment? Following clinical guidelines can be helpful for those with national best practice recommendations, but they can often be overwhelming and not seem relevant to the person before you. A group of stroke and rehabilitation researchers around the world have come together to address this problem. They tackled two main areas: recommendation of which valid and reliable outcome measures should be used to chart progress in impairment, activity and participation domains, but also which interventions are recommended to use with patients at varying stages of their condition. Coming together, these groups developed an algorithm to present the appropriate interventions for each stage of the recovery process. When converted into the app, it allows clinicians to answer simple yes/no questions which then guides them to the appropriate evidence-based interventions that align with their patient's goals.

Professor Steven Wolf is an internationally renowned expert in the field of neurological rehabilitation, and was the lead investigator in the first large, multi-centre trial of constraint induced therapy for upper limb rehabilitation. He will lead the session, with a background on the need for the app and the task of bringing together the international working party. He will be followed by Dr. Mark Bayley, a Rehabilitation Physician who has been instrumental in the SCORE project in Canada: Stroke Canada Optimization of Rehabilitation through Evidence. Using his evidence implementation experiences with the Canadian Stroke Network, he will describe how consultation with clinicians was a driving force behind this initiative, and how the decision making algorithm fills a need for clinicians.

Prof Gert Kwakkel is a leading authority on translating research into best practice, particularly in the area of stroke rehabilitation. He has produced the seminal work in the area regarding intensity of practice, mechanisms that contribute to improvement following stroke as well as determinants that may predict final outcome of the paretic upper limb following stroke. He will share these research highlights and demonstrate how this research has informed the decision making pathway that has been developed into the app. Finally, Dr Michelle McDonnell, an early career researcher and academic, will discuss how the outcome measures will assist with the decision making process for clinicians, and explain how the recommended evidence based interventions included in the app can be incorporated into daily practice by physiotherapists around the world.

This conceptual approach to rehabilitation needs the cooperation of physiotherapists worldwide to implement, refine and update this decision making pathway.

Implications / Conclusions

Experts predict the incidence of stroke will escalate around the world and health care resources will struggle to provide rehabilitation services. Evidence based guidelines exist, but clinicians express frustration with knowing which interventions to prioritise, and which ones are appropriate for subgroups of patients they may be working with. In this session, participants will learn about the best evidence for upper limb rehabilitation, but also how to demystify the various guidelines, streamline assessment and outcome measurement and select the most appropriate interventions that suit a patient's goals and their level of function. The app we will share with the audience is based on expert interpretation of clinical guidelines and careful synthesis of the best research evidence so that clinicians can follow the pathway and have confidence that they are providing rehabilitation that is best able to optimise recovery following stroke. For physiotherapists not working in stroke rehabilitation, we challenge them to consider how a formalised decision making pathway leading to evidence based interventions could enhance their clinical practice.


Rehabilitation; Best practice; Decision making pathway

Funding acknowledgements


Relevance to WCPT and expected audience

As the incidence of stroke increases throughout the world, loss of function and independence caused by upper limb impairment is devastating. Physiotherapists have the potential to drive reorganisation within the brain using several evidence based approaches, but the implementation of these approaches is low. Our international “think tank” has spent 4 years searching and collating the best evidence to develop an app to help clinicians choose optimal interventions for upper limb rehabilitation following stroke.

Target audience

Physiotherapists with an interest in rehabilitation, particularly those in the developing world who may not have access to latest research results or best practice guidelines.