World Stroke Organization (WSO) rehabilitation certification program.

Abstract

Background: Rehabilitation has been identified by the World Stroke Organization (WSO) as a key priority to reduce the global burden of stroke. Global access to rehabilitation is inconsistent and is particularly limited in low-and-middle-income countries. Progress in rehabilitation has not been as well evidenced as progress in acute care. The WSO certification program, which commenced in 2021, focuses on acute interventions. A rehabilitation certification program, applicable in both inpatient and outpatient rehabilitation settings, has been developed to complement the acute certification program to address global implementation of evidence-based stroke care.

Aim: To develop globally applicable, evidence-based, stroke rehabilitation recommendations and performance metrics for use in a stroke rehabilitation certification program.

Methods: Strong recommendations were extracted from high-quality stroke rehabilitation Clinical Practice Guidelines, systematic reviews and syntheses of clinical practice guidelines, and from the defining criteria of the International Stroke Recovery and Rehabilitation Alliance (ISRRA) Centers of Clinical Excellence. The WSO Rehabilitation Implementation Committee led the development of the recommendations and invited input from three international, multidisciplinary consultation groups. Group 1 compared strong recommendations from the Australia/New Zealand Living Guidelines with other international guidelines to identify consistent, high-quality recommendations. Group 2 mapped recommendations from global guideline syntheses against the Australia/New Zealand Living Guidelines. Group 3 reviewed and adapted the ISRRA Center of Clinical Excellence recommendations. Recommendations were consolidated through consensus meetings involving representatives from each workgroup, including people from high, upper-middle, and lower-middle-income countries. Strong recommendations that were consistent across teams, alongside additional recommendations based on certainty of evidence, anticipated risk versus benefit, and relevance across settings, were included as patient-level recommendations in the implementation certification program. Service-level recommendations were generated through consensus or derived from existing guidelines. An implementation manual, outlining "what," "who," and "how," as well as indicators to demonstrate performance of each recommendation, was developed to support clinical implementation and to facilitate assessment for certification. The criteria were piloted between November 2024 and September 2025 at 15 centers in six upper- and lower-middle-income countries (three continents) and subsequently refined. Expectations (mandatory or recommended) for each level of certification (Minimal, Essential and Advanced) were set post-pilot through rating strength of evidence, a series of group discussions and review of pilot data.ResultsFifty-five recommendations were included. Nine recommendations address service-level indicators, and 46 address patient-level indicators. Service-level indicators address defining features of rehabilitation services that are not apparent in individual patient medical record audits. Patient-level indicators address management of swallowing impairment, nutrition and hydration, information provision and goal setting, amount and timing of rehabilitation, exercise and motor rehabilitation, visual function, communication, mood and cognition, management of complications, and discharge planning and support. An implementation manual complements the recommendations to guide clinical care and consistent assessment.ConclusionsThe WSO rehabilitation recommendations and performance metrics incorporate the most current evidence and have been refined following pilot-testing. The recommendations are globally relevant and support both resource-limited and high-income settings in participating in the rehabilitation certification program to advance international stroke rehabilitation delivery.