Gaps in the physical therapy approach to functioning and disability after stroke: a scoping reviewABSTRACT
Investigating the use of the biopsychosocial model in healthcare can point to shortcomings in the approach to health domains that make care less comprehensive. There are gaps of information on how this model is employed by physical therapists in the care of stroke survivors. These data could contribute to health decision-making and targeting of resources across various intervention settings. This scoping review analyzed clinical trials conducted by physical therapists that had functioning/disability in post-stroke adults as an outcome, with the aim of investigating the biopsychosocial model approach. Articles in which the intervention was applied by other professionals and/or published only in languages not mastered by the authors were excluded. Screening by two blinded reviewers returned 25 articles across eight databases (Medline, PEDro, Embase, Scopus, LILACS, CINAHL, Web of Science, and the Cochrane CENTRAL database). The content of the functioning/disability assessment measures was linked to the domains of the International Classification of Functioning, Disability, and Health (ICF). With the ICF categories, a more detailed content analysis was conducted, enabling a precise comparison across intervention settings. We found that the functioning/disability approach mostly focuses on covering the activity elements of the biopsychosocial model, mainly mobility and self-care, regardless of the intervention setting. The results of this study may be useful for guiding the practice of physical therapists, providing data for health managers to officially adopt the model as a decision-making guide and clarifying to patients some of the objectives of physical therapy after stroke.
Keywords
Stroke; Physical Therapy Modalities; International Classification of Functioning, Disability and Health; Health Services
RESUMO
Este estudo buscou investigar se o uso do modelo biopsicossocial na prestação de saúde pode apontar carências na abordagem dos domínios de saúde que tornem o cuidado menos abrangente. Não há informações sobre como o modelo é utilizado por fisioterapeutas no cuidado às pessoas que sofreram Acidente Vascular Cerebral (AVC). Esses dados podem contribuir para as decisões em saúde e para o direcionamento de recursos nos diferentes cenários de intervenção. Esta revisão de escopo analisou ensaios clínicos conduzidos por fisioterapeutas que tiveram a funcionalidade/incapacidade em adultos pós-AVC como desfecho, com o objetivo de investigar a abordagem do modelo biopsicossocial. Foram excluídos deste estudo artigos em que a intervenção foi aplicada por outros profissionais e que foram publicados somente em idiomas não dominados pelos autores. A triagem por dois revisores cegos retornou 25 artigos em oito bases de dados (Medline, PEDro, Embase, Scopus, Lilacs, CINAHL e Web of Science, e base de registros Cochrane Central). O conteúdo das medidas de avaliação da funcionalidade/incapacidade foi vinculado aos domínios da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Com as categorias da CIF, foi conduzida uma análise de conteúdo mais detalhada que permitiu uma comparação precisa entre os cenários de intervenção. A abordagem da funcionalidade/incapacidade concentra-se em cobrir os elementos de atividade do modelo biopsicossocial, principalmente mobilidade e autocuidado, independentemente do ambiente. Os resultados deste estudo podem ser úteis para guiar a prática de fisioterapeutas, oferecer dados para gestores de saúde adotarem oficialmente o modelo como orientador de decisões e esclarecer aos pacientes alguns objetivos do cuidado fisioterapêutico.
Descritores
Acidente Vascular Cerebral; Modalidades de Fisioterapia; Classificação Internacional de Funcionalidade, Incapacidade e Saúde; Serviços de Saúde
RESUMEN
Este estudio pretendió investigar si el uso del modelo biopsicosocial en la atención médica puede apuntar a deficiencias en el enfoque de los dominios de salud que hacen que la atención sea menos integral. No hay información sobre cómo los fisioterapeutas utilizan el modelo en la atención a personas que hayan sufrido un accidente cerebrovascular (ACV). Estos datos pueden contribuir a las decisiones sanitarias y a la asignación de recursos en diferentes escenarios de intervención. Esta revisión del alcance analizó los ensayos clínicos realizados por fisioterapeutas que se enfrentaron a la funcionalidad/discapacidad en adultos pos-ACV como resultado, con el objetivo de investigar el enfoque del modelo biopsicosocial. Se excluyeron de este estudio los artículos en que la intervención fue aplicada por otros profesionales y aquellos que fueron publicados únicamente en idiomas no dominados por los autores. La selección realizada por dos revisores ciegos arrojó 25 artículos en ocho bases de datos (Medline, PEDro, Embase, Scopus, Lilacs, CINAHL y Web of Science, y en Cochrane Central). El contenido de las medidas para evaluar la funcionalidad/discapacidad se vinculó a los dominios de la Clasificación Internacional del Funcionamiento, la Discapacidad y la Salud (CIF). Con las categorías CIF, se realizó un análisis de contenido más detallado que permitió una comparación precisa entre los escenarios de intervención. El enfoque de funcionalidad/discapacidad se centra en cubrir los elementos de actividad del modelo biopsicosocial, principalmente la movilidad y el autocuidado, independientemente del entorno. Los resultados de este estudio pueden ser útiles para orientar la práctica de los fisioterapeutas, al ofrecer datos para que los gestores sanitarios adopten oficialmente el modelo como guía de decisión, y para aclarar algunos objetivos de la atención fisioterapéutica a los pacientes.
Palabras clave
Accidente Cerebrovascular; Modalidades de Fisioterapia; Clasificación Internacional del Funcionamiento, la Discapacidad y la Salud; Servicios de Salud
INTRODUCTION
Since 1990, stroke has remained among the top five leading causes of disability worldwide1. Post-stroke complications can last for days or become permanent, ranging from localized effects such as pain and reduced muscle strength to social impacts, including dependence on others for self-care, delayed return to work, and social restrictions2 - 5. The burden extends to caregivers, families, the healthcare system, and the economy, influencing decisions made by health managers6 - 8.
Admission to a rehabilitation program depends on factors such as injury severity, individual progress, patient preferences and support network, presence of a caregiver, and availability of services9. Hospitals and wards are generally intended for intensive care, as they contain equipment and routines suited to reduce complications and stabilize the clinical condition10. Upon discharge, the individual may be referred to home care services, outpatient clinics, rehabilitation centers, specialized clinics, long-term care institutions, or primary care services10.
Given the broad range of stroke consequences, the use of the biopsychosocial model in clinical practice has been recommended to ensure better quality of care10. The model was introduced in the International Classification of Functioning, Disability, and Health (ICF) and prevents care from being reduced to a single aspect of health, whether biological, personal, social, or related to the health condition11. The positive dynamic interaction between these elements is referred to as functioning. The negative experience of this interaction is called disability11,12. The ICF framework has stood out as a guide for analyzing outcomes in the context of rehabilitation and as a model for assessing functioning in health conditions such as stroke13. In physical therapy, studies focus on investigating the alignment of assessment instruments with the domains of health14 - 18. The results of this investigation highlighted gaps in addressing health domains in the management of orthoses for post-stroke patients. Additionally, they provided data to guide the choice between generic and condition-specific quality of life assessment measures, with the potential to inform decisions on functional health and support the development of public health policies16 - 18.
The study of functionality and disability from the perspective of the biopsychosocial model provides crucial data to identify the population’s health needs and allocate resources across various rehabilitation settings8,13. Information on how physical therapists apply the model in the management of functioning and disability post-stroke is still lacking. Seeking this information may reveal gaps in the biopsychosocial approach, thus providing a more comprehensive understanding of the health condition, offering insights for planning patient-centered interventions, and facilitating collaborative intervention planning between professionals, the patient, and their support network. For healthcare services, the information may enable standardized language among physical therapists, facilitating communication during transitions between healthcare services; prompt reflection on the need for professional training in the biopsychosocial approach; and encourage the development of health policies based not only on mortality and morbidity indicators.
This scoping review aimed to study the use of the biopsychosocial model in addressing functioning/disability in post-stroke care provided by physical therapy across different intervention settings. Other objectives included: (1) Identify the most frequent primary outcomes and measurement instruments in each intervention setting; (2) Examine the alignment of the content of functioning/disability assessment tools with the ICF; and (3) Compare the content and coverage of the ICF across intervention settings.
METHODOLOGY
This scoping review followed the Joanna Briggs Institute guidelines19. The eligibility criteria included clinical trials with an adult population that suffered a stroke and received some form of physical therapy intervention, compared to another intervention or no intervention. The assessment of functioning or disability is considered the primary or secondary outcome of the study. Studies in which the intervention was applied by professionals other than the physical therapist and studies not found in Brazilian Portuguese, English, or Spanish were excluded. The search was conducted in September 2022 across the Medline, PEDro, Embase, Scopus, LILACS, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials databases. DECS, MESH, EMTREE terms, free terms, and their synonyms were used, including but not limited to: stroke, rehabilitation, physical therapy modalities, functioning, and disability.
After removing duplicates, two blinded reviewers screened the studies in two stages. Before each screening, a pilot test was conducted with a random sample to ensure an agreement of ≥75%. After selection, if the disagreements could not be resolved by consensus, a third reviewer was consulted.
The functioning/disability approach was examined based on the ICF framework. With the categories generated by linking the assessment instruments, a content analysis was conducted and compared across the intervention settings.
Analyses
Process of identifying and linking significant concepts
The linking process followed the one proposed by Cieza14. The significant concepts were identified and then blind-coded by two authors, who received training from an experienced coder, also responsible for resolving any discrepancies. Data were only extracted when agreement was ≥74% in each instrument20. Concepts not included in the ICF that were not personal factors were represented as not covered (NC) and were assigned a specific code when related to diagnosis or health condition (NC-HC) and quality of life (NC-QL). Concepts with insufficient information for linking were represented as not defined (ND) and were assigned specific codes when related to general health (ND-GH), quality of life (ND-QL), and disability (ND-DIS).
Agreement analyses
Inter-reviewer agreement was assessed at the following moments: (1) two pilot tests before screening; (2) data extraction from the retrieved studies; and (3) linking process of the assessment instruments to the ICF.
Content analysis
In total, three main estimations were found: content density, content diversity, and bandwidth of content coverage16. Content density identifies the number of significant concepts per item in an assessment instrument. Values equal to one indicate one concept per item. It follows the Formula (1):
Content density = total significant concepts in the x instrument (1)
total x instrument items
The content diversity reflects the range of ICF categories by significant concept in each assessment instrument. The closer to zero, the lower the diversity, as more concepts correspond to the same category. It is estimated by Formula (2):
Content diversity = total categories linked to the ICF in the x instrument (2)
total significant concepts in the x instrument
To estimate the weight of the ICF categories/domains, bandwidthof content coverage was considered, which measures the frequency of categories and domains of the assessment instrument by employing the Formulas (3) and (4). In both, higher values indicate better coverage of the ICF by the instrument.
Total number of categories linked to the ICF in x instrument × 100 (3)
total ICF categories
Total number of categories in y domain in x instrument × 100 (4)
Total number of categories in y domain in the ICF
A total of 1,548 categories were found on the official World Health Organization website in November 2023, of which 522 are covered in the domain of body functions; 309 in body structures; 456 in activity and participation; and 261 in environmental factors21.
RESULTS
The search retrieved 7,054 articles, of which 5,554 remained after duplicates were excluded. The selection and screening process is detailed in Figure 1 and was completed with 25 articles.
Chart 1 summarizes the included articles. The assessment of disability was predominant (n=23, 92%) compared to functioning (n=3, 12%). In total, 11 instruments were found: Action Research Arm Test (ARAT), Index of Extended Activities of Daily Living (IEADL), Motor Assessment Scale (MAS), Stroke Impact Scale (SIS), Timed Up and Go Test (TUG), 10-Meter Walk Test (10MWT), Six-Minute Walk Test (6MWT), Functional Independence Measure (FIM), Rankin Scale (RS), Barthel Index (BI), Berg Balance Scale (BBS). BI and RS were the most commonly used to assess disability, regardless of the setting. The functionality assessment was covered in three articles: two from the same group of authors, who applied a combination of measures, and one that used the SIS to evaluate both self-perceived functionality and disability22.
Regarding intervention settings, the studies were conducted in: community or primary care (C - n=2; 8%), home (H - n=12; 48%), outpatient clinics (OC - n=7; 28%), as well as hospital and wards (HW - n=11; 44%). We found that lower levels of care showed less diverse instruments. There was no assessment of functioning in the community setting. Chart 2 presents the assessment instruments used by intervention setting. For frequency, see Table 1.
In total, two rounds of blind linkage were necessary to achieve the desired agreement (≥74%) among reviewers across all instruments. No version of the IEADL was found, even after attempts to contact the authors. Thus, the measure was not linked to the ICF, nor included in the content analysis (Table 2). The Barthel Index (BI) was the only instrument to cover all four ICF domains and the one that included the highest concentration of categories related to environmental factors. Despite the activity and participation domain being the most covered, only the Stroke Impact Scale (SIS) and the Functional Independence Measure (FIM) included their own categories of participation, considered in this article as d7-d9. However, the FIM only covered aspects of interpersonal interaction and relationships, whereas SIS also covered work and community, social, and civic life. The SIS showed the highest percentage of ICF coverage, whereas the 6MWT and TUG presented the lowest. Coding of environmental factors was generally associated with dependence.
DISCUSSION
The approach to functioning and disability shows low variation across the intervention settings of physical therapy in post-stroke patients. Most instruments showed greater coverage of the activity and participation domain but low diversity of participation categories. We found more diversity and combination of instruments as the level of care increased. Notably, of the three studies that assessed functioning, none were conducted in a community setting. For both outcomes, environmental factors were identified only when related to dependence.
Most instruments employed to assess disability and functioning (BI, RS, ARAT, 6MWT, MAS, FIM, BBS, and TUG) were recommended to assess activity and participation, highlighting the importance of this domain for rehabilitation10,47. However, caution is advised when employing these measures alone, or in combination with each other alone, as these measures would be insufficient to cover the scope of disability/functioning when they are the outcome of interest47. The expression “disability” had already been employed to describe activity limitations before the ICF publication; thus, it is possible that the preference of this term by these instruments is reflecting a confusion in the use of the term for more specific purposes47.
The bandwidth of content coverage followed the weight given to categories in the Brief Core Set of stroke, namely, activities and participation, body functions, environmental factors, and body structures9. This highlights that the choice of instruments may not be arbitrary, but the combination can still be refined to cover all relevant areas. For example, considering the similarity between the content of BI and RS and that both assess from the perspective of dependence, the combination between them would generate repeated information. It is possible to replace one of them with the FIM, which, despite the similarities, adds categories such as memory and communication. Another possibility, not found in this research, would be the World Health Organization Disability Assessment Schedule (WHODAS 2.0). The instrument was constructed to assess health and disability based on the ICF framework, covering all health domains. It has already been validated for the post-stroke population and can be administered in various versions48 - 50.
We found a low coverage of participation in interventions on functioning and disability. However, participation restrictions are associated with patients with a poorer quality of life, becoming an important element for care51. Some instruments that include elements of participation (general aspects of health, quality of life, and social isolation) and that can guide the intervention include the SIS, the Nottingham Health Profile, and the Medical Outcomes Study Short Form 3647,52. Participation is also impacted by potentially modifiable contextual factors, such as motivation, acceptance of health condition, self-esteem, support network, assistive equipment in the community, adjustments to the home environment, and accessibility to social and healthcare services53.
We highlight the importance of assessing participation and environmental factors from the hospital environment. Strong communication between cross-sector teams can lead to benefits for a smoother transition after discharge54. However, this assessment is more evidently needed in the community and home environments, as they tend to show a greater focus on independence in daily activities and social insertion10. Physical therapists must fully utilize the available resources in the environment to identify and address treatment barriers and facilitators, while also developing strategies to enable the individual and/or their support network to do the same3. It is also essential to ensure access to rehabilitation services, whether in the identification of services, transportation, or acquisition of information3.
In cases of low recovery potential, it is necessary to remember that functioning continues to exist in the presence of disability14. A patient who has moved past the spontaneous recovery phase and experiences minimal gains during rehabilitation can still achieve improvements in activity and participation at any time, particularly in an enriched environment and with investment in adaptive and compensatory strategies for activities9,55.
Wade has discussed the need to include the biopsychosocial model in healthcare planning, especially due to the demand for indices that contemplate the impacts generated by the increase in chronic diseases in the population56. The results of this study may contribute, initially, to guide decisions of health managers. Some actions are suggested, including ongoing education for physical therapists on the application of the model, emphasizing and illustrating interventions targeting environmental factors and participation; establishment of functioning and disability indicators in rehabilitation services, such as health literacy levels, presence of an active caregiver, and availability of transportation for rehabilitation appointments; and monitoring these indicators across various intervention settings to allocate resources according to specific needs.
There is a tendency for future trials to show more specific primary outcomes for each health domain3. To prevent readers from interpreting this decision as a fragmentation of care and to facilitate the application of results in health services and policies, we suggest that future trials clearly present the correlation between health components and the implications of the results for functioning and disability.
Limitations
This review shows some limitations. Including only three languages may have restricted the final number of articles. The review protocol was not published as required by the Joanna Briggs Institute. Moreover, the selected studies were not assessed for quality and risk of bias. However, as this research investigated the theoretical approach to functioning and disability, the methodological quality of the studies and the impacts of the interventions did not interfere in the results. Finally, we highlight that clinical trials cannot exactly reproduce the daily routines of physical therapists, who face various situations that cannot be predicted.
CONCLUSION
The approach to functioning and disability by physical therapists in post-stroke patients focuses on covering the elements of the biopsychosocial model related to activity, mainly mobility and self-care, regardless of the intervention setting. The hospital setting showed the greatest diversity of categories related to participation and environmental factors. Conducting a more comprehensive assessment solely in the hospital setting may hinder the patient’s overall progress. We highlight that these assessments must be integrated into the daily routine, as they are also targets for intervention, particularly in the home and community settings, and for individuals with limited potential for spontaneous recovery gains. As there is a limit to professional performance on disability, further trials that adopt functioning as an outcome are suggested.
BI and RS were the most frequent instruments for assessing disability, whereas BI, MAS, and BBS had the highest frequency for functioning. To ensure the coverage of the biopsychosocial model using the instruments found in this research, it is necessary to combine them by observing their diversity of content and bandwidth of content coverage. We underscore that the Stroke Brief Core Set is a useful tool to support the selection of instruments. We also highlight the importance of standardizing health terms as presented in the ICF to facilitate understanding in future research and to standardize language among physical therapists.
The results of this study may facilitate the choice of instruments for assessing post-stroke disability and functioning among physical therapists across various intervention settings. They can also be useful for health managers who plan to consider these outcomes for decision-making. There is no justification for ignoring the use of the concepts set forth in the ICF and the biopsychosocial model, which is based on it, as health indicators. Reading this text is also encouraged for individuals who have had a stroke and wish to understand more about physical therapy, as it provides important information for collaborative treatment planning and contributes to self-management of health.
Acknowledgments
To my colleague Francisco Douglas da Silva Freires Barros, who acted as a reviewer in the stages of selection of studies and in the process of linking concepts to the ICF.
REFERENCES
-
1. Abbafati C, Abbas KM, Abbasi-Kangevari M, Abd-Allah F, Abdelalim A, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-22. doi: 10.1016/S0140-6736(20)30925-9
» https://doi.org/10.1016/S0140-6736(20)30925-9 -
2. Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014;2014(11):CD010820. doi: 10.1002/14651858.CD010820.pub2
» https://doi.org/10.1002/14651858.CD010820.pub2 -
3. Stinear CM, Lang CE, Zeiler S, Byblow WD. Advances and challenges in stroke rehabilitation. Lancet Neurol. 2020;19(4):348-60. doi: 10.1016/S1474-4422(19)30415-6.
» https://doi.org/10.1016/S1474-4422(19)30415-6. -
4. Ullberg T, Zia E, Petersson J, Norrving B. Changes in functional outcome over the first year after stroke an observational study from the Swedish stroke register. Stroke. 2015;46(2):389-94. doi: 10.1161/STROKEAHA.114.006538
» https://doi.org/10.1161/STROKEAHA.114.006538 -
5. Wong AWK, Ng S, Dashner J, Baum MC, Hammel J, et al. Relationships between environmental factors and participation in adults with traumatic brain injury, stroke, and spinal cord injury: a cross-sectional multi-center study Americans with Disabilities Act. Qual Life Res. 2017;26:2633-45. doi: 10.1007/s11136-017-1586-5
» https://doi.org/10.1007/s11136-017-1586-5 -
6. Avan A, Digaleh H, Di Napoli M, Stranges S, Behrouz R, et al. Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017. BMC Med. 2019;17(1):1-30. doi: 10.1186/s12916-019-1397-3.
» https://doi.org/10.1186/s12916-019-1397-3. -
7. Pont W, Groeneveld I, Arwert H, Meesters J, Rambaran R, et al. Caregiver burden after stroke: changes over time? Disabil Rehabil. 2020;42(3):360-7. doi: 10.1080/09638288.2018.1499047
» https://doi.org/10.1080/09638288.2018.1499047 -
8. Rajsic S, Gothe H, Borba HH, Sroczynski G, Vujicic J, et al. Economic burden of stroke: a systematic review on post-stroke care. Eur J Health Econ. 2019;20(1):107-34. doi: 10.1007/S10198-018-0984-0
» https://doi.org/10.1007/S10198-018-0984-0 -
9. 9. Teasell R, Hussein N. Background concepts in stroke rehabilitation. In: Stroke rehabilitation clinician handbook [Internet]. London: EBRSR; 2018 [cited 2024 Dez 18]. Available from: http://www.ebrsr.com/evidence-review/3-background-concepts-stroke-rehabilitation
» http://www.ebrsr.com/evidence-review/3-background-concepts-stroke-rehabilitation -
10. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, et al. Guidelines for adult stroke rehabilitation and recovery. Stroke. 2016;47(6). doi: 10.1161/STR.0000000000000098
» https://doi.org/10.1161/STR.0000000000000098 - 11. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva; 2001.
- 12. Organização Mundial da Saúde. Rumo a uma linguagem comum para funcionalidade, incapacidade e saúde CIF. Genebra; 2002.
-
13. Leonardi M, Lee H, Kostanjsek N, Fornari A, Raggi A, et al. 20 years of ICF-International Classification of Functioning, Disability and Health: uses and applications around the world. Int J Environ Res Public Health. 2022;19(18). doi: 10.3390/ijerph191811321
» https://doi.org/10.3390/ijerph191811321 -
14. Cieza A, Fayed N, Bickenbach J, Prodinger B. Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information. Disabil Rehabil. 2019;41(5):574-83. doi: 10.3109/09638288.2016.1145258
» https://doi.org/10.3109/09638288.2016.1145258 -
15. Jong LD, Van Wijck F, Stewart RE, Geurts ACH, Dijkstra PU. Content of conventional therapy for the severely affected arm during subacute rehabilitation after stroke: an analysis of physiotherapy and occupational therapy practice. Physiother Res Int. 2018;23(1):e1683. doi: 10.1002/pri.1683
» https://doi.org/10.1002/pri.1683 -
16. Geyh S, Cieza A, Kollerits B, Grimby G, Stucki G. Content comparison of health-related quality of life measures used in stroke based on the international classification of functioning, disability and health (ICF): a systematic review. Qual Life Res. 2007;833-51. doi: 10.1007/s11136-007-9174-8
» https://doi.org/10.1007/s11136-007-9174-8 -
17. Ramstrand N, Stevens PM. Clinical outcome measures to evaluate the effects of orthotic management post-stroke: a systematic review. Disabil Rehabil. 2022;44(13):3019-38. doi: 10.1080/09638288.2020.1859630
» https://doi.org/10.1080/09638288.2020.1859630 -
18. Silva SM, Brandão TCP, Silva FP, Buchalla CM. Identification of categories of the International Classification of Functioning, Disability and Health in functional assessment measures for stroke survivors: a systematic review. Disabil Rehabil. 2020;42(2):156-62. doi: 10.1080/09638288.2018.1496149
» https://doi.org/10.1080/09638288.2018.1496149 -
19. 19. Joanna Briggs Institute. JBI manual for evidence synthesis [Internet]. 2024 [cited 2024 Dez 18]. Available from: https://synthesismanual.jbi.global
» https://synthesismanual.jbi.global -
20. Stamm T, Geyh S, Cieza A, Machold K, Kollerits B, et al. Measuring functioning in patients with hand osteoarthritis — content comparison of questionnaires based on the International Classification of Functioning, Disability and Health (ICF). Rheumatology. 2006;45(12):1534-41. doi: 10.1093/rheumatology/kel133
» https://doi.org/10.1093/rheumatology/kel133 -
21. 21. World Health Organization. Internacional Classification of Functioning, Disability and Health (ICF online) [Internet]. 2023 [cited 2024 Dez 18]. Available from: https://icd.who.int/dev11/l-icf/en
» https://icd.who.int/dev11/l-icf/en -
22. Wall A, Borg J, Palmcrantz S. Self-perceived functioning and disability after randomized conventional and electromechanically-assisted gait training in subacute stroke: A 6 months follow-up. Neuro Rehabil. 2019;45(4):501-11. doi: 10.3233/NRE-192929
» https://doi.org/10.3233/NRE-192929 -
23. Ada L, Dean CM, Hall JM, Bampton J, Crompton S. A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebo-controlled, randomized trial. Arch Phys Med Rehabil. 2003;84(10):1486-91. doi: 10.1016/S0003-9993(03)00349-6
» https://doi.org/10.1016/S0003-9993(03)00349-6 -
24. Andersen HE, Schultz-Larsen K, Kreiner S, Forchhammer BH, Eriksen K, et al. Can readmission after stroke be prevented? Results of a randomized clinical study: a postdischarge follow-up service for stroke survivors. Stroke. 2000;31(5):1038-45. doi: 10.1161/01.str.31.5.1038
» https://doi.org/10.1161/01.str.31.5.1038 -
25. Askim T, Mørkved S, Engen A, Roos K, Aas T, et al. Effects of a community-based intensive motor training program combined with early supported discharge after treatment in a comprehensive stroke unit: a randomized, controlled trial. Stroke. 2010;41(8):1697-703. doi: 10.1161/STROKEAHA.110.584284
» https://doi.org/10.1161/STROKEAHA.110.584284 -
26. Cabanas-Valdés GR, Boix Sala L, Guzmán Bernal JA, Torrella Vivó N, Caballero-Gómez FM, et al. The effectiveness of additional core stability exercises in improving dynamic sitting balance, coordination and lower limb spasticity for subacute stroke-survivors (core-trial): a randomized controlled trial. esoc 2022 – late breaking science, ongoing trials & young. Stroke. 2022;7(Suppl 1):546-88. doi: 10.1177/23969873221094907
» https://doi.org/10.1177/23969873221094907 -
27. Chaiyawat P, Kulkantrakorn K. Effectiveness of home rehabilitation program for ischemic stroke upon disability and quality of life: A randomized controlled trial. Clin Neurol Neurosurg. 2012;114(7):866-70. doi: 10.1016/j.clineuro.2012.01.018
» https://doi.org/10.1016/j.clineuro.2012.01.018 -
28. Chaiyawat P, Kulkantrakorn K. Randomized controlled trial of home rehabilitation for patients with ischemic stroke: impact upon disability and elderly depression. Psychogeriatrics. 2012;12(3):193-9. doi: 10.1111/j.1479-8301.2012.00412.x
» https://doi.org/10.1111/j.1479-8301.2012.00412.x -
29. Chen CC, Tang YC, Hsu MJ, Lo SK, Lin JH. Effects of the hybrid of neuromuscular electrical stimulation and noxious thermal stimulation on upper extremity motor recovery in patients with stroke: a randomized controlled trial. Top Stroke Rehabil. 2019;26(1):66-72. doi: 10.1080/10749357.2018.1540458
» https://doi.org/10.1080/10749357.2018.1540458 - 30. Ertekin Ö, Gelecek N, Yıldırım Y, Akdal G. Supervised versus home physiotherapy outcomes in stroke patients with unilateral visual neglect: a randomized controlled follow-up study. J Neurol Sci. 2009;26(3):325-34.
-
31. Feys HM, De Weerdt WJ, Selz BE, Cox Steck GA, Spichiger R, et al. Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. Stroke. 1998;29(4):785-92. doi: 10.1161/01.STR.29.4.785
» https://doi.org/10.1161/01.STR.29.4.785 -
32. Hanger HC, Whitewood P, Brown G, Ball MC, Harper J, et al. A randomized controlled trial of strapping to prevent post-stroke shoulder pain. Clin Rehabil. 2000;14(4):370-80. doi: 10.1191/0269215500cr339oa
» https://doi.org/10.1191/0269215500cr339oa -
33. Hopwood V, Lewith G, Prescott P, Campbell MJ. Evaluating the efficacy of acupuncture in defined aspects of stroke recovery: a randomised, placebo controlled single blind study. J Neurol. 2008;255(6):858-66. doi: 10.1007/s00415-008-0790-1
» https://doi.org/10.1007/s00415-008-0790-1 -
34. Jonsdottir J, Thorsen R, Aprile I, Galeri S, Spannocchi G, et al. Arm rehabilitation in post stroke subjects: a randomized controlled trial on the efficacy of myoelectrically driven FES applied in a task-oriented approach. PLoS One. 2017;12(12):e0188642. doi: 10.1371/journal.pone.0188642
» https://doi.org/10.1371/journal.pone.0188642 -
35. Langhammer B, Stanghelle JK, Lindmark B. Exercise and health-related quality of life during the first year following acute stroke: a randomized controlled trial. Brain Inj. 2008;22(2):135-45. doi: 10.1080/02699050801895423
» https://doi.org/10.1080/02699050801895423 -
36. Langhammer B, Lindmark B. Functional exercise and physical fitness post stroke: the importance of exercise maintenance for motor control and physical fitness after stroke. Stroke Res Treat. 2012;2012:864835. doi: 10.1155/2012/864835
» https://doi.org/10.1155/2012/864835 -
37. Marándola MM, Jiménez Martín I, Rodríguez Yáñez M, Arias Rivas S, Santamaría Calavid M, et al. Constraint-Induced Movement Therapy in the rehabilitation of heminegligect after stroke. Rev Neurol. 2020;70(04):119-26. doi: 10.33588/rn.7004.2019330.
» https://doi.org/10.33588/rn.7004.2019330. -
38. Morone G, Tramontano M, Iosa M, Shofany J, Iemma A, et al. The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial. Biomed Res Int. 2014;2014:1-6. doi: 10.1155/2014/580861
» https://doi.org/10.1155/2014/580861 - 39. Morreale M, Marchione P, Pili A, Lauta A, Castiglia SF, et al. Early versus delayed rehabilitation treatment in hemiplegic patients with ischemic stroke: proprioceptive or cognitive approach? Eur J Phys Rehabil Med. 2016;52(1):81-9.
-
40. Nilsson L, Carlsson J, Danielsson A, Fugl-Meyer A, Hellström K, et al. Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground. Clin Rehabil. 2001;15(5):515-27. doi: 10.1191/026921501680425234.
» https://doi.org/10.1191/026921501680425234. -
41. Pandian JD, Arora R, Kaur P, Sharma D, Vishwambaran DK, et al. Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology. 2014;83(11):1012-17. doi: 10.1212/WNL.0000000000000773
» https://doi.org/10.1212/WNL.0000000000000773 - 42. Sritipsukho P, Riewpaiboon A, Chaiyawat P, Kulkantrakorn K. Cost-effectiveness analysis of home rehabilitation programs for Thai stroke patients. J Med Assoc Thai. 2010;93(Suppl 7):S262-70.
-
43. Tollár J, Nagy F, Csutorás B, Prontvai N, Nagy Z, et al. High Frequency and Intensity Rehabilitation in 641 subacute ischemic stroke patients. Arch Phys Med Rehabil. 2021;102(1):9-18. doi: 10.1016/j.apmr.2020.07.012
» https://doi.org/10.1016/j.apmr.2020.07.012 -
44. Volpe BT, Lynch D, Rykman-Berland A, Ferraro M, Galgano M, et al. Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. Neurorehabil Neural Repair. 2008;22(3):305-10. doi: 10.1177/1545968307311102
» https://doi.org/10.1177/1545968307311102 -
45. Wright A, Stone K, Martinelli L, Fryer S, Smith G, et al. Effect of combined home-based, overground robotic-assisted gait training and usual physiotherapy on clinical functional outcomes in people with chronic stroke: a randomized controlled trial. Clin Rehabil. 2021;35(6):882-93. doi: 10.1177/0269215520984133
» https://doi.org/10.1177/0269215520984133 -
46. Young JB, Forster A. The Bradford community stroke trial: eight week results. Clin Rehabil. 1991;5(4):283-92. doi: 10.1177/026921559100500404
» https://doi.org/10.1177/026921559100500404 -
47. 47. Salter K, Campbell N, Richardson M, Mehta S, Jutai J, et al. Outcome measures in stroke rehabilitation. In: Stroke rehabilitation clinician handbook [Internet]. London: EBRSR; 2013 [cited 2024 Dez 18]. Available from: http://www.ebrsr.com/evidence-review/20-outcome-measures-stroke-rehabilitation
» http://www.ebrsr.com/evidence-review/20-outcome-measures-stroke-rehabilitation -
48. Jen HJ, Kao CM, Chang KH, Yen CF, Liao HF, et al. Assessment of functioning using the Whodas 2.0 among people with stroke in Taiwan: a 4-year follow-up study. Ann Phys Rehabil Med. 2021;64(6):101442. doi: 10.1016/j.rehab.2020.09.006
» https://doi.org/10.1016/j.rehab.2020.09.006 -
49. 49. World Health Organization. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0) [Internet]. Geneva; 2010 [cited 2024 Dez 18]. Available from: https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule
» https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule -
50. Yuliana S, Muslih M, Sim J, Vidyanti AN, Brahmadhi A, et al. Development and validation of the World Health Organization disability Assessment Schedule 2.0 (Whodas 2.0) Indonesian version in stroke survivors. Disabil Rehabil. 2022;44(16):4459-66. doi: 10.1080/09638288.2021.1900413
» https://doi.org/10.1080/09638288.2021.1900413 -
51. Algurén B, Fridlund B, Cieza A, Sunnerhagen KS, Christensson L. Factors associated with health-related quality of life after stroke: a 1-year prospective cohort study. Neurorehabil Neural Repair. 2012;26(3):266-74. doi: 10.1177/1545968311414204
» https://doi.org/10.1177/1545968311414204 -
52. Zhang Q, Schwade M, Smith Y, Wood R, Young L. Exercise-based interventions for post-stroke social participation: a systematic review and network meta-analysis. Int J Nurs Stud. 2020;111:103738. doi: 10.1016/j.ijnurstu.2020.103738
» https://doi.org/10.1016/j.ijnurstu.2020.103738 -
53. Della Vecchia C, Viprey M, Haesebaert J, Termoz A, Giroudon C, et al. Contextual determinants of participation after stroke: a systematic review of quantitative and qualitative studies. Disabil Rehabil. 2021;43(13):1786-98. doi: 10.1080/09638288.2019.1679897
» https://doi.org/10.1080/09638288.2019.1679897 -
54. Mountain A, Patrice Lindsay M, Teasell R, Salbach NM, Jong A, et al. Canadian stroke best practice recommendations: rehabilitation, recovery, and community participation following stroke. Part two: transitions and community participation following stroke. Int J Stroke. 2020;15(7):789-806. doi: 10.1177/1747493019897847
» https://doi.org/10.1177/1747493019897847 -
55. Teasell R, Salbach NM, Foley N, Mountain A, Cameron JI, et al. Canadian stroke best practice recommendations: rehabilitation, recovery, and community participation following stroke. Part one: rehabilitation and recovery following stroke. Int J Stroke. 2020;15(7):763-88. doi: 10.1177/1747493019897843
» https://doi.org/10.1177/1747493019897843 -
56. Wade DT, Halligan PW. The biopsychosocial model of illness: a model whose time has come. Clin Rehabil. 2017;31(8):995-1004. Doi: 10.1177/0269215517709890
» https://doi.org/10.1177/0269215517709890
-
Financing source: Coordination for the Improvement of Higher Education Personnel
-
Approved by the Research Ethics Committee (CAAE)
Publication Dates
-
Publication in this collection
14 Apr 2025 -
Date of issue
2025
History
-
Received
05 Jan 2024 -
Accepted
18 19 2024
