Gaps in the physical therapy approach to functioning and disability after stroke: a scoping review

Vieira, Sofia Queiros; Castro, Shamyr Sulyvan de

doi:10.1590/1809-2950/e23020424en

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REVIEW • Fisioter. Pesqui. 32 • 2025 • https://doi.org/10.1590/1809-2950/e23020424en linkcopy

Gaps in the physical therapy approach to functioning and disability after stroke: a scoping review

Brechas en el enfoque fisioterapéutico de la funcionalidad y la discapacidad posaccidente cerebrovascular: una revisión del alcance

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

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

Author/Year/Journal	Objective	Primary outcome/Measure	Sample characteristics	Intervention	Setting
Ada et al.²³	To evaluate the effectiveness of a treadmill and overground walking program in reducing the disability and handicap associated with poor walking performance after stroke.	Disability. 10-Meter Walk Test	27 (13 experimental, 14 control)	Experimental: 30–45 minutes walk. 1st week: 80% time on the treadmill, 20% overground on different surfaces. Control: stretching, strengthening, balance and coordination).	Community
		(10MWT - Walking speed)	Mean age: 66
		Six-Minute Walk Test (6MWT - Walking capacity)	7-72 months post-stroke
Andersen et al.²⁴	To evaluate two models of follow-up intervention after discharge	Disability. IEADL	155 (54 Group 1, 52 Group 2, 48 control)	Group 1: medications, reference to other services, liaison between the patient and stroke services, and counseling. Group 2: instructions and reeducation on mobility and ADL.Control: outpatient rehabilitation on ordination by a hospital physician	Groups 1 and 2: Home visit
			Min-max age: 56-85 years
			Acute stroke
Askim et al.²⁵	To evaluate the effect of a 4-week community-based intensive motor training (IMT) program combined with early supported discharge after initial treatment in a comprehensive stroke unit on balance and other functional outcome measures.	Disability. Barthel Index (BI)	62 (30 IMT, 32 control)	IMT: 3 additional sessions of motor training for functional tasks, 30-50 minutes each. Control: Conventional treatment by the comprehensive stroke unit.	IMT: Provided by physical therapists in the primary health care system (also administered in the patients’ home, at a rehabilitation clinic, or at an outpatient clinic). Control: Administered as inpatient rehabilitation, outpatient rehabilitation, or as rehabilitation in the patients’ home
			Min-max age: 67-87
			Time after stroke 4-14 days
Cabanas-Valdés et al.²⁶	To evaluate the effectiveness of core stability exercises (CSE) in subacute stroke (<1 month) in addition to conventional physical therapy (CP).	Disability. RS 2005	87 (45 control, 42 CSE)	Control: 30 minutes of conventional physical therapy (mobilization, stretching, strengthening, balance, and gait). CSE: Core stability exercises, 30 minutes each.	Hospital
			Min-max age: 54-84
			Time after stroke: <1 month
Chaiyawat et al.²⁷	To develop and examine the effectiveness of individual 6-month home rehabilitation program in ischemic stroke patients upon disability and quality of life (QoL) at two years	Disability. RS 2005	60 (30 experimental, 30 control)	Experimental: 60 minutes of supervised exercises and counseling, supported by videos that included mobilization, resistance, and ADL. Control: Instruction to seek rehabilitation services after discharge.	Experimental: Place of residence Control: Other services
			Min-max age: 55-77
			Time after stroke: about three days
Chaiyawat et al.²⁸	To evaluate the long-term effectiveness of a home rehabilitation program for patients with middle cerebral artery infarction.	Disability. Barthel Index (BI)	60 (30 control, 30 intervention)	Experimental: 60 minutes of supervised exercises and counseling, supported by videos that included mobilization, resistance, and ADL. Control: received instructions for home rehabilitation.	Experimental: Place of residence Control: Other services
			Min-max age: 55-77
			Time after stroke: about three days
Chen et al.²⁹	To compare the effects of neuromuscular electrical stimulation (NMES), noxious thermal stimulation (NTS), and the hybrid of NMES and NTS (“Hybrid”) on motor recovery of upper extremity for patients with stroke.	Disability. Barthel Index (BI)	43 (13 NMES, 13 NTS, 17 Hybrid)	NMES: 30 min of NMES in 2 sessions. NTS: 30 min of NTS in 2 sessions. Hybrid: 15 min of NTS and 15 min of NMES. All groups were also subjected to traditional rehabilitation.	Outpatient clinic of the Rehabilitation Department
			Min-max age: 39-73
			Time after stroke: >6 months
Ertekin et al.³⁰	To compare the outcomes of a supervised physical therapy program versus home-based physical therapy in individuals with unilateral visual neglect post-stroke.	Disability. Barthel Index (BI)	20 (10 supervised at a rehabilitation clinic. 10 at home)	45-60 minutes of warm-up, strengthening, and stretching. Supervised: 3 times/week. Performed in front of a mirror, with feedback provided. At home: Encouragement by phone 1 time/week.	Supervised: Rehabilitation clinic
			Min-max age: 48-82
			Time after stroke 3-24 months
Feys et al.³¹	To evaluate the effect of additional sensorimotor stimulation on motor and functional recovery of the hemiplegic arm in post-stroke individuals.	Disability. Action Research Arm Test (ARAT) 1981 (upper limb function)	100 (50 control, 50 experimental)	Experimental: 30 minutes of stimulation in hemiplegic arm movements. Additional to standard rehabilitation. Control: same procedures, no stimulation.	Hospital
		Barthel Index (BI) and ADL	Min-max age: 36-88
		Barthel Index (BI) and ADL	Time after stroke 14-35 days
Hanger et al.³²	To determine whether strapping the shoulder in hemiplegic stroke patients: (1) prevents the development, or reduces the severity of shoulder pain. (2) preserves range of movement in the shoulder, and (3) improves the functional outcomes for the arm and patient overall outcomes	Disability. Functional Independence Measure (FIM)	98 (49 control, 49 strapped)	Experimental: Bandaging of the affected shoulder for 6 weeks, or until active movements are possible, or until discharge. Reapplication every 2-3 days. Control: follow-up without bandaging.	Hospital ward.
		Rankin scale (RS) 1957	Min-max age: 70-87.
		Rankin scale (RS) 1957	Acute stroke
Hopwood et al.³³	Investigate the effectiveness of acupuncture in stroke recovery compared to placebo.	Disability. Barthel Index (BI)	105 (57 acupuncture, 48 sham)	Acupuncture: 30 minutes. Started in the hospital and continued at home if necessary. Control: sham/placebo.	Hospital. At home (if discharged within 4 weeks)
			Min-max age: 42-93
			Time after stroke 4-10 days
Jonsdottir et al.³⁴	To investigate the effect of continuous functional electrical stimulation control (CFES) combined with task-oriented therapy (TOT) to assist arm movements, induce recovery of body functions, and address disability.	Disability. Action Research Arm Test (ARAT) 2002	82 (38 M-TOT, 44 C-TOT)	M-TOT: Active upper limb movements oriented toward tasks and associated with the use of MeCFES. C-TOT: Active upper limb movements oriented toward tasks.	Rehabilitation center
			Min-max age: 36-88
			Time after stroke: >1 months
Langhammer et al.³⁵	To evaluate the impact of two physical therapy regimens on self-reported quality of life (QoL) in acute stroke and investigate their impact on QoL.	Functioning: Barthel Index (BI)	75 (35 intensive, 40 regular)	Intensive: Approximately 80 hours of physical therapy focused on endurance, strength, and balance. Standard: physical therapy if needed.	Home, private physical therapy, or hospital ward treatment.
		Motor Assessment Scale (MAS)	Min-max age: 70-76
		Berg Balance Scale (BBS)	Acute-chronic phase
Langhammer et al.³⁶	Investigate how motor function, balance, mobility, walking capacity, and activity patterns differ between two groups with varying functional capacities.	Functioning: Motor Assessment Scale (MAS)	75 (37 MAS<35, 38 MAS>35)	Intensive: physical therapy 2-3 times per week, focusing on endurance, strength, and balance over four periods during the first year post-stroke. Total: about 80 hours. Standard: physical therapy if needed.	Home, private physical therapy, or hospital ward treatment.
		Berg Balance Scale (BBS)	Min-max age: 57-90
		Timed Up and Go (TUG) and Six-Minute Walk Test (6MWT)	Acute-chronic phase
		Barthel Index (BI) and ADL	Acute-chronic phase
Marándola et al.³⁷	To evaluate whether modified constraint-induced movement therapy (mCIMT) is more beneficial than conventional therapy for hemispatial neglect, as well as its effects on autonomy and disability.	Disability.	30 (15 mCIMT, 15 control)	60min. mCIMT: for upper and lower limbs. Control: Upper and lower limb exercises.	Home visit
		Modified Rankin Scale (mRS) 1988	Min-max age: 53-86
		Modified Rankin Scale (mRS) 1988	Time after stroke: <30 days
Morone et al.³⁸	To investigate the effectiveness of balance training using video games on functional balance and disability in individuals with hemiparesis after stroke.	Disability.	50 (25 Wii Group, 25 control)	12 sessions of 20 minutes, 3 times per week. Wii Group: Balance, coordination, and endurance training using Wii Fit video games. Control: Balance training	Hospital rehabilitation unit
		Barthel Index (BI)	Min-max age: 36-76
		Barthel Index (BI)	Time after stroke: <3 months
Morreale et al.³⁹	Compare Proprioceptive Neuromuscular Facilitation (PNF) techniques with Cognitive Therapeutic Exercise (CTE) at two different times after stroke.	Disability.	340 (110 early PNF, 110 early CTE, 60 late PNF, 60 late CTE)	Early PNF and CTE (24 hours post-stroke): 1-2 hours of daily mobilization with PNF or CTE. Late PNF and CTE (72 hours post-stroke): Posture and positioning in bed during the first 72 hours. Afterward, they followed early PNF or CTE intervention.	Hospital, Intensive Rehabilitation Unit
		Modified Rankin Scale (mRS) 1988	Min-max age: 48-78
		Barthel Index (BI)	Time after stroke 6-24 hours
Nilsson et al.⁴⁰	To compare the impact between treadmill walking training with weight support and floor training in the early rehabilitation stage of patients with hemiparesis post-stroke.	Disability. Functional Independence Measure (FIM)	73 (36 experimental, 37 control)	Experimental: 30 minutes of treadmill walking with weight support. Control: 30 minutes of overground walking.	Rehabilitation Department of the University Hospital
			Min-max age: 24-67
			Time after stroke: <8 weeks
Pandian et al.⁴¹	Explore the effectiveness of Mirror Therapy (MT) in treating unilateral neglect in stroke patients.	Disability.	48 (27 MT, 21 control)	MT: 1-2 hours, exercises with affected upper limb. Control: TM-like exercises, without a mirror.	Conducted in the hospital or at home (if >4 weeks)
		Modified Rankin Scale (mRS) 1988	Min-max age: 52-76
		Modified Rankin Scale (mRS) 1988	Time after stroke: >48
Sritipsukho et al.⁴²	To compare the costs and effects between a home rehabilitation program and conventional hospital care for patients with ischemic stroke in a healthcare service in Thailand.	Disability.	60 (30 experimental, 30 control)	Experimental: 1 visit of 1 hour per month for 3 months, exercise in exercise physiology, and motor learning with the help of DVD video recordings. Control: conventional hospital care and rehabilitation prescribed by a physician.	Home visit
		RS 2005	Min-max age: 55-77
		Barthel Index (BI)	Time after stroke: >3 days - 3 months
Tollár et al.⁴³	To compare the impacts of high-intensity and frequent exergaming mobility rehabilitation on symptoms of blood pressure, mobility, and stroke.	Disability.	580 (290 Exergaming 2×, 290 Exergaming 1×, 100 control)	Exergaming: 1 hour, of which 25 minutes were spent on exergaming. Group 1: 1 time/day. Group 2: 2 times/day. Control: standard care with low intensity.	Groups 1 and 2: Physical therapy gym in the hospital outpatient clinic.
		Modified Rankin Scale (mRS) 1988	Min-max age: 58-70
		Modified Rankin Scale (mRS) 1988	Time after stroke 2-4 weeks
Volpe et al.⁴⁴	To determine, in patients with upper limb disability post-stroke, whether robotic movement therapy or therapist-delivered therapy using an intensive training protocol is superior.	Disability. Stroke Impact Scale (SIS)	21 (11 experimental, 10 control)	1 hour. Control: adapted exercises using Bobath. Experimental: robot-assisted exercises.	Outpatient clinic
		Action Research Arm Test (ARAT) 1981	Min-max age: 57-65
		Action Research Arm Test (ARAT) 1981	Time after stroke: >6 months
Wall et al.²²	Compare self-perceived functioning, disability, and recovery after Electromechanical-Assisted Gait Training (EAGT) and conventional training.	Self-perceived functioning and disability:	28 (15 EAGT, 13 control)	EAGT: conventional physical therapy using the assistive device. Control: conventional program.	Rehabilitation Department of the University Hospital
		Stroke Impact Scale (SIS)	Min-max age: 48-64
		Stroke Impact Scale (SIS)	Subacute phase
Wright et al.⁴⁵	Evaluate the effect of home-based robot-assisted gait training (O-RAGT) using the AlterG Bionic Leg orthosis on functional clinical outcomes in individuals with chronic stroke.	Disability.	34 (16 O-RAGT, 18 control)	O-RAGT: robot-assisted gait training, as well as conventional physical therapy. Control: conventional physical therapy (stretching, strengthening, and activity training).	Conducted at home or in a stroke outpatient clinic.
		RS 2005	Min-max age: 49-79
		RS 2005	Time after stroke: >3 months - 5 years
Young et al.⁴⁶	To compare outpatient hospital care and home physical therapy for stroke patients discharged from the hospital to determine which service shows greater functional and social improvement.	Disability.	124 (61 control, 63 experimental)	Experimental: home physical therapy at 15 visits. Control: physical therapy in the outpatient hospital.	Home visit
		Barthel Index (BI)	Min-max age: 60-89
		Barthel Index (BI)	Intervals: <4 weeks / 4-7 weeks / 8-11 weeks / >12 weeks

		RS	ARAT	Barthel Index (BI)	IEADL	Motor Assessment Scale (MAS)	Stroke Impact Scale (SIS)	Berg Balance Scale (BBS)	TUG	10-Meter Walk Test	6MWT	Functional Independence Measure (FIM)	Location
													C	H	OC	HW
1	Ada et al. ²³									X	X		·
2	Andersen et al. ²⁴				X									·
3	Askim et al. ²⁵			X									·
4	Cabanas-Valdés et al. ²⁶	X														·
5	Chaiyawat et al. ²⁷	X												·
6	Chaiyawat et al. ²⁸			X										·
7	Chen et al. ²⁹			X											·
8	Ertekin et al. ³⁰			X										·
9	Feys et al. ³¹		X	X												·
10	Hanger et al. ³²	X										X				·
11	Hopwood et al. ³³			X										·		·
12	Jonsdottir et al. ³⁴		X												·
13	Langhammer et al. ³⁵			X		X		X						·	·	·
14	Langhammer et al. ³⁶			X		X		X	X		X			·	·	·
15	Marándola et al. ³⁷	X												·
16	Morone et al. ³⁸			X												·
17	Morreale et al. ³⁹	X		X												·
18	Nilsson et al. ⁴⁰											X				·
19	Pandian et al. ⁴¹	X												·		·
20	Sritipsukho et al. ⁴²	X		X										·
21	Tollár et al. ⁴³	X													·
22	Volpe et al. ⁴⁴		X				X								·
23	Wall et al. ²²						X									·
24	Wright et al. ⁴⁵	X												·	·
25	Young et al. ⁴⁶			X										·

	Community Primary care	Home	Outpatient clinic	Hospital Ward
RS		20% (5)	8% (2)	16% (4)
ARAT			8% (2)	4% (1)
Barthel Index (BI)	4% (1)	20% (5)	4% (1)	12% (3)
		8% (2)*	8% (2)*	8% (2)*
IEADL		4% (1)
Motor Assessment Scale (MAS)		8% (2)*	8% (2)*	8% (2)*
Stroke Impact Scale (SIS)			4% (1)	4% (1)
				4% (1)*
Berg Balance Scale (BBS)		8% (2)*	8% (2)*	8% (2)*
TUG		4% (1)*	4% (1)*	4% (1)*
10-Meter Walk Test	4% (1)
6MWT	4% (1)	4% (1)*	4% (1)*	4% (1)*
Functional Independence Measure (FIM)				8% (2)

	TOTAL	ARAT	Barthel Index (BI)	Berg Balance Scale (BBS)	Functional Independence Measure (FIM)	Motor Assessment Scale (MAS)	RS	Stroke Impact Scale (SIS)	6MWT	TUG	10-Meter Walk Test
No. of Items	307	23	40	84	25		7	69	1	1	1
No. of Concepts	458	23	62	138	26	101	19	84	1	3	1
No. of Concepts linked to the ICF	445	23	62	138	26	101	11	79	1	3	1
Content density	1.49	1	1.55	1.64	1.04	1.80	2.71	1.21	1	3	1
No. of Categories linked to the ICF and not repeated (of different levels)	178	7	31	15	21	32	6	61	1	3	1
Content diversity	0.38	0.3	0.5	0.1	0.8	0.31	0.31	0.72	1	1	1
Bandwidth of content coverage (%)	11.49	0.45	2	0.96	1.35	2.06	0.38	3.94	0.06	0.19	0.06
Function	38	--	2	3	4	9	1	16	1	1	1
Structure	2	--	2	--	--	--	--	--	--	--	--
Activity and participation	131	7	24	11	17	22	3	45	--	2	--
Environmental factors	7	--	3	1	--	1	2	--	--	--	--
Bandwidth of content coverage of each domain (%)
Function (%)	7.27	--	0.38	0.57	0.76	1.72	0.19	3.06	0.19	0.19	0.19
Structure (%)	0.64	--	0.64	--	--	--	--	--	--	--	--
Activity and participation (%)	28.72	1.53	5.26	2.41	3.72	4.82	0.65	9.86	--	0.43	--
Environmental factors (%)	2.68	--	1.14	0.38	--	0.38	0.76	--	--	--	--

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[1] ADL: Activity of Daily Living; QoL: Quality of Life