Abstract
Background
The International Classification of Functioning, Disability and Health (ICF) is widely used as a framework for post-stroke rehabilitation, but its clinical application requires further synthesis.
Objective
This narrative review examined the current applications of ICF in post-stroke rehabilitation, benchmarked against the United Kingdom Stroke Guideline (UK Guideline).
Methods
The review followed the Scale for the Assessment of Narrative Review Articles. ICF-based assessments and interventions described by the original study authors from selected studies were extracted.
Results
A total of 546 assessments were mapped to the ICF across 166 studies, overlapping with more than 80% of the UK Guideline topics. These assessments appeared to be primarily Body Function-based (40.7%) and Activity-based (27.1%). For ICF-based interventions, 247 interventions were identified across 66 studies and covered fewer than half of the UK Guideline topics. Mapping based on intervention content covered 36% of the combined Activity and Participation component. Both assessment and intervention mapping allocated less attention to the Participation component and Contextual Factors (CF), indicating limited specificity to community reintegration after stroke.
Conclusions
To promote the holistic ICF framework in post-stroke rehabilitation, more work is needed to address the assessment-intervention mismatch in current practice, particularly for Participation and CF. Resources, such as clinician training and service-level support, should also be mobilized to support the routine clinical application of the ICF.
Keywords
Introduction
Stroke is a neurological condition that damages neural systems (Harris et al., 2022), and affects patients’ motor, cognitive, and emotional functions (Shi et al., 2017; Stoodley et al., 2016). Immediate treatment and intensive rehabilitation have been found to be effective in enhancing the physical, mental, and social recovery of patients with stroke (Dworzynski et al., 2015; Ru et al., 2017). Given these multidimensional impacts and recovery needs, a comprehensive framework is required to assess functioning and guide rehabilitation goals beyond impairment-level outcomes.
The International Classification of Functioning, Disability and Health (ICF) is grounded in a biopsychosocial model and was developed by the World Health Organization in 2001 (World Health Organization, 2002; Figure 1). The framework emphasizes functioning rather than disability or disease at both individual and population levels (Kuipers et al., 2019). It comprises components including Body Functions (BF; e.g., muscle tone functions), Body Structures (BS; e.g., structures of the upper extremity and shoulder region), and Activity and Participation (A&P; e.g., mobility and changing basic body positions). Contextual Factors (CF) influence all other components and are divided into Environmental Factors (EF; e.g., health services, systems, and policies) and Personal Factors (PF; e.g., culture, age, and gender, which are recognized but not coded in the ICF). The ICF specifies the role of EF in the creation of disability, highlights the relevance of associated health conditions and their effects, and considers PF to enhance applicability across diverse populations.
Visual illustration of the International Classification of Functioning, Disability and Health (ICF).
In the past two decades, the clinical application of the ICF in post-stroke rehabilitation has been extensively researched, and gaps have been identified. For instance, one scoping review found that BF and Activity components were treated as core treatment outcomes in post-stroke rehabilitation, whereas the Participation component was not (Engel-Yeger et al., 2018); another scoping review indicated that EF and PF were understudied in routine practice (Viktorisson et al., 2022). Frontline clinicians expressed difficulty applying the ICF in routine practice due to ambiguous definitions and content of “Activity” and “Participation” (Playford, 2020); the lengthy administration time (i.e., 40 min) covering the ICF subset and tools (Johansen et al., 2022); insufficient ICF-related training led clinicians to use the ICF superficially (Paltamaa et al., 2024); and gaps between the ICF core and service models (Wong et al., 2023a). Issues identified in previous studies are in the unclear definitions and relationships between the “Activity” and “Participation” components, and logistics in the clinical applications of ICF in post-stroke rehabilitation. The purpose of this narrative review is to articulate how the ICF concepts are operationalized in the assessment and intervention practices for post-stroke patients. By benchmarking against an established post-stroke rehabilitation guideline, this review identifies the alignments and gaps in ICF-based practices, addresses the issues mentioned above, and informs future framework development.
To benchmark ICF-based assessment and intervention against an established clinical pathway, we reviewed international stroke rehabilitation guidelines (e.g., Canada and Australia) and selected one primary comparator to structure this review. The United Kingdom (UK) National Clinical Guideline for Stroke (“the UK Guideline”) was chosen because it provides detailed, implementable specifications for outpatient and community-based rehabilitation within a publicly funded health system (Royal College of Physicians, 2023). The guideline from the United States (US) also offers high-quality clinical recommendations (Winstein et al., 2016), but it is optimized for a mixed-payer US context. Focusing on a public-system framework, as in the UK, increases applicability to countries with similar financing and service organization, including European systems such as Italy (Signorelli et al., 2020), parts of Asia (e.g., Hong Kong), and Canada (Martin et al., 2018). The UK Guideline also emphasizes outpatient and community-based rehabilitation to support long-term recovery and cost-effective post-discharge care, which may be more comparable across health systems than the US Guideline. Accordingly, the current review focused on outpatient and community rehabilitation practices rather than acute inpatient practices and was structured according to the practices under the UK Guideline topics of functional recovery patterns of post-stroke patients (Bernhardt et al., 2017).
Methods
Design
This narrative review followed the Scale for the Assessment of Narrative Review Articles (SANRA; Baethge et al., 2019), which covers six aspects: review rationale, concrete research questions, literature search description, use of references to support statements, scientific presentation, and use of data to support evidence. To identify trends in assessments and interventions mapped to the ICF in post-stroke rehabilitation, we included a quantitative summary of frequency counts in the Results section.
Keyword Extraction from the UK Guideline for Content Mapping
The 2023 edition of the UK Guideline was published by the Royal College of Physicians to encourage service quality improvement in stroke care (Royal College of Physicians, 2023). The UK Guideline adopts an evidence-based approach and covers the recovery pathway and corresponding interventions from acute care to longer-term management across three chapters. Additional chapters describe the guideline development process, stroke service types and providers in the UK, long-term management, and secondary prevention.
Chapter 4 of the UK Guideline is “Rehabilitation and recovery,” focusing on the clinical management of post-stroke functional loss. The chapter is organized into topics (e.g., 4.8 Independence in daily living), with related concepts listed under each topic (e.g., “personal activities of daily living” under 4.8 Independence in daily living). Keywords were identified as follows: 1) first- and second-level topics (e.g., “4.8 Independence in daily living” and “4.22 Walking”), but not third-level topics or beyond (e.g., “4.23.2 Musculoskeletal pain” was grouped under “4.23 Pain”); and 2) the concepts stipulated under the selected topics (e.g., “arm recovery” is the concept under the “4.18 Arm function” topic). In total, 33 UK Guideline topics and 81 concepts were extracted for the content mapping process (Supplementary Table 1).
Search Strategies for Identifying ICF-Based Studies
An iterative process was employed to identify the ICF-based literature published in various formats (e.g., scoping reviews, systematic reviews, and meta-analyses; Jellema et al., 2017). Preliminary searches were conducted in PubMed, CINAHL, and Google Scholar using terms from the International Classification of Functioning, Disability and Health (ICF) and its abbreviation, as well as terms related to stroke, post-stroke rehabilitation, and stroke management. The titles, abstracts, author keywords, and indexing terms of relevant reviews and primary studies were examined to identify additional search terms. The search strategy was then refined and rerun until no further relevant terms or eligible studies were identified among the published works in PubMed, CINAHL, and Google Scholar through October 2024 (Table 1). The list of core search terms was as follows:
− ICF terms: “International Classification of Functioning, Disability and Health” OR ICF − Stroke terms: stroke OR “post-stroke” OR “cerebrovascular accident” OR CVA − Rehabilitation/management terms: rehabilitation OR “stroke rehabilitation” OR “stroke management” OR “stroke care” OR “post-stroke rehabilitation” OR “post-stroke management” OR “post-stroke care” − Application/assessment/intervention terms: application OR assessment* OR screen* OR measure* OR intervention* OR implement*
Detailed Search Keywords Used for PubMed, CINAHL, and Google Scholar in the Present Study.
The search was restricted to studies written in English or Chinese. In addition to the terms mentioned above, two criteria were set for study inclusion. First, ICF-related content relevance was defined as: a) an application of the ICF framework or concept; b) ICF linking rules; or c) ICF components (i.e., BF, BS, A&P, EF, or PF) or ICF categories (e.g., “b730 Muscle power functions” or “d450 Walking”) in assessments or interventions. Second, the studies’ aims should cover the topics and concepts in the UK Guideline related to post-stroke rehabilitation. Studies were excluded if they were protocols, economic evaluations, or focused on interventions such as medication, brain stimulation, or botulinum injections, or if the full text was unavailable. The screening process of the identified articles is presented in Figure 2.
Visual illustration of the identification and screening of ICF-based papers included in the present narrative review. *Some studies overlapped between the assessment and intervention mapping. Note: A&P, Activity & Participation; BF, Body Functions; BS, Body Structures; CF, Contextual Factors; EF, Environmental Factors; PF, Personal Factors.
Data Analysis
A concept-based mapping approach was adopted to place the keywords extracted from the ICF-based post-stroke rehabilitation literature, including assessments and interventions, alongside the topics and concepts in Chapter 4 of the UK Guideline. For studies reporting ICF-related assessments, the full texts of included papers were manually searched using the search function in PDF or Word format. Search terms were derived from the topics and their associated concepts in the UK Guideline.
Once potentially relevant guideline-related information was identified, the surrounding text was examined to determine whether corresponding ICF-related content was reported (i.e., ICF linking rules, ICF components, or ICF categories). A data extraction and mapping table was developed to record the name of each clinical assessment, the corresponding UK Guideline topic or concept, and the relevant ICF component-level mapping. These component-level mappings were used for frequency counts. For example, the Brunel Balance Assessment was categorized as a balance-related assessment in Alhasani et al. (2022). This corresponded to the UK Guideline topic “4.20 Balance” and was mapped under the ICF A&P component.
For intervention mapping, two approaches were used: 1) intervention content-based classification and 2) outcome-based classification. Intervention content-based classification involved mapping the intervention according to the ICF components or categories explicitly used to structure or describe the intervention in the original study. For example, in Ding and Chen (2023), the nursing intervention content for ameliorating dysphagia among stroke patients was structured according to the ICF components of BF, BS, A&P, and EF. This intervention can be mapped to the UK Guideline topic “4.16 Swallowing” according to the concept of “dysphagia.” Outcome-based classification involved mapping the intervention according to the ICF components or categories reflected in the reported outcome measures, using the same procedure as assessment mapping.
All ICF-based post-stroke interventions were initially mapped using intervention content-based classification. If insufficient information was available in the original paper to classify the intervention based on its content, outcome-based classification was then applied. If an intervention could be mapped using both approaches, intervention content-based classification was prioritized.
Results
A total of 192 studies incorporating ICF-based post-stroke rehabilitation assessments and interventions were identified.
Assessment Mapping
Of the 192 studies, 166 ICF-related studies involving 546 assessments were identified (Table 2). These assessments were mapped to 28 topics (84.8%) to those stipulated in the UK Guideline topics and concepts. Exact ICF-related matches were found for seven assessments across six topics of the UK Guideline (Supplementary Table 2), such as the Nottingham Sensory Assessment under the “Sensation” topic. Assessments that appeared more than once across the included studies were counted only once.
Frequency Count of the Clinical Assessments Organized by UK Guideline Topics and Mapped to the ICF.
Note: The number of clinical assessments mapped to the ICF may cover more than one UK Guideline topic/concept and more than one ICF component. *Each assessment was counted only once in the “All assessments” frequency count. A, Activity; BF, Body Functions; BS, Body Structures; CF, Contextual Factors; EF, Environmental Factors; P, Participation; PF, Personal Factors.
The highest frequency of the ICF-to-UK Guideline assessment matches was in the BF component (222; 40.7%), followed by the Activity component (148; 27.1%). The next level of matches was in the combined BF and BS, and the combined A&P components, which accounted for 98 (17.9%) and 123 (22.5%) assessments, respectively. In contrast, substantially fewer assessment matches were in the Participation (36; 6.6%) and CF (32; 5.9%) components.
The best matches were between assessments under the UK Guideline “Walking” topic (154; 28.2%) and those mapped to the A&P (68; 44.2%) and Activity (65; 42.2%) components, respectively. The second-best matches were between assessments under the UK Guideline “Aphasia” topic (111 out of 546; 20.3%) and those mapped to the BF component (63; 56.8%).
Intervention Mapping
There were 247 interventions identified across 66 ICF-related studies (Table 3). However, only 128 interventions from 18 studies labelled their contents with ICF components and codes. The remaining 119 interventions from 48 studies labelled their outcomes with ICF components but not for their content. The mapping of the 128 interventions with ICF components content labels covered 15 UK Guideline topics (45.5%), such as “Independence in daily living,” “Arm function,” and “Walking.”
Frequency Count of the Clinical Interventions Organized by UK Guideline Topics and Mapped to the ICF.
Note: The number of interventions mapped to the ICF may cover more than one UK Guideline topic/concept and more than one ICF component. *Each intervention was counted only once in the “All interventions” frequency count. #Some studies overlapped between the assessment and intervention mapping. A, Activity; BF, Body Functions; BS, Body Structures; CF, Contextual Factors; EF, Environmental Factors; P, Participation; PF, Personal Factors.
Intervention (Content)
The 128 ICF-related interventions (51.8% out of 247 interventions) were mapped to the 10 UK Guideline topics, such as “Neglect” and “Mood and well-being” (Table 3), while the exact content matches were found between 19 ICF-related interventions and three topics in the UK Guideline, such as lower limb resistance training under the “Motor impairment” topic (Supplementary Table 2).
Other intervention content matched with those of the UK Guideline was found in 46 (35.9%) combined A&P components, 15 (11.7%) Activity, and 27 (21.1%) Participation components. The intervention contents matched between ICF and UK Guideline were also clustered in the BF component (35; 27.3%), the combined BF and BS components (27; 21.1%), and the BS component (10; 7.81%). In contrast, only eight intervention contents (6.3%) belonged to the EF, and two intervention contents (1.6%) belonged to the PF.
At the UK Guideline topic-level, among the 128 intervention contents, 48 (37.5%) belonged to the combined A&P components, while 42 intervention contents (32.8%) were mapped to the UK Guideline “Extended activities of daily living” topic. Twenty-five intervention contents (59.5%) belonged to the Participation component, and 17 interventions (40.5%) belonged to the combined A&P component.
Intervention (Outcomes)
There were 119 interventions (48.2% out of 247 interventions) with outcomes labelled using ICF components and codes, which were mapped to 11 UK Guideline topics, including “Independence in daily living” and “Extended activities of daily living” (Table 3). Exact matches of the intervention outcomes were found in 12 intervention types under five UK Guideline topics, such as “Treadmill training with or without body weight” under the “Walking” topic (Supplementary Table 2).
Among the ICF-to-UK Guideline matches, 80 (67.2%) of the intervention outcomes belonged to the Activity component, while 69 of them (58.0%) covered the BF component. Relatively fewer intervention outcomes belonged to the combined BF and BS components (34; 28.6%) and the combined A&P components (37; 31.1%). Relatively fewer intervention outcomes were found to belong to the ICF CF, with four (3.4%) covered by the EF and three (2.5%) covered by the PF.
At the topic level, the ICF-to-UK Guideline matches showed that the largest cluster of ICF intervention outcomes was mapped to the UK Guideline “Arm function” topic (50; 42.5%). Among the 50 intervention outcomes, 48 (96.0%) belonged to the Activity component, and 32 (64.0%) belonged to the combined BF and BS components. The second largest cluster included 45 (37.8%) ICF intervention outcomes mapped to the UK Guideline “Cognitive screening/Cognitive assessment” topic. All 45 ICF intervention outcomes were covered by the BF component, and 25 (55.6%) also belonged to the Activity component.
Discussion
This narrative review mapped the ICF-based assessments and interventions reported in post-stroke rehabilitation studies to the UK National Clinical Guideline for Stroke. The key findings are that the ICF-based assessments identified from the selected studies could be mapped to more than 80% of the UK Guideline topics. The mapped assessments were found to cover the ICF BF and Activity components more frequently than the Participation and CF components. In contrast, the ICF-based interventions were mapped to less than half of the UK Guideline topics. The discrepancies in the ICF-to-UK Guideline mappings between assessments and interventions suggest that researchers and clinicians may be more ready to adopt ICF concepts when developing assessments for post-stroke patients. Assessments of the ICF BF and Activity components may be more readily implemented than those of the Participation and CF components in clinical settings where rehabilitation services are commonly accessible to post-stroke patients. Wider coverage of assessments on the Participation and CF components may be challenging in view of their complex scopes and unclear definitions, resulting in limited development in post-stroke rehabilitation.
Dominance of BF and Activity Components in ICF-Based Assessments
The extensive mapping of ICF-based assessments (about 80%) to the UK Guideline topics suggests that ICF concepts have been well incorporated into post-stroke rehabilitation. Researchers and clinicians appear to have developed the expertise and competence, as reflected in the more than 500 assessment items identified, to embed ICF-based assessments in their studies and daily clinical services, respectively. It is noteworthy that the findings on the prevalence of assessments in the ICF BF component (40.7%), followed by the Activity component (27.1%), differ from those reported in previous studies. For example, Silva et al. (2025) reported an opposite pattern, in which the 29 (53%) commonly used assessments covered the Activity component more than the BF component. Another study indicated that treatment goals set during ICF-based assessments covered the combined A&P components (73%) more than the BF component (20%; Leonardi & Fheodoroff, 2021).
The UK Guideline is intended to cover the entire rehabilitation journey of post-stroke patients. This journey begins in acute hospital settings and progresses into community and home settings. In acute hospital settings, rehabilitation begins when patients’ medical conditions stabilize, with a focus on recovery of function and the management of self-care and mobility (Li et al., 2024). The greater emphasis on assessment of the ICF BF component than the Activity component reflects a sequential approach adopted in post-stroke rehabilitation. Rehabilitation professionals tend to play an important role in assessing the body functional impacts of stroke on patients in the acute phase (Winstein et al., 2016), which explains the dominance of BF and Activity component assessments. Participation in life-role activities and home-, work-, and social-related involvement is likely to occur after discharge from inpatient settings such as hospitals and rehabilitation centers (Bollinger et al., 2024; World Health Organization, 2002).
The second observation is that a substantially larger proportion of assessment content was mapped to the A&P component (22.5%) than to the Participation component alone (6.59%). A closer look at the A&P component-related content found that it clustered around UK Guideline topics such as “Extended activities of daily living,” “Independence in daily living,” and “Walking.” In other words, the A&P components herein appear to be more inclined towards the Activity component than the Participation component. The combined A&P versus standalone Activity or Participation component is an ongoing subject of debate among ICF researchers. Earlier studies attempted to differentiate the two components by suggesting that solitary tasks (e.g., self-care and walking) should be grouped under Activity, while group or social tasks (e.g., social relationships and community gatherings) should be grouped under Participation (Hoyle et al., 2012). Other researchers have analyzed task content and offered a consolidated perspective on this issue. For instance, tasks related to an individual's Participation are broader and more context-dependent than those related to Activity (e.g., walking and dressing; Hamid et al., 2025). Silva et al. (2025) illustrated these broader and context-dependent ideas by citing ICF chapter-level domains: Chapters d1 to d5 (e.g., “d4 Mobility” and “d5 Self-care”) are Activity-related, while Chapters d6 to d9 (e.g., “d6 Domestic life” and “d9 Community, social and civic life” are Participation-related. These researchers offered an evidence-based differentiation of the Activity and Participation components.
Existing clinical assessments are developed to evaluate the competence level of patients’ task-based performance, such as the Action Research Arm Test (Lemmens et al., 2012) and Wolf Motor Function Test (Ekechukwu et al., 2020). Results of these assessments are valuable because they can inform the impacts of stroke on patients’ functional performance (Harrison et al., 2013). In real-life clinical practice, patients’ evaluation and expectations towards recovery often go beyond functional performance affected by stroke. Clinicians, therefore, should not only evaluate whether patients can live independently at home, but also the extent to which they can resume parent or worker roles in the community (Ashaie & Castro, 2022). In this case, assessments covering the combined A&P components are important (Badley, 2008; Silva et al., 2025). Examples identified in this study include the Functional Independence Measure (Veerbeek et al., 2017) and Stroke Impact Scale (Alhasani et al., 2022). Wong et al. (2023a) further substantiated the importance of A&P-related goal-setting for informing intervention planning to promote post-stroke outcomes in a community-based rehabilitation program. The results of these studies further reveal the need to design and validate additional A&P assessments (e.g., the Modified Barthel Index and Elderly Mobility Scale) as post-stroke rehabilitation aims to help patients maximize their role performance at home, at work, and in the community.
Another observation is that CF (i.e., Contextual Factors) were underrepresented in both the ICF-based literature and the UK Guideline. Only 0.73% to 4.03% of assessment content was mapped to CF, including Environmental and Personal Factors. In addition to the combined A&P components, the overall lack of CF in the identified assessment content has previously been suggested to potentially limit post-stroke patients’ community involvement and social reintegration (Dos Santos et al., 2022; Ezekiel et al., 2019). Evaluating an individual's CF would inform the design of personalized interventions (Berzina et al., 2013; Glässel et al., 2012) and quality of life-related care (Della Vecchia et al., 2023; Hoyle et al., 2012). Wong et al. (2023a, 2023b) illustrated that, for instance, successful return to work involves assessing Participation, “d850 Remunerative employment,” alongside EF, “e540 Transportation services,” “e150 Design, construction and building products and technology of buildings for public use,” and “e1351 Assistive products and technology for employment,” together with PF such as mobility confidence and fatigue self-management. The EF mentioned compose the main part of the CF that enable the combined A&P of “Walking” and “Remunerative employment,” informing a holistic approach to operationalizing the ICF in post-stroke rehabilitation (Della Vecchia et al., 2023; Jellema et al., 2017). In view of the intertwined relationships among A&P and CF, future research may consider developing modular rather than task-based assessments that are life-role specific, such as for a homemaker, worker, or volunteer. Life roles can stipulate the A&P task items as well as the personalized CF to be included in the evaluation process (Della Vecchia et al., 2018). Other considerations include adopting a goal-setting process to maximize personalization (Wong et al., 2023b) and modified qualifiers to improve efficiency (e.g., mild, moderate, or severe barriers; Yeung et al., 2026).
Overall Underrepresentation of ICF-Based Interventions
Compared with assessments, the mapping of ICF-related post-stroke interventions showed substantially lower coverage (45.5% versus 84.8%) in both the study search and the UK Guideline. In other words, post-stroke patients may have been assessed with ICF-based assessments but may not necessarily receive interventions informed by the results. The intervention content identified was mainly matched with the “Aphasia” and “Extended activities of daily living” interventions in the UK Guideline, which were mapped mainly to the combined A&P components (46.9%). An example of an intervention mapped to the combined A&P component is a community participation program addressing the “Extended activities of daily living” topic (Lee et al., 2019). The content targeted patients’ A&P, such as interpersonal relations and use of transportation. An example under the “Aphasia” topic is a life participation program that focuses on real-life goals to improve communication abilities for performing daily activities (Galletta & Barrett, 2014). Both examples highlight the relevance of conducting interventions in community-based settings to enhance community integration.
In contrast, the intervention studies identified with ICF-based outcomes focused largely on the BF and Activity components under the “Arm function” and “Cognitive screening/Cognitive assessment” topics in the UK Guideline. This pattern is comparable with that revealed among the ICF-related assessment content, due to the overlap of assessments in both sections, such as the Barthel Index (García-Rudolph et al., 2019) and Modified Ashworth Scale (Buchignani et al., 2019). Our findings about the mismatches between intervention content and outcomes indicate a likelihood that ICF concepts have not been comprehensively applied in clinical settings. This proposition is supported by the similar focus on the BF and Activity components between assessment content and intervention outcomes, while intervention content largely covered the A&P components. Another plausible reason is that the ICF may have remained deployed as a classification system for patient record management in clinical settings (Han et al., 2015). To promote comprehensive adoption of ICF concepts, intervention planning should be closely tied to assessment results (Lexell & Brogårdh, 2015; Li et al., 2024) and should leverage the advantages of treatment goal-setting processes (Wong et al., 2023a) to further strengthen assessment-intervention-outcome connections. Comprehensive coverage will require greater incorporation of CF into these tripartite connections (Bollinger et al., 2024). Other studies have suggested the deployment of additional service-delivery frameworks (e.g., the Social Ecological Model and Chronic Care Model), and implementation science frameworks (e.g., RE-AIM and Normalization Process Theory) to standardize clinical protocols and clinicians’ practices. The former can help identify patients’ needs and predict their outcomes (Bachani et al., 2025; Cheng et al., 2018), whereas the latter can guide the implementation of ICF-based practices and their outcome evaluation in both outpatient and community settings (Wong et al., 2023b).
Clinical Implications
The current review of ICF-based assessment and intervention content against the UK Guideline topics identifies current research and clinical gaps. The findings are useful for guiding recommendations on further applying ICF concepts in clinical practice for the rehabilitation of post-stroke patients.
First, the debate on combined versus separate Activity and Participation components suggests the value of using A&P components when conceptualizing assessment and intervention planning. Clinicians are encouraged to regard A&P components as a contextual continuum depending on patients’ stage of rehabilitation (i.e., hospital, home, and community), and treatment goal-setting. A&P components should be extended to include CF to allow the formulation of interventions that are personalized to patients’ rehabilitation needs. The assessment-intervention-outcome connections can be strengthened when clinicians work with researchers to translate ICF concepts into clinical protocols and skills. These include assessment instruments, instrument administration manuals, goal-setting interview formats and guidelines, treatment protocols and schedules, and instruments for tracking outcomes.
Second, the availability of training opportunities to equip clinicians with the necessary knowledge and skills is crucial for the successful implementation of ICF-based programs for post-stroke patients (Tempest & Jefferson, 2015; Wong et al., 2023b). Clinicians may lack in-depth knowledge and experience in using the ICF. Training programs that incorporate practical and context-specific applications can help clinicians translate the ICF into routine rehabilitation practice. Such programs can also enhance personalized goal-setting, support clinical reasoning, clarify team roles, and promote holistic communication in multidisciplinary teams.
Third, the ICF may support cross-system applicability beyond the UK healthcare context, as it provides a common language for describing health and functioning. Applying ICF-based rehabilitation internationally requires adaptation to local guidelines, workforce structures, reimbursement systems, service pathways, and culturally relevant Participation goals. This is important for context-specific EF and PF. In low-resource settings, where rehabilitation may rely more heavily on community-based services and low-cost environmental modifications, ICF-based rehabilitation may help make Participation restrictions and contextual barriers more visible (Kayola et al., 2023).
Limitations and Future Directions
Several limitations should be acknowledged in this narrative review. First, we did not exclusively apply the ICF linking rules during the assessment and intervention mapping process. Instead, we relied on the ICF-based mapping reported by authors of the included studies, which may have introduced subjectivity and inconsistency into the mapping process. Second, due to the methodological limitations inherent to narrative reviews, procedures in standardized reviews (e.g., review registration, systematic synthesis, and risk-of-bias assessment) were not performed. Thus, findings should be interpreted cautiously and cannot support causal conclusions. Although this review provides a broad overview of current ICF applications in outpatient and community-based post-stroke rehabilitation, future systematic reviews with rigorous search strategies, predefined inclusion criteria, and standard reporting methods (e.g., PRISMA) are needed before recommendations for practice change can be made.
Conclusion
Using the UK National Clinical Guideline for Stroke as a benchmark, our findings highlight opportunities to advance ICF-based post-stroke rehabilitation and improve the alignment of interventions with the ICF. ICF-related assessments have received greater attention than interventions and show broad coverage, but they remain largely focused on BF and Activity components and limited attention to Participation and CF. Future research should prioritize the development and validation of assessments that better capture real-life participation and contextual influences on recovery. In contrast, ICF-related interventions remain limited in scope and require clearer mapping to the ICF to strengthen linkages among assessment findings, rehabilitation goals, intervention content, and outcomes. To support implementation, clinician training should emphasize practical and context-specific applications of the ICF, including goal-setting, clinical reasoning, role clarification, and multidisciplinary communication. These efforts may promote more coherent, holistic, and person-centered post-stroke rehabilitation.
Supplemental Material
sj-docx-1-nre-10.1177_10538135261464191 - Supplemental material for Applications of ICF-Based Assessments and Interventions in Post-Stroke Rehabilitation: A Narrative Review
Supplemental material, sj-docx-1-nre-10.1177_10538135261464191 for Applications of ICF-Based Assessments and Interventions in Post-Stroke Rehabilitation: A Narrative Review by Mabel N. K. Wong and Chetwyn Che Hin Chan in NeuroRehabilitation
Footnotes
Acknowledgements
None.
Ethical Approval and Informed Consent Statements
There are no human participants in this article and informed consent is not required.
Author Contributions
MW: Data curation, Formal analysis. Investigation, Writing – Original Draft Preparation. CC: Conceptualization, Methodology, Supervision, Writing – Review & Editing.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially supported by the Peter T. C. Lee Endowed Professorship fund held by CCH Chan (Grant no.: S2006).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Supplemental Material
Supplemental material for this article is available online.
References
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