INTRODUTION

Cerebrovascular accident (CVA) can be defined as a cardiovascular disease caused by the interruption of the blood supply to the brain, with a decrease or absence of oxygen and nutrients supply, causing damage to the brain tissue.¹

Stroke has a high worldwide prevalence.² This pathology is the second leading cause of death worldwide, accounting for approximately 5.7 million deaths, equivalent to 9.9% of all deaths.¹

The incidence of stroke, adjusted to the World Health Organization (WHO) standard world population, ranged from 76 per 100,000 population per year in Australia (2009-10) to 119 per 100,000 population per year in New Zealand (2011-12).³ The incidence of stroke has increased worldwide, in both men and women of all ages.⁴

At the beginning of the 21^st century, the age-standardized incidence of stroke in Europe ranged from 95 to 290/100,000 per year, with monthly mortality rates ranging from 13 to 35%.⁵

In Portugal, between 1990 and 2012, there was an increase in the incidence rate of stroke from 265.1/10⁵ to 343.7/10⁵.⁶

In 2015, there were 11,778 deaths in Portugal due to cerebrovascular diseases. By gender, there were 5057 deaths of men and 6,721 of women.⁷

In addition to the high mortality rate, this clinical condition is assumed to be one of the main causes of morbidity, with high social and economic burdens, since only 10% of stroke survivors recover almost entirely, 25% recover with minimal sequelae, 40% are left with moderate to severe disability, requiring specialized care, 10% need long-term care requiring institutionalization, and 15% die after stroke.⁸ In this perspective, the person after a stroke, it has some altered functions, with implications for activity and participation and consequently for its functionality, namely with regard to basic, instrumental and social activities of daily living. The ICF presents a conceptual framework that allows analyzing the person's functionality under these conditions.

The ICF resulted from the revision of the previous International Classification of Impairments, Disabilities and Handicaps (ICIDH), experimental version published in 1980 by WHO. In 2001, WHO proposed an update to the old model, creating the ICF.⁹ This new model has the general objective of providing a unified and standardized language as well as a framework for the description of health and health-related conditions. The ICF includes all aspects of human health and some health-relevant components related to well-being and describes them in terms of health domains and health-related domains. These domains describe changes in physiological functions and body structures, describing the ability of a person with a certain health condition to influence their environment and performance.⁹

This is a very extensive classification, which may be one of the reasons for its little use in clinical practice, so WHO and its collaborators have developed smaller code lists called Score Sets. Score Sets arise from several processes, which require several steps and are still in the process of development and study, with the aim of facilitating its applicability in clinical practice, in research and service management.^10-11

In this way, it is intended to speed up the assessment of the person with stroke, since, instead of evaluating all aspects of their functionality; the most significant categories for them are evaluated. The selection of codes for the elaboration of the Score set based on the ICF will serve as a minimum standard for the assessment and documentation of functionality and health in clinical studies, clinical meetings and comprehensive multiprofessional assessment.¹¹

The Stroke Score Set theme based on the ICF was chosen because of its current prevalence, which gives it special importance in the field of rehabilitation nursing. Thus, this study aims to identify the most appropriate Score Set based on the ICF for assessing functionality and health-related aspects of stroke patients.

METHOD

It was decided to carry out a SLR, as it is intended to answer a clearly formulated question using systematic and explicit methods to identify, select and critically evaluate relevant research and collect and analyze data from studies included in the review.¹² With this methodology, the strategies used reduce biases in the selection of articles and, based on a well-defined question, synthesize the results of primary studies in a given area.¹³

For an analysis of all the available evidence and, in order to understand if a practice is effective or not, it is necessary to follow several steps: 1. Elaboration of the research question; 2. Literature search; 3. Selection of articles; 4. Data extraction; 5. Assessment of methodological quality; 6. Data synthesis; 7. Assessment of the quality of evidence; and 8. Writing and publication of results.¹⁴

The research question was elaborated according to the recommendations of the Joanna Briges Institute (JBI)¹⁵ from the PICo¹⁶ strategy (Population, Interest phenomenon, Context). Each dimension of the PICo contributed to the definition of inclusion criteria, namely Population (P) Person with stroke; Interest phenomenon (I) ICF Score set; Context (Co) Community. What is the most suitable ICF-based Score Set for the person with stroke in the community?

As a form of exclusion from the studies, the criteria used were, language other than English, Spanish, Portuguese, studies referring to children that are not provided in full texts, studies that do not address the topic of ICF in people with stroke and, finally, articles that present quality criteria below 75%, in the JBI grids.¹⁵

The research was carried out from October 19th to November 19th, 2017, in the Medline, SciELO, virtual health library, EBSCO, Nurses Order and General Directorate of Health databases, including articles and books published between 2013 and 2017.

The descriptors were validated in the platforms, Health Sciences Descriptors (DeSC) and Medical Subject Headings 2017 (MeSH), using a Boolean equation in the research, (International Classification of Functioning, Disability and Health) OR (ICF)) AND (Stroke).

After outlining the strategy, research and selection of articles were carried out according to the indications of the PRISMA recommendations ¹⁷ (Figure I).

The results were obtained by reading the title, after the abstract and later, the full text. For greater credibility of the study, the results were compared and the agreement between the researchers was verified.

Figure I Identification, analysis and selection of articles 

RESULTS

Out of the 11 articles analyzed, three were published in 2013,^18-20 three in 2014,^21-23 three in 2015,^24-26, one in 2016¹⁰ and one in 2017²⁷.

As far as countries of origin Brazil,^18,20,27 USA,²¹ Sweden,^19,22 Spain,²⁴ Germany ²⁶ China ^10,23 and Finland²⁵ were included.

The samples used in the analyzed studies ranged between 12¹⁸ and 227¹⁰ persons diagnosed with stroke.

The studies analyzed are descriptive quantitative studies^{10,19,20-21,23-27} and qualitative studies,^19,22 with level of evidence III.

After analyzing the different articles, their objectives, their level of evidence were identified and the ICF codes mentioned in each article were grouped (Chart 1).

After analyzing the 11 articles, it appears that 160 ICF codes are mentioned, divided by Body Functions (53 codes, 33%), Activities and Participation (61 codes, 38%), Environmental Factors (40 codes, 25%) and Structures of the Body (6 codes, 4%).

Codes were selected with a frequency ≥ 50% and a total of 21 codes were identified, of which 6 codes (29%) related to the Body Functions component, 13 codes (61%) related to the Activities and Participation component, 2 codes (10%) referring to the Environmental Factors component.

In a comparative analysis of all the codes obtained, with codes with a frequency ≥ 50%, we can conclude that the Body Functions and Activities and Participation are the most evident categories, with a percentage of 33% and 38%, respectively. With regard to codes with a frequency ≥ 50%, it was found that Activities and Participation (61%) have greater evidence than body functions (29%). Regarding the Environmental Factors and Structures of the Body, they continued to have less evidence in patients with stroke, both in all articles and in ≥ 50% (Table 2).

The proposed core set for people with stroke features twenty-one main codes. The body functions component has six codes: b144 Memory functions, b730 Muscle strength functions, b114 Orientation functions, b140 Attention functions, b167 Mental language functions, b320 Joint functions.

In the Activities and Participation component, 13 codes are highlighted, d450 walking, d510 Washing, d530 Care related to the excretion processes, d330 Speaking, d540 Dressing, d550 Eating, d160 Focusing attention, d310 Communicating and receiving oral messages, d345 Writing messages, d410 Change basic body position, d420 Auto-transfers, d430 lifting and carrying objects and d455 moving.

In the Environmental Factors component, 2 codes are highlighted, e355 Health Professionals, e580 Services, Systems and Policies related to health (Table 3).

DISCUSSION

In this SLR, 11 articles were included, nine present designs that fit a quantitative approach. Study designs are heterogeneous, which may limit the results of this study.

It was possible to identify the score set most frequently used in studies carried out in people with stroke.

It should be noted that body structures have no evidence in the score set, as there is no code with a percentage ≥ 50%, so it seems that health professionals who care for people with stroke value Body Functions and Activities and Participation, in detriment of the Structures of the Body.

The results obtained in this SLR corroborate those obtained by Geyh et al.²⁸ since, as in the score set presented here (Table 3), the greatest evidence lies in the Body Functions and Activities and Participation. However, these authors ²⁸ evidence two codes in the structures of the body, s730 Structure of the Upper Limb and s110 Structure of the Brain, which, even not being included in the score set for this SLR, are the codes with the highest percentage (47% and 36%, respectively) within the Structures of the Body, accompanied by the code s750 Structure of the lower limb (36%).

In a study carried out in Sweden ²⁹ the most affected functions after 6 months were: b130 Energy and conduction functions, b144 memory function, b455 exercise tolerance functions, b730 muscle strength, b740 muscle endurance functions, and b770 functions of the gait pattern. In terms of activity and participation, the most frequently mentioned ICF codes were: d630 preparing meals, d640 performing domestic tasks, d920 recreation and leisure. At least 50% of persons after stroke had problems at work, namely, d220 multiple tasks, d440 use fine hand movements, d450 walking and d460 moving in different places.

This SLR corroborates the results found in other studies carried out before 2013 (28,0) in which the functions of orientation, memory and attention, language and muscle strength stood out in the dimension of body functions; in activities and participation, the main areas mentioned were walking, washing, talking, dressing, eating, communicating and receiving oral messages and writing messages; and in the environment dimension, health professionals were mentioned, as well as health-related services, systems and policies. Furthermore, in the study by Seyh et al.²⁸ at the level of the environment dimension, they address the immediate family (e310) and in the body structure they refer to the brain (s110).

As limitations of this study, we considered the heterogeneity of the designs of the included studies and the fact that one of the inclusion criteria was the availability of full texts.

Body functions are the physiological functions of organic systems (ICF) that, even if the body structures are altered due to stroke sequelae, the person is able, through a rehabilitation program, to overcome these changes and acquire skills to rebuild their autonomy and independence. For this reason, even if a person has a change in an organ or member (Body Structures), the most important thing is their independence and the ability to perform tasks and keep them involved in their everyday activities (Activities and Participation). These activities are related to the basic and instrumental activities of daily living,³¹ in which the specialist nurse in rehabilitation nursing plays an important role in enabling the person through teaching, instruction and training in activities of daily living.³²

CONCLUSIONS

In this SLR, 11 studies were analyzed identifying 160 ICF codes used to classify and assess the characteristics of post-stroke patient.

After analyzing all the codes, more than 50% of the codes were selected, making a total of 21, distributed by the categories Body Functions, Activities and Participation and Environmental Factors, thus constituting the score set for patients with stroke.

It is important to introduce this information into the practice of specialist nurses in rehabilitation nursing, since the standardized classifications and languages describe and organize the data, in order to highlight the health gains sensitive to rehabilitation nursing care