Access to this full-text is provided by Georg Thieme Verlag KG.
Content available from Arquivos de Neuro-Psiquiatria
This content is subject to copyright.
A physiotherapy protocol
for stroke patients in acute
hospital settings: expert consensus from the Brazilian
early stroke rehabilitation task force
Iara Maso1,2 Gustavo José Luvizutto3Jéssica Mariana de Aquino Miranda3
Carla Ferreira do Nascimento1,2 Luana Aparecida Miranda Bonome4Elen Beatriz Pinto2
Fabiane Maria Klitzke5Ricardo Machado Souza6Carla Heloisa Cabral Moro7Rodrigo Bazan4
Pedro Antonio Pereira de Jesus1,8 EduardodeMeloCarvalhoRocha
9Cesar Minelli10,11
Sheila Ouriques Martins12,13,14,15 Jussara Almeida de Oliveira Baggio16
1Hospital Geral Roberto Santos, Unidade de AVC, Salvador BA, Brazil.
2Escola Bahiana de Medicina e Saúde Pública, Grupo de Pesquisa
Comportamento Motor e Reabilitação Neurofuncional,Salvador BA ,Brazil.
3Universidade Federal do Triângulo Mineiro, Departamento de
Fisioterapia Aplicada, Uberaba MG, Brazil.
4Universidade Estadual Paulista, Faculdade de Medicina de
Botucatu, Botucatu SP, Brazil.
5Hospital Municipal São José, Programa de Residência
Multiprofissional em Neurologia, Joinville SC, Brazil.
6Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto,
Hospital das Clínicas, Unidade de AVC, Ribeirão Preto SP, Brazil.
7Hospital São José, Unidade de AVC, Joinville SC, Brazil.
8Universidade Federal da Bahia, Instituto de Ciências da Saúde,
Salvador BA, Brazil.
Arq. Neuro-Psiquiatr. 2025;83(4):s00451806924.
Address for correspondence Iara Maso (email: iaramaso@gmail.com)
9SantaCasadeSãoPaulo,FaculdadedeCiênciasMédicas,SãoPaulo
SP, Brazil.
10Hospital Carlos Fernando Malzoni, Matão SP, Brazil.
11Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto,
Programa de Pós-Graduação do Departamento de Neurociências e
Ciências do Comportamento, Ribeirão Preto SP, Brazil.
12Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil.
13Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil.
14Rede Brasil AVC, Porto Alegre RS, Brazil.
15World Stroke Organization, Geneva, Switzerland.
16Universidade Federal de Alagoas, Curso de Medicina, ArapiracaAL, Brazil.
received
April 3, 2024
received in its final form
January 20, 2025
accepted
February 3, 2025
DOI https://doi.org/
10.1055/s-0045-1806924.
ISSN 0004-282X.
Editor-in-Chief: Ayrton Roberto
Massaro.
Associate Editor: ChienHsinFen.
© 2025. The Author(s).
This is an open access article published by Thieme under the terms of the
Creative Commons Attribution 4.0 International License, permitting copying
and reproduction so long as the original work is given appropriate credit
(https://creativecommons.org/licenses/by/4.0/)
Thieme Revinter Publicações Ltda., Rua Rego Freitas, 175, loja 1,
República, São Paulo, SP, CEP 01220-010, Brazil
This protocol has been endorsed by the Brazilian Academy of
Neurology and the Brazilian Association of Neurofunctional
Physiotherapy.
Keywords
►Stroke
►Stroke Rehabilitation
►Physical Therapy
Modalities
►Early Ambulation
Abstract The present protocol provides general recommendations based on the best evidence
currently available for physiotherapists to use as a guide for the care of stroke patients
during hospitalization. The Brazilian Early Stroke Rehabilitation Task Force, comprising
physical therapy experts and researchers from different Brazilian states, was organized to
develop this care protocol based on a bibliographical survey, including meta-analyses,
systematic reviews, clinical trials, and other more recent and relevant scientific publica-
tions. Professionals working in stroke units were also included in the task force to ensurethe
practicality of the protocol in different contexts. This protocol provides guidance on
assessment strategies, safety criteria for the mobilization of patients with stroke, recom-
mendations for mobilization and proper positioning, as well as evidence-based practices for
treatment during hospitalization, including preventive measures for shoulder pain and
shoulder-hand syndrome. The protocol also provides information on the organization of the
physiotherapy service at stroke units, guidelines for hospital discharge, and quality
indicators for physiotherapy services. We have included detailed activities that can be
THIEME
Brazilian Academy of Neurology 1
Article published online: 2025-04-22
INTRODUCTION
In 2022, stroke was the leading cause of death in Brazil and
has remained among the main global causes of hospitaliza-
tion and disability in recent years.1,2 Among neurological
disorders, it is considered to represent the greatest rehabili-
tation demand for the global population.3Recent data has
shown that 612,646 individuals aged 50 and over were
hospitalized for stroke in Brazil between January 2020 and
November 2022, while hospital morbidity was almost 5% for
this age group during the same period.2
Given its epidemiological importance and the disparities
found in the type of care offered, there have been growing
efforts aimed at stroke prevention, increasing survival rates,
and reducing disabilities caused by stroke.4,5 These actions
include an increase in access to proper care in both the
hyperacute (first 24 hours) and acute phases (up to 7 days), in
addition to evidence and guidelines that directly assist the
population affected by this disease.5–8
Although there is consensus regarding the importance of
physical therapy after stroke, some aspects have not yet been
fully established. Recent studies have pointed out that in-
tensive early mobilization, if started within the first 24 hours
after stroke, does not contribute to a favorable functional
outcome; however, gaps remain regarding the ideal frequen-
cy and intensity of motor training during acute stroke
rehabilitation.9
National and international rehabilitation guidelines for
patients with stroke represent a major advance in scientific
knowledge and care.7,10–13 These guidelines address the
timing of mobilization but do not discuss the ideal dose
(frequency, duration, and intensity) or the safety criteria for
mobilization. Certain characteristics of the acute and hyper-
acute stroke phases, such as clinical and hemodynamic
instability, bleeding risk, and care for cerebral hypoperfu-
sion,14,15 as well as other aspects that permeate hospitaliza-
tion, pose specific challenges for physical therapists
providing assistance to this population.
In Brazil, specialization courses in neurofunctional phys-
iotherapy are generally aimed at the rehabilitation of
patients with neurological diseases, without a specific focus
on patients with stroke, and several do not address all
particularities of the hyperacute and acute phases. Addition-
ally, a significant number of physiotherapists working in
hospitals have specializations in respiratory physiotherapy
and intensive care, without specific training in neuroreha-
bilitation. In view of the heterogeneity found in professional
training and hospital care, there is a need to develop an
evidence-based protocol to guide the physical therapeutic
approach for hospitalized stroke patients within the context
of the Brazilian social and public health realities. This proto-
col may also direct the implementation of training programs
specifically aimed at physiotherapists working in units that
treat patients in the acute and subacute phases after stroke.
A working group of physical therapy experts and researchers
from different Brazilian states was organized to develop a care
protocol based on a bibliographical survey, including meta-
analyses, systematic reviews, clinical trials, and other more
recent and relevant scientific publications. In addition to evi-
dence found in the literature, the working group also considered
the experience of professionals working in stroke units, aiming
to render the protocol viable for administration in Brazil.
This protocol aims to optimize physical therapeutic assis-
tance for patients with stroke during hospitalization. It was
developed specifically for Stroke Units but can also be used as a
guidelineto care for stroke patients hospitalized in other units,
such as emergencywards and intensive care units (ICUs). It is
worth emphasizing that services catering to stroke patients
should adopt the stroke unit model, given the robust evidence
of improved outcomes in both the short and long term.16 The
protocol can be used for individuals who are hospitalized after
an ischemic or hemorrhagic stroke, whether undergoing re-
perfusion therapy or not (intravenous chemical thrombolysis/
mechanical thrombectomy).
PROTOCOL DEVELOPMENT METHODOLOGY
Experts in stroke rehabilitation with clinical experience in
the field were invited to form the Brazilian Early Stroke
Rehabilitation Task Force. Brazil is a continental country
with different socioeconomic realities; for this reason, the
group was composed by professionals from different geo-
graphical regions and various specialties.
The first meeting of the task force took place during the
Global Stroke Alliance, in August 2022, with the attendance
of stroke rehabilitation experts, representatives from the
Ministry of Health of Brazil, and people with lived experience
with stroke. During the meeting, a thematic panel was held
where the main gaps related to the rehabilitation of stroke
patients were identified, and it was decided to start by
developing national rehabilitation protocols.
Following the identification of task force priorities, a
group responsible for the preparation of this protocol was
formed. It consisted of 8 physiotherapists chosen based on
the following criteria: living in different regions of Brazil,
having publication in the field, and/or having at least 5 years
of clinical experience in stroke units.
performed during mobilization in the supplementary material, such as postural control
training, sensory and perceptual stimulation, task-oriented training, and activities involving
an enriched environment. The protocol was written in a user-friendly format to facilitate its
application in different social and cultural contexts, utilizing resources readily available in
most clinical settings.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.2
The group conducted a literature search until Decem-
ber 2022. The search details for this scoping review are
presented in ►Supplementary Material I (available at
https://www.arquivosdeneuropsiquiatria.org/wp-content/
uploads/2025/02/ANP-2024.0096-Supplementary-Materi-
al-1.pdf). Subsequently, the group discussed the evidence in
the field and determined the main objective and subtopics of
the protocol. Between January and June 2023, the writing of
the protocoltook place, involving monthly online meetings for
discussions. Thisco-production was based on shared decision-
making, mutual respect, and learning. At the onset of the
protocoldevelopment, guidelines were established and shared
as a reference document, outlining the Brazilian Early Stroke
Rehabilitation Task Force’s objectives, expectations, and com-
munication methods. Building on this foundation, the deci-
sion-making process adhered to criteria previously defined
within the group, allowing all members the opportunity to
provide input. Following these criteria, the coordinator iden-
tified key points requiring group discussion, and each member
had the chance to express their position, drawing on both
scientific evidence and professional experience. Discrepancies
were then resolved through voting, with consensus achieved
by majority vote. In all topics, consensus was reached, and no
disagreements persisted after the voting process. The prees-
tablished relationships within the group were crucial to the
successful completion of the project.
Once the protocol writing was finalized, we invited a
panel of reviewers, which included an expert physiothera-
pist in stroke rehabilitation, stroke neurologists, and a
physiatrist. After the review process, we made necessary
changes, and the final manuscript underwent further revi-
sion by representatives of the Brazilian Association of Neuro-
functional Physiotherapy and the Scientific Department of
Neurological Rehabilitation of the Brazilian Academy of
Neurology. The physiotherapists who developed the protocol
approved the final version of the manuscript.
►Figure 1 presents the structured decision-making pro-
cess used for the in person and virtual consensus meetings.
Additionally, ►Supplementary Figure I (online only) shows
the profile of physiotherapists involved in the development
of the protocol, along with the profile of the panel of
reviewers (►Supplementary Material I; online only).
ASSESSMENT OF STROKE PATIENTS IN ACUTE
HOSPITAL SETTINGS
Before the intervention, patients must be carefully evaluated
to adequately plan physical therapy procedures, which will
be performed according to the individual’s functional level.
Physical therapeutic evaluation may follow the evaluation
form templates for each service, with the recommen dation of
including the information described in ►Supplementary
Table 1 (online only) (►Supplementary Material I; online
only).
The inclusion of validated clinical scales with medium-
and long-term prognostic values is recommended during
hospitalization, allowing for quantitative assessment of the
patient’s evolution during physical therapy. The suggested
tools were selected through a consensus of a group of experts,
based on the scientific literature.7,17,18 The criteria for classi-
fying the instruments as Highly Recommended Assessment
Tools were: evidence-based support of their use in acute or
subacute phase of stroke patients, validation in Brazilian
Portuguese, adequate measurement properties, and ease of
application in clinical practice.19–24 The instruments catego-
rized as Recommended Assessment Tools followed the same
criteria, but require more time to administer. Additionally, we
included among the Recommended Assessment Tools sometests
that are quick and easy to apply but have limitations prevent-
ing their use with all poststroke patients. For example, aphasic
patients may be unable to complete the Borg Rating of
Perceived Exertion25 and Star Cancelation Test.26
►Table 1 27,28 shows selected tools that were classified as
Highly Recommended Assessment Tools,while►Table 2–29
shows tools that were classified as Recommended Assessment
Tools. Paid assessment tools were not included, as this would
hinder their implementation in Brazil given the country’s
socioeconomic context.
In services with a reduced number of physical therapists,
we suggest that at least the following scales be applied:
•National Institutes of Health Stroke Scale (NIHSS): score
daily.
•Hospital Mobility Scale (HMS): score daily.
•Modified Rankin Scale (mRS): score at hospital discharge.
The selection of the NIHSS, mRS, and HMS was based on
recommendations from the scientific literature regarding
the use of these scales in clinical practice17,19–21,27. Addi-
tionally, we considered that all of them have been validated
for the Brazilian population, with adequate measurement
properties, and are easy to apply in clinical settings.
We recommend using the mRS, as this tool is quick to
administer, free of charge, widely accepted in clinical prac-
tice, and commonly used in international clinical trials
involving stroke patients. Due to its widespread use, we
recommend applying the mRS both prior to the stroke
(data already collected for reperfusion therapy decisions30)
and at hospital discharge. The objective of the mRS is to
assess overall functionality; however, its interpretation in a
hospital setting is limited.17 Therefore, services with greater
availability of professionals can replace the mRS with the
Barthel Index (BI), another widely used scale for assessing
stroke patients,31 particularly in evaluating the activity
component of the International Classification of Functioning
(ICF). Since it requires more time to administer, we classified
the BI as a recommended scale. If possible, we suggest that
these daily life activity assessment scales be administered by
a multidisciplinary team, dividing the workload and enhanc-
ing team integration. T he scales are easy to administer, so the
main barrier would be the availability of professionals’time.
The Recommended Assessment Tools, described in
►Table 2, can be used with patients who require a more
detailed evaluation of specific aspects. For example, a patient
with specific upper-limb demands can be assessed with the
Fugl-Meyer29 if the team has sufficient time available. Similar-
ly,patients with particular demands relatedtoposturalcontrol
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 3
can be evaluatedwith the Postural Assessment Scale for Stroke
(PASS).29 The Borg Rating of Perceived Exertion25 can be used
with patients with respiratory issues, while the Star Cancella-
tion Test26 can be applied to those with perceptual deficits.
However, as we discussed previously, these last two tests may
not be appropriate for aphasic patients. Therefore, we do not
recommend applying all scales to assess every patient; rather,
we advocate for the individual assessment of patients and the
tailored selectionof instruments based on their specific needs.
DESCRIPTION OF THE PROCEDURES
The procedures described in this protocol are:
•Mobilization.
•Positioning in bed.
•Preventive measures for shoulder pain and shoul der-hand
syndrome.
NOTE: The description of respiratory procedures is not part
of the objectives of this protocol and must follow local proto-
cols for respiratory physical therapy (oxygen therapy, trache-
ostomy, and invasive and noninvasive mechanical ventilation
protocols). If the service lacks these protocols, you may refer to
the Brazilian and International Guidelines for the same.32–41
Neurocritical patients who require admission to an
intensive care unit (ICU) have peculiarities that are not
described in this protocol because they do not represent
the profiles of patients in stroke units. We suggest reading
papers that discuss the mobilization of this specific group of
patients.42,43
Figure 1 Structured decision-making process used for in-person and virtual consensus meetings.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.4
Table 1 Highly recommended stroke rehabilitation assessment tools
Assessment
tool
Purpose ICF domain Description Specialized
training
When to apply
National
Institutes of
Health Stroke
Scale (NIHSS)
17,19
Measures the severity
of neurological
symptoms
Body
Function
11 items assessing level of consciousness, conjugate gaze, visual fields,
facial palsy, motor strength upper limbs, motor strength lower limbs,
ataxia, sensory, language, dysarthria, extinction or inattention. Scores
range from 0 to 42 points, with higher scores indicating greater severity
of the stroke.
Link to training:
https://www.youtube.com/watch?v=pbUOytrTQ8I
Required Daily
Modified Rankin
Scale (mRS)19,27 Categorizes level of
functional
independence
Activity mRS is a disability scale that includes gait, basic activities and usual
activities assessment.
The mRS score ranges from 0 to 6, with 0 - Asymptomatic and 6–Death.
Link to training:
https://www.youtube.com/watch?v=pbUOytrTQ8I
Required At admission,
collect previous mRS
At hospital discharge
Hospital
Mobilit y Scale
(HMS)20,21
Evaluates the
mobility of stroke
patients in the
hospital environment
Activity The HMS evaluate three mobility tasks: sitting, standing and gait. This
scale is based on the amount of assistance in performing these mobility
tasks (performs independently, needs help from 1 person, needs help
from 2 people, or fails to perform the task). The total score ranges from
0 to 12, and the higher the score, the greater the degree of dependence.
Link to access the scale free of charge:
http://www5.bahiana.edu.br/index.php/fisioterapia/article/view/3199
Not required Daily
10 Meter Walk
Test17,28 Measures walking
speed
Activity The time to cover the given distance is recorded. Not required When the patient
starts walking
At hospital discharge
Abbreviation: ICF, International Classification of Func tioning, Disabilit y and Health.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 5
Table 2 Recommended stroke rehabilitation assessment tools
Assessment
tool
Purpose ICF domain Description Specialized
training
When to apply
Barthel Index
(BI)19 Evaluates autonomy
in activities of daily
living (ADLs)
Activity There are 10 items that assess activities related to clothing, nutrition,
personal hygiene, and transfers. Each item is scored as 0, 5, 10, or 15,
resulting in a total score of 100. A higher score indicates greater
functional independence.
Not required In the first evaluation
At hospital discharge
Fugl-Meyer29 Evaluates the motor
function of the upper
and lower limbs
Body
Function
The subscale assesses motor recovery of the upper and lower limbs. The
maximum score for the upper limb is 66, and for the lower limb is 34. The
higher the score, the better the motor function.
Link to training:
https://www.gu.se/en/neuroscience-physiology/fugl-meyer-assessment
Required In the first evaluation
At hospital discharge
Postural
Assessment
Scale for Stroke
(PASS)29
Evaluates poststroke
postural control
Activity There are 12 items divided into postural maintenance (5 items) and
postural changes (7 items). Each item is scored from 0 to 3, with a
maximum score of 36 points. The higher the score, the better the
postural function.
Not required In the first evaluation
At hospital discharge
Borg Rating of
Perceived
Exertion25
Measure aerobic
capacity
Body
Function
A scale from 6 to 20 is used for individuals to assess their perception of
the intensity of the prescribed exercise.
Aphasic patients may be unable to complete this test.
Not required Daily
Star Cancelation
Test26 Evaluates spatial
neglect
Body
Function
Screening test for spatial neglect. The test consists of 52 large stars, 13
small stars, words, and letters among th e stars. The instruction is to mark
all the small stars. The sheet is positioned along the patient’smidline.
Aphasic patients may be unable to complete this test.
Not required In the first evaluation
At hospital discharge
Timed Up and
Go29 Evaluates mobilit y Activity The patient starts sitting on a chair, upon the evaluator’scommand,
walks 3 m, returns, and sits back on the chair.
Not required When the patient
starts walking
At hospital discharge
Abbreviation: ICF, International Classification of Func tioning, Disabilit y and Health.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.6
At the end of the protocol, we include the following
information:
•Organization of the physiotherapy service at stroke units.
•Guidelines for hospital discharge.
•Quality indicators for physiotherapy after a stroke
(►Supplementary Material I; online only).
•Postural control training (►Supplementary Material I;
online only).
•Sensory and perceptual aspects (►Supplementary
Material I; online only).
•Task-oriented training (►Supplementary Material I;
online only).
•Enriched environment (►Supplementary Material I;
online only).
Mobilization
Definition of mobilization
Mobilization was defined by Langhorne et al. as situations in
which: “The patient is assisted and encouraged in functional
tasks, including activities such as sitting over the edge of the
bed, standing up, sitting out of be d and walking.”44 Therefore,
passive exercises performed with patients lying in bed
should not be considered as mobilization. During mobiliza-
tion, it is important for patients to be actively engaged.
Safety criteria for mobilization
►Figure 2 shows the safety classification codes and descrip-
tions, while ►Figures 3–5list the criteria to be met by the
patients, along with their respective codes, for mobilization
and/or low-intensity exercises in bed.
For situations in which poststroke population studies
were not found, we used the safety criteria to mobilize
critically ill patients admitted to the ICU.45,46
The low-intensity bed exercises mentioned in
►Figures 3–5werescoredbetween6and10ontheBorg
Rating of Perceived Exertion (20-point scale) (RPE20).25 If
the patient is unable to respond to the Borg scale, the
physical therapist can observe the patient’s signs. Low-
intensity exercises are those the patient can perform
without difficulty or fatigue, being able to speak during
the exercises, and exhibiting minimal or no changes in
respiratory rate (RR) or heart rate (HR).
The described safety criteria must always be followed
before a patient is mobilized, regardless of whether they are
undergoing reperfusion therapy (intravenous chemical
thrombolysis/mechanical thrombectomy). For less common
clinical situations in stroke units, check the full study by
Hodgson et al..45 We used the European Stroke Organization
guidelines and a systematic review of global stroke guide-
lines from the World Stroke Organization to define the safety
criteria related to blood pressure.47,48
Most of the safety criteria presented rely on basic assess-
ments and vital signs, which are standard in ho spital settings.
In situations in which continuous monitoring with individu-
al monitors is unavailable in the unit, we suggest using a
portable sphygmomanometer and finger oximeter, along
with manually monitoring respiratory and heart rates. Por-
table devices that use either auscultatory or oscillometric
methods of measurement provide reliable blood pressure
values.49 Pulse oximeters, mainly in the middle finger,50 can
be similarly effective in preserving sensitivity to clinically
relevant hypoxia.51 If these devices are also unavailable,
clinical and neurological signs such as decreased responsive-
ness, dizziness, vertigo, nausea, vomiting, headache, pallor,
and sweating should be observed. We recommend analyzing
each situation on a case-by-case basis and discussing them
with the multidisciplinary team.
When to start mobilization
The recommendations for mobilization in this protocol are
primarily based on the results of the A Very Early Rehabilita-
tion Trial (AVERT), which is the largest rehabilitation clinical
trial conducted with stroke patients.52 This multicenter,
Figure 2 Safety criteria codes.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 7
Abbreviation: NIHSS, National Institutes of Health Stroke Scale.
Figure 3 Neurological safety considerations.
Abbreviations: BP, blood pressure; mmHg, millimeters of mercury; SBP, systolic blood pressure; HR, heart rate; bpm, beats per minute.
Figure 4 Cardiovascular safety considerations.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.8
randomized controlled trial was conducted in 5 6 stroke units
and included 2,104 subjects.52 The results, published in
2015, demonstrated that early and intensive mobilization
within the initial 24 hours reduced the odds of favorable
functional outcomes (no or minimal disability according to
mRS). Furthermore, the number of serious adverse events or
deaths at 3 months poststroke did not differ significantly
between the control and intervention groups.52 Therefore, in
2016, the American Heart Association/American Stroke As-
sociation guidelines do not recommend high doses of very
early mobilization within the first 24 hours of stroke.10
Similarly, the United Kingdom Guidelines recommend that
mobilization within 2 4 hours of st roke onset should only be
considered for patients who require minimal or no assistance
to mobilize.13
More recently, systematic reviews and meta-analyses
published in 2018 and 2020, and including 9 and 6 studies,
respectively, have shown findings similar to those of
AVERT.9,53 Consequently, the Australian and New Zealand
Clinical Guidelines for Stroke Management strongly advise
against initiating intensive out-of-bed activities within
24 hours of stroke onset.12
The systematic review published in 2018 showed that
very early mobilization may reduce the length of hospital
stay by about one day.53 However, the authors emphasize
that this result is based on low-quality evidence; therefore,
not sufficient to guide practices.
In light of the aforementioned findings, we suggest that
patients undergo m obilization bet ween 24 and 48 h ours
after stroke onset. Patients who score between 0 and 7 on
the NIHSS and require minimal or no assistance in walking
may be allowed to walk to the bathroom within the first
24 hours. These criter ia should be appl ied to both patients
undergoing reperfusion therapy (intravenous chemical
thrombolysis/mechanical thrombectomy) and those who
are not. Whenever possible, the initial mobilization should
be performed by physiotherapists.
The decision of when to begin mobilization should always
take into account t he safety criteria outlined i n ►Figures 4–6,
especially within the first 24 to 48 hours. T he presence of
dizziness and nausea is categorized in ►Figure 3 as a relative
contraindication for mobilization. However, within the first
24 to 48 hours, it is generally safer to avoid mobilizing these
patients, as these symptoms may signal early neurological
deterioration. Overall, during the initial two days, it is
advisable not to mobilize patients who exhibit conditions
marked in yellow (relative contraindications) in the safety
criteria.
The subgroup analysis of the AVERTstudy did not show any
difference between patients who did and those who did not
undergo chemical reperfusion therapy.52 Therefore, the rec-
ommendations regarding when to initiate mobilization apply
to both groups of patients.However, when feasible, we suggest
that patients undergoing chemical and/or mechanical reper-
fusion therapy be mobilized after undergoing follow-up com-
puted tomography scans and receiving medical clearance,
owing to the risk of hemorrhagic transformation. Another
important consideration for this group of patients is the
need for increased attention to any signs of hemorrhagic
transformation, such as headache, dizziness, nausea, vomiting,
Abbreviations: SpO2, peripheral capillary oxygen saturation; RR, respiratory rate; °C, degrees Celsius.
Figure 5 Respiratory and other safety considerations.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 9
or worsening in the NIHSS score. If the patient presents with
any of the symptoms mentioned above, they should not be
mobilized until hemorrhagic transformation is ruled out.
Additionally, patients undergoing mechanical thrombec-
tomy or femoral artery angiography should only be mobi-
lized 6 hours after the procedure or 6 hours after the removal
of the sheath or compressive dressing, whichever occurs last.
Before mobilizing the patient, the physiotherapist should
observe for any bleeding or discomfort at the procedural
site.54 It is worth highlighting that whether the patient has
undergone thrombectomy or not does not influence the
frequency or duration of mobilization. These factors are
determined by the severity of the stroke, as will be discussed
in the following sections.
In cases in which pati ents undergoing reperfusion therapy
(intravenous chemical thrombolysis) require airway suction-
ing, the risk/benefit should be evaluated due to the risk of
bleeding.
Frequency of mobilization
The dose–response analysis from the AVERTstudy, published
in 2016, demonstrated that shorter and more frequent
mobilization sessions lead to improved functional outcomes
following a stroke. The findings indicated that while keeping
the frequency constant , increasing the du ration of out-of-bed
activities reduced the likelihood of achieving minimal or no
disability three months poststroke. These benefits were also
evident in patients with more severe strokes (NIHSS >13.5),
in whom a greater number of sessions correlated with more
favorable outcomes compared with fewer sessions.55
Therefore, we suggest that the physiotherapy team dis-
tributes the mobilization of each patient at various times of
the day (between two and four sessions) with shorter
durations. In services with a reduced number of professio-
nals, we recommend that the team aims to achieve at least
the goal of two mobilizations per day. These recommenda-
tions apply to both mild and severe patients, with either
ischemic or hemorrhagic strokes.
Other professional categories, such as nurses, speech
therapists, and occupational therapists, can also contribute
to increasing the frequency of patient mobilization during
their interventions. For instance, patients can be encouraged
to sit on the bed, a chair, or an armchair during swallowing
evaluations or while being assisted with feeding by speech-
language pathologists. Nursing professionals can, whenever
possible, motivate patients to walk or use wheelchairs to
access the bathroom instead of performing bed baths.
For patients with higher levels of dependency, mobiliza-
tion may require the assistance of two individuals. In such
cases, it is essential for physical therapists to plan their
sessions early in the shift and coordinate with other profes-
sionals to determine the best time to assist the patient.
Additionally, students and family members can contribute
to mobilization efforts in units with limited staff availability.
This approach aims to achieve the highest possible level of
mobility and the ideal frequency of mobilization for each
hospitalized patient.
We also recommend that physical therapists perform
activities focused on postural control training and task-
oriented therapy during mobilization sessions.
Abbreviation: NIHSS, National Institutes of Health Stroke Scale.
Figure 6 Flowchart of patient mobilization after stroke in the hyperacute and acute phases.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.10
Duration of mobilization
There is no consensus in the literature regarding the duration
of mobilization. As previously mentioned, the dose–re-
sponse analysis for the AVERT study suggests that a higher
frequency of mobilizations is preferable to fewer sessions
with long duration.55 In the absence of a study that specifies
the ideal duration of mobilization, we estimated this time
based on the results of the AVERT study published in 2015, in
which the median in the group that showed a better func-
tional outcome was 10 minutes (0.0–18.0) per day spent in
out-of-bed activity.52 Therefore, we suggest that th e duration
of each mobilization should be 10 mi nutes. Th e session
duration does not need to be exactly 10 minutes; it can vary
slightly based on the patient’s tolerance. The physical thera-
pist should use clinical judgment to assess whether the
patient is tolerating the session well or showing signs of
fatigue or discomfort. Patients with mild motor deficits may
tolerate longer sessions, while those with more significant
deficits may need shorter sessions.
A systematic review published in 2020 reported findings
consistent with those of AVERT, indicating that early and
intensive mobilization may be more harmful for patients
with severe and hemorrhagic stroke.9Thus, in patients with
an NIHSS score greater than 16, we suggest that mobilization
should not exceed 10 minutes, and exercise intensity should
be low.56 We also recommend greater attention and care for
patients with hemorrhagic stroke and those aged >80
years.55 Additionally, mobilization should be approached
with extra caution in the first three days poststroke due to
greater clinical instability. An ongoing clinical trial, the
AVERT DOSE, will elucidate the optimal treatment doses
for patients with stroke in the acute phase.57
Mobilization time includes only the time when the pa-
tient is actively performing out-of-bed tasks and does not
include rest time, checking vital signs, or organizing materi-
als. There is no time limit for performing personal care tasks
and nursing care activities such as going to the bathroom,
taking a shower, and sitting down to eat.
►Figure 6 presents a flowchart for our proposed physio-
therapy management in the acute and hyperacute phases of
stroke, including the recommended duration of mobilization
according to stroke severity.
When to stop mobilization
Mobilization should be interrupted, and the patient should
be repositioned in bed when:44
•the physiotherapist or another member of the team
determines that mobilization is not tolerated (such as
decreased responsiveness, dizziness, vertigo, nausea,
vomiting, headache, pallor, sweating, or other reasons);
•heart rate remains >120 bpm;
•SpO
2
remains <90%;
•the patient complains of chest pain (evaluate cardiac
causes).
Mobilization plan
A mobilization plan should be defined according to an
individual’s functional mobility level, considering the HMS
score. Physiotherapists should reassess the level of func-
tional mobility daily to progress mobilization. The main
objective of each session should be to achieve a higher
level of mobility than in the previous session. It is impor-
tant to emphasize that mobilization should be performed
with the best possible biomechanical alignment to prevent
compensation and development of inappropriate motor
patterns.58
During the first three days, low-intensity exercises should
be performed with gradual progression based on the
patient’s tolerance. ►Table 3 provides a summary of the
mobilization plan. In this table, we suggest simpler and less
intensive exercises for patients with severe conditions and
greater mobility restrictions. As the patient demonstrates
functional improvement, the difficulty and intensity of the
exercises can be progressively increased. The physiotherap ist
should use their clinical judgment and closely monitor the
patient’s tolerance to the exercises, taking into account the
previously described safety criteria.
We have included detailed activities that can be performed
duringmobilizationin the►Supplementary Material I (online
only) (►Appendix 1. Postural control training; ►Appendix 2.
Sensory and perceptual aspects; ►Appendix 3. Task-oriented
training; ►Appendix 4. Enriched environment).
Early mobilization is multidisciplinary and requires the
collaboration of several health professionals, especially in
patients with severe neurological deficits. Cormican et al.
identified barriers and facilitators perceived by healthcare
professionals in impleme nting clinical practice guidelines for
stroke rehabilitation.59 Among the most frequently men-
tioned challenges were organizational factors, including
time constraints and limited resources.
To address these issues, we propose strategies to facili-
tate the application of this protocol in hospitals with
limited resources. The mobility training that we suggest
can be performed without any equipment, relying solely
on the physiotherapist’s hands. In hospitals with material
resources,instrumentssuchasplatforms,balls,cones,and
obstacles can be incorporated into physiotherapy sessions
to diversify exercises. In more resource-constrained set-
tings, postural control training can be adapted to occur
without equipment, utilizing strategies such as narrowing
the base of support, closing the eyes, and incorporating
directional changes. Additionally, upper-limb activity
training can be performed using personal care items
available at the patient’s bedside, such as moisturizers,
toothbrushes, and deodorants. These adaptations make
the protocol more accessible and practical across different
contexts.
Regarding time constraints, we propose a mobilization
session duration of 10 minutes, which is not overly lengthy
for a physiotherapy session. A significant challenge for
services with a reduced number of professionals can be
achieving the goal of two mobilizations per day. However,
this can be facilitated through teamwork, including mobi-
lizations conduc ted during care provided by other healthcare
professionals, such as nursing, occupational therapy, and
speech therapy.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 11
Bed positioning
Therapeutic positioning in a bed, chair, or wheelchair aims to
reduce skin damage, limb edema, pain or discomfort, and
maximize function while maintaining soft-tissue
length.13 ►Figure 7–60 presents some considerations related
to bed positioning.
Studies using transcranial doppler have shown a clear
increase in cerebral blood flow when patients with ischemic
stroke are positioned in the lying-flat head position. Howev-
er, these studies did not assess whether the increased cere-
bral blood flow improves functional outcomes.61 The
HeadPost trial, a clinical study involving 11,093 patients
(85% ischemic stroke and 15% hemorrhagic stroke), com-
pared patients positioned in the lying-flat position versus
those in a sitting-up position with the head elevated to at
least 30 degrees during the first 24 hours postst roke.62 The
results showed no differences between the groups regarding
functional outcomes, mortality, or adverse events such as
pneumonia. Patients positioned in the lying-flat position
were less likely to maintain this position for 24 hours,
potentially due to discomfort caused by the posture. It is
worth noting that the HeadPost trial excluded patients with
clinical contraindications to lying flat position and that most
participants had mild neurological deficits.
A systematic review revealed conflicting results regarding
the influence of head positioning on oxygen saturation levels
in poststroke patients.61 Some studies reported higher oxy-
gen saturation levels in the upright head positions compared
with the supine position, while others found no changes. The
HeadPost trial results demonstrated no differences in oxygen
saturation levels between the two groups.62
Observational studies have shown a reduction in intra-
cranial pressure when the head is elevated in patients with
brain injuries.61 These findings have been used as a rationale
for recommending head elevation in patients with acute
intracerebral hemorrhage. However, the HeadPost trial,
which included 931 patients with hemorrhagic stroke, found
no differences in outcomes between patients in the lying-flat
position and those in the upright head positions.62
In light of the evidence from the HeadPost study,62
clinicians may choose the most comfortable position for
patients with ischemic or hemorrhagic stroke in the acute
phase, as no differences were observed between the groups.
We suggest that patients with mild neurological deficits be
positioned in the lying-flat position when feasible, aiming to
optimize biomechanic al alignment, particula rly in the lateral
decubitus position. For more severe patients with clinical
contraindications to lying flat (e.g., use of nasoenteric feed-
ing tubes, high risk of aspiration, invasive or non-invasive
mechanical ventilation, respiratory discomfort, or SpO2
desaturation), who represent a different profile from those
included in the HeadPost trial, we recommend maintaining
the sitting-up position with the head elevated to at least
30 degrees.
Prevention of shoulder pain and shoulder-hand
syndrome
Poststroke patients frequently experience complications in
the upper limbs, such as shoulder pain and complex regional
pain syndrome type I, also known as shoulder-hand syn-
drome. The prevalence of shoulder pain within 6 months of
stroke is estimated to be 17 to 25%.13 We recommend care
strategies for the upper limbs during mobilization to prevent
the occurrence of these painful conditions (►Figure 8).
Pain levels should be assessed daily, and patient manage-
ment should involve a multidisciplinary approach. Active
motor training is essential to improving function in patients
with shoulder pain.12 This condition can be managed
Table 3 Mobilization plan for hospitalized patients after stroke
Mobility level HMS score Summary of the mobilization plan
1–Remains only in
decubitus
Score 6 in sitting task of the
Hospital Mobility Scale
–Exercises in bed
–Transfer training in bed
2–Sits with assistance
but cannot stand
Score 2 or 4 on the sitting task
of the Hospital Mobility Scale.
Score 3 on both the standing
task and the gait task.
–Transfer training
–Trunk control training in sitting position
–Task–oriented training in sitting position
3–Stands with
assistance
but cannot walk
Score 1 or 2 on the standing
task of the Hospital Mobility
Scale. Score 3 on the gait task.
–Transfer training
–Posturalcontroltraininginsittingandstandingposition
–Task–oriented training in sitting and standing position
4–Walks with
assistance
or supervision
Score 1 or 2 on the gait task of
the Hospital Mobility Scale.
–Transfer training
–Posturalcontroltraininginsittingandstandingposition
–Task–oriented training in sitting and standing position
–Gait training
5–Walking
independently
Score 0 on the gait task of the
Hospital Mobility Scale.
–Postural control training in standing position
–Gait training on uneven terrain, outdoors, maneuvering around
or overcoming obstacles
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.12
through gentle alignment movements and mobilization with
external rotation and abduction.7Additionally, handling and
positioning recommendations, as described in ►Figure 8,are
important for pain control when the condition is already
established.12
The physiotherapists should collaborate with the medical
team to discuss the need for pharmacological measures for
pain management. Patients with severe hypertonicity in
hemiplegic shoulder muscles may benefit from Botulinum
toxin injections for pain control.10 National and international
guidelines provide further details on the pharmacological
options for management of shoulder pain in patients with
stroke.7,10,12 These guidelines also address treatments such
as electrostimulation and magnetic stimulation, which are
not included in this protocol due to the limited availability of
such equipment in most hospitals in Brazil.
ORGANIZATION OF THE PHYSIOTHERAPY
SERVICEATSTROKEUNITINBRAZIL
Ordinance Nos. 665/2012 and 800/2015, issued by the Minis-
try of Health of Brazil, established qualification criteria for
hospital establishments as Emergency Care Centers for
Patients with Stroke under the Unified Health System
(SUS).63,64 These ordinances classify centers as type I, II (Acute
Urgent Care Centers), or III (Comprehensive Stroke Care Units).
They describe the physical structure of each type of center
and establish a minimum requirement for the number of
Note: Drawings reprinted from the manual Shoul der Pain Syndrome af ter Stroke, by Associação Br asil AVC, 60 with permission from the authors.
Figure 7 Bed positioning.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 13
physiotherapists in stroke centers. In acute centers, a physio-
therapist mustbe present daily without specifying the number
of hours; and in comprehensive centers, there should be at
least one physiotherapist for every 10 beds available for
6 hours a day.63,64 However, this number is insufficient to
achieve the recommended mobilization frequency of at least
two mobilizations per day, as suggested in this protocol. A
dose–response analysis of the AVERT study published in 2016
demonstrated that an increased frequency of mobilization
leads to better functional outcomes after hospital discharge.55
The Brazilian Federal Council of Physical Therapy and Occupa-
tional Therapy (Conselho Federal de Fisioterapia e Terapia
Ocupacional –COFFITO, in Portuguese) Resolution No. 444 of
26/04/2014 for specialized hospital unitsrecommends a mini-
mum of one physiotherapist should be allocated for every 8 to
10 patients for a 6-hour period.65 The resolution highlights
that the specific number of patients to be attended to by each
physiotherapist is determined by the chief physiotherapist,
considering the level of complexity of the unit and adherence
to the principles of dignity and professional ethics.
Recommendation of this protocol:
To ensure that the patient receives at least 2 physiotherapy
sessions per day (1 in the morning and another in the
afternoon), a unit with 8 to 10 patients should have at least
1 physiotherapist for a 12-hour period.
In units where physical therapy coverage doesnot meet the
12-hour standard, we propose some measures to increasethe
frequency of mobilization:
•To train nursing staff, patients, and caregivers in simple
mobilization activities that can be performed between
supervised sessions.
•To develop educational programs such as internships and
physical therapy residency programs to increase the
number of individuals involved in mobilization.
•To assess the redistribution of professionals across differ-
ent units to meet the demand in areas with a high
concentration of stroke cases.
•To prioritize patients with a higher potential for function-
al recovery or a greater risk of complications due to
immobility.
•To monitor quality indicators to support the justification
for hiring additional professionals.
Studies investigating the practical application of guide-
lines in the rehabilitation of patients after a stroke identified
that insufficient knowledge and skills among healthcare
professionals are significant barriers to the implementation
of these guidelines.59 The authors highlighted that facilitat-
ing factors included organizational support, which encom-
passes training and the presence of local protocols. We
believe that the current protocol, which considered the
specificities of the Brazilian healthcare system, can assist
in guiding clinical practice and facilitate the implementation
of a mobilization plan. The protocol can also be used as
training material for teams, as it provides easier language
and a more pract ical approach than rehabilitation guidelines.
The physical therapy team should be trained to provide
care for stroke patients based on the best available evidence.
Note: Drawings reprinted from the manual Shoul der Pain Syndrome af ter Stroke, by Associação Br asil AVC, 60 with permission from the authors.
Figure 8 Preventive measures for shoulder pain and shoulder-hand syndrome.
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.14
Rede Brasil AVC recommends a minim um of 4 hour s of team
training per year. The World Stroke Organization and Rede
Brasil AVC offer an online training platform for Stroke Centers
(https://avc.encontrodigital.com.br/). This platform provides
free online courses, certifications for the application of
evaluation tools, live sessions, and activities on clinical
treatment and rehabilitation of patients with stroke. This
material can contribute to the development of a continuing
education program within hospitals. ►Supplementary
Table 2 (►Supplementary Material I; online only) highlights
some of the courses and training available on the platform.
We also present the website where international certifica-
tion for the application of NIHSS and ERm can be obtained.
The expansion of online education is crucial to ensuring
that physical therapists in remote areas or those with limited
access to training centers can receive adequate education.
However, online training may not be the most suitable
method for developing practical skills. We recommend
that, within the resources and possibilities available in
each region, physiotherapists and hospital managers pursue
hands-on training opportunities, particularly to address the
practical skills needed for complex mobilization scenarios
involving patients with varying degrees of impairment.
GUIDELINES FOR HOSPITAL DISCHARGE
Individuals who have had a stroke often experience motor,
sensory, and/or cognitive impairments that significantly
affect their lifestyle and overall quality of life. Consequently,
it is crucial for a multidisciplinary team in the stroke unit to
provide comprehensive guidance on patient care beyond
hospital stay. It is recommended that the guidance process
for both patients and caregivers commence upon admission
and continues throughout the hospitalization period until
discharge, to avoid an overwhelming amount of information
on the day of discharge, which could be detrimental. This
process should involve a multi-disciplinary approach.
►Supplementary Figure II (►Supplementary Material I)
outlines the key areas that the physiotherapy team should
address during the guidance sessions with patients and their
family members. These points are presented in the form of a
checklist that should be completed before the patient is
discharged from the hospital. This ensures that the essential
aspects of care will be thoroughly discussed and understood
by patients and caregivers. The use of the checklist facilitates
the process of identifying individual needs and ensuring
appropriate referrals by the multidisciplinary team.
We recommend that patients and caregivers not only
receive guidelines during physiotherapy, but also actively
participate in training sessions. These sessions should in-
volve the provision of manuals or educational materials
containing information about the disease, significance of
hospitalization in a specialized stroke care unit, and guid-
ance on postdischarge care. Healthcare professionals must
explain the content of these materials and address any
questions or concerns that may arise. For patients with
limited mobility, it is particularly important to provide
practical demonstrations and training sessions on proper
positioning techniques and transfers. This hands-on ap-
proach will facilitate a better understanding and application
of the training content , increasing caregivers’confidence and
competence in performing essential tasks such as transfers
and personal care.
Caregivers play an important role in patient care after
stroke and are crucial to the successful transition from
hospital to home. Their primary responsibilities include
environmental adaptations, social support, assistance with
mobility, and activities of daily living.66 The caregiving
burden is substantial, often resulting in significant mental
health impacts.
To support this challenging role, we developed
►Supplementary Table 3 (►Supplementary Material I;(on-
line only) to provide resources designed to guide families and
caregivers, aiming to improve the quality of care after hospital
discharge. Many of these materials were prepared in plain
language to ensure accessibility across diverse social contexts.
The postdischarge manuals include guidance on maintaining
proper posture at home and preventing complications after a
stroke. Additionally, we provide a link to the website and
YouTube channel of Associação Brasil AVC, which features
videos on positioning, transfer techniques, and mobility exer-
cises for home practice. The table also includes a list of patient
associations that offer free emotional support and guidance to
patients and their families, further enhancing the support
network available postdischarge.
The transition of care from hospital to home is a complex
issue that requires further study in the Brazilian context. A
systematic review published by Cochrane in 2021 suggests
that providing information actively to patients improves
stroke knowledge and reduces anxiety.67 However, a recent
meta-analysis published in 2024 analyzed the effectiveness
of different interventions in reducing caregiver burden and
found no significant effect.68 Thus, there is still a lack of
studies proving the best intervention and its timing. For this
reason, we chose to suggest educational materials and adopt
an active approach in which the professional identifies the
patient’s and caregiver’s n eeds, provides guidance, and of fers
opportunities to clarify doubts and reinforce instructions.
It is highly recommended that rehabilitation services be
accessed promptly after hospital discharge, as there is an
optimal period for functional recovery characterized by
heightened neuroplasticity. This critical phase occurs be-
tween the acute stage and the early subacute phase of stroke
(7 days to 3 months).6Therefore, it is imperative that stroke
units collaborate with local health authorities to prioritize
posthospital discharge rehabilitation as an essential compo-
nent of stroke patient care. By ensuring effective coordina-
tion, patients will have improved access to rehabilitation
services, thereby maximizing their chances of optimal re-
covery and rehabilitation outcomes.
QUALITY INDICATORS FOR PHYSIOTHERAPY
AFTER A STROKE
Quality indicators are valuable tools in health management.
In ►Appendix 5 (►Supplementary Material I; online only),
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 15
we propose a list of indicators specifically tailored to phys-
iotherapy services.
Study Limitations
International studies show that proper care transition from
hospital to home increases the chances of functional indepen-
dence and recovery after stroke.69 However, in Brazil,there is a
need for further studies on effective models of caretransition.
Although we acknowledge the importance of this issue, the
focus of the protocol was to optimize physiotherapy inter-
ventions during the hospital phase, without discussing in
detail the transition of care to the home setting. We included
a hospital discharge checklist to guide physiotherapists in
identifying the patient’s needs and assisting with appropriate
referrals for rehabilitation after discharge. We provide links to
websites with information for families on how to care for
stroke patients at home. Additionally, we recommend that the
hospital team conducts follow-ups 3 months poststroke to
assess the number of patients who were able to continue
rehabilitation. This allows the multidisciplinary team to
develop local strategies to ensure continuity of care.
Another limitation of the current protocol is the need for
future studies to evaluate its feasibility in different regions of the
country. Given Brazil’s vast geographical extent, stroke care is
influenced by the social inequalities present in the country:
whilemoreprosperousregionscanaffordhigh-qualityresour-
ces,underservedareas facesevere limitations in access to stroke
prevention, treatment, and rehabilitation.70 Therefore, studying
the implementation of the protocol across Brazil and addressing
regional specificities is of utmost importance.
Portuguese Version of the Protocol
In ►Supplementary Material II (online only; available at
https://www.arquivosdeneuropsiquiatria.org/wp-content/
uploads/2025/02/ANP-2024.0096-Supplementary-Materi-
al-2.pdf), we present the Portuguese version of this protocol.
Acknowledgments
The authors would like to acknowledge the Brazilian
Association of Neurofunctional Physiotherapy, the Brazil-
ian Academy of Neurology, and Rede Brasil AVC for the
support and assistance throughout this project.
Authors’Contributions
IM, GJL, JMAM, CFN, LAMB, EBP, FMK, RMS, PAPJ, JAOB:
conceptualization, writing, review, editing, and validation
of the original draft. CHCM, RB: conceptualization of the
original draft and participation as reviewer. EMCR, CM,
SOM: participation as reviewers. All authors reviewed and
approved the final version of the manuscript.
Conflict of Interest
The authors have no conflict of interest to declare.
References
1Vos T, Abajobir AA, Abate KH, et al; GBD 2016 Disease and Injury
IncidenceandPrevalenceCollaborators.Global,regional,andnational
incidence, prevalence, and years lived with disability for 328 diseases
and injuries for 195 countries, 1990-2016: a systematic analysis for
the Global Burden of Disease Study 2016. Lancet 2017;390
(10100):1211–1259. Doi: 10.1016/S0140-6736(17)32154-2
2Ministério da Saúde Departamento de Informática do Sistema Único
de Saúde (DATASUS), http://www2.datasus.gov.br/DATASUS/index.
php?area=0206&id=6942&VObj=http://tabnet.datasus.gov.br/cgi/
deftohtm.exe?ibge/cnv/pop (2023, accessed 24 January 2023)
3Cieza A, Causey K, KamenovK, HansonSW, Chatterji S, Vos T. Global
estimates of the need for rehabilitation basedon the Global Burden
ofDiseasestudy 2019: a systematicanalysisfortheGlobalBurden of
Disease Study 2019. Lancet 2021;396(10267):2006–2017. Doi:
10.1016/S0140-6736(20)32340-0
4Owolabi MO, Thrift AG, Martins S, et al; Stroke Experts Collabora-
tion Group. The state of stroke services across the globe: Report of
World Stroke Organization-World Health Organization surveys. Int
J Stroke 2021;16(08):889–901. Doi: 10.1177/17474930211019568
5Martins SCO, Lavados P, Secchi TL, et al. Fighting Against Stroke in
Latin America: A Joint Effort of Medical Professional Societies and
Governments. Front Neurol 2021;12(October):743732. Doi:
10.3389/fneur.2021.743732
6Bernhardt J, Hayward KS, Kwakkel G, et al. Agreed definitions and
a shared vision for new sta ndards in stroke recovery research: The
Stroke Recovery and Rehabilitation Roundtable taskforce. Int J
Stroke 2017;12(05):444–450. Doi: 10.1177/1747493017711816
7Minelli C, Bazan R, Pedatella MTA, et al. Brazilian Academy of
Neurology pract ice guidelines for stroke rehabilitation: part I. Arq
Neuropsiquiatr 2022;80(06):634–652. Doi: 10.1590/0004-282X-
ANP-2021-0354
8Ouriques Martins SC, Sacks C, Hacke W, et al. Priorities to reduce
the burden of stroke in Latin American countries. Lancet Neurol
2019;18(07):674–683. Doi: 10.1016/S1474-4422(19)30068-7
9Rethnam V, Langhorne P, Churilov L, et al. Early mobilisation post-
stroke: a systematic review and meta-analysis of individual
participant data. Disabil Rehabil 2022;44(08):1156–1163. Doi:
10.1080/09638288.2020.1789229
10 Winstein CJ, Stein J, Arena R, et al; American Heart Association
Stroke Council, Council on Cardiovascular and Stroke Nursing,
Council on Clinical Cardiology, and Council on Quality of Care and
Outcomes Research. Guidelines for Adult Stroke Rehabilitation
and Recovery: A Guideline for Healthcare Professionals From the
American Heart Association/American Stroke Association. Stroke
2016;47(06):e98–e169. Doi: 10.1161/STR.0000000000000098
11 Teasell R, Salbach NM, Foley N, et al. Canadian Stroke Best Practi ce
Recommendations: Rehabilitation, Recovery, and Community
Participation following Stroke. Part One: Rehabilitation and Re-
covery Following Stroke; 6th Edition Update 2019 Int J Stroke
2020;15(07):763–788. Doi: 10.1177/1747493019897843
12 Stroke Foundation Clinical Guidelines for Stroke Management,
https://informme.org.au/guidelines/living-clinical-guidelines-
for-stroke-management (2023, accessed 7 November 2023)
13 Royal College of Physicians National clinical guideline for stroke,
https://www.rcplondon.ac.uk/guidelines-policy/stroke-guide-
lines-2016 (2016, accessed 7 November 2023)
14 Li J, Zhang P, Wu S, et al. Stroke-related complications in large
hemisphere infarction: incidence and influence on unfavorable
outcome. Ther Adv Neurol Disord 2019;12:1756286419873264.
Doi: 10.1177/1756286419873264
15 Phipps MS, Cronin C A. Management of acute ischemic stroke. BMJ
2020;368:l6983. Doi: 10.1136/bmj.l6983
16 Langhorne P, Ramachandra SStroke Unit Trialists’Collaboration.
Organised inpatient (stroke unit) care for stroke: network meta-
analysis. Cochrane Database Syst Rev 2020;4(04):CD000197. Doi:
10.1002/14651858.CD000197.pub4
17 Kwakkel G, Lannin NA, Borschmann K, et al. Standardized Mea-
surement of Sensorimotor Recovery in Stroke Trials: Consensus-
Based Core Recommendations from the Stroke Recovery and
Rehabilitation Roundtable. Neurorehabil Neural Repair 2017;31
(09):784–792. Doi: 10.1177/1747493017711813
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.16
18 Academy of Neurologic Physical Therapy StrokEDGE II Outcome
Measures Acute Care, https://www.neuropt.org/docs/default-
source/edge-updates-november-2021/stroke-edge-acute-care.
pdf?sfvrsn=6f2f5c43_2 (2021, accessed 22 October 2024)
19 Cincura C, Pontes-Neto OM, Neville IS, et al. Validation of the
National Institutes of Health Stroke Scale, modified Rankin Scale
and Barthel Index in Brazil: the role of cultural adaptation and
structured interviewing. Cerebrovasc Dis 2009;27(02):119–122.
Doi: 10.1159/000177918
20 Maso I, Pinto EB, Monteiro M, et al. A Simple Hospital Mobility
Scale for Acute Ischemic Stroke Patients Predicts Long-term
Functional Outcome. Neurorehabil Neural Repair 2019;33(08):
614–622. Doi: 10.1177/1545968319856894
21 Maso I, Mascarenhas L, Makhoul M, et al. Reliability and concur-
rent validity of the Hospital Mobility Scale in acute stroke
patients. J Physiother Res 2020;10(03):505–511. Doi: 10.17267/
2238-2704rpf.v10i3.3199
22 Cheng DK, Nelson M, Brooks D, Salbach NM. Validation of stroke-
specific protocols forthe 10-meter walk testand 6-minute walktest
conducted using 15-meter and 30-meter walkways. Top Stroke
Rehabil 2020;27(04):251–261. Doi: 10.1080/10749357.2019.169
1815
23 Tilson JK, Sullivan KJ, Cen S Y, et al; Locomotor Experience Applied
Post Stroke (LEAPS) Investigative Team. Meaningful gait speed
improvement during the first 60 days poststroke: minimal clini-
cally important difference. Phys Ther 2010;90(02):196–208. Doi:
10.2522/ptj.20090079
24 Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change
and responsiveness in common physical performance measures in
older adults. J Am Geriatr Soc 2006;54(05):743–749. Doi: 10.1111/
j.1532-5415.2006.00701.x
25 Borg GAV. Psychophysical bases of perceived exertion. Med Sci
Sports Exerc 1982;14(05):377–381
26 Wilson B, CockburnJ, Halligan P. Developmentof a behavioral testof
visuospatial neglect. Arch Phys Med Rehabil 1987;68(02):98–102
27 Baggio JA, Santos-Po ntelli TE, Cougo-Pinto PT, et al. Validation of a
structured interview for telephone assessment of the modified
Rankin Scale in Brazilian stroke patien ts. Cerebrovasc Dis 2014;38
(04):297–301. Doi: 10.1159/000367646
28 Lin JH, Hsu MJ, Hsu HW, Wu HC, Hsieh CL. Psychometric comparisons
of 3 functional ambulation measures for patients with stroke. Stroke
2010;41(09):2021–2025. Doi: 10.1161/STROKEAHA.110.589739
29 Sullivan JE, Crowner BE, Kluding PM, et al. Outcome measures for
individuals with stroke: process and recommendations from the
American Physical Therapy Association neurology section task force.
Phys Ther 2013;93(10):1383–1396. Doi: 10.2522/ptj.20120492
30 Ministério da Saúde - Brasil Linha de cuidado do Acidente Vascular
Cerebral (AVC) no adulto, https://linhasdecuidado.saude.gov.br/por-
tal/acidente-vascular-cerebral-(AVC)-no-adulto/ (2020, accessed 25
October 2024)
31 Duffy L, Gajree S, Langhor ne P, Stott DJ, Quinn TJ. Reliability (inter-
rater agreement) of the Barthel Index for assessment of stroke
survivors: systematic review and meta-analysis. Stroke 2013;44
(02):462–468. Doi: 10.1161/STROKEAHA.112.678615
32 Barbas CSV, Ísola AM, Farias Ade C, et al. Brazilian recommenda-
tions of mechanica l ventilation 2013. Part I. Rev Bras Ter Intensiva
2014;26(02):89–121. Doi: 10.5935/0103-507x.20140017
33 Barbas CSV, Ísola AM, Farias Ade C, et al. Brazilian recommenda-
tions of mechanical ventilation 2013. Part 2. Rev Bras Ter Inten-
siva 2014;26(03):215–239. Doi: 10.5935/0103-507X.20140034
34 Blakeman TC, Scott JB, Yoder MA , Capellari E, Strickla nd SL. AARC
Clinical Practice Guidelines: Artificial Airway Suctioning. Respir
Care 2022;67(02):258–271. Doi: 10.4187/respcare.09548
35 Fan E, Del Sorbo L, Goligher EC, et al; American Thoracic Society,
European Society of Intensive Care Medicine, and Society of
Critical Care Medicine. An Official American Thoracic Society/
European Society of Intensive Care Medicine/Society of Critical
Care Medicine Clinical Prac tice Guideline: Mechanical Ventilation
in Adult Patients with Acute Respiratory Distress Syndrome. Am J
Respir Crit Care Med 2017;195(09):1253–1263. Doi: 10.1164/
rccm.201703-0548ST
36 Keenan SP, Sinuff T, Burns KEA, et al; Canadian Critical Care
Trials Group/Canadian Critical Care Society Noninvasive Ven-
tilation Guidelines Group. Clinical practice guidelines for the
use of noninvasive positive-pressure ventilation and noninva-
sive continuous positive airway pressure in the acute care
setting. CMAJ 2011;183(03):E195–E214. Doi: 10.1503/cmaj.
100071
37 MacIntyre NR, Cook DJ, Ely EW Jr, et al; American College of Chest
Physicians American Association for Respiratory Care American
College of Critical Care Medicine. Evidence-based guidelines for
weaning and discontinuing ventilatory support: a collective task
force facilitated by the American College of Chest Physicians; the
American Associationfor Respiratory Care;and the American College
of Critical Care Medicine. Chest 2001;120(6, Suppl)375S–395S. Doi:
10.1378/chest.120.6_suppl.375s
38 Mussa CC, Gomaa D, Rowley DD, Schmidt U, Ginier E, Strickland
SL. AARC Clinical Practice Guideline: Management of Adult
Patients with Tracheostomy in the Acute Care Setting. Respir
Care 2021;66(01):156–169. Doi: 10.4187/respcare.08206
39 Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical
practice guidelines: noninvasive ventilation for acute respiratory
failure. Eur Respir J 2017;50(02):1602426. Doi: 10.1183/13993003.
02426-2016
40 Berbenetz N, Wang Y, Brown J,et al. Non-invasive positive pressure
ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary
oedema. Cochrane Database Syst Rev 2019;4(04):CD005351. Doi:
10.1002/14651858.CD005351.pub4
41 Robba C,Poole D, McNett M, et al. Mechanicalventilation in patients
with acute brain injury: recommendations of the European Society
of Intensive Care Medicine consensus. Intensive Care Med 2020;46
(12):2397–2410. Doi: 10.1007/s00134-020-06283-0
42 Young B, Moyer M, Pino W, Kung D, Zager E, Kumar MA. Safety and
Feasibility of Early Mobilization in Patients with Subarachnoid
Hemorrhage and Externa l Ventricular Drain. Neurocrit Care 2019;
31(01):88–96. Doi: 10.1007/s12028-019-00670-2
43 Kumar MA, Romero FG, Dharaneeswaran K. Early mobilization in
neurocritical care patients. Curr Opin Crit Care 2020;26(02):
147–154. Doi: 10.1097/MCC.0000000000000709
44 Langhorne P, Wu O, Rodgers H, Ashburn A, Bernhardt J. A Very
Early Rehabilitation Trial after stroke (AVERT): a Phase III, multi-
centre, randomised controlled trial. Health Technol Assess 2017;
21(54):1–120. Doi: 10.3310/hta21540
45 Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and
recommendations on safety criteria for active mobilization of
mechanically ventilated critically ill adults. Crit Care 2014;18
(06):658. Doi: 10.1186/s13054-014-0658-y
46 Conceição TMAD, Gonzáles AI, Figueiredo FCXS, Vieira DSR,
Bündchen DC. Safety criteria to start early mobilization in inten-
sive care units. Systematic review. Rev Bras Ter Intensiva 2017;29
(04):509–519. Doi: 10.5935/0103-507X.20170076
47 Sandset EC, Anderson CS, Bath PM, et al. European Stroke Organi-
sation (ESO) guidelines on blood pressure management in acute
ischaemic stroke and intracerebral haemorrhage. Eur Stroke J
2021;6(02):II. Doi: 10.1177/23969873211026998
48 Mead GE, Sposato LA, Sampaio Silva G, et al. A systematic review
and synthesis of global stroke guidelines on behalf of the World
Stroke Organization. Int J Stroke 2023;18(05):499–531. Doi:
10.1177/17474930231156753
49 Graettinger WF, Lipson JL, Cheung DG, Weber MA. Validation of
portable noninvasive blood pressure monitoring devices: com-
parisons with intra-arterial and sphygmomanometer measure-
ments. Am Heart J 19 88;116(04):1155–1160. Doi: 10.1016/0002-
8703(88)90181-0
50 SwainSM, Lata M, Kumar S, Mondal S, Behera JK, Mondal H. A Cross-
Sectional Study on the Agreement of Perfusion Indexes Measured
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al. 17
on Different Fingersby a Portable Pulse Oximeter in Healthy Adults.
Cureus 2022;14(05):e24853. Doi: 10.7759/cureus.24853
51 Louie A, Feiner JR, Bick ler PE, Rhodes L, Bernstein M, Lucero J. Four
Types of Pulse Oximeters Accurately Detect Hypoxia during Low
Perfusion and Motion. Anesthesiology 2018;128(03):520–530.
Doi: 10.1097/ALN.0000000000002002
52 Bernhardt J,L anghorneP, LindleyR I, etal; AVERT Trial Collaboration
group. Efficacy and safety of very early mobilisation within 24h of
stroke onset (AVERT): a randomised controlled trial. Lancet 2015;
386(9988):46–55. Doi: 10.1016/S0140-6736(15)60690-0
53 Langhorne P, Collier JM, Bate PJ, Thuy MN, Bernhardt J. Very early
versus delayed mobilisation after stroke. Cochrane Database Syst
Rev 2018;10(10):CD006187. Doi: 10.1002/14651858.CD006187.
pub3
54 Directorate General of Health Services - Ministry of Health and
Family Welfare. Guidelines for prevention and management of
stroke. Natl Program Prev Control Cancer, Diabetes, Cardiovasc
Dis Stroke Guidel, https://main.mohfw.gov.in/sites/default/files/
Guidelines for Prevention and Managment of Stroke.pdf (2019,
accessed 07 November 2023)
55 Bernhardt J, Churi lov L, Ellery F, et al; AVERT Collaboration Group.
Prespecified dose-response analysis for A Very Early Rehabilita-
tion Trial (AVERT). Neurology 2016;86(23):2138–2145. Doi:
10.1212/WNL.0000000000002459
56 Dutch Society for Neurology Herseninfarct en hersenbloeding,
https://richtlijnendatabase.nl/richtlijn/herseninfarct_en_hersen-
bloeding/revalidatie_na_herseninfarct_-bloeding.html#verant-
woording (2017, accessed 7 November 2023)
57 Bernhardt J, Churilov L, Dewey H, et al; AVERT DOSE Trialist
Collaboration. A phase III, multi-arm multi-stage covariate-ad-
justed response-adaptive randomized trial to determine optimal
early mobility training after stroke (AVERT DOSE). Int J Stroke
2023;18(06):745–750. Doi: 10.1177/17474930221142207
58 Jones TA. Motor compensation and its effects on neural reorgani-
zation after stroke. Nat Rev Neurosci 2017;18(05):267–280. Doi:
10.1038/nrn.2017.26
59 Cormican A, Hirani SP, McKeown E. Healthcare professionals’
perceived barriers and facilitators of implementing clinical practice
guidelines for stroke rehabilitation: A systematic review. Clin
Rehabil 2023;37(05):701–712. Doi: 10.1177/02692155221141036
60 Associação Brasil AVC. Ombro doloroso após AVC. http://abavc.org.
br/wp-content/uploads/2021/12/ABAVC-Folder-Ombro-Doloroso.
pdf, (2022, accessed 7 November 2023)
61 Anderson CS, Olavarría VV. Head Positioning in Acute Stroke:
Down but Not Out. Stroke 2019;50(01):224–228. Doi: 10.1161/
STROKEAHA.118.020087
62 Anderson CS, Arima H, Lavados P, et al; HeadPoST Investigators
and Coordinators. Cluster-Randomized, Crossover Trial of Head
Positioning in Acute Stroke. N Engl J Med 2017;376(25):2437-
–2447. Doi: 10.1056/NEJMoa1615715
63 Ministério da Saúde (Brasil) Portaria n°. 665, de 12 de abril de
2012. Dispõe sobre os critérios de habilitação dos estabelecimen-
tos hospitalares como Centro de Atendimento de Urgência aos
Pacientes com Acidente Vascular Cerebral (AVC), no âmbito do
Sistema Único de Saúde (SUS), institui o respectivo incentivo
financeiro e aprova a Linha de Cuidados em AVC.
64 Ministério da Saúde (Brasil) Portaria n° 800, de 17 de junho de
2015. Altera, acresce e revoga dispositivos da Portaria n°
665/GM/MS, de 12 de abril de 2012, que dispõe sobre os critérios
de habilitação dos esta belecimentos hospitalares como Centro de
Atendimento de Urgência aos Pacientes com Acidente Vascular
Cerebral (AVC), no âmbito do Sistema Único de Saúde (SUS),
institui o respectivo incentivo financeiro e aprova a Linha de
Cuidados em AVC.
65 Conselho Federal de Fisioterapia e Terapia Ocupacional (Brasil)
Resolução COFFITO N° 444 de 26 de abril de 2014. Altera a
Resolução COFFITO n° 387/2011, que fixa e estabelece os Parâ-
metros Assistenciais Fisioterapêuticos nas diversas modalidades
prestadas pelo fisioterapeuta.
66 Murayama LHV, Filho PTH, Winckler FC, et al. Caregiver burden,
hopelessness, and anxiety: Association between sociodemo-
graphic and clinical profiles of patients with stroke. J Stroke
Cerebrovasc Dis 2024;33(11):107905. Doi: 10.1016/j.jstrokecer-
ebrovasdis.2024.107905
67 Crocker TF, Brown L, Lam N, Wray F, Knapp P, Forster A. Information
provision for stroke survivors and their carers. Cochrane Database
Syst Rev2021;11(11):CD001919. Doi: 10.1002/14651858.CD001919.
pub4
68 Jammal M, KoltGS, Liu KPY, Guagliano JM, Dennaoui N, GeorgeES. A
systematic review and meta-analysis of randomized controlled
trials to reduce burden, stress, and strain in informal stroke care-
givers. Clin Rehabil 2024;38(11):1429–1445. Doi: 10.1177/026921
55241271047
69 Mountain A, Patrice Lindsay M, Teasell R, et al. Canadian Stroke
Best Practice Recommendations: Rehabilitation, Recovery, and
Community Participation following Stroke. Part Two: Transitions
and Community Par ticipation Following Stroke. Int J Stroke 2020;
15(07):789–806. Doi: 10.1177/1747493019897847
70 Martins SC, Pontes-Neto OM, Alves CV, et al; Brazilian Stroke
Network. Past, present, and future of stroke in middle-income
countries: the Brazilian experience. Int J Stroke 2013;8(Suppl
A100):106–111. Doi: 10.1111/ijs.12062
Arquivos de Neuro-Psiquiatria Vol. 83 No. 4/2025 © 2025. The Author(s).
An early physiotherapy protocol for stroke patients Maso et al.18
