Functional Status and Rehabilitation Barriers in Adults of Working Age After Stroke: A Cross-Sectional Study

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Methods In this cross-sectional study, 59 working-age stroke survivors were recruited from post-stroke rehabilitation clinics. Median age was 48 years (IQR 44–54), and 54% were male. Standardized assessments included the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI), Stroke Impact Scale (SIS), and Cardiac Rehabilitation Barriers Scale (CRBS). Results Participants demonstrated mild to moderate neurological impairment and moderate functional limitations, particularly in motor domains, with reduced independence in daily activities. Functional independence (mBI) was moderately to strongly correlated with SIS mobility (ρ = 0.57; 95% CI 0.36–0.72) and ADL/IADL domains (ρ = 0.48; 95% CI 0.25–0.65). Perceived rehabilitation barriers were most prominent in domains related to perceived needs and access, with strong interrelationships among contextual and personal barrier domains. Direct associations between barrier scores and functional measures were limited. Conclusions Adults of working age recovering from stroke experience substantial functional challenges. Perceived rehabilitation barriers cluster mainly around contextual and personal factors rather than directly reflecting functional severity. Integrated, person-centered rehabilitation models are required to address both clinical recovery and broader socioeconomic determinants to optimize reintegration and participation. Stroke Post-stroke rehabilitation Treatment adherence Socioeconomic barriers Functionality Figures Figure 1 INTRODUCTION Stroke is a leading cause of long-term disability worldwide and is characterized by the sudden onset of neurological deficits resulting from ischemic or hemorrhagic events affecting cerebral vessels [ 1 ]. Although stroke is frequently associated with older populations, approximately 75% of cases occur in individuals under 65 years of age, thereby significantly impacting adults of working age [ 2 ]. In Brazil, stroke remains one of the primary causes of death and disability [ 3 ], accounting for approximately 2% of the national healthcare budget in 2016 [ 4 – 7 ]. Pronounced regional disparities persist, with higher mortality rates observed in the North and Northeast regions, often associated with socioeconomic inequalities and limited access to healthcare resources [ 8 ]. Among adults of working age, stroke frequently leads to persistent impairments in motor, cognitive, and communication functions, which compromise functional independence, social participation, and the ability to return to work [ 9 , 10 ]. As part of the cardiovascular disease (CVD) spectrum, stroke shares common risk factors and pathophysiological mechanisms with other CVDs, underscoring the relevance of integrated and comprehensive rehabilitation approaches [ 11 ]. Evidence derived from cardiac rehabilitation (CR) programs has contributed to best practices in post-stroke rehabilitation, particularly regarding strategies aimed at improving functional capacity, social participation, and return to productive activities [ 12 ]. However, both stroke and CR services are affected by similar systemic and structural barriers, including limited access to services, transportation difficulties, socioeconomic constraints, and insufficient awareness of rehabilitation benefits [ 13 , 14 ]. Addressing barriers for CR programs addresses barrier domains is thus highly relevant to stroke survivors, particularly those of working age who must balance health demands with occupational and family responsibilities. Qualitative research has highlighted systemic barriers affecting stroke recovery, including limited collaboration with health teams and inadequate community support [ 15 ]. A recent systematic review identified intrapersonal factors as the most frequent determinants of adherence, highlighting the multidimensional nature of rehabilitation engagement [ 16 ]. However, similar comprehensive syntheses are lacking in stroke populations, particularly among working-age adults. Despite growing recognition of the multidimensional consequences of stroke, few studies in Brazil have examined the combined relationships between functional status and perceived rehabilitation barriers among adults of working age after stroke. Brazilian epidemiological studies in young adults have primarily focused on risk factor profiles and stroke subtype distribution [ 17 ]. However, functional outcomes and perceived barriers to rehabilitation were not addressed. Moreover, evidence remains limited regarding how barriers identified through instruments such as the CRBS relate to functional outcomes in this population. The primary aims of this study were: (1) to describe functional status in adults of working age after stroke; and (2) to examine the associations between functional status and perceived barriers to rehabilitation participation. We hypothesized that adults of working age after stroke would present relevant limitations in functional status. Additionally, we hypothesized that higher perceived socioeconomic and structural barriers, as assessed by the CRBS, were expected to be associated with poorer functional status. METHODS Ethical Considerations This study adhered to ethical standards outlined in the Declaration of Helsinki. The study protocol was approved by the Research Ethics Committee before execution following national regulations (approval number: CAAE: 76491623.0.0000.5235). Written informed consent was obtained from all participants before their inclusion in the study. Study Design and Setting This was a cross-sectional observational study reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines [ 18 ]. The study was carried out in rehabilitation clinics located in Juazeiro do Norte, Ceará, Brazil. Data collection occurred during the months of July 2024 to November 2024. Sample Size The sample size was estimated based on the primary objective of assessing correlations between functional status and rehabilitation barriers. Using G*Power 3.1.9.7 [ 19 ], a priori analysis was conducted for a correlation analysis. Assuming a moderate effect size (0.40), α = 0.05 (two-tailed), and power (1–β) = 0.80, the required sample size was 46 participants. Participants Participants were consecutively recruited from clinical records of selected rehabilitation clinics, aiming to represent adults receiving post-stroke rehabilitation in the region. Eligible participants were adults of working age (18–65 years) of both sexes who had experienced a stroke. Individuals were required to have sufficient motor, cognitive, and communicative capacity to complete the study assessments. Exclusion criteria included the presence of neurodegenerative or musculoskeletal conditions that prevented test completion, as well as inability to communicate orally or to read and write. Data Collection and Outcomes Data collection was conducted in person by trained professionals using standardized protocols to ensure consistency across assessments. Assessments were performed in clinical or home settings according to participant availability. All instruments were administered at study entry, defined as the period following hospital discharge and at the initiation of outpatient rehabilitation. Data were recorded in electronic spreadsheets to ensure data integrity and facilitate statistical analysis. All outcome measures were administered in a structured interview format to enhance comprehension and ensure accurate responses. Sociodemographic and Clinical Data Sociodemographic and clinical information – including age, sex, marital status, body mass index (BMI), type and location of neurological lesion, comorbidities, medication use, and lifestyle factors – was collected through structured interviews and review of medical records. Cognitive status was assessed using the Mini-Mental State Examination (MMSE) [ 20 ], validated for the Brazilian population, with established cut-off values for the Brazilian population [ 21 ]. Functional Assessments Neurological impairment severity was assessed using the Portuguese-Brazil version [ 22 ] of the NIHSS [ 23 ], which quantifies deficits across domains such as level of consciousness, motor function, language, and sensory function. Higher scores indicate greater neurological impairment. Global disability and dependence in daily activities were evaluated using the Portuguese-Brazil version [ 22 ] of the Modified Rankin Scale (mRS) [ 24 ]. The mRS ranges from 0 (no symptoms) to 6 (death), with higher scores reflecting greater disability. Independence in basic activities of daily living was assessed using the Portuguese-Brazil version [ 22 ] of the modified Barthel Index (mBI) [ 25 ], which evaluates functions such as feeding, bathing, and mobility. Total scores range from 0 to 100, with higher scores indicating greater functional independence. The subjective impact of stroke was assessed using the Portuguese-Brazil version [ 26 , 27 ] of the Stroke Impact Scale (SIS). The SIS evaluates multiple domains, including physical function, memory, emotion, communication, and social participation, with higher scores indicating better perceived functional status and quality of life. Barriers to Cardiac Rehabilitation Perceived barriers to cardiac rehabilitation were assessed using the Portuguese-Brazil version [ 28 ] of the CRBS [ 29 ]. The CRBS identifies obstacles across domains such as logistical challenges (e.g., transportation, distance), socioeconomic factors, lack of information, and personal attitudes. Each item is rated on a Likert scale, with higher scores indicating greater perceived barriers. Bias Control Selection bias was minimized through the consecutive recruitment of eligible participants from multiple rehabilitation clinics. Information bias was reduced by the use of validated and standardized assessment instruments. All assessments were conducted by trained personnel following standardized protocols, who were blinded to the specific study hypotheses. No missing data were observed for the study variables; therefore, all analyses were conducted using complete-case data. Statistical Analysis All statistical analyses were conducted using R software version 4.5.2 (R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were assessed for distributional characteristics and, given the non-normal distribution of most outcomes, were summarized using medians and 25th–75th percentiles (P25–P75). Categorical variables were summarized as absolute and relative frequencies (n, %). Correlations between functional status measures (NIHSS, mRS, mBI, and SIS domains) and perceived rehabilitation barriers (CRBS domains and total score) were examined using Spearman rank correlation coefficients, due to the ordinal nature of several scales and the non-normal distribution of the data. Correlations were computed using pairwise complete observations. For each correlation, 95% confidence intervals and corresponding P-values were estimated. To account for multiple comparisons, p-values were adjusted using the false discovery rate (FDR) method according to Benjamini and Hochberg. Both unadjusted and FDR-adjusted p-values are reported. Correlation matrices were visualized graphically using correlation plots, in which the magnitude and direction of associations were represented by proportional symbols. Statistical significance was assessed at a two-sided alpha level of 0.05. RESULTS Sample characteristics A total of 59 working-age stroke survivors participated in the study (Table 1 ). The sample comprised 54% men and 46% women, with a median age of 48 years (P25–P75: 44–54). Regarding ethnicity, 41% of participants self-identified as White, 27% as Black, 29% as mixed, and 3% as Asian. Most participants were married (64%), followed by single (19%), separated (12%), and widowed (5%). The median body mass index (BMI) was 26 kg/m² (P25–P75: 24–27). Median cognitive performance, assessed by the Mini-Mental State Examination (MMSE), was 24 points (P25–P75: 22–26). Approximately 27% of participants reported a history of previous stroke. The median length of hospital stay was 8 days (P25–P75: 6–11), and the median time from hospital discharge to study entry assessment was 145 days (P25–P75: 8–366). Hypertension (58%), diabetes mellitus (41%), and primary cardiovascular disease (66%) were the most prevalent comorbidities. Additionally, 21% reported other comorbid conditions. Table 1 Demographic characteristics of the study sample. Variables Total (N = 59) Sex (n) Female 27 (46%) Male 32 (54%) Ethnicity (n) Asian 2 (3%) Black 16 (27%) Mixed 17 (29%) White 24 (41%) Age (years) 48 (44–54) Body mass (kg) 72 (63–78) Height (cm) 166 (160–172) Body mass index (kg/m²) 26 (24–27) Marital status (n) Married 38 (64%) Separated 7 (12%) Single 11 (19%) Widowed 3 (5%) Mini Mental State Examination (points) 24 (22–26) Previous stroke (n) No 43 (73%) Yes 16 (27%) Length of stay (days) 8 (6–11) Length from hospital discharge to study entry assessment (days) 145 (8–366) Primary CVD (n) No 20 (34%) Yes 39 (66%) Hypertension (n) No 25 (42%) Yes 34 (58%) Diabetes (n) No 35 (59%) Yes 24 (41%) Other comorbidities (n) No 38 (64%) Yes 21 (36%) Values are presented as median (interquartile range) or n (%). Abbreviations: MEEM, Mini Mental State Examination; CVD, cardiovascular disease. PLEASE INSERT Table 1 HERE Functional characteristics Table 2 summarizes the functional characteristics of the study sample. The median NIHSS score was 4 (P25–P75: 2–8). Functional independence, assessed using the mBI, showed a median score of 48 (P25–P75: 30–54), while the mRS demonstrated a median score of 2 (P25–P75: 1–3). Although the median mRS indicated mild disability, the median Barthel score suggests residual limitations in basic activities, reinforcing the multidimensional nature of post-stroke functional impairment. Table 2 Functional characteristics of the study sample. Variables Summary (N = 59) NIHSS (points) 4 (2–8) mRS (points) 2 (1–3) mBI (points) 48 (30–54) SIS (Strength) (points) 25 (0–50) SIS (Hand function) (points) 25 (0–62) SIS (Mobility) (points) 55 (30–82) SIS (ADL/IADL) (points) 50 (23–76) SIS (Memory) (points) 88 (62–98) SIS (Communication) (points) 93 (75–98) SIS (Emotion) (points) 44 (25–50) SIS (Participation) (points) 50 (33–75) Values are presented as median (interquartile range) or n (%). Abbreviations: NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; mBI, modified Barthel Index; SIS, Stroke Impact Scale. SIS domain scores varied across functional domains. Median scores were 25 (P25–P75: 0–50) for SIS-Strength, 25 (P25–P75: 0–62) for SIS-Hand Function, and 55 (P25–P75: 30–82) for SIS-Mobility. The median SIS-ADL/IADL score was 50 (P25–P75: 23–76), and SIS-Participation was 50 (P25–P75: 33–75), indicating moderate limitations in daily activities and social participation. SIS-Communication (93, P25–P75: 75–98) and SIS-Memory (88, P25–P75: 62–98) scores were relatively preserved, whereas SIS-Emotion showed greater variability (44, P25–P75: 25–50). PLEASE INSERT Table 2 HERE Perceived barriers Perceived barriers to CR demonstrated a heterogeneous profile across domains (Table 3 ). The median CRBS sum score was 11 (P25–P75: 8–15), indicating a moderate overall burden of perceived barriers. Among subdomains, perceived needs showed a median score of 3 (P25–P75: 0–5), and access-related barriers had a median of 2 (P25–P75: 0–5), suggesting that informational gaps and structural limitations were relatively prominent in this cohort. In contrast, personal/family problems and travel/work conflicts presented low median scores of 0 (P25–P75: 0–1), indicating that these barriers were less frequently endorsed. The comorbidities/functional status domain showed a median score of 5 (P25–P75: 0–5), reflecting variability in how participants perceived health-related constraints affecting rehabilitation participation. Table 3 Rehabilitation barriers of the study sample. Variables Summary (N = 59) CRBS (Comorbidities/Functional status) (points) 5 (0–5) CRBS (Perceived needs) (points) 3 (0–5) CRBS (Personal/Family problems) (points) 0 (0–1) CRBS (Travel/Work conflicts) (points) 0 (0–1) CRBS (Access) (points) 2 (0–5) CRBS sumscore (points) 11 (8–15) Values are presented as median (interquartile range) or n (%). Abbreviations: CRBS, Cardiac Rehabilitation Barriers Scale. PLEASE INSERT Table 3 HERE Correlation analysis Correlation analysis revealed significant associations between functional status and perceived barriers to rehabilitation participation (Fig. 1 ; Supplementary File 1). After FDR adjustment, Spearman correlation coefficients showed that the mBI was strongly and positively correlated with SIS mobility (ρ = 0.57, 95% CI [0.36, 0.72], p < 0.001) and SIS ADL/IADL (ρ = 0.48, 95% CI [0.25, 0.65], p < 0.001), indicating that higher levels of functional independence were associated with better mobility and performance of daily activities. In addition, SIS hand function and SIS mobility demonstrated a strong positive association (ρ = 0.67, 95% CI [0.49, 0.79], p < 0.001), reflecting substantial overlap between upper-limb function and mobility-related domains. PLEASE INSERT FIGURE 1 HERE Regarding perceived rehabilitation barriers, FDR adjustment showed significant positive associations were observed between the CRBS domains of perceived needs and personal/family problems (ρ = 0.37, 95% CI [0.12, 0.57], p = 0.025). In addition, the CRBS total score showed strong correlations with its subdomains, particularly perceived needs (ρ = 0.64, 95% CI [0.45, 0.77], p < 0.001) and personal/family problems (ρ = 0.39, 95% CI [0.14, 0.58], p = 0.017), reflecting internal coherence among barrier domains. DISCUSSION This study aimed to assess functional status among adults of working age after stroke and to explore their correlations with perceived barriers to CR participation. Our findings indicate that participants presented with mild to moderate disability and reduced independence in daily activities. Perceived rehabilitation barriers were prominent, especially in domains related to perceived needs and access, and showed strong interrelationships among contextual and personal factors. Although direct correlations between rehabilitation barriers and functional or work outcomes were limited, the clustering of socioeconomic and structural barriers highlights the complexity of challenges faced by working-age stroke survivors. Together, these findings suggest the importance of rehabilitation models that integrate clinical recovery with strategies addressing contextual and social determinants, which may be particularly relevant for supporting return to productive life after stroke. The findings of this study are consistent with prior literature indicating that stroke among adults of working age is frequently associated with persistent limitations across physical, cognitive, and occupational domains. Even relatively mild strokes can be accompanied by substantial psychological and functional sequelae, particularly when reintegration into work and social life is delayed [ 9 , 10 ]. These findings are in line with those reported by Santos et al., who emphasize the importance of multidimensional assessments for capturing the complex effects of stroke on daily functioning and participation [ 30 ]. In addition, the prominence of structural and socioeconomic barriers identified through the CRBS is consistent with evidence describing transportation difficulties, limited awareness, and systemic constraints as major challenges to rehabilitation access in cardiovascular disease contexts, including stroke [ 12 , 14 ]. The predominance of intrapersonal and contextual barriers observed in our cohort aligns with findings from other rehabilitation populations, as adherence to exercise-based rehabilitation in musculoskeletal conditions is largely influenced by intrapersonal determinants such as self-efficacy and perceived benefits, as well as environmental constraints [ 16 ]. Similar contextual challenges have been described from the perspective of family caregivers of stroke survivors [ 15 ], including lack of collaboration with the health care team, insufficient discharge coordination, and limited community support were perceived as major barriers to sustaining post-stroke care. This issue is particularly relevant in Brazil, where regional disparities in healthcare access persist [ 8 ], potentially placing working-age stroke survivors at increased risk of delayed or fragmented rehabilitation. Collectively, these findings reinforce the importance of rehabilitation models that extend beyond clinical interventions to address contextual and social determinants of recovery, including flexible service delivery and integration with primary care to improve reach among underserved populations. The interrelationships between functional status, emotional well-being, and perceived rehabilitation barriers emerged as relevant aspects of this study. Lower scores in the SIS emotion domain suggest that psychological challenges (e.g., emotional distress, frustration, and reduced self-efficacy) may coexist with functional limitations among adults of working age after stroke. This observation is consistent with prior literature highlighting the psychological burden experienced by stroke survivors during the recovery process [ 10 ], and suggests the need for care models that extend beyond physical rehabilitation alone. The correlations observed between CRBS subdomains – particularly perceived needs and personal or family-related problems – indicate clustering of logistical, social, and contextual challenges. These overlapping barriers may be associated with increased emotional strain and reduced perceived capacity to engage in rehabilitation activities. Taken together, these findings highlight the potential value of personalized rehabilitation strategies that incorporate psychological support, family education, and social assistance. Public rehabilitation initiatives may benefit from integrating mental health resources, family-centered approaches, and community-based support networks to promote continuity of care and address the broader determinants of recovery. This study has several limitations that should be acknowledged. First, the cross-sectional design precludes causal inference regarding the observed associations and limits the ability to examine temporal changes in functional status and perceived rehabilitation barriers. Second, the regional scope of the sample may limit the generalizability of the findings to other populations of adults of working age after stroke in Brazil or in different healthcare contexts. Despite these limitations, the study also presents important strengths. To our knowledge, it is among the first studies in Brazil to examine, within a single analytical framework, the relationships between functional status and perceived rehabilitation barriers among adults of working age after stroke, using a multidimensional approach and validated assessment instruments. Future studies employing longitudinal designs are warranted to better characterize changes over time and to clarify the directionality of these relationships. CONCLUSIONS Adults of working age recovering from stroke experience substantial challenges related to functional limitations. This study demonstrates that perceived rehabilitation barriers – particularly those related to access, perceived needs, and personal or family circumstances – were prominent and showed substantial interrelationships. Integrated and person-centered rehabilitation approaches that extend beyond physical recovery are required to address emotional well-being and broader socioeconomic conditions. Declarations Funding This study was supported by the Fundacao Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro [FAPERJ, No. E-26/211.104/2021]; Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, Finance Code 001) [No. 88881.708719/2022-01], [No. 88887.708718/2022- 00]. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Data collection was performed by Paulo Cesar de Lima Andrelino. Data analysis was performed by Arthur de Sá Ferreira. The first draft of the manuscript was written by Paulo Cesar de Lima Andrelino and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data Availability Due to ethical restrictions, the datasets generated during and analysed during the current study are available from the corresponding author on request. Ethics approval This study adhered to ethical standards outlined in the Declaration of Helsinki. The study protocol was approved by the Research Ethics Committee before execution following national regulations (approval number: CAAE: 76491623.0.0000.5235). Consent to participate Written informed consent was obtained from all participants before their inclusion in the study. References Coupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of stroke. J R Soc Med. 2017;110:9–12. https://doi.org/10.1177/0141076816680121 . Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, et al. Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association. Circulation. 2023;147. https://doi.org/10.1161/CIR.0000000000001123 . de Oliveira GMM, Brant LCC, Polanczyk CA, Malta DC, Biolo A, Nascimento BR, et al. Cardiovascular Statistics - Brazil 2021. Arq Bras Cardiol. 2022;118:115. https://doi.org/10.36660/ABC.20211012 . Lotufo PA. 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Arq Bras Cardiol [Internet]. 2012;98:344–52. https://doi.org/10.1590/S0066-782X2012005000025 . Shanmugasegaram S, Gagliese L, Oh P, Stewart DE, Brister SJ, Chan V, et al. Psychometric validation of the Cardiac Rehabilitation Barriers Scale. Clin Rehabil [Internet]. 2012;26:152–64. https://doi.org/10.1177/0269215511410579 . Santos ME dos, Fernandes D, de Silva S, de Matiello MP, de Braga F, Cervantes PG, INSTRUMENTOS UTILIZADOS NA AVALIAÇÃO DA CAPACIDADE FUNCIONAL, FRAGILIDADE E SARCOPENIA EM IDOSOS. ER, : REVISÃO INTEGRATIVA. Cogitare Enfermagem. 2023;28. https://doi.org/10.1590/ce.v28i0.89719 Additional Declarations No competing interests reported. Supplementary Files TableS1.docx Supplementary Information Table S1. Correlation matrix between functional status and rehabilitation barriers. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8920372","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594542250,"identity":"17c90eae-fe34-403e-9d35-db4ee8657f2d","order_by":0,"name":"Paulo Cesar Lima Andrelino","email":"","orcid":"","institution":"University Center Augusto Motta","correspondingAuthor":false,"prefix":"","firstName":"Paulo","middleName":"Cesar Lima","lastName":"Andrelino","suffix":""},{"id":594542253,"identity":"e71c93a7-4fb1-4183-93ff-68ab6f65d9f7","order_by":1,"name":"Erika Rodrigues","email":"","orcid":"","institution":"D’Or Institute for Research and Education","correspondingAuthor":false,"prefix":"","firstName":"Erika","middleName":"","lastName":"Rodrigues","suffix":""},{"id":594542254,"identity":"91318470-54c5-4f7d-9ae8-f6d9e5447346","order_by":2,"name":"Laura Alice Santos Oliveira","email":"","orcid":"","institution":"University Center Augusto Motta","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"Alice Santos","lastName":"Oliveira","suffix":""},{"id":594542255,"identity":"2e42eef2-72f6-4240-a751-c023e05e2392","order_by":3,"name":"Arthur Sá Ferreira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYHACNiBmZuCHcCQQ4gY4dTBDtEg2kKzF4AC6BC4t/LPPH3vMu8dazvj84WPSvDss7A2On05g+FGxjcFcGsMUiEPOJbMb8zxLNza7kZYmzXtGInHDmdwNjD1nbjNY9iVgt+YMM5s0z4HDidtu8JhJ87ZJJBgcyN3AzNh2m8HgDHYd8lAt9Zv7z4C12Bucf4tfiwFUS4IBQw5YC+OGGwRsMTzDbCY550C64YwbacmWc9skEmfeeLvhINAvPJY92LXInWF8JvHmgLU8f//hgzfettXZ853P3fjgR8VtOXMe7FqwgwNATJKGUTAKRsEoGAWoAABMq1kp65IMFgAAAABJRU5ErkJggg==","orcid":"","institution":"University Center Augusto Motta","correspondingAuthor":true,"prefix":"","firstName":"Arthur","middleName":"Sá","lastName":"Ferreira","suffix":""}],"badges":[],"createdAt":"2026-02-19 19:23:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8920372/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8920372/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103216387,"identity":"352f0f24-da3c-42ce-8e70-acdba83c80d9","added_by":"auto","created_at":"2026-02-23 09:33:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":198809,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation matrix of functional status (National Institutes of Health Stroke Scale, NIHSS; Modified Rankin Scale, mRS; modified Barthel Index, mBI; and Stroke Impact Scale subdomains, SIS) and cardiac rehabilitation barriers (Cardiac Rehabilitation Barriers Scale and its subdomains, CRBS). Significant correlations (p \u0026lt; 0.05) are highlighted, while insignificant ones are left blank\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8920372/v1/0881faa8f465becf121d0d0e.png"},{"id":103509436,"identity":"4054254e-093a-4570-bdbb-8642f4f56d68","added_by":"auto","created_at":"2026-02-26 13:58:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1294009,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8920372/v1/e8337a57-ca7c-4c15-86d2-6b07c28588dc.pdf"},{"id":103505613,"identity":"452699e7-da6b-4b50-ad04-a20b97c4ac4b","added_by":"auto","created_at":"2026-02-26 13:32:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33465,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable S1\u003c/strong\u003e. Correlation matrix between functional status and rehabilitation barriers.\u003c/p\u003e","description":"","filename":"TableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8920372/v1/3ea9aebd1ae1c91991dc9151.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFunctional Status and Rehabilitation Barriers in Adults of Working Age After Stroke: A Cross-Sectional Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eStroke is a leading cause of long-term disability worldwide and is characterized by the sudden onset of neurological deficits resulting from ischemic or hemorrhagic events affecting cerebral vessels [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although stroke is frequently associated with older populations, approximately 75% of cases occur in individuals under 65 years of age, thereby significantly impacting adults of working age [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Brazil, stroke remains one of the primary causes of death and disability [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], accounting for approximately 2% of the national healthcare budget in 2016 [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Pronounced regional disparities persist, with higher mortality rates observed in the North and Northeast regions, often associated with socioeconomic inequalities and limited access to healthcare resources [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Among adults of working age, stroke frequently leads to persistent impairments in motor, cognitive, and communication functions, which compromise functional independence, social participation, and the ability to return to work [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs part of the cardiovascular disease (CVD) spectrum, stroke shares common risk factors and pathophysiological mechanisms with other CVDs, underscoring the relevance of integrated and comprehensive rehabilitation approaches [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Evidence derived from cardiac rehabilitation (CR) programs has contributed to best practices in post-stroke rehabilitation, particularly regarding strategies aimed at improving functional capacity, social participation, and return to productive activities [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, both stroke and CR services are affected by similar systemic and structural barriers, including limited access to services, transportation difficulties, socioeconomic constraints, and insufficient awareness of rehabilitation benefits [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Addressing barriers for CR programs addresses barrier domains is thus highly relevant to stroke survivors, particularly those of working age who must balance health demands with occupational and family responsibilities. Qualitative research has highlighted systemic barriers affecting stroke recovery, including limited collaboration with health teams and inadequate community support [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A recent systematic review identified intrapersonal factors as the most frequent determinants of adherence, highlighting the multidimensional nature of rehabilitation engagement [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, similar comprehensive syntheses are lacking in stroke populations, particularly among working-age adults.\u003c/p\u003e \u003cp\u003eDespite growing recognition of the multidimensional consequences of stroke, few studies in Brazil have examined the combined relationships between functional status and perceived rehabilitation barriers among adults of working age after stroke. Brazilian epidemiological studies in young adults have primarily focused on risk factor profiles and stroke subtype distribution [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, functional outcomes and perceived barriers to rehabilitation were not addressed. Moreover, evidence remains limited regarding how barriers identified through instruments such as the CRBS relate to functional outcomes in this population.\u003c/p\u003e \u003cp\u003eThe primary aims of this study were: (1) to describe functional status in adults of working age after stroke; and (2) to examine the associations between functional status and perceived barriers to rehabilitation participation. We hypothesized that adults of working age after stroke would present relevant limitations in functional status. Additionally, we hypothesized that higher perceived socioeconomic and structural barriers, as assessed by the CRBS, were expected to be associated with poorer functional status.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eThis study adhered to ethical standards outlined in the Declaration of Helsinki. The study protocol was approved by the Research Ethics Committee before execution following national regulations (approval number: CAAE: 76491623.0.0000.5235). Written informed consent was obtained from all participants before their inclusion in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design and Setting\u003c/h3\u003e\n\u003cp\u003eThis was a cross-sectional observational study reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The study was carried out in rehabilitation clinics located in Juazeiro do Norte, Cear\u0026aacute;, Brazil. Data collection occurred during the months of July 2024 to November 2024.\u003c/p\u003e\n\u003ch3\u003eSample Size\u003c/h3\u003e\n\u003cp\u003eThe sample size was estimated based on the primary objective of assessing correlations between functional status and rehabilitation barriers. Using G*Power 3.1.9.7 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], a priori analysis was conducted for a correlation analysis. Assuming a moderate effect size (0.40), α\u0026thinsp;=\u0026thinsp;0.05 (two-tailed), and power (1\u0026ndash;β)\u0026thinsp;=\u0026thinsp;0.80, the required sample size was 46 participants.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eParticipants were consecutively recruited from clinical records of selected rehabilitation clinics, aiming to represent adults receiving post-stroke rehabilitation in the region. Eligible participants were adults of working age (18\u0026ndash;65 years) of both sexes who had experienced a stroke. Individuals were required to have sufficient motor, cognitive, and communicative capacity to complete the study assessments. Exclusion criteria included the presence of neurodegenerative or musculoskeletal conditions that prevented test completion, as well as inability to communicate orally or to read and write.\u003c/p\u003e\n\u003ch3\u003eData Collection and Outcomes\u003c/h3\u003e\n\u003cp\u003eData collection was conducted in person by trained professionals using standardized protocols to ensure consistency across assessments. Assessments were performed in clinical or home settings according to participant availability. All instruments were administered at study entry, defined as the period following hospital discharge and at the initiation of outpatient rehabilitation. Data were recorded in electronic spreadsheets to ensure data integrity and facilitate statistical analysis. All outcome measures were administered in a structured interview format to enhance comprehension and ensure accurate responses.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and Clinical Data\u003c/h2\u003e \u003cp\u003eSociodemographic and clinical information \u0026ndash; including age, sex, marital status, body mass index (BMI), type and location of neurological lesion, comorbidities, medication use, and lifestyle factors \u0026ndash; was collected through structured interviews and review of medical records. Cognitive status was assessed using the Mini-Mental State Examination (MMSE) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], validated for the Brazilian population, with established cut-off values for the Brazilian population [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFunctional Assessments\u003c/h3\u003e\n\u003cp\u003eNeurological impairment severity was assessed using the Portuguese-Brazil version [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] of the NIHSS [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which quantifies deficits across domains such as level of consciousness, motor function, language, and sensory function. Higher scores indicate greater neurological impairment.\u003c/p\u003e \u003cp\u003eGlobal disability and dependence in daily activities were evaluated using the Portuguese-Brazil version [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] of the Modified Rankin Scale (mRS) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The mRS ranges from 0 (no symptoms) to 6 (death), with higher scores reflecting greater disability.\u003c/p\u003e \u003cp\u003eIndependence in basic activities of daily living was assessed using the Portuguese-Brazil version [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] of the modified Barthel Index (mBI) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], which evaluates functions such as feeding, bathing, and mobility. Total scores range from 0 to 100, with higher scores indicating greater functional independence.\u003c/p\u003e \u003cp\u003eThe subjective impact of stroke was assessed using the Portuguese-Brazil version [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] of the Stroke Impact Scale (SIS). The SIS evaluates multiple domains, including physical function, memory, emotion, communication, and social participation, with higher scores indicating better perceived functional status and quality of life.\u003c/p\u003e\n\u003ch3\u003eBarriers to Cardiac Rehabilitation\u003c/h3\u003e\n\u003cp\u003ePerceived barriers to cardiac rehabilitation were assessed using the Portuguese-Brazil version [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] of the CRBS [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The CRBS identifies obstacles across domains such as logistical challenges (e.g., transportation, distance), socioeconomic factors, lack of information, and personal attitudes. Each item is rated on a Likert scale, with higher scores indicating greater perceived barriers.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBias Control\u003c/h2\u003e \u003cp\u003eSelection bias was minimized through the consecutive recruitment of eligible participants from multiple rehabilitation clinics. Information bias was reduced by the use of validated and standardized assessment instruments. All assessments were conducted by trained personnel following standardized protocols, who were blinded to the specific study hypotheses. No missing data were observed for the study variables; therefore, all analyses were conducted using complete-case data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using R software version 4.5.2 (R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were assessed for distributional characteristics and, given the non-normal distribution of most outcomes, were summarized using medians and 25th\u0026ndash;75th percentiles (P25\u0026ndash;P75). Categorical variables were summarized as absolute and relative frequencies (n, %).\u003c/p\u003e \u003cp\u003eCorrelations between functional status measures (NIHSS, mRS, mBI, and SIS domains) and perceived rehabilitation barriers (CRBS domains and total score) were examined using Spearman rank correlation coefficients, due to the ordinal nature of several scales and the non-normal distribution of the data. Correlations were computed using pairwise complete observations. For each correlation, 95% confidence intervals and corresponding P-values were estimated. To account for multiple comparisons, p-values were adjusted using the false discovery rate (FDR) method according to Benjamini and Hochberg. Both unadjusted and FDR-adjusted p-values are reported.\u003c/p\u003e \u003cp\u003eCorrelation matrices were visualized graphically using correlation plots, in which the magnitude and direction of associations were represented by proportional symbols. Statistical significance was assessed at a two-sided alpha level of 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSample characteristics\u003c/h2\u003e \u003cp\u003eA total of 59 working-age stroke survivors participated in the study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The sample comprised 54% men and 46% women, with a median age of 48 years (P25\u0026ndash;P75: 44\u0026ndash;54). Regarding ethnicity, 41% of participants self-identified as White, 27% as Black, 29% as mixed, and 3% as Asian. Most participants were married (64%), followed by single (19%), separated (12%), and widowed (5%). The median body mass index (BMI) was 26 kg/m\u0026sup2; (P25\u0026ndash;P75: 24\u0026ndash;27). Median cognitive performance, assessed by the Mini-Mental State Examination (MMSE), was 24 points (P25\u0026ndash;P75: 22\u0026ndash;26). Approximately 27% of participants reported a history of previous stroke. The median length of hospital stay was 8 days (P25\u0026ndash;P75: 6\u0026ndash;11), and the median time from hospital discharge to study entry assessment was 145 days (P25\u0026ndash;P75: 8\u0026ndash;366). Hypertension (58%), diabetes mellitus (41%), and primary cardiovascular disease (66%) were the most prevalent comorbidities. Additionally, 21% reported other comorbid conditions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the study sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (44\u0026ndash;54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (63\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e166 (160\u0026ndash;172)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (24\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMini Mental State Examination (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (22\u0026ndash;26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious stroke (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (73%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6\u0026ndash;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength from hospital discharge to study entry assessment (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (8\u0026ndash;366)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary CVD (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHypertension (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (58%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (59%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther comorbidities (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eValues are presented as median (interquartile range) or n (%). Abbreviations: MEEM, Mini Mental State Examination; CVD, cardiovascular disease.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e HERE\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFunctional characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the functional characteristics of the study sample. The median NIHSS score was 4 (P25\u0026ndash;P75: 2\u0026ndash;8). Functional independence, assessed using the mBI, showed a median score of 48 (P25\u0026ndash;P75: 30\u0026ndash;54), while the mRS demonstrated a median score of 2 (P25\u0026ndash;P75: 1\u0026ndash;3). Although the median mRS indicated mild disability, the median Barthel score suggests residual limitations in basic activities, reinforcing the multidimensional nature of post-stroke functional impairment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFunctional characteristics of the study sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSummary\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIHSS (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emRS (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emBI (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (30\u0026ndash;54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Strength) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (0\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Hand function) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (0\u0026ndash;62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Mobility) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (30\u0026ndash;82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (ADL/IADL) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (23\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Memory) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (62\u0026ndash;98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Communication) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (75\u0026ndash;98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Emotion) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (25\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIS (Participation) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (33\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eValues are presented as median (interquartile range) or n (%). Abbreviations: NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; mBI, modified Barthel Index; SIS, Stroke Impact Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSIS domain scores varied across functional domains. Median scores were 25 (P25\u0026ndash;P75: 0\u0026ndash;50) for SIS-Strength, 25 (P25\u0026ndash;P75: 0\u0026ndash;62) for SIS-Hand Function, and 55 (P25\u0026ndash;P75: 30\u0026ndash;82) for SIS-Mobility. The median SIS-ADL/IADL score was 50 (P25\u0026ndash;P75: 23\u0026ndash;76), and SIS-Participation was 50 (P25\u0026ndash;P75: 33\u0026ndash;75), indicating moderate limitations in daily activities and social participation. SIS-Communication (93, P25\u0026ndash;P75: 75\u0026ndash;98) and SIS-Memory (88, P25\u0026ndash;P75: 62\u0026ndash;98) scores were relatively preserved, whereas SIS-Emotion showed greater variability (44, P25\u0026ndash;P75: 25\u0026ndash;50).\u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e HERE\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePerceived barriers\u003c/h2\u003e \u003cp\u003ePerceived barriers to CR demonstrated a heterogeneous profile across domains (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The median CRBS sum score was 11 (P25\u0026ndash;P75: 8\u0026ndash;15), indicating a moderate overall burden of perceived barriers. Among subdomains, perceived needs showed a median score of 3 (P25\u0026ndash;P75: 0\u0026ndash;5), and access-related barriers had a median of 2 (P25\u0026ndash;P75: 0\u0026ndash;5), suggesting that informational gaps and structural limitations were relatively prominent in this cohort. In contrast, personal/family problems and travel/work conflicts presented low median scores of 0 (P25\u0026ndash;P75: 0\u0026ndash;1), indicating that these barriers were less frequently endorsed. The comorbidities/functional status domain showed a median score of 5 (P25\u0026ndash;P75: 0\u0026ndash;5), reflecting variability in how participants perceived health-related constraints affecting rehabilitation participation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRehabilitation barriers of the study sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSummary\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRBS (Comorbidities/Functional status) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRBS (Perceived needs) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRBS (Personal/Family problems) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRBS (Travel/Work conflicts) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRBS (Access) (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRBS sumscore (points)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (8\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eValues are presented as median (interquartile range) or n (%). Abbreviations: CRBS, Cardiac Rehabilitation Barriers Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e HERE\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation analysis\u003c/h2\u003e \u003cp\u003eCorrelation analysis revealed significant associations between functional status and perceived barriers to rehabilitation participation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Supplementary File 1). After FDR adjustment, Spearman correlation coefficients showed that the mBI was strongly and positively correlated with SIS mobility (ρ\u0026thinsp;=\u0026thinsp;0.57, 95% CI [0.36, 0.72], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and SIS ADL/IADL (ρ\u0026thinsp;=\u0026thinsp;0.48, 95% CI [0.25, 0.65], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that higher levels of functional independence were associated with better mobility and performance of daily activities. In addition, SIS hand function and SIS mobility demonstrated a strong positive association (ρ\u0026thinsp;=\u0026thinsp;0.67, 95% CI [0.49, 0.79], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting substantial overlap between upper-limb function and mobility-related domains.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePLEASE INSERT FIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e HERE\u003c/p\u003e \u003cp\u003eRegarding perceived rehabilitation barriers, FDR adjustment showed significant positive associations were observed between the CRBS domains of perceived needs and personal/family problems (ρ\u0026thinsp;=\u0026thinsp;0.37, 95% CI [0.12, 0.57], p\u0026thinsp;=\u0026thinsp;0.025). In addition, the CRBS total score showed strong correlations with its subdomains, particularly perceived needs (ρ\u0026thinsp;=\u0026thinsp;0.64, 95% CI [0.45, 0.77], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and personal/family problems (ρ\u0026thinsp;=\u0026thinsp;0.39, 95% CI [0.14, 0.58], p\u0026thinsp;=\u0026thinsp;0.017), reflecting internal coherence among barrier domains.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study aimed to assess functional status among adults of working age after stroke and to explore their correlations with perceived barriers to CR participation. Our findings indicate that participants presented with mild to moderate disability and reduced independence in daily activities. Perceived rehabilitation barriers were prominent, especially in domains related to perceived needs and access, and showed strong interrelationships among contextual and personal factors. Although direct correlations between rehabilitation barriers and functional or work outcomes were limited, the clustering of socioeconomic and structural barriers highlights the complexity of challenges faced by working-age stroke survivors. Together, these findings suggest the importance of rehabilitation models that integrate clinical recovery with strategies addressing contextual and social determinants, which may be particularly relevant for supporting return to productive life after stroke.\u003c/p\u003e \u003cp\u003eThe findings of this study are consistent with prior literature indicating that stroke among adults of working age is frequently associated with persistent limitations across physical, cognitive, and occupational domains. Even relatively mild strokes can be accompanied by substantial psychological and functional sequelae, particularly when reintegration into work and social life is delayed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These findings are in line with those reported by Santos et al., who emphasize the importance of multidimensional assessments for capturing the complex effects of stroke on daily functioning and participation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, the prominence of structural and socioeconomic barriers identified through the CRBS is consistent with evidence describing transportation difficulties, limited awareness, and systemic constraints as major challenges to rehabilitation access in cardiovascular disease contexts, including stroke [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The predominance of intrapersonal and contextual barriers observed in our cohort aligns with findings from other rehabilitation populations, as adherence to exercise-based rehabilitation in musculoskeletal conditions is largely influenced by intrapersonal determinants such as self-efficacy and perceived benefits, as well as environmental constraints [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similar contextual challenges have been described from the perspective of family caregivers of stroke survivors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], including lack of collaboration with the health care team, insufficient discharge coordination, and limited community support were perceived as major barriers to sustaining post-stroke care. This issue is particularly relevant in Brazil, where regional disparities in healthcare access persist [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], potentially placing working-age stroke survivors at increased risk of delayed or fragmented rehabilitation. Collectively, these findings reinforce the importance of rehabilitation models that extend beyond clinical interventions to address contextual and social determinants of recovery, including flexible service delivery and integration with primary care to improve reach among underserved populations.\u003c/p\u003e \u003cp\u003eThe interrelationships between functional status, emotional well-being, and perceived rehabilitation barriers emerged as relevant aspects of this study. Lower scores in the SIS emotion domain suggest that psychological challenges (e.g., emotional distress, frustration, and reduced self-efficacy) may coexist with functional limitations among adults of working age after stroke. This observation is consistent with prior literature highlighting the psychological burden experienced by stroke survivors during the recovery process [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and suggests the need for care models that extend beyond physical rehabilitation alone.\u003c/p\u003e \u003cp\u003eThe correlations observed between CRBS subdomains \u0026ndash; particularly perceived needs and personal or family-related problems \u0026ndash; indicate clustering of logistical, social, and contextual challenges. These overlapping barriers may be associated with increased emotional strain and reduced perceived capacity to engage in rehabilitation activities. Taken together, these findings highlight the potential value of personalized rehabilitation strategies that incorporate psychological support, family education, and social assistance. Public rehabilitation initiatives may benefit from integrating mental health resources, family-centered approaches, and community-based support networks to promote continuity of care and address the broader determinants of recovery.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. First, the cross-sectional design precludes causal inference regarding the observed associations and limits the ability to examine temporal changes in functional status and perceived rehabilitation barriers. Second, the regional scope of the sample may limit the generalizability of the findings to other populations of adults of working age after stroke in Brazil or in different healthcare contexts. Despite these limitations, the study also presents important strengths. To our knowledge, it is among the first studies in Brazil to examine, within a single analytical framework, the relationships between functional status and perceived rehabilitation barriers among adults of working age after stroke, using a multidimensional approach and validated assessment instruments. Future studies employing longitudinal designs are warranted to better characterize changes over time and to clarify the directionality of these relationships.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eAdults of working age recovering from stroke experience substantial challenges related to functional limitations. This study demonstrates that perceived rehabilitation barriers \u0026ndash; particularly those related to access, perceived needs, and personal or family circumstances \u0026ndash; were prominent and showed substantial interrelationships. Integrated and person-centered rehabilitation approaches that extend beyond physical recovery are required to address emotional well-being and broader socioeconomic conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Fundacao Carlos Chagas Filho de Amparo \u0026agrave; Pesquisa do Estado do Rio de Janeiro [FAPERJ, No. E-26/211.104/2021]; Coordena\u0026ccedil;\u0026atilde;o de Aperfei\u0026ccedil;oamento de Pessoal de N\u0026iacute;vel Superior (CAPES, Finance Code 001) [No. 88881.708719/2022-01], [No. 88887.708718/2022- 00].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Data collection was performed by Paulo Cesar de Lima Andrelino. Data analysis was performed by Arthur de S\u0026aacute; Ferreira. The first draft of the manuscript was written by Paulo Cesar de Lima Andrelino and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to ethical restrictions, the datasets generated during and analysed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to ethical standards outlined in the Declaration of Helsinki. The study protocol was approved by the Research Ethics Committee before execution following national regulations (approval number: CAAE: 76491623.0.0000.5235).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants before their inclusion in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCoupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of stroke. J R Soc Med. 2017;110:9\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0141076816680121\u003c/span\u003e\u003cspan address=\"10.1177/0141076816680121\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, et al. 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Cogitare Enfermagem. 2023;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/ce.v28i0.89719\u003c/span\u003e\u003cspan address=\"10.1590/ce.v28i0.89719\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stroke, Post-stroke rehabilitation, Treatment adherence, Socioeconomic barriers, Functionality","lastPublishedDoi":"10.21203/rs.3.rs-8920372/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8920372/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo describe functional status in working-age stroke survivors and examine its associations with perceived rehabilitation barriers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this cross-sectional study, 59 working-age stroke survivors were recruited from post-stroke rehabilitation clinics. Median age was 48 years (IQR 44\u0026ndash;54), and 54% were male. Standardized assessments included the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI), Stroke Impact Scale (SIS), and Cardiac Rehabilitation Barriers Scale (CRBS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants demonstrated mild to moderate neurological impairment and moderate functional limitations, particularly in motor domains, with reduced independence in daily activities. Functional independence (mBI) was moderately to strongly correlated with SIS mobility (ρ\u0026thinsp;=\u0026thinsp;0.57; 95% CI 0.36\u0026ndash;0.72) and ADL/IADL domains (ρ\u0026thinsp;=\u0026thinsp;0.48; 95% CI 0.25\u0026ndash;0.65). Perceived rehabilitation barriers were most prominent in domains related to perceived needs and access, with strong interrelationships among contextual and personal barrier domains. Direct associations between barrier scores and functional measures were limited.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAdults of working age recovering from stroke experience substantial functional challenges. Perceived rehabilitation barriers cluster mainly around contextual and personal factors rather than directly reflecting functional severity. Integrated, person-centered rehabilitation models are required to address both clinical recovery and broader socioeconomic determinants to optimize reintegration and participation.\u003c/p\u003e","manuscriptTitle":"Functional Status and Rehabilitation Barriers in Adults of Working Age After Stroke: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-23 09:33:44","doi":"10.21203/rs.3.rs-8920372/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"22c0e96a-2954-403e-9968-04d4c6d092d1","owner":[],"postedDate":"February 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T09:33:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-23 09:33:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8920372","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8920372","identity":"rs-8920372","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}