Table 1 Study assessment tools

The MTS measures spasticity [39]. Descriptively, the MTS has two measurements, the quality of muscle reaction (ordinal scale) and the angle of reaction or angle of catch (ratio). The quality of muscle is scored from 0–5; 0 implies no resistance to Passive Range of Movement (PROM) and 5 indicating joint immobile. On the other hand Angle of catch can be understood via two factors of PROM, the speed of movement and joint angle. The reporting of MTS summarily, involve the quality of muscle and angle of reaction components making it to fit into the body structure and function of the ICF absolutely. It has excellent test retest reliability (ICC = 0.86) in stroke patient [40], with good convergent validity for both elbow and ankle joints (r = 0.86 and r = 0.62 respectively) [39].

MMT will be used to assess muscle strength for upper and lower extremities, attention will be paid to specific joints of both extremities. For the upper extremity attention will be focused on shoulder, elbow and wrist joints and for the lower extremity joints hip, knee and ankle will be measured. MMT is the best known and most frequently employed muscle strength grading system for manual muscle testing (MMT) [41]. It has a score range of 0–5, with 0 being the minimum and 5/5 the maximum. An excellent test-retest reliability for both right and left hip joints (ICC = 0.98 and ICC = 0.97 respectively) with osteoarthritis [42]. Its convergent validity ranges between adequate to excellent in different body parts [43].

The MRS is a hierarchical scale of 0–6 points that indicate “global disability”. It is the most prevalent functional outcome measure for stroke research. Lower scores on the scale suggest more independence and higher scores signify increased dependency. Its test-retest reliability ranged between adequate to excellent (Kappa = 0.67-0.96) [44], with an excellent convergent validity [45].

The MBI assesses ten functional tasks of daily living (activities of daily living – ADL). It scores the individual based on independence in each task. Scores range from 0 and 100, with a higher score indicating greater independence. The inter-rater reliability is sufficient at the item level (kappa 0.50–0.78) and good for the overall inter-rater agreement (intraclass correlation coefficient [ICC] 0.77) [46, 47].

6MWT is a clinically useful measure of walking ability post stroke, which incorporates the important requirements of ambulation, such as walking speed, dynamic balance, and submaximal endurance. It is performed at the individually determined fastest speed possible during walking, making it ideal for stroke survivors [48]. It measures an individual’s ability to walk for a maximum distance (meters) within 6 min. This test exhibits excellent test-retest reliability (ICC = 0.973; 95 % CI = 0.925 to 0.988), a minimal detectable change of 54.1 m, and an acceptable concurrent validity (r = 0.52 to 0.89) [48].

Participants’ gait speed will be measured using 10MWT [48], which will be calculated by the time required to cover a distance of 10 m. Participants will be asked to walk at their maximal speed using their regular foot wear and walking aids (for those who use aids). The test will be performed on a 14 m walkway, to avoid the effects of acceleration and deceleration, therefore the individual may accelerate 2 m before entering the 10 m distance and 2 m to decelerate afterward, this will ensure a steady velocity within the 10 m mark. 10MWT shows a high intra-observer reliability (ICC = 0.95) and validity (r = 0.79) in stroke survivors [49].

The ARAT is a criterion-rated assessment of upper extremity activity limitations [50]. The ARAT includes 19 items divided into four subscales: grasp, grip, pinch, and gross movement. The items within each subtest are ranked based on a four-point ordinal scale ranging from zero to three, where three symbolises normal performance on each item. The items are ordered in a hierarchy, allowing skipping some items if the person is unable to do an earlier item normally. A score of 57 indicates normal performance. The test has a good test-retest reliability for both chronic and acute stroke, ICC = 0.963 [51], internal consistency α = 0.985 [50] and construct validity in relation to the arm section of Fugl Meyer, ICC = 0.925 [51].

The motor activity log (MAL) is a rating scale that evaluates how the affected hand is used to perform 30 daily activities (e.g., feeding, turning a door handle). For each activity, the patient rates how much the affected hand is used (amount of use, AOU) and how well the activity is performed (quality of movement, QOM). Ratings are usually on a scale of 0 to 5, with higher scores representing better functions. Scores on each scale are calculated as the mean of the scored items attempted with the affected arm. Its internal consistency is good, α > 0.81, with acceptable test retest reliability r > 0.91 and stability ratio >3 for the QOM and AOU, though not found to be reliable [52].

SS-QOL is selected to assess community participation. The SS-QOL is a self-report questionnaire consisting of 49 items cutting across 12 domains of mobility, energy, upper extremity (UE) function, work/productivity, mood, self-care, social roles, family roles, vision, language, thinking, and personality specific for stroke survivors. The domains are graded individually, and a total grade is also rendered [53]. SS-QOL has a good content validity, kappa coefficient ranged from 0.75-1.00, it demonstrated multiple representations of the ICF categories and covered a broad range of the ICF components that were meaningful for the stroke subjects [54].

To assess acceptability participants will complete a purpose-designed questionnaire [55]. The tool is a six-item scale adapted from the original treatment acceptability questionnaire, it is a seven point scale, with lower score indicating lower acceptability. Possible score on the scale ranged from 6–42. Participants in all the intervention groups and the control will be asked to provide information specific to their treatment. The test has not been tested for reliability and validity.