Predictors of Burden for First-Ever Stroke Survivor's Long-Term Caregivers: A Study of KOSCO.

Long-term changes in caregiver burden should be clarified considering that extended post-stroke disability can increase caregiver stress. We assessed long-term changes in caregiver burden severity and its predictors. This study was a retrospective analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Patients with an acute first-ever stroke were enrolled from August 2012 to May 2015. Data were collected at 6 months and 6 years after stroke onset. The caregiver burden was measured with a subjective caregiver burden questionnaire based on the Korean version of the Caregiver Burden Inventory. The caregivers' characteristics and patients' clinical and functional status were also examined at each follow-up. A high caregiver burden, which suggests a risk of burnout, was reported by 37.9% and 51.7% of caregivers at 6 months and 6 years post-stroke, respectively. Both the caregiver burden total score and proportion of caregivers at risk of burnout did not decrease between 6 months and 6 years. The patients' disability (OR = 11.60; 95% CI 1.58-85.08; p = 0.016), caregivers' self-rated stress (OR = 0.03; 95% CI 0.00-0.47; p = 0.013), and caregivers' quality of life (OR = 0.76; 95% CI 0.59-0.99; p = 0.042) were burden predictors at 6 months. At 6 years, only the patients' disability (OR = 5.88; 95% CI 2.19-15.82; p < 0.001) and caregivers' psychosocial stress (OR = 1.26; 95% CI 1.10-1.44; p = 0.001) showed significance. Nearly half of the caregivers were at risk of burnout, which lasted for 6 years after stroke onset. The patients' disability and caregivers' stress were burden predictors in both subacute and chronic phases of stroke. The findings suggest that consistent interventions, such as emotional support or counseling on stress relief strategies for caregivers of stroke survivors, may reduce caregiver burden. Further research is needed to establish specific strategies appropriate for Korean caregivers to alleviate their burden in caring for stroke patients.

Long-Term Functional Outcome in Patients With Isolated Thalamic Stroke: The KOSCO Study.

BACKGROUND: Information on the long-term prognosis in patients with isolated thalamic stroke is sparse. We report the functional outcomes of patients with thalamic stroke up to 24 months from the KOSCO (Korean Stroke Cohort for Functioning and Rehabilitation) study. METHODS AND RESULTS: Isolated thalamic stroke was defined as the presence of lesions solely in the thalamus, excluding cases with lesions in other brain parenchyma areas apart from the thalamus, as identified by brain magnetic resonance imaging or computed tomography scans. The Fugl-Meyer Assessment, the Functional Ambulatory Category, the Korean Mini-Mental State Examination, the American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, and the short version of the Korean Frenchay Aphasia Screening Test were used to assess physical impairment. The Functional Independence Measure and modified Rankin Scale were used to assess functional outcomes. All measurements were conducted up to 24 months poststroke. A total of 297 patients were included, consisting of 235 with ischemic and 62 with hemorrhagic stroke. Except for the Functional Ambulatory Category and Functional Independence Measure, all physical impairments showed significant improvement up to 3 months poststroke (P<0.001) and reached a plateau. The Functional Ambulatory Category and Functional Independence Measure scores continued to improve up to 12 months poststroke (P<0.05) and reached a plateau. At 7 days poststroke, 47.5% of patients had no disability (modified Rankin Scale score<2), whereas at 24 months poststroke, 76.4% of patients had no significant disability. CONCLUSIONS: Patients showed rapid recovery from physical impairment up to 3 months poststroke, with additional improvements in ambulatory function and independence observed up to 12 months poststroke. Additionally, relatively favorable long-term functional prognosis at 24 months after onset was demonstrated. These results could provide insights into the proper management regarding functional outcomes of patients with isolated thalamic stroke.

Incidence of Altered Level of Consciousness in Hemorrhagic Stroke Survivors: Associated Factors From a Korean Nationwide Study.

OBJECTIVE: This study aimed to demonstrate the incidence of altered level of consciousness after hemorrhagic stroke and identify factors associated with altered level of consciousness at 3 mos after stroke. DESIGN: This study used data from a prospective multicenter cohort study conducted in nine hospitals in Korea and included 1677 patients with first-ever hemorrhagic stroke. Patients were dichotomized into those with and without altered level of consciousness at 3 mos after stroke. Multivariate logistic regression analysis was performed to identify factors associated with subacute to chronic stage altered level of consciousness. RESULTS: Among patients with hemorrhagic stroke (age: 20-99 yrs, female 50.21%), the prevalence of altered level of consciousness at admission was 38.58% (25.4% [drowsy], 6.38% [stupor], and 6.8% [coma]) and 17.29% 3 mos after stroke. Multivariate logistic regression analysis revealed that independent factors associated with altered level of consciousness at 3 mos after stroke included late seizure (odds ratio [95% confidence interval], 5.93 [1.78-20.00]), stroke progression (3.84 [1.48-9.64]), craniectomy (2.19 [1.19-4.00]), history of complications (1.74 [1.18-2.55]), age at stroke onset (1.08 [1.07-1.10]), and initial Glasgow Coma Scale score category (0.36 [0.30-0.44]). CONCLUSIONS: The factors associated with altered level of consciousness at 3 mos after stroke should be considered when explaining long-term consciousness status and focused management of modifiable factors in acute care hospitals could help ameliorate altered level of consciousness and promote recovery after stroke.

A Randomized, Double-Blind, Active Control, Multicenter, Phase 3 Study to Evaluate the Efficacy and Safety of Liztox® versus Botox® in Post-Stroke Upper Limb Spasticity.

Botulinum toxin type A (BTX-A) injection is a commonly used therapeutic intervention for upper limb spasticity in stroke patients. This study was designed as a randomized, active-drug-controlled, double-blind, multicenter, phase 3 clinical trial to evaluate the safety and efficacy of Liztox® in comparison to onabotulinum toxin A (Botox®) for individuals with post-stroke upper limb spasticity. The primary outcome was the alteration in wrist flexor muscle tone from the initial assessment to the fourth week, evaluated using the modified Ashworth scale (MAS). Secondary outcomes included MAS score changes for the wrist at weeks 8 and 12 from baseline; MAS score changes for finger and elbow flexors; and changes in the Disability Assessment Scale (DAS), Subject's Global Assessment (SGA), the Investigator's Global Assessment (IGA), and Caregiver Burden Scale (CBS) at weeks 4, 8, and 12 from baseline. The MAS score for wrist flexor spasticity decreased by -1.14 ± 0.59 in the Liztox® group and -1.22 ± 0.59 in the Botox® group from baseline to week 4. The difference [97.5% confidence interval (CI)] between the test and control groups was 0.08 [-∞, 0.26], confirming the non-inferiority of the test group compared to the control group. Furthermore, there were consistent improvements in the IGA, SGA, and CBS scores across all assessment intervals, with no statistically significant variances detected between the two groups. No safety-related concerns were reported during the study. In conclusion, Liztox® injection proved to be a secure and efficacious intervention for managing upper extremity spasticity in post-stroke patients.

Effect of Anterioposterior Weight-Shift Training with Visual Biofeedback in Patients with Step Length Asymmetry after Subacute Stroke.

Step length asymmetry is a characteristic feature of gait in post-stroke patients. A novel anterioposterior weight-shift training method with visual biofeedback (AP training) was developed to improve the forward progression of the trunk. This study aimed to investigate the effect of AP training on gait asymmetries, patterns, and gait-related function in subacute stroke patients. Forty-six subacute stroke patients were randomly assigned to the AP training group or the control group. The AP training group received conventional gait training and AP training five times per week for 4 weeks. The control group received the same intensity of conventional gait training with patient education for self-anterior weight shifting. Plantar pressure analysis, gait analysis, energy consumption, and gait-related behavioral parameters were assessed before and after training. The AP training group showed significant improvement in step length asymmetry, forefoot contact area and pressure, Berg balance scale score, and Fugl-Meyer assessment scale of lower extremity score compared to the control group (p < 0.05). However, there was no significant between-group difference with respect to energy cost and kinetic and kinematic gait parameters. In conclusion, AP training may help improve the asymmetric step length in stroke patients, and also improve anterior weight shifting, balance, and motor function in subacute stroke survivors.

End-effector lower limb robot-assisted gait training effects in subacute stroke patients: A randomized controlled pilot trial.

BACKGROUND: This pilot study investigated end-effector lower limb rehabilitation robot training effects in subacute stroke patients. METHODS: Forty-nine stroke patients were randomly assigned to 2 treatment groups: a 30-minute end-effector lower limb rehabilitation robot training plus 1.5-hour conventional physiotherapy (robot group; n = 26), or a 2-hour conventional physiotherapy (control group; n = 23). All patients received 5 treatments weekly for 4 weeks. The functional ambulatory category was the primary outcome and the motricity index, Fugl Meyer assessment-lower extremity, rivermead mobility index, 10 meter walk test, Berg balance scale, and modified Barthel index were secondary outcomes. RESULTS: All outcome measures significantly improved in both groups after training (P > .05). The robot group improved more in FAC than the control group (P = .005). CONCLUSIONS: Compared with conventional physiotherapy alone, end-effector lower limb robot-assisted gait training with conventional physiotherapy improved subacute stroke patients walking ability.

Gait Pattern in Charcot-Marie-Tooth Disease Type 1A According to Disease Severity.

The aim of this study was to evaluate the characteristics of gait patterns in Charcot-Marie-Tooth disease type 1A (CMT1A) patients according to disease severity. Twenty-two CMT1A patients were enrolled and classified into two groups, according to the disease severity. The healthy control group consisted of 22 subjects with no gait impairment. Full barefoot three-dimensional gait analysis with temporospatial, kinematic, and kinetic data was performed among the mild and moderate CMT1A group and the control group. Minimal hip abduction, maximal hip extension generation, peak knee flexion moment at stance, ankle dorsiflexion at initial contact, maximal ankle plantarflexion at push-off and maximal ankle rotation moment at stance in the CMT1A group showed a significant difference compared to the control group (p < 0.05). In the moderate group, there were greater maximal hip flexion angles in swing, and smaller dorsiflexion angles at initial contact compared to the control group and mild group. CMT patients had typical gait characteristics and their gait patterns were different according to severity. The analysis of gait patterns in patients with CMT1A will help to understand gait function and provide important information for the treatment of patients with CMT in the future.

Kinematic analysis of movement patterns during a reach-and-grasp task in stroke patients.

Background: This study aimed to evaluate the kinematic movement patterns during a reach-and-grasp task in post-stroke patients according to the upper extremity impairment severity. Methods: Subacute stroke patients (n = 46) and healthy controls (n = 20) were enrolled in this study. Spatiotemporal and kinematic data were obtained through 3D motion analysis during the reach-and-grasp task. Stroke patients were grouped using the Fugl-Meyer Assessment (FMA) scale, and a comparison of the groups was performed. Results: The severe group showed a significantly longer movement time, lower peak velocity, and higher number of movement units than the mild group during the reach-and-grasp task (p < 0.05). Characteristic compensatory movement patterns, such as shoulder abduction, thoracic posterior tilting, and upward and external rotation were significantly greater during the forward transporting phase in the severe group than in the mild group (p < 0.05). The FMA score was significantly associated with the movement time during the forward transporting phase, number of movement units during the reaching phase, range of shoulder abduction-adduction and wrist flexion-extension movements during the reaching phase, and range of thoracic internal-external rotation during the backward transporting phase (p < 0.05). Conclusion: Post-stroke patients have unique spatiotemporal and kinematic movement patterns during a reach-and grasp-task according to the impairment severity.

Predictors of quality of life at 6 months in patients with mild stroke: A prospective observational cohort study.

OBJECTIVES: This study aimed to analyze the factors affecting the long-term quality of life of patients with mild stroke and evaluate the differences according to age and sex. MATERIALS AND METHODS: The Korean Stroke Cohort for functioning and rehabilitation data was used, and patients with mild stroke with a National Institute of Health Stroke Scale score of < 5 were included. Quality of life after 6 months was analyzed using EuroQol-5 dimensions. Demographic and clinical characteristics were evaluated, and factors affecting the quality of life at 6 months were analyzed. RESULTS: Age, current drinking, marital status, length of stay, and modified Rankin Scale, Fugl-Meyer assessment, Functional Independence Measure, and Geriatric Depression Scale scores affected the quality of life at 6 months in patients with mild stroke. Fugl-Meyer assessment score was a predictor for those aged < 65 years, while the functional ambulatory category was a predictor for those aged ≥ 65 years. Predictors of quality of life, excluding alcohol consumption, were comparable between male and female. CONCLUSIONS: Among patients aged <65 years, individuals who consumed alcohol, and those who showed better motor function and fewer comorbidities had a higher quality of life. Among patients aged ≥65 years, quality of life was higher in males, younger age, married individuals, those with diabetes, and those with a better walking ability. Among male, individuals who consumed alcohol had a higher quality of life. Rehabilitation treatment should prioritize improving modifiable factors to enhance the quality of life in patients with mild stroke.

Exoskeletal wearable robot on ambulatory function in patients with stroke: a protocol for an international, multicentre, randomised controlled study.

INTRODUCTION: The purpose of this study is to determine the effect of overground gait training using an exoskeletal wearable robot (exoskeleton) on the recovery of ambulatory function in patients with subacute stroke. We also investigate the assistive effects of an exoskeleton on ambulatory function in patients with subacute stroke. METHODS AND ANALYSIS: This study is an international, multicentre, randomised controlled study at five institutions with a total of 150 patients with subacute stroke. Participants will be randomised into two groups (75 patients in the robot-assisted gait training (RAGT) group and 75 patients in the control group). The gait training will be performed with a total of 20 sessions (60 min/session); 5 sessions a week for 4 weeks. The RAGT group will receive 30 min of gait training using an exoskeleton (ANGEL LEGS M20, Angel Robotics) and 30 min of conventional gait training, while the control group will receive 60 min conventional gait training. In all the patients, the functional assessments such as ambulation, motor and balance will be evaluated before and after the intervention. Follow-up monitoring will be performed to verify whether the patient can walk without physical assistance for 3 months. The primary outcome is the improvement of the Functional Ambulatory Category after the gait training. The functional assessments will also be evaluated immediately after the last training session in the RAGT group to assess the assistive effects of an exoskeletal wearable robot. This trial will provide evidence on the effects of an exoskeleton to improve and assist ambulatory function in patients with subacute stroke. ETHICS AND DISSEMINATION: This protocol has been approved by the Institutional Review Board of each hospital and conforms to the Declaration of Helsinki. The results will be disseminated through publication. TRIAL REGISTRATION NUMBER: Protocol was registered at ClinicalTrials.gov (NCT05157347) on 15 December 2021 and CRIS (KCT0006815) on 19 November 2021.

Clinical Practice Guideline for Stroke Rehabilitation in Korea-Part 1: Rehabilitation for Motor Function (2022).

This clinical practice guideline (CPG) is the fourth edition of the Korean guideline for stroke rehabilitation, which was last updated in 2016. The development approach has been changed from a consensus-based approach to an evidence-based approach using the Grading of Recommendations Assessment Development and Evaluation (GRADE) method. This change ensures that the guidelines are based on the latest and strongest evidence available. The aim is to provide the most accurate and effective guidance to stroke rehabilitation teams, and to improve the outcomes for stroke patients in Korea. Fifty-five specialists in stroke rehabilitation and one CPG development methodology expert participated in this development. The scope of the previous clinical guidelines was very extensive, making it difficult to revise at once. Therefore, it was decided that the scope of this revised CPG would be limited to Part 1: Rehabilitation for Motor Function. The key questions were selected by considering the preferences of the target population and referring to foreign guidelines for stroke rehabilitation, and the recommendations were completed through systematic literature review and the GRADE method. The draft recommendations, which were agreed upon through an official consensus process, were refined after evaluation by a public hearing and external expert evaluation.

Clustering and prediction of long-term functional recovery patterns in first-time stroke patients.

Objectives: The purpose of this study was to cluster long-term multifaceted functional recovery patterns and to establish prediction models for functional outcome in first-time stroke patients using unsupervised machine learning. Methods: This study is an interim analysis of the dataset from the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO), a long-term, prospective, multicenter cohort study of first-time stroke patients. The KOSCO screened 10,636 first-time stroke patients admitted to nine representative hospitals in Korea during a three-year recruitment period, and 7,858 patients agreed to enroll. Early clinical and demographic features of stroke patients and six multifaceted functional assessment scores measured from 7 days to 24 months after stroke onset were used as input variables. K-means clustering analysis was performed, and prediction models were generated and validated using machine learning. Results: A total of 5,534 stroke patients (4,388 ischemic and 1,146 hemorrhagic; mean age 63·31 ± 12·86; 3,253 [58.78%] male) completed functional assessments 24 months after stroke onset. Through K-means clustering, ischemic stroke (IS) patients were clustered into five groups and hemorrhagic stroke (HS) patients into four groups. Each cluster had distinct clinical characteristics and functional recovery patterns. The final prediction models for IS and HS patients achieved relatively high prediction accuracies of 0.926 and 0.887, respectively. Conclusions: The longitudinal, multi-dimensional, functional assessment data of first-time stroke patients were successfully clustered, and the prediction models showed relatively good accuracies. Early identification and prediction of long-term functional outcomes will help clinicians develop customized treatment strategies.

Gender differences in mortality and long-term functional outcomes after first-ever ischemic stroke: A prospective cohort study.

BACKGROUND: Although many studies about survival rates and functional outcomes after stroke have been published, studies on gender differences have reported conflicting results. AIMS: To determine whether there are differences in mortality and functional outcomes during the first 5 years after a first-ever ischemic stroke in Korean males and females. METHOD: This is an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation, a prospective multicenter cohort study. Multifaceted functional assessments were performed repeatedly from 7 days to 60 months after stroke onset to test motor, ambulatory, cognitive, language, and swallowing functions as well as activities of daily living (ADLs) in patients with first-ever stroke. Of 10,636 first-ever-stroke patients admitted to nine representative hospitals in Korea, 8210 were ischemic stroke patients included in the mortality analysis. Among them, 6258 patients provided informed consent and 3508 completed functional assessments for 60 months. Gender-related differences in 5-year mortality and functional recovery were analyzed. RESULT: Women showed a significantly higher 5-year mortality rate than men after correction for possible covariates (p < 0.05). In terms of functional outcomes, women showed worse ambulatory, cognitive, language, and ADL outcomes than men after adjusting for covariates (all p < 0.05). The 5-year recovery pattern differed significantly between genders only for ADL function (ß-coefficient estimate = 0.34; p = 0.03). CONCLUSION: Five-year mortality rate, functional outcomes, and recovery patterns after first-ever ischemic stroke differed significantly by gender. These results suggest the need for gender-specific stroke care and long-term management strategies.

Contributing Factors to the Burden on Primary Family Caregivers of Stroke Survivors in South Korea.

The purpose of this study is to identify the factors associated with the burden on primary family caregivers of stroke patients at home without care services. For this study, the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) data were used. Of the total 8010 caregivers, 1133 family caregiver burden was assessed with the shortened Caregiver Burden Inventory (CBI) 3 months after stroke. Patient and caregiver-related factors affecting the heavier burden of caregivers were identified by comparing the heavier caregiver burden group and the lighter caregiver burden group, which divided according to the CBI scores. The 719 (63.5%) family caregiver cared for patients at home without care services. Logistic regression analysis showed that four or more comorbidities (p = 0.002), neurological impairment at early onset (p < 0.001), dependence on daily life (p < 0.001), aphasia (p = 0.024), and depression(p < 0.001) were associated with a heavier burden of care. According to the shortened CBI, caregivers tended to be concerned more about psychological stress than physical strain. The findings suggest the importance of proactively guiding the emotional support services to caregivers who are at high risk of the heavier burden of patient care.

Safety and efficacy of MT10107 in post-stroke upper limb spasticity treatment: A phase I randomized controlled trial.

BACKGROUND: Botulinum toxin type A injection is widely used treatment option for the treatment of upper limb spasticity in stroke patients. The purpose of this study was to explore the safety and efficacy of MT10107, a new botulinum toxin type A, in patients with post-stroke upper limb spasticity. METHODS: A prospective, randomized, double-blind, active drug-controlled, multi-center, phase I clinical trial. Thirty patients with post-stroke upper limb spasticity were received either MT10107 or onabotulinumtoxinA. Primary endpoint was change of modified Ashworth scale (MAS) score for wrist flexor from baseline to week 4. The secondary endpoints were changes of MAS scores for elbow and finger flexors, response rate, Disability Assessment Scale (DAS), and global assessment of treatment. The safety endpoints such as adverse events, vital signs, physical examination, and laboratory test were evaluated. The outcome measures were evaluated from baseline to week 4. RESULTS: The primary endpoints were -1.07 ± 0.70 and -1.23 ± 0.56 for the MT10107 and onabotulinumtoxinA groups, respectively. The intergroup difference of change between the 2 groups was 0.17 (95% confidence interval -0.31 to 0.64, P = .5769). In secondary endpoints, both groups showed a significant improvement in both MAS and DAS. There was no significant between-group difference in all secondary endpoints and safety measures. CONCLUSION: The safety and efficacy of MT10107 showed no significant difference compared to onabotulinumtoxinA in post-stroke upper limb spasticity treatment.

Efficacy and Safety of Botulinum Toxin Type A (NABOTA) for Post-stroke Upper Extremity Spasticity: A Multicenter Phase IV Trial.

OBJECTIVE: To evaluate the efficacy and safety of Daewoong botulinum toxin type A (NABOTA) after its launch in South Korea. METHODS: This prospective, multicenter, open-label phase IV clinical trial included 222 patients with stroke. All patients visited the clinic at baseline and at weeks 4, 8, and 12 after injection of upto 360 units of NABOTA into the wrist, elbow, and finger flexor muscles at the first visit. The primary outcome was the change in Modified Ashworth Scale (MAS) score for the wrist flexor muscles between baseline and week 4. The secondary outcomes were the changes in MAS, Disability Assessment Scale (DAS), and Caregiver Burden Scale (CBS) scores between baseline and each visit, and the Global Assessment Scale (GAS) score at week 12. RESULTS: There was a statistically significant decrease in the MAS score for the wrist flexors between baseline and week 4 (-0.97±0.66, p<0.001). Compared with baseline, the MAS, DAS and CBS scores improved significantly during the study period. The GAS was rated as very good or good by 86.8% of physicians and by 60.0% of patients (or caregivers). The incidence of adverse events was 14.4%, which is smaller than that in a previous trial. CONCLUSION: NABOTA showed considerable efficacy and safety in the management of upper limb spasticity in stroke patients.

Clinical Characteristics and Risk Factors of First-Ever Stroke in Young Adults: A Multicenter, Prospective Cohort Study.

Stroke in young adults has catastrophic consequences and has increased in prevalence, contrary to the trends of most other diseases. This study aimed to determine the major characteristics and risk factors for stroke in younger adults compared with older adults. From the Korean Stroke Cohort for Functioning and Rehabilitation, 10,584 patients with first-ever stroke between August 2012 and March 2015 were enrolled retrospectively and divided into younger (age ≤ 45) and older groups (age > 45). The clinical characteristics and risk factors of stroke were compared between the younger and older groups. The younger group comprised 915 patients (8.6%). The proportion of hemorrhage strokes in the younger group (42.3%) was significantly higher than in the older group (20.0%) (p < 0.001). Obesity, current smoking, and heavy alcohol consumption were significantly more common risk factors in the younger group than in the older group for all stroke types, whereas hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and coronary heart disease were significantly more frequent in the older group (both p < 0.001). The major risk factors in the younger group may be lifestyle-related. Therefore, increasing awareness of lifestyle-related risk factors may be necessary to prevent stroke in young adults.

Multifaceted Assessment of Functional Outcomes in Survivors of First-time Stroke.

Importance: Because stroke causes diverse functional deficits, understanding the long-term recovery pattern of each functional domain may inform prognosis and therapeutic strategies. Objective: To observe long-term changes in functional status and residual disability in survivors of first-time stroke. Design, Setting, and Participants: This cohort study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Between August 2012 and May 2015, 7858 of 10 636 screened patients with first-time strokes from 9 district hospitals in Korea provided informed consent to participate. Data were analyzed from September 2021 through February 2022. Exposure: First-time stroke. Main Outcomes and Measures: Study data include multifaceted face-to-face functional assessments obtained at 8 to 9 points until 60 months after stroke onset. The Korean Mini-Mental State Examination (K-MMSE), Fugl-Meyer Assessment, Functional Ambulatory Category, American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, and Short Korean version of the Frenchay Aphasia Screening Test were performed from 7 days to 60 months after stroke. The Korean Modified Barthel Index was measured from 3 months to 60 months after stroke. Results: A total of 4443 patients (2649 men [59.62%]; mean [SD] age 62.13 [12.43] years) who underwent repeated functional assessments for 60 months after stroke (3508 patients with ischemic and 935 patients with hemorrhagic stroke) were included. Overall, functions plateaued between 12 and 18 months after stroke and declined after 30 months; for example, mean (SD) K-MMSE improved from 7 days (22.89 [7.89]) to 12 months (26.03 [5.48]) (P < .001), plateaued until 36 months (26.03 [5.84]), and decreased to 48 months (26.02 [5.82]) (P < .001). Interaction associations were found between time after stroke and age, stroke severity, and stroke type in functional assessment outcomes. For example, mean (SE) FMA for ages 65 years or younger vs older than 65 years was 81.64 (0.63) vs 80.69 (0.68) at 7 days and 91.28 (0.47) vs 88.46 (0.58) at 6 months (P for interaction < .001), and for IS vs HS, it was 84.46 (0.47) vs 69.02 (1.24) at 7 days and 91.20 (0.38) vs 85.51 (0.98) at 6 months (P for interaction < .001). Mean (SE) FMA was 94.39 (0.21) at 7 days and 97.57 (0.14) at 6 months for mild stroke, 44.69 (1.18) at 7 days and 70.43 (1.21) at 6 months for moderate stroke, and 13.22 (0.99) at 7 days and 48.07 (2.62) at 6 months for severe stroke (P for interaction < .001). Factors associated with activities of daily living independence at 60 months included older age (ß per 1-year increase = -0.35; standard error [SE], 0.03; P < .001), male sex (ß = 2.12; SE, 0.73; P = .004), and hemorrhagic stroke type (ß vs ischemic stroke = 2.35; SE, 0.81; P = .004). Conclusions and Relevance: This study found that long-term recovery patterns in multifaceted functional domains differed from one another and varied by patient age, stroke severity, and stroke type. Understanding the diversity of long-term functional recovery patterns and factors associated with these outcomes in survivors of stroke may help clinicians develop strategies for effective stroke care and rehabilitation.

Changes in Long-Term Functional Independence in Patients with Moderate and Severe Ischemic Stroke: Comparison of the Responsiveness of the Modified Barthel Index and the Functional Independence Measure.

This study investigated the long-term functional changes in patients with moderate-to-severe ischemic stroke. In addition, we investigated whether there was a difference between the modified Barthel Index (MBI) and Functional Independence Measure (FIM) according to severity. To evaluate the changes in the long-term functional independence of the subjects, six evaluations were conducted over 2 years, and the evaluation was performed using MBI and FIM. A total of 798 participants participated in this study, of which 673 were classified as moderate and 125 as severe. During the first 3 months, the moderate group showed greater recovery than the severe group. The period of significant change in the National Institutes of Health Stroke Scale (NIHSS) score was up to 6 months after onset in the moderate group, and up to 3 months after onset in the severe group. In the severe group, MBI evaluation showed significant changes up to 6 months after onset, whereas FIM showed significant changes up to 18-24 months. Our results showed that functional recovery of patients with ischemic stroke in the 3 months after onset was greater in the moderate group than in the severe group. FIM is more appropriate than MBI for evaluating the functional status of patients with severe stroke.

Understanding of the Lower Extremity Motor Recovery After First-Ever Ischemic Stroke.

BACKGROUND: We aimed to verify the validity of the proportional recovery model for the lower extremity. METHODS: We reviewed clinical data of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was calculated as the amount of motor recovery over initial motor impairment, measured as the Fugl-Meyer Assessment of Lower Extremity score. We used the logistic regression method to model the probability of achieving the full Fugl-Meyer Assessment of Lower Extremity score, whereby we considered the ceiling effect of the score. To show the difference in the prevalence of achieving the full Fugl-Meyer Assessment of Lower Extremity score between 3 and 6 months poststroke, we constructed a marginal model through the generalized estimating equation method. We also performed the propensity score matching analysis to show the dependency of recovery proportion on the initial motor deficit at 3 and 6 months poststroke. RESULTS: We evaluated 1085 patients. The recovery proportions at 3 and 6 months poststroke were 0.67±0.42 and 0.75±0.39, respectively. A 1-unit decrease in the initial neurological impairment and the age at stroke onset increased the probability of achieving the full Fugl-Meyer Assessment of Lower Extremity score, which occurred at both 3 and 6 months poststroke. The prevalence of those who reach full lower limb motor recovery differs significantly between 3 and 6 months poststroke. We also found out that the recovery proportion at both 3 and 6 months poststroke is determined by the initial motor deficits of the lower limb. These results are not consistent with the proportional recovery model. CONCLUSIONS: Our results demonstrated that the proportional recovery model for the lower limb is invalid.