New Data on Stroke Recovery Patterns May Guide Rehabilitation

Long-term recovery patterns after a stroke differ in different functional domains and vary by patient age, stroke severity, and stroke type, a new study shows.  

The results also suggest that improvements occur in many functional domains over a longer timescale than previously thought, with consequent implications for rehabilitative care. 

“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,” the Korean authors conclude.

The study was published online September 23 in JAMA Network Open.

The researchers, led by Seyoung Shin, MD, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea, explain that a thorough understanding of long-term functional outcomes after stroke is important for setting suitable management plans and correctly informing patients and their families about prognoses.

They note that while disability and mortality are the most important outcomes, stroke is associated with diverse functional impairments that vary by lesion location or size, and long-term outcomes in different functional domains need to be understood separately to establish adequate stroke management strategies in accordance with individual patient needs. Moreover, it would be worthwhile to examine whether functional recovery patterns differ by clinical characteristics already known to be associated with stroke prognosis, such as age, stroke type, or stroke severity, they write.

For the current study, the researchers examined long-term recovery patterns in diverse functional domains and factors associated with outcomes among patients with first-time stroke.  

They analyzed data from a cohort of 4443 patients (3508 with ischemic and 935 patients with hemorrhagic stroke) who underwent repeated functional assessments for 60 months after their stroke.

Recovery Continued Up to 18 Months

Overall, functional scores showed significant improvement in most domains until 12 or 18 months after stroke onset and then plateaued and declined after 30 months.

However, recovery patterns differed significantly by age, initial stroke severity, and stroke type.

Some reports have suggested that activities of daily living (ADL) and motor functions plateau after 6 months, they write, “however, our results demonstrated that recovery continued for more than 1 year in all functional domains and until 18 months in motor, ambulatory, and ADL functions.”

These suggest that these outcomes may be associated with improvements in structural stroke care and comprehensive rehabilitation services in recent years.

Functional recovery occurred “rapidly in acute and subacute phases of stroke, especially in younger patients, those with moderate or severe stroke severity,” and patients with hemorrhagic stroke, they add. “Those phases are a time when patients should receive as much restorative therapy as needed to obtain maximal recovery,” the researchers state.

In the chronic stage of stroke, on the other hand, functional decline occurred beginning 30 months after onset, which suggests that maintenance care strategies are of utmost importance at that time, they add.

Noting that a previous study has found that late recovery was associated with reduced mortality and healthcare cost in patients with stroke, they say that stroke care should be extended to provide rehabilitation services needed by individual patients even in the chronic phase.

The study also showed that age is an important factor associated with functional outcomes after stroke, with older patients (65 years plus) having lower scores than younger patients in all functional domains at every time point. While older patients with stroke had noticeable functional recovery during the subacute phase, most functions declined from 18 to 60 months after stroke.

“These findings emphasize that older patients with stroke should be monitored closely for possible functional deterioration in the chronic stage,” the researchers say.

Functional recovery patterns also differed by stroke severity and type, with moderate and severe groups showing rapid recovery during the first 6 to 12 months after stroke, and patients with hemorrhagic stroke, who had higher severity at onset, experiencing more rapid restoration of function in the first 12 months after stroke than patients with ischemic stroke.

The study also found that functional status at 7 days after stroke was associated with outcomes of other functional domains after 60 months. For example, higher scores at day 7 on the Korean Mini-Mental State Examination (K-MMSE) scale were associated with good functional outcomes in all six functional domains, including motor, ambulatory, swallowing, language, and ADL performance.

Implications for Post-Stroke Rehabilitation

Commenting on the study for | Medscape Cardiology, Wendy Ziai, MD, professor of neurology, neurosurgery, anesthesiology & critical care medicine at Johns Hopkins University School of Medicine, Baltimore, Maryland, said: “This study is important because it highlights, as with other types of acute brain injury, that full recovery takes a very long time. Also noteworthy is that most measures of disability, especially motor and cognitive function, recover concomitantly and may be interdependent.”

She added: “This has implications for post-stroke rehabilitation and the duration over which such interventions may continue to optimize functional recovery. It also implies limits on ultimate recovery, especially at higher age, although it is not known whether efforts to maintain functional plateaus may be effective.”

Ziai noted that the data support the use and potential benefit of longer-term follow-up for stroke clinical trials. 

She also pointed out that the current study used standardized tests of motor, ambulatory, cognitive, language, swallowing, and ADL functions, and future research is required to translate these outcomes into those that are important to stroke survivors including return to work, driving, and participation in other meaningful social activities.

This study was supported by grants from the Korea Disease Control and Prevention Agency and the National Research Foundation of Korea. The researchers have reported no relevant financial relationships.

JAMA Netw Open 2022. Published online September 23, 2022. Full text

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