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.

Training intensity of robot-assisted gait training in children with cerebral palsy.

AIM: We compared three different intensities of robot-assisted gait training (RAGT) for achieving favourable outcomes in children with cerebral palsy (CP). METHOD: This study was conducted using a randomized controlled, single-blind design. Thirty children (19 males and 11 females; mean age 6 years 1 month, SD 2 years) with CP classified in Gross Motor Function Classification System levels II and III were assigned to three different RAGT intensity groups: high-intensity (fastest walking speed and lowest body weight support [BWS]), low-intensity (slowest speed and highest BWS), and comfortable intensity (intermediate speed and intermediate BWS). The RAGT intervention was performed three times a week for 6 weeks. Outcome measures included the 88-item Gross Motor Function Measure, stability index, spatiotemporal parameters of gait analysis, paediatric functional independence measure, and the Canadian Occupational Performance Measure. RESULTS: The 88-item Gross Motor Function Measure was significantly improved after training in the high-intensity (D Δ8.3 ± 15.6; E Δ3.8 ± 4.1) and comfortable intensity (D Δ2.9 ± 3.1; E Δ1.2 ± 2.0) groups, whereas gait speed was improved in the comfortable intensity group, without statistically significant group differences. Only the low-intensity group showed improvement on the stability index (Δ -0.6 ± 0.9, p = 0.05). Everyday functional performance significantly improved in all three groups, with the comfortable intensity group showing the greatest improvement. INTERPRETATION: Different training intensities produced improvement in different areas; individualized RAGT intensity adjustment is therefore needed based on the rehabilitation goal.

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.

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.

Investigation of the efficacy of low-frequency repetitive transcranial magnetic stimulation on upper-limb motor recovery in subacute ischemic stroke without cortical involvement: a protocol paper for a multi-center, double-blind randomized controlled trial.

Introduction: The incidence of stroke is increasing steadily due to factors such as population aging. Approximately 80% of stroke survivors have motor disorders affecting their daily lives. Repetitive transcranial magnetic stimulation (rTMS) has been reported to maximize functional recovery after stroke along with exercise intervention in upper limb rehabilitation treatment. However, whether rTMS affects the recovery of upper limb function in patients with stroke remains unclear. Therefore, in this trial, we will investigate the efficacy of low-frequency rTMS in patients with subcortical and brainstem ischemic stroke. Methods: This study has been designed as a multi-center, double-blind, randomized controlled trial to compare the efficacy of low-frequency rTMS over the contralesional M1 with sham stimulation. Overall, 88 participants will be allocated to the intervention or control group in a 1:1 ratio, with stratification according to their initial upper extremity Fugl-Meyer assessment (UE-FMA) score. The participants will receive either 30 min of real rTMS (intervention group) or sham rTMS (control group), followed by 30 min of occupational therapy for 10 consecutive workdays. All the participants will receive the same amount of rehabilitation therapy throughout the intervention period. Evaluations will be performed at baseline (T0), at the end of treatment (T1), and 4 weeks after the end of treatment (T2), including the box and block test (BBT), UE-FMA, Korean version of the Modified Barthel Index, and NIH Stroke Scale scores, Finger tapping test, Brunnstrom stage, modified Ashworth scale, and grip strength. The primary outcome will be the change in the BBT score between T0 and T2. Conclusion: This study will provide evidence on the efficacy of low-frequency rTMS in motor function recovery of the upper limb in patients with subacute, subcortical, and brainstem ischemic stroke. Clinical trial registration: ClinicalTrials.gov, identifier [NCT05535504].

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.

Clinical characteristics of chronic rhinitis following stroke.

Background: We previously observed that patients with stroke complained of rhinitis symptoms that developed following the occurrence of stroke. Objectives: To investigate the relationship between chronic rhinitis (CR) and stroke. Methods: This retrospective study analyzed the medical records and questionnaires of patients with stroke who visited our outpatient clinic from June to December 2020. Stroke lesions were mainly classified as supratentorial, infratentorial, and supra/infratentorial lesions. Supratentorial lesions were further divided into cortex, subcortex, and mixed. Participants were screened for CR and were subsequently divided into the CR and non-CR groups. The Sino-Nasal Outcome Test questionnaire and a questionnaire on autonomic nervous system symptoms were administered to all patients. Results: Clinically evaluated indicators were not significantly different between the two groups. The number of patients with lesions in both the cortex and subcortex was significantly higher in the CR group than in the non-CR group. The risk of CR was higher in male patients with stroke than their female counterparts; additionally, the risk of CR was higher in patients with stroke who had both cortical and subcortical lesions, as well as autonomic dysfunction. Conclusions: Individuals with subcortical stroke damage had a greater probability of developing CR. The risk was increased in men, as compared with that in women, when autonomic symptoms were present.

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.

Financial InceNtives for cArdiac rehabilitatioN ComplEtion (FINANCE) (single blind pragmatic RCT).

INTRODUCTION: Cardiac rehabilitation (CR) is strongly indicated in patients with acute myocardial infarction (MI), and has been proven to reduce mortality and recurrence and improve patients quality of life. Although clinical guidelines for CR have already been developed domestically and internationally, hospital-based CR remains underutilized. Currently, studies exploring strategies to improve CR participation in South Korea and Asia are limited. OBJECTIVES: This study aims to compare the effect of providing CR financial incentives to post-MI patients referred for outpatient CR and to confirm the effect of increasing CR participation and completion rates. METHODS: This single-blind, pragmatic, randomized controlled trial will be conducted at 2 tertiary hospitals for CR after acute MI. The control and experimental groups will be randomized, with each group consisting of 24 participants (total of 48 participants) assigned in a 1:1 ratio. The experimental group will receive 4, 7, and 11 USD per completed session of CR during the 1st to 12th, 13 to 24th, and 25th to 36th sessions of CR, respectively, for 3 months after enrollment. Participants who completed the 36 sessions will receive 260 USD incentives. The primary outcomes at 3 months will be used to assess the CR participation rate, as the number of CR sessions completed, and CR completion, as attendance of sessions greater than 50%, thus completion of ≥18 sessions. The outcomes will be used to compare changes in cardiorespiratory function (VO2 max, VO2 at anabolic threshold), the Korean activity scale index, EuroQol 5 dimensions, and the patient health questionnaire at 3 months after discharge and 6 and 12 months after baseline. DISCUSSION: Providing financial incentives may confirm the effect of increasing CR on participation and completion rates.

Reliability of electroencephalogram indicator and event related potential in subacute stroke.

Cognitive impairment is observed in 12% to 56% of stroke patients, and screening for cognitive impairment is often complex and time-consuming, with results dependent on patient compliance. Therefore, there is a need for an objective method to assess cognitive impairment regardless of patient compliance. Objective evaluation methods include electroencephalogram (EEG) and event-related potential (ERP). This study was conducted to assess intra-tester reliability of resting EEG-based spectral features and auditory/visual P300 latency/amplitude in patients with subacute ischemic stroke. Twenty patients with subacute ischemic stroke were included in the study. The resting EEG and P300 wave using an auditory and visual oddball paradigm were measured at baseline and once again in 24 hours. The following electrode positions (10-20 system) were constantly recorded: F3 (Frontal), Fz, F4, C3 (Central), Cz, C4, P3 (Parietal), Pz, P4. DAR (delta/alpha ratio) and BSI (brain symmetry index) were determined using EEG data. F3 and F4, C3 and C4 and P3 and P4 were switched according to the stroke side and classified as affected hemisphere (AH) and unaffected hemisphere (UH) after the evaluation. In ERP, the amplitude and latency of P300 were obtained. In reliability analysis of EEG-based spectral characteristics, significant reliability was observed for DAR (ICC = 0.447), BSldir (ICC = 0.713) and BSIdirtheta (ICC = 0.724) (Table 4). DAR was showed a poor ICC level, and BSIdir and BSIdirtheta had a moderate ICC level. Visual P300 latency showed excellent intraclass correlation coefficient (ICC) in several montages (PUH = 0.972, Pz = 0.945). In 6 montages, auditory P300 latency was reliable, while in 9 montages, visual P300 latency was reliable. In 4 montages, auditory P300 amplitude was reliable, while visual P300 amplitude was reliable in 7. The visual P300 was more reliable than the auditory P300. The ICC values for P300 latency were greater than those for amplitude. Therefore, when ERP is performed on subacute stroke patients, visual has higher reliability than auditory.

Comparison of Factors Associated With Direct Versus Transferred-in Admission to Government-Designated Regional Centers Between Acute Ischemic Stroke and Myocardial Infarction in Korea.

BACKGROUND: There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI. METHODS: Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed. RESULTS: Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI; additionally, age (65-74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI. CONCLUSIONS: Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

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.

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.

Comparison of the Forefoot Pressure-Relieving Effects of Foot Orthoses.

PURPOSE: Metatarsal pads are prescribed to decrease forefoot plantar pressure. However, the appropriate metatarsal pad placement location remains a debated issue. We aimed to identify the most effective insole design that reduces forefoot plantar pressure and determine the optimal position for metatarsal pad placement. MATERIALS AND METHODS: We recruited 16 healthy adult volunteers, and measured their plantar pressure data during walking while using an in-shoe system. The volunteers were randomly assigned to one of four insole conditions: 1/16-inch insole (i.e., control), 1/4-inch soft plastazote (SP) flat insole, metatarsal pad positioned proximal to the metatarsal head (MTH) on the control insole (P0), and metatarsal pad positioned 10 mm distal from the proximal border of the MTH on the control insole (P10). A masking protocol was created by dividing the forefoot into three subareas, distal to the MTH (dMTH), beneath to the MTH (bMTH), and proximal to the MTH (pMTH). The participants reported their comfort level for each insole using a visual analog scale. RESULTS: The SP flat insole and metatarsal pads both had a forefoot plantar pressure-reducing effect and provided insole comfort. Of the three insole designs, the SP flat insole was the most effective. No clear difference existed in efficacy in terms of the location of the metatarsal pad placement. CONCLUSION: Considering the possibility of discomfort caused by improper metatarsal pad placement, the SP that increases shock absorption may be more clinically useful.

Elastic Dynamic Sling on Subluxation of Hemiplegic Shoulder in Patients with Subacute Stroke: A Multicenter Randomized Controlled Trial.

Background: Shoulder subluxation occurs in 17−64% of hemiplegic patients after stroke and develops mostly during the first three weeks of hemiplegia. A range of shoulder orthoses has been used in rehabilitation to prevent subluxation. However, there is little evidence of their efficacy. AIM: This study aimed to investigate whether there is a difference in the subluxation distance, pain, and functional level of the hemiplegic upper extremity among patients with two different shoulder orthoses. Design: This is a prospective, randomized controlled trial with intention-to-treat analysis. SETTING: Multicenter, rehabilitation medicine department of two university hospitals in South Korea. Population: Forty-one patients with subacute stroke with shoulder subluxation with greater than 0.5 finger width within 4 weeks of stroke were recruited between January 2016 and October 2021. Methods: The experimental group used an elastic dynamic sling while sitting and standing to support the affected arm for eight weeks. The control group used a Bobath sling while sitting and standing. The primary outcome was to assess the distance of the shoulder subluxation on radiography. The secondary outcomes were upper-extremity function, muscle power, activities of daily living, pain and spasticity. Result: The horizontal distance showed significant improvement in the elastic dynamic sling group, but there were no significant differences in the vertical distance between the elastic dynamic and Bobath sling groups. Both groups showed improvements in upper-extremity movements and independence in daily living after 4 and 8 weeks of using shoulder orthoses, and the differences within the groups were significant (p < 0.05). However, there were no significant differences in upper-extremity movements and independence in daily living between the two groups. Conclusions: The subluxation distance showed better results in the elastic dynamic sling, which has both proximal and distal parts, than in the Bobath sling, which holds only the proximal part. Both shoulder orthoses showed improvements in the modified Barthel index, upper-extremity function, and manual muscle testing.

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.

A survey of the perceptions of barriers to and facilitators of cardiac rehabilitation in healthcare providers and policy stakeholders.

BACKGROUND: Cardiac rehabilitation (CR) is a prognostic management strategy to help patients with CVD achieve a good quality of life and lower the rates of recurrence, readmission, and premature death from disease. Globally, cardiac rehabilitation is poorly established in hospitals and communities. Hence, this study aimed to investigate the discrepancies in the perceptions of the need for CR programs and relevant health policies between directors of hospitals and health policy personnel in South Korea to shed light on the status and to establish practically superior and effective strategies to promote CR in South Korea. METHODS: We sent a questionnaire to 592 public health policy managers and directors of selected hospitals, 132 of whom returned a completed questionnaire (response rate: 22.3%). The participants were categorized into five types of organizations depending on their practice of PCI (Percutaneous Coronary Intervention), establishment of cardiac rehabilitation, director of hospital, and government's policy makers. Differences in the opinions between directors of hospitals that perform/do not perform PCI, directors of hospitals with/without cardiac rehabilitation, and between hospital directors and health policy makers were analyzed. RESULTS: Responses about targeting diseases for cardiac rehabilitation, patients' roles in cardiac rehabilitation, hospitals' roles in cardiac rehabilitation, and governmental health policies' roles in cardiac rehabilitation were more positive among hospitals that perform PCI than those that do not. Responses to questions about the effectiveness of cardiac rehabilitation and hospitals' roles in cardiac rehabilitation tended to be more positive in hospitals with cardiac rehabilitation than in those without. Hospital directors responded more positively to questions about targeting diseases for cardiac rehabilitation and governmental health policies' roles in cardiac rehabilitation than policy makers, and both hospitals and public organizations provided negative responses to the question about patients' roles in cardiac rehabilitation. Responses to questions about targeting diseases for cardiac rehabilitation, patients' roles in cardiac rehabilitation, and governmental health policies' roles in cardiac rehabilitation were more positive in hospitals that perform PCI than those that do not and public organizations. CONCLUSIONS: Hospitals must ensure timely referral, provide education, and promote the need for cardiac rehabilitation. In addition, governmental socioeconomic support is needed in a varity of aspects.

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.