Long-term Time Course of Activities of Daily Living in First-ever Stroke According to Initial Stroke Severity: Multicenter Prospective Cohort Study

Research Objectives: Stroke is one of the most devastating neurological diseases causing long-term disabilities and survivors are left to continue their lives with neurologic sequela affecting activities of daily living (ADL). The aim of this study was to investigate recovery patterns and characteristics of ADL according to initial stroke severity through long-term follow-up.

Design: Prospective cohort study with 36 months follow-up.

Setting: Nine tertiary hospitals.

Participants: 10,636 patients who met the following inclusion criteria were recruited: (1) first time acute stroke, (2) 19 years or older, (3) within 7 days from onset of stroke. 7,858 patients consented to the follow-up and 4,453 were analyzed in this study after excluding those lost to follow-up.

Interventions: Not applicable.

Main Outcome Measures: The primary outcome was Functional Independence Measure (FIM), which evaluates limitations in ADL. FIM was documented following acute management and at 3, 6, 12, 18, 24, 30 and 36 months after onset. Initial stroke severity was assessed seven days after onset using the National Institutes of Health Stroke Scale (NIHSS) and categorized into five groups: no neurological impairment (NIHSS 0), mild (NIHSS 1-4), moderate (5-15), moderate to severe (16-20), and severe (NIHSS 21-42).

Results: Statistically significant difference in improvement of FIM was shown according to initial severity in total patients (p < 0.001). FIM of total population significantly improved until 18 months after onset and declined from 24 months. The mild impairment group reached a plateau of FIM at 18 months. However, moderate and moderate to severe impairment reached a plateau at 12 months, while no and severe impairment groups peaked at 6 months. All five groups demonstrated the peak FIM efficiency at the 0-3 months period compared to other follow-up periods (p < 0.001). All FIM sub-items from the domains of self-care, transfer, and locomotion reached a functional plateau at 18 months. However, other sub-items reached earlier plateaus; with bowel management, comprehension, expression and problem solving at 6 months, and bladder management and memory at 12 months (p < 0.007). At 36 months post-stroke, locomotion of stair and bathing were the lowest sub-items, while sphincter control of bowel and bladder were the two highest (p < 0.001).

Conclusions: This study revealed that recovery pattern was largely dependent on the initial stroke severity, and sub-items of FIM also showed different recovery patterns. These findings may offer valuable insights for post-stroke rehabilitation plans.

Author(s) Disclosures: None.