Tamaya Van Criekinge, PT, PhD
Regaining the ability to walk is the primary therapy goal for the majority of stroke survivors. However, gait rehabilitation does not end when a patient is able to walk up and down the corridor for six meters. People living with stroke need to be able to walk independently, with or without aids, on stable and unstable surfaces, in crowded environments full of distractions, under time pressure of moving traffic, while performing dual tasks, and all this in an energy-efficient manner. To optimize the walking pattern of stroke survivors, we need to fully understand the underlying impairments and recovery process. The aim of this study was to investigate the longitudinal progression in functional mobility during the first year after stroke and determine the rate of change between different levels of stroke severity.
In total, 140 participants who are over 18 years of age, diagnosed with stroke according to the World Health Organization (WHO) criteria, living near the rehabilitation center (Sahlgrenska University Hospital, Sweden), The National Institutes of Health Stroke Scale (NIHSS) ≤16, Barthel Index (BI) ≥50, life expectance ≥1 year, were included in this study. The Timed up-and-Go test (TUG) was used to assess functional mobility after 5 days of onset, within 24 hours of discharge, 1 after discharge, 3 months and 1-year post-stroke. In addition, clinical and activity limitations were assessed with the NIHSS, Fugl-Meyer Assessment, Montreal Cognitive Assessment, modified Rankin Scale (mRS) and BI.
Due to loss at baseline, only 135 participants (median age 76 years, range 37–96, 52 females [39%]) were included at baseline. Another 44 patients were excluded as a result of drop-out or recurrent stroke. The remaining 91 participants were included in a baseline cluster analysis, dividing participants into two distinct groups: 52% had a moderate stroke, and 48% had mild stroke. The most important variables contributing to the distinction were TUG time, TUG steps, mRS, total BI, and ability to independently use the toilet. The authors further analyzed the recovery processes of the two groups.
Assessment baseline to 1 year: Functional mobility significantly recovered in the moderate stroke group after 1 year post-stroke; patients with age <75 improved 7.2 s in TUG time, while those >75 years improved 5.8 s. On the other hand, in patients with mild stroke, tendency to improve was evident but not statistically significant. However, subgroup analysis showed significant improvements in the group in patients who were <75 years of age, but not in the older group. Differences in functional mobility between the two groups were clearly present at baseline but diminished at 3 months post-stroke and increased again to 1 year.
Assessment baseline to 3 months: During the first three months, the maximum rate of improvement was greater in the moderate stroke group (improvement of 8.2 s in TUG time) as compared to the mild group.
Assessment 3 months to 1 year: After three months, the functional mobility worsened in the moderate group, which was mainly apparent in patients aged >75 years (12% increase in TUG time). No significant decline was found in the mild group.
This study shows that recovery of functional mobility is clearly different between patients with moderate and mild stroke. Patients with moderate stroke improve their functional mobility mostly in the first three months; afterwards, decline may present (especially in patients >75 years). In the mild group, no significant improvement was found in the course of 1 year. A relatively large sample size, multiple assessment points, and long follow-up period are important strengths of the study. Results of this study confirm that recovery declines as soon as rehabilitation ends, suggesting that long-term rehabilitation is needed. Spontaneous neurological recovery may also decrease at this time. However, this should only explain a decrease in rate of recovery and not a decline in functional motility. Future investments in long-term rehabilitation, more intensive follow-up, and support resources after discharge will be crucial to maintain recovery achievements obtained during the first three months after stroke.