Clinical Practice Guideline for Stroke Rehabilitation in Korea PDF 2022

Brain Neurorehabil. 2023 Jul;16(2):e18 https://doi.org/10.12786/bn.2023.16.e18 pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation Clinical Practice Guideline...

Brain Neurorehabil. 2023 Jul;16(2):e18 https://doi.org/10.12786/bn.2023.16.e18 pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation Clinical Practice Guideline Clinical Practice Guideline for Stroke Rehabilitation in Korea—Part 1: Rehabilitation for Motor Function (2022) Doo Young Kim, Byungju Ryu, Byung-Mo Oh, Dae Yul Kim, Da-Sol Kim, Deog Young Kim, Don-Kyu Kim, Eun Joo Kim, Hoo Young Lee, Hyoseon Choi, Hyoung Seop Kim, Hyun Haeng Lee, Hyun Jung Kim, Hyun Mi Oh, Hyun Seok, Jihye Park, Jihyun Park, Jin Gee Park, Jong Moon Kim, Jongmin Lee, Joon-Ho Shin, Ju Kang Lee, Ju Sun Oh, Ki Deok Park, Kyoung Tae Kim, Min Cheol Chang, Min Ho Chun, Min Wook Kim, Min-Gu Kang, Min-Keun Song, Miyoung Choi, Myoung-Hwan Ko, Na Young Kim, Nam-Jong Paik, Se Hee Jung, Seo Yeon Yoon, Seong Hoon Lim, Seong Jae Lee, Seung Don Yoo, Seung Hak Lee, Seung Nam Yang, Si-Woon Park, So Young Lee, Soo Jeong Han, Sook Joung Lee, Soo-Kyung Bok, Suk Hoon Ohn, Sun Im, Sung-Bom Pyun, Sung Eun Hyun, Sung Hoon Kim, Sung-Hwa Ko, Sungju Jee, SuYeon Kwon, Tae-Woo Kim, Won Hyuk Chang, Won Kee Chang, Woo-Kyoung Yoo, Yeo Hyung Kim, Yeun Jie Yoo, Yong Wook Kim, Yong-Il Shin, Yoon Ghil Park, Yoon-Hee Choi, Youngkook Kim, KSNR Stroke CPG Writing Group Received: May 9, 2023 Accepted: Jul 6, 2023 HIGHLIGHTS Published online: Jul 17, 2023 This clinical practice guideline is the fourth edition of the Korean guideline for stroke Correspondence to rehabilitation, which was last updated in 2016. Min Wook Kim The development approach has been changed from a consensus-based approach to Department of Rehabilitation Medicine, Incheon St. Mary’s Hospital, College of an evidence-based approach using the Grading of Recommendations Assessment Medicine, The Catholic University of Korea, Development and Evaluation method. 56 Dongsu-ro, Bupyeong-gu, Incheon 21431, Korea. Email: [email protected] Copyright © 2023. Korean Society for Neurorehabilitation i Brain Neurorehabil. 2023 Jul;16(2):e18 https://doi.org/10.12786/bn.2023.16.e18 pISSN 1976-8753·eISSN 2383-9910 Brain & NeuroRehabilitation Clinical Practice Guideline Clinical Practice Guideline for Stroke Rehabilitation in Korea—Part 1: Rehabilitation for Motor Function (2022) Doo Young Kim ,1 Byungju Ryu ,2 Byung-Mo Oh ,3,4,5 Dae Yul Kim ,6,7 Da-Sol Kim ,8 Deog Young Kim ,9 Don-Kyu Kim ,10 Eun Joo Kim ,11 Hoo Young Lee ,3,4 Hyoseon Choi ,12 Hyoung Seop Kim ,13 Hyun Haeng Lee ,14 Hyun Jung Kim ,12 Hyun Mi Oh ,3,4 Hyun Seok ,15 Jihye Park ,16 Jihyun Park ,17 Jin Gee Park ,18 Jong Moon Kim ,19 Jongmin Lee ,14 Joon-Ho Shin ,11 Ju Kang Lee ,20 Ju Sun Oh ,21 Ki Deok Park ,20 Kyoung Tae Kim ,22 Min Cheol Chang ,23 Min Ho Chun ,6,7 Min Wook Kim ,16 Min-Gu Kang ,24 Min-Keun Song ,25 Miyoung Choi ,26 Myoung-Hwan Ko ,8 Na Young Kim ,9 Nam-Jong Paik ,3,27 Se Hee Jung ,3,28 Seo Yeon Yoon ,9 Seong Hoon Lim ,16 Seong Jae Lee ,29 Seung Don Yoo ,30 Seung Hak Lee ,6,7 Received: May 9, 2023 Seung Nam Yang ,31 Si-Woon Park ,1 So Young Lee ,32 Soo Jeong Han ,33 Accepted: Jul 6, 2023 Sook Joung Lee ,16 Soo-Kyung Bok ,34 Suk Hoon Ohn ,17 Sun Im ,16 Published online: Jul 17, 2023 Sung-Bom Pyun ,31 Sung Eun Hyun ,3,5 Sung Hoon Kim ,35 Sung-Hwa Ko ,36 Sungju Jee ,34 SuYeon Kwon ,33 Tae-Woo Kim ,3,4 Won Hyuk Chang ,37 Correspondence to Min Wook Kim Won Kee Chang ,3,27 Woo-Kyoung Yoo ,17 Yeo Hyung Kim ,16 Yeun Jie Yoo ,16 Department of Rehabilitation Medicine, Yong Wook Kim ,9 Yong-Il Shin ,36 Yoon Ghil Park ,9 Yoon-Hee Choi ,15 Incheon St. Mary’s Hospital, College of Youngkook Kim 16, KSNR Stroke CPG Writing Group Medicine, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon 21431, Department of Rehabilitation Medicine, International St. Mary’s Hospital, Catholic Kwandong University College 1 Korea. of Medicine, Incheon, Korea Email: [email protected] 2 Department of Physical Medicine and Rehabilitation, Sahmyook Medical Center, Seoul, Korea 3 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea Copyright © 2023. Korean Society for 4 Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea Neurorehabilitation 5 Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea 6 Department of Rehabilitation Medicine, University of Ulsan College of Medicine, Ulsan, Korea This is an Open Access article distributed 7 Department of Rehabilitation Medicine, Asan Medical Center, Seoul, Korea under the terms of the Creative Commons 8 Department of Physical Medicine and Rehabilitation, Jeonbuk National University Medical School, Jeonju, Korea Attribution Non-Commercial License (https:// 9 Department of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea creativecommons.org/licenses/by-nc/4.0) 10 Department of Physical and Rehabilitation Medicine, College of Medicine, Chung-Ang University, Seoul, Korea which permits unrestricted non-commercial 11 Department of Rehabilitation Medicine, National Rehabilitation Center, Seoul, Korea use, distribution, and reproduction in any 12 Department of Rehabilitation Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, medium, provided the original work is properly Seoul, Korea cited. 13 Department of Physical medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea ORCID iDs 14 Department of Rehabilitation Medicine, Konkuk University School of Medicine, Seoul, Korea Doo Young Kim 15 Department of Physical Medicine and Rehabilitation, Soonchunhyang University College of Medicine, Asan, Korea https://orcid.org/0000-0003-1327-5348 16 Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Byungju Ryu 17 Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Chuncheon, Korea https://orcid.org/0000-0003-0109-9885 18 Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University Byung-Mo Oh School of Medicine, Changwon, Korea https://orcid.org/0000-0001-9353-7541 19 Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea 20 Department of Rehabilitation Medicine, Gachon University, Gil Medical Center, Incheon, Korea Dae Yul Kim 21 Department of Physical medicine and Rehabilitation, Seoul Medical Center, Seoul, Korea https://orcid.org/0000-0003-1275-1736 22 Department of Rehabilitation Medicine, Keimyung University School of Medicine, Keimyung University Dongsan Da-Sol Kim Hospital, Daegu, Korea https://orcid.org/0000-0002-7745-978X 23 Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Korea Deog Young Kim 24 Department of Rehabilitation Medicine, Daegu Workers’ Compensation Hospital, Daegu, Korea https://orcid.org/0000-0001-7622-6311 25 Department of Rehabilitation Medicine, Chonnam National University Medical School, Gwangju, Korea Don-Kyu Kim 26 National Evidence-based Healthcare Collaborating Agency, Seoul, Korea https://orcid.org/0000-0001-8619-830X 27 Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, Korea https://e-bnr.org 1/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation Eun Joo Kim 28 Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul, Korea https://orcid.org/0000-0001-6166-7886 29 Department of Rehabilitation Medicine, Dankook University College of Medicine, Seoul, Korea Hoo Young Lee 30 Department of Rehabilitation Medicine, Kyung Hee University School of Medicine, Seoul, Korea https://orcid.org/0000-0003-3846-943X 31 Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea Hyoseon Choi 32 Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea https://orcid.org/0000-0002-2781-2557 33 Department of Rehabilitation Medicine, Ewha Womans University College of Medicine, Seoul, Korea Hyoung Seop Kim 34 Department of Rehabilitation Medicine, College of Medicine, Chungnam National University, Daejeon, Korea https://orcid.org/0000-0002-5310-4802 35 Department of Rehabilitation Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Hyun Haeng Lee 36 Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea https://orcid.org/0000-0001-6666-6284 37 Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School Hyun Jung Kim of Medicine, Seoul, Korea https://orcid.org/0000-0002-2198-5668 Hyun Mi Oh ABSTRACT https://orcid.org/0000-0001-5493-4691 Hyun Seok https://orcid.org/0000-0001-7266-6045 Jihye Park This clinical practice guideline (CPG) is the fourth edition of the Korean guideline for https://orcid.org/0000-0002-9764-128X stroke rehabilitation, which was last updated in 2016. The development approach has been Jihyun Park changed from a consensus-based approach to an evidence-based approach using the Grading https://orcid.org/0000-0002-2172-1072 of Recommendations Assessment Development and Evaluation (GRADE) method. This Jin Gee Park change ensures that the guidelines are based on the latest and strongest evidence available. https://orcid.org/0000-0003-2672-1618 Jong Moon Kim The aim is to provide the most accurate and effective guidance to stroke rehabilitation https://orcid.org/0000-0002-8684-8736 teams, and to improve the outcomes for stroke patients in Korea. Fifty-five specialists in Jongmin Lee stroke rehabilitation and one CPG development methodology expert participated in this https://orcid.org/0000-0001-8718-0099 development. The scope of the previous clinical guidelines was very extensive, making it Joon-Ho Shin difficult to revise at once. Therefore, it was decided that the scope of this revised CPG would https://orcid.org/0000-0001-6447-8829 be limited to Part 1: Rehabilitation for Motor Function. The key questions were selected Ju Kang Lee https://orcid.org/0000-0002-8335-9785 by considering the preferences of the target population and referring to foreign guidelines Ju Sun Oh for stroke rehabilitation, and the recommendations were completed through systematic https://orcid.org/0000-0002-0994-3051 literature review and the GRADE method. The draft recommendations, which were agreed Ki Deok Park upon through an official consensus process, were refined after evaluation by a public hearing https://orcid.org/0000-0003-1684-4737 and external expert evaluation. Kyoung Tae Kim https://orcid.org/0000-0001-9355-8326 Keywords: GRADE Approach; Korea; Practice Guideline; Rehabilitation; Stroke Min Cheol Chang https://orcid.org/0000-0002-7629-7213 Min Ho Chun https://orcid.org/0000-0001-8666-7225 INTRODUCTION Min Wook Kim https://orcid.org/0000-0003-4505-809X Stroke is one of the leading causes of death in South Korea as well as around the world. Min-Gu Kang Globally, in 2019, the incidence of stroke was 12.2 million, the prevalence was 110 million, https://orcid.org/0000-0002-0680-9607 Min-Keun Song the disability-adjusted life-years lost due to stroke was 143 million, and the number of deaths https://orcid.org/0000-0001-8186-5345 were 6.55 million. According to the Korean Statistical Information Services, the number Miyoung Choi of stroke patients in South Korea has been over 110,000 per year for the past five years. https://orcid.org/0000-0002-2424-9965 Comprehensive and specialized rehabilitation treatment starting from the acute phase of Myoung-Hwan Ko stroke can improve functional recovery and minimize disability [3-5]. Many countries have https://orcid.org/0000-0002-0566-3677 Na Young Kim recognized the need for stroke rehabilitation and developed clinical practice guidelines https://orcid.org/0000-0001-9888-3953 (CPG) for stroke rehabilitation tailored to their individual circumstances [6-9]. Korean Nam-Jong Paik Society for NeuroRehabilitation (KSNR) has also published and revised CPGs for stroke https://orcid.org/0000-0002-5193-8678 rehabilitation, most recently the third edition in 2016. Since the publication of the third Se Hee Jung edition, a number of important studies in stroke rehabilitation have been published, and it https://orcid.org/0000-0002-0623-8752 has become clear that the CPG need to be revised to reflect these recent findings. https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 2/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation Seo Yeon Yoon AIM OF CPG https://orcid.org/0000-0002-0365-2923 Seong Hoon Lim The aim of this CPG is to provide medical professionals with the necessary information for https://orcid.org/0000-0002-5475-4153 the rehabilitation process of stroke patients, from acute to chronic stages, based on scientific Seong Jae Lee https://orcid.org/0000-0001-7867-4695 and objective evidence. The CPG also seeks to reduce variability in the quality of care received Seung Don Yoo by stroke patients in different medical settings. This CPG aims to help the patient recover https://orcid.org/0000-0003-4513-2560 their function, prevent complications, and facilitate their return to society. Seung Hak Lee https://orcid.org/0000-0002-3017-8497 Seung Nam Yang https://orcid.org/0000-0003-2850-0341 TARGET POPULATION AND SCOPE Si-Woon Park https://orcid.org/0000-0002-1787-4914 The “Clinical Practice Guideline for Stroke Rehabilitation in Korea. Part 1: Rehabilitation for So Young Lee Motor Function (2022)” is the 4th edition of CPG for stroke rehabilitation in Korea, which https://orcid.org/0000-0002-2832-6083 updates the 3rd edition published in 2016 , and it deals with the rehabilitation of adult Soo Jeong Han male and female stroke patients with motor dysfunction caused by stroke. Pediatric stroke is https://orcid.org/0000-0002-5685-0384 Sook Joung Lee not covered in this guideline, and both ischemic and hemorrhagic strokes are included. https://orcid.org/0000-0002-6894-445X Soo-Kyung Bok https://orcid.org/0000-0002-8957-2827 END-USERS AND SETTINGS Suk Hoon Ohn https://orcid.org/0000-0002-1139-1946 Sun Im The primary target users of this CPG are physicians and therapists who provide care for https://orcid.org/0000-0001-8400-4911 patients with disabilities in activities of daily living, including motor dysfunction due to Sung-Bom Pyun stroke, at primary, secondary, and tertiary medical facilities. https://orcid.org/0000-0002-1933-038X Sung Eun Hyun https://orcid.org/0000-0003-3114-5504 Sung Hoon Kim METHOD OF CPG DEVELOPMENT https://orcid.org/0000-0001-6043-7640 Sung-Hwa Ko Building of CPG development group https://orcid.org/0000-0003-4900-5972 The development team for clinical guidelines was composed of the operational committee, Sungju Jee the practical committee, and the advisory committee. The head of the development team https://orcid.org/0000-0002-9400-9609 for clinical guidelines was appointed based on the consensus of the KSNR after considering SuYeon Kwon https://orcid.org/0000-0003-2840-4982 the expertise and representativeness, and 11 operational committee members, including the Tae-Woo Kim head of the committee, secretary, and one methodologist expert, were selected to form the https://orcid.org/0000-0003-4017-549X operational committee. The practical committee for the development of clinical guidelines Won Hyuk Chang was composed of 54 specialists from 26 universities and 5 hospitals nationwide. The advisory https://orcid.org/0000-0002-4969-7895 committee provided advice and reviewed the recommendations during the development Won Kee Chang process for the substantive content covered by the clinical guidelines. The advisory https://orcid.org/0000-0001-9756-6817 Woo-Kyoung Yoo committee included the chairperson, vice chairperson, and eight members of the KSNR who https://orcid.org/0000-0002-1273-0647 have expertise and representativeness in the related field. Yeo Hyung Kim https://orcid.org/0000-0002-3951-7205 Decision of CPG development method Yeun Jie Yoo Although this clinical guideline is an updated version of “Clinical Practice Guideline for https://orcid.org/0000-0003-1323-4503 Yong Wook Kim Stroke Rehabilitation in Korea,” the development approach has been changed from an https://orcid.org/0000-0002-5234-2454 expert-opinion based to an evidence-based clinical guideline development method (Grading Yong-Il Shin of Recommendations Assessment Development and Evaluation, GRADE). This clinical https://orcid.org/0000-0001-7894-0930 guideline is partially updated from the previous clinical guideline, but systematic search Yoon Ghil Park and analysis of reference literature is being conducted for the first time, so it was decided https://orcid.org/0000-0001-9054-5300 to develop it as a de novo (new development). The selection of key questions was based on the previous clinical guideline, but it was decided to consider the latest foreign clinical https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 3/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation Yoon-Hee Choi guidelines, the perspectives and preferences of the target population, and the results of the https://orcid.org/0000-0001-6651-7908 survey when selecting key questions. Youngkook Kim https://orcid.org/0000-0003-3964-026X Decision of CPG scope Funding The revision of this CPG has been transformed into an evidence-based clinical guideline None. development method through systematic evidence search and analysis, GRADE, while the extensive previous clinical guidelines have been divided into three parts and will be Conflict of Interests All researchers involved in the development sequentially updated in phases. With the advice of the operations committee and the of this clinical guideline were instructed to advisory committee, the scope of this clinical guideline has finally been determined as Part 1: indicate any conflicting interests related to Rehabilitation for Motor Function. the study (involvement in similar clinical guideline development, employment, financial Evaluation of foreign stroke clinical guidelines understanding, and other potential conflicts). All researchers except for six declared that To select the key questions, references were made to foreign guidelines for stroke they have no conflicting interests. Researchers rehabilitation. The stroke rehabilitation guidelines published in Canada (2019) [7,9], the with personal interests in the content of this United States (2019) , and Australia (Living updated CPG) were evaluated using the clinical guideline have excluded themselves Korean appraisal of guidelines for research and evaluation II (K-AGREE II). Each guideline from making recommendations regarding was evaluated by two researchers, and all three foreign guidelines were referred to by the specific items (botulinum toxin, virtual reality, guideline operating committee and the practical committee in selecting the key questions. robot rehabilitation, medication). Perspectives and preferences of the target population The operating committee summarized 39 key questions that were relevant to the scope of this study, based on the key questions of the previous CPG and the latest foreign guidelines for rehabilitation after stroke. They surveyed the perspectives and preferences of the target population regarding these key questions. A survey was conducted on 11 stroke patients and their caregivers who were hospitalized in the hospital where the operating committee members belong. The preferences of the target population regarding each key question were surveyed using an 11-point Likert scale, with the perspective of the target population on the importance or desired coverage in the treatment guidelines. Selection of key questions The operating committee organized 39 key questions that are relevant to the scope of the study from the key questions of the existing clinical guidelines and the latest foreign guidelines for stroke rehabilitation and surveyed the perspectives and preferences of the target population and the members of practical committee. The results of the survey were discussed by the operating committee, and based on this, 24 final key questions were selected from the 39 candidate key questions. Searching and selecting evidence-based literature The literature search was conducted by entrusting it to 6 information search experts, using three overseas databases, PubMed (https://pubmed.ncbi.nlm.nih.gov/), EMBASE (http:// embase.com), and Cochrane Library (http://cochranelibrary.com). The search range for a comprehensive literature search was not specified for the starting point and was until February 28, 2022. The results of the search were finally selected by at least 2 clinical experts in charge of each key question, according to the PRISMA flow diagram. Evaluation of risk of bias The final selected literature was individually evaluated by a minimum of two clinical specialists for each key question, using a literature screening evaluation tool. A systematic review was conducted using AMSTAR (A MeaSurement Tool for Assessment of multiple https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 4/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation systematic Reviews) 1.0, and for randomized controlled trial (RCT) studies, Cochrane’s Risk of Bias (RoB 1.0) was used, while for non-RCT studies, the Risk of Bias Assessment tool for Non-randomized Study 2.0 (RoBANS 2.0) was used. The evaluations were then reviewed through a consensus process. Analysis of evidence The clinical experts responsible for each key question summarized the results of the final selected studies and, if a meta-analysis was feasible, performed a meta-analysis. If a meta- analysis was possible, the data heterogeneity was assessed. For data with high heterogeneity, a random-effects model was applied, and subgroup analyses was conducted. Publication bias was assessed using Egger’s test and the trim-and-fill method if the number of studies included in the synthesis was over 10. Review Manager (RevMan) Version 5.4 (Copenhagen: The Nordic Cochrane Center) was used for meta-analysis. Assessment of certainty of the evidence and level of recommendation The level of certainty of evidence and recommendation grades were carried out using the GRADE method , based on the results of the blinding evaluation and the evaluation and analysis of evidence. The process was carried out by at least two clinical experts who evaluated individually and reached a consensus. We presented certainty of evidence as summary of findings table. Formal consensus and conflict of interests Among the development members, if there was even a slight interest in the result of the declaration of interest, it was excluded from the development process of individual clinical questions with interest and the official agreement process. Prior to reaching a formal consensus, a preliminary consensus was reached through a review meeting for each team, and an additional preliminary consensus meeting was held at the operating committee. The recommendations revised and supplemented through informal consensus were subsequently followed by a formal consensus-building process using the RAND-UCLA Appropriateness Method (RAM) method. Opinion of the persons concerned/appraisal from outside expert After drafting, a public hearing was held by inviting stakeholders to improve the quality of the guideline, the developed CPG was evaluated by experts (include representatives of related academic societies) who were not involved in the guideline development process. The completed CPG will be entrusted to the Clinical Practice Guideline Expert Committee of the Korean Medical Association for external evaluation, and the pointed-out points will be referred to in the next revision. Distribution and implement This CPG will be released free of charge on the website of the KSNR and will be distributed through publicity. Plan of revision/update The revision/update of the CPG will be based on the contents of the previous 3rd CPG but will be conducted with GRADE method. The scope of the previous clinical guidelines was very extensive, making it difficult to revise at once. Therefore, the previous version of the CPG was divided into three parts and updated sequentially: 1) motor/sensory function, 2) non-motor function, 3) other (general, complications, chronic rehabilitation, etc.). https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 5/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation RESULTS As a result of the above development process, evidence-based CPG was developed including recommendations for a total of 24 key questions (Table 1) A Korean version of the recommendation summary is available as Supplementary Data 1, and the detailed development process and rationale for the recommendation is available as Supplementary Data 2. DISCUSSION In Korea, research on guidelines for rehabilitation treatment for stroke started in 2006 and the first edition of “Clinical Practice Guideline for Stroke Rehabilitation in Korea.” was published in 2009. The 2009 guidelines were based on guidelines for stroke treatment in the United States (2005) , Europe (2003) , UK (2004) , Scotland (2002) , Table 1. Summary of recommendations (See Supplementary Data 1 for a summary in Korean) KQ Division Recommendation LoE LoR KQ 1. Early mobilization Update 1-1. Early mobilization is recommended within 24–48 hours of stroke onset as it improves functional Low A independence and walking ability in stroke patients, unless contraindicated. 1-2. Selective consideration is given to very early mobilization within 24 hours of stroke onset. High B *Early mobilization: Out-of-bed activities such as sitting, standing, and walking performed during the acute phase of stroke KQ 2. Total amount Update 2. It is recommended to increase the total amount of exercise therapy, considering the patient's Low B neurological and medical status, to improve activities of daily living and motor function in stroke patients. KQ 3. Exercise therapy Update 3. As there is no superior exercise therapy method among various methods that have the effect Moderate A method of improving motor function, such as exercise relearning, neurophysiological approach, and biomechanical approach, it is recommended to apply them individually in combination according to the patient’s condition. KQ 4. Task-specific Update 4-1. Task-specific training is recommended for the improvement of upper limb function. Low A training 4-2. Task-specific training is recommended for the improvement of lower limb function. Moderate A KQ 5. Progressive Update 5-1. For stroke patients with upper limb weakness, progressive resistance training of the upper limb Very low A resistance training is recommended for improving upper limb strength, motor function, and activities of daily living, compared to not receiving rehabilitation therapy. 5-2. For stroke patients with upper limb weakness, there is no significant difference in improving upper Low B limb strength, motor function, and activities of daily living between progressive resistance training of the upper limb and other rehabilitation methods. Therefore, it is considered to apply depending on the patient's condition. 5-3. For stroke patients with lower limb weakness, progressive resistance training of the lower limb is Moderate A recommended for improving lower limb strength and motor function, compared to not receiving rehabilitation therapy. 5-4. For stroke patients with lower limb weakness, there is no significant difference in improving lower Low B limb strength and motor function between progressive resistance training of the lower limb and other rehabilitation methods, so it is recommended depending on the patient's condition. KQ 6. Aerobic exercise Update 6-1. Regular aerobic exercise, considering appropriate medical evaluation and functional limitations Moderate A due to concurrent diseases, is recommended for stroke patients as it has a positive effect on cardiorespiratory function, motor function, disability improvement, and quality of life. 6-2. High intensity interval training (HIIT) in chronic stroke patients can have positive effects on the Moderate B recovery of cardiovascular and motor function, so it is recommended with appropriate medical evaluation and consideration of coexisting conditions and functional limitations. 6-3. Educating home-returning stroke patients on aerobic exercise, considering comorbidities and Moderate B functional limitations as well as accessibility, and providing community-based long-term intervention may help improve their exercise capacity, so it is recommended depending on the patient’s condition. KQ 7. Treadmill exercise Update 7-1. In stroke patients, gait training in a treadmill is recommended over no intervention, as it is more High A effective in improving walking function. 7-2. Compared to conventional therapy, it cannot be said that gait training in a treadmill is superior in High B improving walking function, so it should be applied selectively. KQ 8. Functional Update 8-1. Functional electrical stimulation therapy is recommended for improving upper limb function and High A electrical performing daily activities in stroke patients. stimulation 8-2. Functional electrical stimulation therapy is recommended for improving lower limb function. High A 8-3. Functional electrical stimulation therapy is recommended for improving shoulder joint subluxation. High A (continued to the next page) https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 6/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation Table 1. (Continued) Summary of recommendations (See Supplementary Data 1 for a summary in Korean) KQ Division Recommendation LoE LoR KQ 9. Ankle-foot orthosis Update 9-1. In stroke patients with foot drop, considering the use of an ankle-foot orthosis is recommended, as it Moderate B improves walking. 9-2. Regarding whether ankle-foot orthosis or functional electrical stimulation therapy is more effective Moderate B in improving walking in stroke patients with foot drop, no method can be said to be superior, so they should be applied selectively according to the patient's condition. In this statement, functional electrical stimulation therapy, compared to ankle-foot orthosis, is limited to a treatment method that uses electrical stimulation to prevent foot drop in accordance with the walking cycle. KQ 10. Repetitive Update 10-1. Adding repetitive transcranial magnetic stimulation to rehabilitation therapy in stroke patients has Low B transcranial a positive effect on improving upper limb motor function, grip strength, and hand function, so it is magnetic recommended depending on the patient's condition. stimulation 10-2. The evidence for repetitive transcranial magnetic stimulation to improve lower limb function in I stroke patients is insufficient, so a recommendation level cannot be determined. 10-3. Adding repetitive transcranial magnetic stimulation to rehabilitation therapy in stroke patients has a Low B positive effect on improving upper limb spasticity, so it is recommended depending on the patient's condition. 10-4. The evidence for repetitive transcranial magnetic stimulation to improve lower limb spasticity in I stroke patients is insufficient, so a recommendation level cannot be determined. KQ 11. Robot Update 11-1. In stroke patients, when applying machine-assisted training, including upper limb robots, there High B is an improvement in upper limb function and daily living ability compared to conventional rehabilitation therapy, so it is recommended depending on the patient's condition and the medical institution's circumstances. 11-2. In stroke patients, when applying machine-assisted training, including lower limb robots, there High B is an improvement in balance ability compared to conventional rehabilitation therapy, so it is recommended depending on the patient's condition and the medical institution's circumstances. KQ 12. Virtual reality Update 12-1. Virtual reality therapy for stroke patients is more effective in improving upper limb motor function Low B compared to conventional rehabilitation therapy, but it can have side effects, so it is recommended depending on the patient’s condition. 12-2. Virtual reality therapy for stroke patients is effective in improving balance compared to conventional Low B rehabilitation therapy, but it can have side effects. KQ 13. Transcranial Update 13-1. Transcranial direct current stimulation can have a positive effect on improving upper limb motor/ High B direct current function in stroke patients, and it is recommended in conjunction with rehabilitation therapy stimulation considering the patient’s condition. 13-2. Transcranial direct current stimulation can have a positive effect on improving the ability to perform Moderate B daily life activities in stroke patients, and it is recommended in conjunction with rehabilitation therapy considering the patient’s condition. KQ 14. Individualized Update 14-1. Individualized exercise and functional task training are recommended to improve upper limb motor Moderate A exercise and function in stroke patients. functional task 14-2. Individualized exercise and functional task training are recommended to improve the ability to Low B training perform daily life activities in stroke patients. KQ 15. Constraint Update 15-1. In stroke patients with hemiparesis, if constraint-induced movement therapy (CIMT) is deemed Moderate A induced feasible given the affected upper extremity strength, CIMT is recommended to improve upper limb movement therapy motor function and daily life activity performance. KQ 16. Mirror therapy Update 16-1. Mirror therapy can have a positive effect on the recovery of upper limb motor function and the Low B ability to perform daily life activities in stroke patients, and it is recommended in conjunction with other rehabilitation therapies depending on the patient's condition. 16-2. Mirror therapy can have a positive effect on the recovery of lower limb function in stroke patients, it is Moderate B recommended in conjunction with other rehabilitation therapies depending on the patient's condition. KQ 17. Motor imagery Update 17-1. To enhance the recovery of upper limb motor function after a stroke, motor imagery training is Moderate B training recommended in addition to rehabilitation using actual movements, but it can be selectively applied depending on the patient's condition. 17-2. To enhance the recovery of upper limb function after a stroke, motor imagery training is Moderate B recommended in addition to rehabilitation using actual movements, but it can be selectively applied depending on the patient's condition. 17-3. To improve the ability to perform daily life activities after stroke, motor imagery training is Moderate B recommended in addition to rehabilitation using actual movements, but it can be selectively applied depending on the patient's condition. KQ 18. Balance training Update 18. Balance training is recommended for stroke patients with impaired balance, as it can improve Moderate A balance, gait, and reduce the risk of falls. KQ 19. Balance training Update 19. Recommended effective balance training methods include trunk training/sitting balance training, Moderate B method task-specific training, and biofeedback using force plates. KQ 20. Medication for Update 20-1. Serotonergic agents and Cerebrolysin is recommended for improving motor function in stroke Very low B motor recovery patients, depending on the patient's condition and risk of side effects. 20-2. Additional research is needed to establish the efficacy of dopamine agonists in improving motor I function in stroke patients. (continued to the next page) https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 7/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation Table 1. (Continued) Summary of recommendations (See Supplementary Data 1 for a summary in Korean) KQ Division Recommendation LoE LoR KQ 21. Spasticity Update 21-1. Proper posture, joint exercises, and stretching are recommended for preventing and treating Expert prevention stiffness in stroke patients. Consensus 21-2. Foot braces are recommended when lying down or standing to prevent foot contracture in stroke Expert patients. Consensus KQ 22. Botulinum toxin Update 22-1. Botulinum toxin injections are recommended for reducing spasticity in stroke patients. High A 22-2. It is recommended to perform splinting or casting in conjunction with botulinum toxin injection Very low B therapy for the treatment of contracture in stroke patients, as there are reports that this helps improve contracture due to spasticity. KQ 23. Medication for Update 23-1. Oral administration of tizanidine (LoE: Low), baclofen (LoE: Very low), and dantrolene (LoE: Low) Low B spasticity are recommended because they improve clinical muscle tone with a low risk of serious adverse Very low events (LoE: Low). Low 23-2. Benzodiazepines such as diazepam should not be orally administered for controlling spasticity in Low C stroke patients during the recovery phase, except when specifically needed, due to their negative impact on functional recovery. KQ 24. Intrathecal New 24. Intrathecal baclofen infusion is recommended for the treatment of severe spasticity that does not Moderate B baclofen respond to conventional spasticity therapy. KQ, key question; LoE, level of evidence; LoR, level of recommendation. *LoR A: strong for recommend; LoR B: conditional for recommend; LoR C: conditional against recommend; LoR D: strong against recommend; LoR I: inconclusive. Italy (2002) , and New Zealand (2003) and on articles published from January 1, 2004 to June 30, 2007. After the distribution of the first edition of the guideline, the need for supplementation was raised as the guideline was used in clinical practice. With the publication of new foreign guidelines for rehabilitation treatment for stroke and related research, the need for periodic revision of the guidelines has become more recognized. Based on five foreign CPGs from Scotland (2010) , Australia (2010) , Canada (2010) , and the United States (2010) [23,24] and on articles published from July 1, 2007 to June 30, 2012, the first edition of “Clinical Practice Guideline for Stroke Rehabilitation in Korea.” was revised and the second edition was published in 2012. The 3rd “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016.” was published based on foreign CPGs from Canada (2015) and the United States (2016) , as well as research published between July 1st 2012 and June 30th 2016. After the release of the 3rd edition of the clinical guidelines, the need for a revision of the clinical guidelines from an expert-opinion-based to an evidence-based approach (GRADE) was emphasized. The discussion on this revision took place among the clinical guidelines committee in the planned year of revision, 2020. Subsequently, in this 4th edition, the development approach has been changed from a consensus-based approach to an evidence- based approach using the GRADE method. This change in development method ensures that the guidelines are based on the latest and strongest evidence available, rather than just the opinions of experts. The scope of the previous clinical guidelines was very extensive, making it difficult to revise at once. Therefore, the previous version of the CPG was divided into three parts and updated sequentially: 1) motor/sensory function, 2) non-motor function, 3) other (general, complications, chronic rehabilitation, etc.). This clinical guideline is a partial (Part 1. Motor Function Rehabilitation) update of the clinical guideline published in 2016, and there are still non-updated recommendations in the previous version of CPG. Regular updates/revisions will be made in the future. As a limitation of this CPG, although the development committee consists only of specialists in rehabilitation medicine, but it is judged that the validity of the recommendation will not be biased because the opinions of experts in other occupations in related fields with interests are collected and reflected. The re-establishment of some key question will be required in a future update, details of which can be found in Other Considerations of that Advisory. https://e-bnr.org https://doi.org/10.12786/bn.2023.16.e18 8/11 2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation The CPGs systematically summarize the scientific evidence for stroke rehabilitation and provide guidance for medical decision-making. However, while CPGs are developed to help medical decisions based on scientific evidence, they should not be applied uniformly to all patients. The physician must consider the medical condition of the patient and other circumstances before making a final decision. The physicians’ medical practices should not be limited or judged based on CPGs. CONCLUSION “Clinical Practice Guideline for Stroke Rehabilitation in Korea. Part 1: Rehabilitation for Motor Function (2022)” is the updated 4th edition of the CPG for stroke rehabilitation in Korea. The development approach has been changed from a consensus-based approach to an evidence-based approach using the GRADE method. The change in development method ensures that the guidelines are based on the latest and strongest evidence, rather than just expert opinions, to provide accurate and effective guidance to stroke rehabilitation teams and improve outcomes for stroke patients in Korea. SUPPLEMENTARY MATERIALS Supplementary Data 1 Korean version of Clinical Practice Guideline for Stroke Rehabilitation in Korea - Part 1: Rehabilitation for Motor Function (2022) - Summary of recommendations Click here to view Supplementary Data 2 Korean version of Clinical Practice Guideline for Stroke Rehabilitation in Korea. Part 1: Rehabilitation for Motor Function (2022) Click here to view REFERENCES 1. GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990- 2019: a systematic analysis for the Global Burden of Disease Study 2019. 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