20231016991087
02
Brain Neurorehabil. 2023 Jul;16(2):e18
https://doi.org/.12786/bn...e18
pISSN 1976-53·eISSN 2383-
Brain & NeuroRehabilitation
Clinical Practice
Clinical Practice Guideline for Stroke
Guideline
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, 202
HIGHLIGHTS
Accepted: Jul 6, 202
Published online: Jul 1, 202
? This c linical 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,
an evidence-based approach using the Grading of Recommendations Assessment
Incheon St. Mary’s Hospital, College of
Development and Evaluation method.
Medicine, The Catholic University of Korea,
56 Dongsu-ro, Bupyeong-gu, Incheon 2,
Korea.
Email: msdykim@catholic.ac.kr
Copyright ? 202. Korean Society for Neurorehabilitation
i
3
1431
3 7
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336162016331141731201362023151631216379211718331099231199162111513222921634255117268873581693499108103293117301612166
02
Brain Neurorehabil. 2023 Jul;16(2):e18
https://doi.org/.12786/bn...e18
pISSN 1976-53·eISSN 2383-
Brain & NeuroRehabilitation
Clinical Practice
Clinical Practice Guideline for Stroke
Guideline
Rehabilitation in Korea—Part 1:
Rehabilitation for Motor Function (2022)
,4, ,7
Doo Young Kim , Byungju Ryu , Byung-Mo Oh , Dae Yul Kim ,
Da-Sol Kim , Deog Young Kim , Don-Kyu Kim , Eun Joo Kim ,
,4
Hoo Young Lee , Hyoseon Choi , Hyoung Seop Kim , Hyun Haeng Lee ,
,4
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 ,
,7
Kyoung Tae Kim , Min Cheol Chang , Min Ho Chun , Min Wook Kim ,
Min-Gu Kang , Min-Keun Song , Miyoung Choi , Myoung-Hwan Ko ,
3, 3,
Na Young Kim , Nam-Jong Paik , Se Hee Jung , Seo Yeon Yoon ,
,7
Seong Hoon Lim , Seong Jae Lee , Seung Don Yoo , Seung Hak Lee ,
Seung Nam Yang , Si-Woon Park , So Young Lee , Soo Jeong Han ,
Received: May 9, 202
Sook Joung Lee , Soo-Kyung Bok , Suk Hoon Ohn , Sun Im ,
Accepted: Jul 6, 202
3,
Published online: Jul 1, 202 Sung-Bom Pyun , Sung Eun Hyun , Sung Hoon Kim , Sung-Hwa Ko ,
,4
Sungju Jee , SuYeon Kwon , Tae-Woo Kim , Won Hyuk Chang ,
Correspondence to
3,
Won Kee Chang , Woo-Kyoung Yoo , Yeo Hyung Kim , Yeun Jie Yoo ,
Min Wook Kim
Yong Wook Kim , Yong-Il Shin , Yoon Ghil Park , Yoon-Hee Choi ,
Department of Rehabilitation Medicine,
Youngkook Kim , KSNR Stroke CPG Writing Group
Incheon St. Mary’s Hospital, College of
Medicine, The Catholic University of Korea,
Department of Rehabilitation Medicine, International St. Mary’s Hospital, Catholic Kwandong University College
56 Dongsu-ro, Bupyeong-gu, Incheon 2,
of Medicine, Incheon, Korea
Korea.
Department of Physical Medicine and Rehabilitation, Sahmyook Medical Center, Seoul, Korea
Email: msdykim@catholic.ac.kr
Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
Copyright ? 202. Korean Society for
Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
Neurorehabilitation
Department of Rehabilitation Medicine, University of Ulsan College of Medicine, Ulsan, Korea
This is an Open Access article distributed
Department of Rehabilitation Medicine, Asan Medical Center, Seoul, Korea
under the terms of the Creative Commons
Department of Physical Medicine and Rehabilitation, Jeonbuk National University Medical School, Jeonju, Korea
Attribution Non-Commercial License (https://
Department of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
creativecommons.org/licenses/by-nc/.)
Department of Physical and Rehabilitation Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
which permits unrestricted non-commercial
Department of Rehabilitation Medicine, National Rehabilitation Center, Seoul, Korea
use, distribution, and reproduction in any
Department of Rehabilitation Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine,
medium, provided the original work is properly
Seoul, Korea
cited. Department of Physical medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital,
Goyang, Korea
ORCID iDs
Department of Rehabilitation Medicine, Konkuk University School of Medicine, Seoul, Korea
Doo Young Kim Department of Physical Medicine and Rehabilitation, Soonchunhyang University College of Medicine, Asan, Korea
Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
https://orcid.org/0000-0003--
Department of Physical Medicine and Rehabilitation, Hallym University College of Medicine, Chuncheon, Korea
Byungju Ryu
Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University
https://orcid.org/0000-0003-0109-
School of Medicine, Changwon, Korea
Byung-Mo Oh
Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
https://orcid.org/0000-0001-3-
Department of Rehabilitation Medicine, Gachon University, Gil Medical Center, Incheon, Korea
Dae Yul Kim
Department of Physical medicine and Rehabilitation, Seoul Medical Center, Seoul, Korea
https://orcid.org/0000-0003-5-
Department of Rehabilitation Medicine, Keimyung University School of Medicine, Keimyung University Dongsan
Da-Sol Kim
Hospital, Daegu, Korea
https://orcid.org/0000-0002-5-X
Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Korea
Deog Young Kim
Department of Rehabilitation Medicine, Daegu Workers’ Compensation Hospital, Daegu, Korea
https://orcid.org/0000-0001--6
Department of Rehabilitation Medicine, Chonnam National University Medical School, Gwangju, Korea
Don-Kyu Kim National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
https://orcid.org/0000-0001-19-X Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
https://e-bnr.org 1/
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02
2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation
Eun Joo Kim Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
Department of Rehabilitation Medicine, Dankook University College of Medicine, Seoul, Korea
https://orcid.org/0000-0001-6166-
Department of Rehabilitation Medicine, Kyung Hee University School of Medicine, Seoul, Korea
Hoo Young Lee
Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
https://orcid.org/0000-0003-3846-X
Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University College of
Hyoseon Choi
Medicine, Jeju, Korea
https://orcid.org/0000-0002--
Department of Rehabilitation Medicine, Ewha Womans University College of Medicine, Seoul, Korea
Hyoung Seop Kim
Department of Rehabilitation Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
https://orcid.org/0000-0002-310-4
Department of Rehabilitation Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
Hyun Haeng Lee
Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
https://orcid.org/0000-0001-6666-6284
Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School
Hyun Jung Kim
of Medicine, Seoul, Korea
https://orcid.org/0000-0002--
Hyun Mi Oh
https://orcid.org/0000-0001-493-469
ABSTRACT
Hyun Seok
https://orcid.org/0000-0001-266-604
This clinical practice guideline (CPG) is the fourth edition of the Korean guideline for
Jihye Park
stroke rehabilitation, which was last updated in 2016. The development approach has been
https://orcid.org/0000-0002-64-X
Jihyun Park
changed from a consensus-based approach to an evidence-based approach using the Grading
https://orcid.org/0000-0002--
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--
The aim is to provide the most accurate and effective guidance to stroke rehabilitation
Jong Moon Kim
teams, and to improve the outcomes for stroke patients in Korea. Fifty-five specialists in
https://orcid.org/0000-0002-8684-
Jongmin Lee stroke rehabilitation and one CPG development methodology expert participated in this
https://orcid.org/0000-0001--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/0000-0001-644-
be limited to Part 1: Rehabilitation for Motor Function. The key questions were selected
Ju Kang Lee
by considering the preferences of the target population and referring to foreign guidelines
https://orcid.org/0000-0002-5-
for stroke rehabilitation, and the recommendations were completed through systematic
Ju Sun Oh
https://orcid.org/0000-0002-0994-
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/0000-0003-1684-4
and external expert evaluation.
Kyoung Tae Kim
https://orcid.org/0000-0001-5-
Keywords: GRADE Approach; Korea; Practice Guideline; Rehabilitation; Stroke
Min Cheol Chang
https://orcid.org/0000-0002-9-
Min Ho Chun
https://orcid.org/0000-0001-8666- 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-
the disability-adjusted life-years lost due to stroke was 143 million, and the number of deaths
Min-Keun Song
were 6.55 million []. According to the Korean Statistical Information Services, the number
https://orcid.org/0000-0001-8186-
Miyoung Choi
of stroke patients in South Korea has been over 110,00 per year for the past five years [].
https://orcid.org/0000-0002-4-
Comprehensive and specialized rehabilitation treatment starting from the acute phase of
Myoung-Hwan Ko
stroke can improve functional recovery and minimize disability [-]. Many countries have
https://orcid.org/0000-0002-0566-
recognized the need for stroke rehabilitation and developed clinical practice guidelines
Na Young Kim
(CPG) for stroke rehabilitation tailored to their individual circumstances [-]. Korean
https://orcid.org/0000-0001--
Nam-Jong Paik Society for NeuroRehabilitation (KSNR) has also published and revised CPGs for stroke
https://orcid.org/0000-0002-5193-
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-
has become clear that the CPG need to be revised to reflect these recent findings.
https://e-bnr.org https://doi.org/.12786/bn...e18 2/
8752
8678
3953 9888
3677
9965 242
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7213 762
8326 935
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32
943
31
30
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29
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02
2022 KSNR CPG for Stroke Rehabilitation (Part 1. Motor Function) Brain & NeuroRehabilitation
Seo Yeon Yoon AIM OF CPG
https://orcid.org/0000-0002-0365-
Seong Hoon Lim
The aim of this CPG is to provide medical professionals with the necessary information for
https://orcid.org/0000-0002-5-415
the rehabilitation process of stroke patients, from acute to chronic stages, based on scientific
Seong Jae Lee
and objective evidence. The CPG also seeks to reduce variability in the quality of care received
https://orcid.org/0000-0001--4695
by stroke patients in different medical settings. This CPG aims to help the patient recover
Seung Don Yoo
https://orcid.org/0000-0003-4513-
their function, prevent complications, and facilitate their return to society.
Seung Hak Lee
https://orcid.org/0000-0002--
Seung Nam Yang
TARGET POPULATION AND SCOPE
https://orcid.org/0000-0003-2850-03
Si-Woon Park
https://orcid.org/0000-0002--49 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--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
not covered in this guideline, and both ischemic and hemorrhagic strokes are included.
Sook Joung Lee
https://orcid.org/0000-0002-6894-44X
Soo-Kyung Bok
https://orcid.org/0000-0002--
END-USERS AND SETTINGS
Suk Hoon Ohn
https://orcid.org/0000-0002-1139-
The primary target users of this CPG are physicians and therapists who provide care for
Sun Im
patients with disabilities in activities of daily living, including motor dysfunction due to
https://orcid.org/0000-0001-00-49
Sung-Bom Pyun stroke, at primary, secondary, and tertiary medical facilities.
https://orcid.org/0000-0002-3-038X
Sung Eun Hyun
https://orcid.org/0000-0003-4-
METHOD OF CPG DEVELOPMENT
Sung Hoon Kim
https://orcid.org/0000-0001-6043-
Building of CPG development group
Sung-Hwa Ko
https://orcid.org/0000-0003-4900-
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/0000-0002-00-
for clinical guidelines was appointed based on the consensus of the KSNR after considering
SuYeon Kwon
the expertise and representativeness, and 11 operational committee members, including the
https://orcid.org/0000-0003-0-4982
head of the committee, secretary, and one methodologist expert, were selected to form the
Tae-Woo Kim
https://orcid.org/0000-0003-4-49X 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-
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/0000-0001-56-681
committee included the chairperson, vice chairperson, and eight members of the KSNR who
Woo-Kyoung Yoo
have expertise and representativeness in the related field.
https://orcid.org/0000-0002-73-064
Yeo Hyung Kim
https://orcid.org/0000-0002--
Decision of CPG development method
Yeun Jie Yoo
Although this clinical guideline is an updated version of “Clinical Practice Guideline for
https://orcid.org/0000-0003-3-4
Stroke Rehabilitation in Korea,” the development approach has been changed from an
Yong Wook Kim
expert-opinion based to an evidence-based clinical guideline development method (Grading
https://orcid.org/0000-0002-4-
Yong-Il Shin of Recommendations Assessment Development and Evaluation, GRADE) []. This clinical
https://orcid.org/0000-0001-894-0930
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/0000-0001-4-
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/.12786/bn...e18 3/
5300 905
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02
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-
survey when selecting key questions.
Youngkook Kim
https://orcid.org/0000-0003-3964-026X
Decision of CPG scope
The revision of this CPG has been transformed into an evidence-based clinical guideline
Funding
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
sequentially updated in phases. With the advice of the operations committee and the
All researchers involved in the development
advisory committee, the scope of this clinical guideline has finally been determined as Part 1:
of this clinical guideline were instructed to
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).
To select the key questions, references were made to foreign guidelines for stroke
All researchers except for six declared that
rehabilitation. The stroke rehabilitation guidelines published in Canada (2019) [ ,], the
they have no conflicting interests. Researchers
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
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7908161112102023
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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
rd
The revision/update of the CPG will be based on the contents of the previous 3 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.).
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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 206 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 (202) [ ],
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. Early mobilization is recommended within 2–4 hours of stroke onset as it improves functional Low A
independence and walking ability in stroke patients, unless contraindicated.
-2. Selective consideration is given to very early mobilization within 2 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 . 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. Ex ercise therapy Update . As ther e 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. T ask-specific Update -1. Task-specific training is recommended for the improvement of upper limb function. Low A
training
-2. Task-specific training is recommended for the improvement of lower limb function. Moderate A
KQ 5. Pr ogressive Update -1. F or 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.
-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.
-3. F or 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.
-4. F or 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. Aer obic exercise Update -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.
-2. High int ensity 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.
-3. E ducating 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. T readmill exercise Update -1. In str oke patients, gait training in a treadmill is recommended over no intervention, as it is more High A
effective in improving walking function.
-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 -1. F unctional electrical stimulation therapy is recommended for improving upper limb function and High A
electrical performing daily activities in stroke patients.
stimulation
-2. F unctional electrical stimulation therapy is recommended for improving lower limb function. High A
-3. Functional electrical stimulation therapy is recommended for improving shoulder joint subluxation. High A
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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 -1. In stroke patients with foot drop, considering the use of an ankle-foot orthosis is recommended, as it Moderate B
improves walking.
-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 1. Repetitive Update -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
-2. The e vidence for repetitive transcranial magnetic stimulation to improve lower limb function in I
stroke patients is insufficient, so a recommendation level cannot be determined.
-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.
-4. The e vidence for repetitive transcranial magnetic stimulation to improve lower limb spasticity in I
stroke patients is insufficient, so a recommendation level cannot be determined.
KQ 1. Robot Update -1. In str oke 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.
-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 1. Virtual r eality Update -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.
-2. Virtual r eality therapy for stroke patients is effective in improving balance compared to conventional Low B
rehabilitation therapy, but it can have side effects.
KQ 1. Transcranial Update -1. T ranscranial 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.
-2. T ranscranial 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 1. Individualized Update -1. Individualized exercise and functional task training are recommended to improve upper limb motor Moderate A
exercise and function in stroke patients.
functional task
-2. Individ ualized exercise and functional task training are recommended to improve the ability to Low B
training
perform daily life activities in stroke patients.
KQ 15. Constr aint Update -1. In str oke 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 1. Mirr or therapy Update -1. Mirr or 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.
-. Mirr or 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 1. Mot or imagery Update -1. T o 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.
-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.
-3. T o 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 1. Balance training Update . Balance tr aining is recommended for stroke patients with impaired balance, as it can improve Moderate A
balance, gait, and reduce the risk of falls.
KQ 1. Balance training Update . R ecommended effective balance training methods include trunk training/sitting balance training, Moderate B
method task-specific training, and biofeedback using force plates.
KQ 2. Medication for Update -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.
-2. Additional research is needed to establish the efficacy of dopamine agonists in improving motor I
function in stroke patients.
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Table 1. (Continued) Summary of recommendations (See Supplementary Data 1 for a summary in Korean)
KQ Division Recommendation LoE LoR
KQ 2. Spasticity Update -1. Proper posture, joint exercises, and stretching are recommended for preventing and treating Expert
prevention stiffness in stroke patients. Consensus
-2. F oot braces are recommended when lying down or standing to prevent foot contracture in stroke Expert
patients. Consensus
KQ 2. Botulinum t oxin Update -1. Botulinum t oxin injections are recommended for reducing spasticity in stroke patients. High A
-2. It is r ecommended 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 2. Medication for Update -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
-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 2. Intrathecal New . 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 (202) [], and New Zealand (2003) [ ] and on articles published from January 1,
04 to June 30, 20. 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 , ] 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 [25 ]. 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.
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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
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