Lifetime and Acute Stress Predict Functional Outcomes Following Stroke: Findings From the Longitudinal STRONG Study
Authors: Holman E. Alison , Cramer Steven C. , Shah Shreyansh , Griessenauer Christoph J. , Patel Nirav , Lin David J. , Gee Joey , Moon Johnson , Schwertfeger Julie , Jayaraman Arun , Lee Robert , Lansberg Maarten , Payne Jeremy , Patten Carolynn , Agrawal Kunal , DeJong Stacey , Cole John , Silver Brian , Cucchiara Brett , Busza Ania , Liew Sook-Lei , Alderman Susan , Hayes Heather , Majersik Jennifer J. , Worrall Brad , Tirschwell David , Bushnell Cheryl , El Husseini Nada , Lee Jin-Moo , Falcone Guido J. 
Published: September 2023

BACKGROUND:
Stroke is a sudden-onset, uncontrollable event; stroke-related stress may impede rehabilitation and recovery. Lifetime stress may sensitize patients to experiencing greater stroke-related stress and indirectly affect outcomes. We examine lifetime stress as predictor of poststroke acute stress and examine lifetime and acute stress as predictors of 3- and 12-month functional status. We also compare acute stress and baseline National Institutes of Health Stroke Scale as predictors of poststroke functional status.

METHODS:
Between 2016 and 2020 the STRONG Study (Stroke, Stress, Rehabilitation, and Genetics) enrolled adults with new radiologically confirmed stroke 2 to 10 days poststroke onset at 28 acute care US hospitals. Participants were interviewed 3 times: acute admission (acute stress; Acute Stress Disorder Interview), 3 months (Fugl-Meyer Upper Extremity motor impairment [Fugl-Meyer Upper Arm Assessment; N=431], modified Rankin Scale [3 months; N=542], Stroke Impact Scale-Activities of Daily Living [3 months; N=511], Lifetime Stress Exposure Inventory), and 12 months (modified Rankin Scale, N=533; Stroke Impact Scale 3.0 Activities of Daily Living; N=485; Telephone Montreal Cognitive Assessment; N=484) poststroke. Structural equation models examined whether acute stress predicted 3- and 12-month functional outcomes, and mediated an association between lifetime stress and outcomes controlling for demographics and initial National Institutes of Health Stroke Scale. Standardized betas are reported.

RESULTS:

Sample (N=763) was 19 to 95 years old (mean=63; SD=14.9); 448 (58.7%) were male. Acute stress scores ranged from 0 to 14 (mean, 3.52 [95% CI, 3.31–3.73]). Controlling for age, gender, baseline National Institutes of Health Stroke Scale, and race and ethnicity, higher lifetime stress predicted higher acute stress (β=0.18,
P
<0.001), which predicted lower 3-month Fugl-Meyer Upper Arm Assessment scores (β=−0.19,
P
<0.001), lower Stroke Impact Scale 3.0 Activities of Daily Living scores at 3 months (β=−0.21,
P
<0.001) and 12 months (β=−0.21,
P
<0.001), higher modified Rankin Scale scores at 3 months (β=0.23,
P
<0.001) and 12 months (β=0.22,
P
<0.001), and lower 12-month Telephone Montreal Cognitive Assessment scores (β=−0.20,
P
<0.001). Acute stress predicted 12-month tMoCA (χ

2

[1]=5.29,
P
=0.022) more strongly, 3-month and 12-month modified Rankin Scale and SIS scores as strongly (all
P
s>0.18), but Fugl-Meyer scores (χ

2

[1]=7.01,
P
=0.008) less strongly than baseline National Institutes of Health Stroke Scale.

CONCLUSIONS:
Lifetime stress/trauma is associated with more poststroke acute stress, which is associated with greater motor and cognitive impairment and disability 3 and 12 months poststroke. Poststroke interventions for acute stress may help mitigate stroke-related disability.