{
  "abstract": "Background Stroke is the leading cause of death and disability among adults in China, with a growing disease burden. Data from the China Stroke Prevention and Treatment Report 2023 show that the incidence rate of stroke in China is approximately 246.8 per 100 000 population, with over 2 million new cases annually. Among surviving patients, 60%–70% experience varying degrees of hand dysfunction after discharge, and only 10%–20% can recover to near-normal levels. As the most refined and core motor function of the human body, hand function recovery essentially reflects motor cortical neuroplasticity (synaptic remodelling and cortical reorganisation). Its recovery directly affects the independence of activities of daily living (ADLs) such as eating, dressing and personal hygiene, markedly reducing quality of life and increasing family care burden and social medical costs.Currently, clinical rehabilitation interventions for patients who had a stroke are mostly concentrated during hospitalisation, focusing on acute-phase stability and basic function recovery. However, postdischarge rehabilitation follow-up coverage is fewer than 40%, and community rehabilitation resources are disparately distributed, leaving most patients facing the dilemma of ‘interrupted rehabilitation after discharge’. Additionally, existing studies mostly focus on short-term follow-up (3–6 months) and lack systematic investigation of the long-term trajectory of hand function recovery (6 months to 1 year), key turning points and influencing factors—especially the regulatory role of multidisciplinary intervention on neuroplasticity. The integrated ‘hospital-community-family’ multidisciplinary collaborative management model remains underdeveloped.Objective This study aims to describe the dynamic trajectory of hand function and overall rehabilitation outcomes in patients who had a stroke at 6 months and 1 year postdischarge, analyse the key influencing factors of hand function recovery (with a focus on the regulatory role of multidisciplinary collaborative intervention on motor cortical neuroplasticity), verify the effectiveness of the multidisciplinary collaborative management model on complications and rehabilitation satisfaction, and ultimately construct a continuous rehabilitation management model adapted to the current status of primary medical care in China.Methods A single-centre, prospective cohort study design will be used. A total of 120 patients who had a stroke with hand dysfunction discharged from the Department of Rehabilitation Medicine, The Second People’s Hospital of Hefei Guangde Road Campus between February 2026 and February 2027 will be enrolled. A multidisciplinary team (MDT) consisting of rehabilitation physicians, rehabilitation therapists, community doctors/nurses and family caregivers will be established to implement a three-stage intervention: discharge connection, community intervention and online support (incorporating neuroplasticity initiation, enhancement and maintenance strategies).Hand function (primary outcome) will be assessed using the Fugl-Meyer Assessment for Hand (FMA-Hand) at baseline (1–3 days predischarge, T0), 3 months postdischarge (T1), 6 months postdischarge (T2) and 12 months postdischarge (T3). Secondary outcomes include overall motor function (FMA Total Score, FMA-Total) and ADL (Modified Barthel Index). Influencing factor data will be collected using structured questionnaires, and neuroplasticity will be indirectly evaluated using transcranial magnetic stimulation-derived motor evoked potentials.SPSS V.26.0 software will be used for statistical analyses. Quantitative data will be expressed as (x̄±s) or (M (IQR)) depending on normality; categorical data will be presented as (n (%)). Repeated measures analysis of variance will compare functional changes across time points, and multiple linear regression will identify independent influencing factors of hand function recovery.Expected results Patients will show progressive hand function recovery within 1 year after discharge, with the fastest recovery at 3–6 months and stabilisation from 6 to 12 months. Younger age, higher baseline function, better rehabilitation adherence and active multidisciplinary intervention are associated with greater neuroplasticity and better hand function recovery. The MDT model may reduce complications and improve rehabilitation satisfaction and ADL.Conclusions The results of this study will fill the data gap in long-term postdischarge rehabilitation trajectories of patients who had a stroke, clarify the regulatory role of multidisciplinary collaborative intervention on motor cortical neuroplasticity and provide scientific evidence and practical references for optimising postdischarge rehabilitation follow-up programmes and improving the primary rehabilitation service system.Ethics and dissemination This study was approved by the Biomedical Research Ethics Committee of The Second People’s Hospital of Hefei (No. 2024-KY-089). Written informed consent was obtained from all participants. The results will be published in peer-reviewed journals and disseminated to participants and community health institutions.Trial registration number ChiCTR2600119007.",
  "authors": [
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Fangjun Xu"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Shaowei Wu"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Li Mao"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Shengchao Pan"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Kang Zhou"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Yunwei Liu"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Xiaoguang Cao"
    },
    {
      "affiliations": [
        "Department of Rehabilitation Medicine, The Second People’s Hospital, Hefei, China"
      ],
      "name": "Xiumin Wang"
    }
  ],
  "title": "Follow-up monitoring, rehabilitation status and hand function recovery in patients who had a stroke at 1 year after discharge (FOLLOW-STROKE-HAND): protocol for a longitudinal observational study",
  "uid": "f61ad260-7e28-5a54-ad61-c92624f9a8b6"
}