Comparisons of Functional, Physical, and Mental Health Outcomes Among Young and Old Stroke Survivors
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThis manuscript addresses an important and timely public health question by examining functional, physical, and mental health outcomes among younger and older stroke survivors using a large, nationally representative dataset. The study is well motivated, and the use of BRFSS data allows for meaningful population-level inference. The manuscript is generally well written, and the analytic approach is appropriate for the research questions posed.
The methods section is clearly described and demonstrates careful attention to survey design and weighting procedures. The inclusion of interaction terms between age and employment status adds depth to the analysis and yields findings that are both clinically and policy relevant. Results are presented clearly, and the tables effectively support the narrative in the text.
A few points may strengthen the manuscript further. First, while the rationale for dichotomizing age and income is explained, a brief sensitivity discussion acknowledging how alternative cut points might influence interpretation would be helpful. Second, although employment status emerges as a central factor across multiple outcomes, the discussion could benefit from a more explicit consideration of potential bidirectional relationships between employment, functional limitation, and mental health. Finally, the conclusions would be strengthened by briefly outlining how these findings could inform targeted rehabilitation, vocational, or community-based interventions for younger stroke survivors.
Overall, this is a strong and well-executed study that makes a meaningful contribution to the literature on stroke outcomes across the life course.
Author Response
Comment 1: A few points may strengthen the manuscript further. First, while the rationale for dichotomizing age and income is explained, a brief sensitivity discussion acknowledging how alternative cut points might influence interpretation would be helpful.
Response 1:We acknowledge that dichotomizing age (<50 vs ≥50) and income (<$50,000 vs ≥$50,000) at the cut-offs we selected may influence the interpretation. We added the following to the limitations on p.14, paragraph 2, lines 437-449: “Additionally, age and income were operationalized as dichotomous variables to enhance interpretability and model parsimony. Young stroke was defined as age <50 years, consistent with prior literature and epidemiologic conventions distinguishing early-onset stroke from more traditional, later-onset presentations. However, alternative cut points (e.g., <45 years or <55 years) may yield modest differences in effect magnitude, particularly given the gradient of stroke risk and functional decline across midlife. Similarly, household income was dichotomized at $50,000 to approximate economic vulnerability; nonetheless, alternative thresholds or modeling income as an ordinal or continuous measure could capture additional heterogeneity in socioeconomic gradients. While dichotomization facilitates interpretation and policy relevance, future research should examine whether associations between age, income, and post-stroke outcomes demonstrate nonlinear or threshold effects across more granular categories.”
Comment 2: Second, although employment status emerges as a central factor across multiple outcomes, the discussion could benefit from a more explicit consideration of potential bidirectional relationships between employment, functional limitation, and mental health.
Response 2: We can add this to the Discussion p.13, paragraph 2, lines 382-395: “While employment status emerged as a strong and consistent correlate of functional and mental health outcomes, the cross-sectional nature of the data precludes establishing directionality. The relationship between employment, functional limitation, and mental health is likely bidirectional and mutually reinforcing. Functional impairments may limit an individual’s ability to maintain employment, while job loss or labor force detachment may contribute to worsening psychological distress, financial strain, and reduced access to employer-sponsored resources that support recovery. In younger stroke survivors in particular, identity formation, financial independence, and social integration are often closely tied to employment status, potentially amplifying the psychological consequences of workforce disengagement. Conversely, poor mental health may impede return-to-work efforts and exacerbate perceived functional difficulty. These interdependent pathways suggest that employment should not be viewed solely as a predictor of health outcomes, but rather as part of a dynamic recovery process requiring integrated vocational, psychological, and rehabilitative interventions.”
Comment 3: Finally, the conclusions would be strengthened by briefly outlining how these findings could inform targeted rehabilitation, vocational, or community-based interventions for younger stroke survivors.
Response 3: We have added details about targeted intervention to improve outcomes for both stroke groups. We have added the following to p14, paragraph 3, line 461-466 “Future studies should also consider targeted interventions to address the unique needs of both young and older stroke survivors. Targeted interventions should consider issues beyond rehabilitation but also the unique vocational and community reintegration needs of young and old stroke survivors [41-43].”
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors present the results of a study based on the 2023 BRFSS, a nationally representative, cross-sectional self-reported survey in the US, aimed to examine differences in functional, mental, and physical health outcomes between younger and older stroke survivors. A total of 17,756 patients were included in the study, of whom 90.65% were aged 50 or older. The authors highlight that strokes among young adults are relatively uncommon, yet prevalence rates have recently been increasing and that younger stroke survivors who were out of the labor force had significantly greater odds of difficulty concentrating and an increase in days of poor mental and physical health. The study is potentially interesting, but some aspects of the manuscript might be improved by taking into account the following points:
1.Please refine in the Abstract section the definition of younger and older stroke survivors.
2.It would be useful to mention in the text that acute strokes in young people differ from acute strokes in non-young people in the distribution of risk factors, stroke subtypes, stroke severity, and outcome. In a clinical study, factors independently associated with acute ischemic lacunar stroke in patients aged ≤55 years were heavy smoking, alcohol consumption, and obesity (Expert Review of Neurotherapeutics, 2015; 15:7, 825-831). Did the authors consider this in their study?.
3.Did the authors find clinical differences with respect to sex? The impact of female sex can be observed for example in the distribution of risk factors, stroke subtype, stroke severity, and outcome (see data and comment on the reference on Cerebrovasc Dis 2025;54(1):11-19. doi: 10.1159/000536436. Epub 2024 Jan 29. PMID: 38286114). Did the authors take this into account in their study protocol?
4.It would be interesting to highlight in the text that a future line of research on the topic discussed in the paper would be to study the diagnosis and the relationship between white matter alterations rate and functional, physical, and mental health outcomes among young and old stroke survivors after an acute stroke. (see data and comment on the study published in BMC Neurol. 2010 Jul 27;10:64. doi: 10.1186/1471-2377-10-64. PMID: 20663196; PMCID: PMC2920865). Did the authors consider this in their study?
5.A brief concluding comment on other possible lines of future research on the presented topic would be appreciated.
Author Response
Comment 1.Please refine in the Abstract section the definition of younger and older stroke survivors.
Response 1: We have defined both groups as recommended. See abstract line 14
Comment 2.It would be useful to mention in the text that acute strokes in young people differ from acute strokes in non-young people in the distribution of risk factors, stroke subtypes, stroke severity, and outcome. In a clinical study, factors independently associated with acute ischemic lacunar stroke in patients aged ≤55 years were heavy smoking, alcohol consumption, and obesity (Expert Review of Neurotherapeutics, 2015; 15:7, 825-831). Did the authors consider this in their study?.
Response 2: This information was noted in the original draft “The underlying cause of stroke among young adults varies dramatically from older and more traditional age individuals, who experience stroke in both associated risk factors and underlying causes.[3]” We have offered additional details to further highlight this issue on p.14, paragraph 3, line 461-466.
Comment 3.Did the authors find clinical differences with respect to sex? The impact of female sex can be observed for example in the distribution of risk factors, stroke subtype, stroke severity, and outcome (see data and comment on the reference on Cerebrovasc Dis 2025;54(1):11-19. doi: 10.1159/000536436. Epub 2024 Jan 29. PMID: 38286114). Did the authors take this into account in their study protocol?
Response 3: We did not consider sex in the study outcomes. We have added the following to the conclusions p.14, paragraph 3, line 466-468. “ In addition to age, differential patterns between men and women should be considered particularly given reports to sex differences in stroke-related risk factors, sex/age stroke onset and stroke outcomes [44].
- Torres-Riera S, Arboix A, Parra O, García-Eroles L, Sánchez-López MJ. Predictive Clinical Factors of In-Hospital Mortality in Women Aged 85 Years or More with Acute Ischemic Stroke. Cerebrovasc Dis. 2025;54(1):11-19. doi: 10.1159/000536436. Epub 2024 Jan 29. PMID: 38286114.
Comment 4.It would be interesting to highlight in the text that a future line of research on the topic discussed in the paper would be to study the diagnosis and the relationship between white matter alterations rate and functional, physical, and mental health outcomes among young and old stroke survivors after an acute stroke. (see data and comment on the study published in BMC Neurol. 2010 Jul 27;10:64. doi: 10.1186/1471-2377-10-64. PMID: 20663196; PMCID: PMC2920865). Did the authors consider this in their study?
Response 4: We did not consider this kind of follow-up clinical study because the data utilized in this study was national health-services type data that does not include that level of clinical information. We have included this issue in the conclusions. We have added the following p14., paragraph 3, line 460-461: Those studies should consider clinical variables such as stroke type and associated cerebrovascular disease contributions to outcomes [40].
- Segura B, Jurado MA, Freixenet N, Bargalló N, Junqué C, Arboix A. White matter fractional anisotropy is related to processing speed in metabolic syndrome patients: a case-control study. BMC Neurol. 2010 Jul 27;10:64. doi: 10.1186/1471-2377-10-64. PMID: 20663196; PMCID: PMC2920865.
Comment 5.A brief concluding comment on other possible lines of future research on the presented topic would be appreciated.
Response 5: We have added additional information about future directions in the conclusion. We have added the following on p14, paragraph 3, lines 461-466 “Future studies should also consider targeted interventions to address the unique needs of both young and older stroke survivors. Targeted interventions should consider issues beyond rehabilitation but also the unique vocational and community reintegration needs of young and old stroke survivors in addition to constantly evolving technologies designed to improve stroke outcomes [41-43].”
- Leung LY, Lee S, Singhal AB; Stroke and Young Adults (SAYA) Consortium. Building Centers of Excellence for the Care of Young Adults With Stroke. J Am Heart Assoc. 2024 Nov 5;13(21):e035606. doi: 10.1161/JAHA.124.035606. Epub 2024 Oct 30. PMID: 39474734; PMCID: PMC11935696.
- Lutski M, Zucker I, Shohat T, Tanne D. Characteristics and Outcomes of Young Patients with First-Ever Ischemic Stroke Compared to Older Patients: The National Acute Stroke ISraeli Registry. Front Neurol. 2017 Aug 21;8:421. doi: 10.3389/fneur.2017.00421. PMID: 28871237; PMCID: PMC5566555.
- Hestetun-Mandrup AM, Hamre C, Lund A, Martinsen ACT, He HG, Pikkarainen M. Exploring people with stroke's perceptions of digital technologies in post-stroke rehabilitation - a qualitative study. Disabil Rehabil. 2026 Jan;48(2):359-368. doi: 10.1080/09638288.2025.2504615. Epub 2025 May 18. PMID: 40382688.
Reviewer 3 Report
Comments and Suggestions for AuthorsThe study explores how younger and older stroke survivors' functional, mental, and physical health outcomes is different. There are significant disfferences in their functional, physical, and mental health outcomes. Due to their clinical characteristics and rehabilitation requirements, younger stroke survivors typically experience better results than their older counterparts. The differences between the two populations highlight the need for targeted interventions across age groups to optimize recovery and support (10.3389/FNEUR.2017.00421; 10.21608/svuijm.2024.262392.1777). The authors should consider the role and the impact of rehabilitation treatment in the two populations: older stroke survivors often experience more significant restrictions in participation compared to their younger counterparts. There is a need for rehabilitation technologies to be tailored to older adults' specific requirements, including elements that encourage involvement and social interaction. In order to enable older adults to fully participate in rehabilitation programs, these devices' design must take into account the obstacles they experience (10.1097/DBP.0000000000000357). Using technology like force feedback rehabilitation robots for task-oriented training is crucial. While stroke survivors of all ages can gain from this type of training, older adults may benefit more from these tools. This implies that in order to optimize the efficacy of rehabilitation devices, age-specific considerations must be incorporated into their design (10.1186/s12883-015-0420-3; 10.1186/s13063-022-06812-w; 10.1002/jnr.23962). Further studies should address the obstacles to older adults' participation in rehabilitative technology by integrating social engagement techniques.
Author Response
Comment 1: The differences between the two populations highlight the need for targeted interventions across age groups to optimize recovery and support (10.3389/FNEUR.2017.00421; 10.21608/svuijm.2024.262392.1777). The authors should consider the role and the impact of rehabilitation treatment in the two populations: older stroke survivors often experience more significant restrictions in participation compared to their younger counterparts. There is a need for rehabilitation technologies to be tailored to older adults' specific requirements, including elements that encourage involvement and social interaction.
Comment 1: We have added details about targeted intervention to improve outcomes for both stroke groups as also noted by Reviewer 1.We have added the following p14, paragraph 3, lines 461-466 “Future studies should also consider targeted interventions to address the unique needs of both young and older stroke survivors. Targeted interventions should consider issues beyond rehabilitation but also the unique vocational and community reintegration needs of young and old stroke survivors in addition to constantly evolving technologies designed to improve stroke outcomes [41-43].”
- Leung LY, Lee S, Singhal AB; Stroke and Young Adults (SAYA) Consortium. Building Centers of Excellence for the Care of Young Adults With Stroke. J Am Heart Assoc. 2024 Nov 5;13(21):e035606. doi: 10.1161/JAHA.124.035606. Epub 2024 Oct 30. PMID: 39474734; PMCID: PMC11935696.
- Lutski M, Zucker I, Shohat T, Tanne D. Characteristics and Outcomes of Young Patients with First-Ever Ischemic Stroke Compared to Older Patients: The National Acute Stroke ISraeli Registry. Front Neurol. 2017 Aug 21;8:421. doi: 10.3389/fneur.2017.00421. PMID: 28871237; PMCID: PMC5566555.
- Hestetun-Mandrup AM, Hamre C, Lund A, Martinsen ACT, He HG, Pikkarainen M. Exploring people with stroke's perceptions of digital technologies in post-stroke rehabilitation - a qualitative study. Disabil Rehabil. 2026 Jan;48(2):359-368. doi: 10.1080/09638288.2025.2504615. Epub 2025 May 18. PMID: 40382688.
Comment 2: In order to enable older adults to fully participate in rehabilitation programs, these devices' design must take into account the obstacles they experience (10.1097/DBP.0000000000000357). Using technology like force feedback rehabilitation robots for task-oriented training is crucial. While stroke survivors of all ages can gain from this type of training, older adults may benefit more from these tools. This implies that in order to optimize the efficacy of rehabilitation devices, age-specific considerations must be incorporated into their design (10.1186/s12883-015-0420-3; 10.1186/s13063-022-06812-w; 10.1002/jnr.23962). Further studies should address the obstacles to older adults' participation in rehabilitative technology by integrating social engagement techniques.
Comment 2: We agree with this statement and addressed the issue in the conclusions. We have added p14, paragraph 3, line 465-466: “………………………..in addition to constantly evolving technologies designed to improve stroke outcomes [41-43].
- Hestetun-Mandrup AM, Hamre C, Lund A, Martinsen ACT, He HG, Pikkarainen M. Exploring people with stroke's perceptions of digital technologies in post-stroke rehabilitation - a qualitative study. Disabil Rehabil. 2026 Jan;48(2):359-368. doi: 10.1080/09638288.2025.2504615. Epub 2025 May 18. PMID: 40382688.
