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Clinical Neurology: Research Article

Eur Neurol 2022;85:273–279 Received: October 26, 2021

Accepted: January 24, 2022
DOI: 10.1159/000522254 Published online: March 29, 2022

Practical Machine Learning Model to

Predict the Recovery of Motor Function
in Patients with Stroke
Jeoung Kun Kim a Zhihan Lv b Donghwi Park c Min Cheol Chang d
aDepartment of Business Administration, School of Business, Yeungnam University, Gyeongsan-Si, Republic of

Korea; bDepartment of Game Design, Faculty of Arts, Uppsala University, Uppsala, Sweden; cDepartment of Physical
Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic
of Korea; dDepartment of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of
Korea

Keywords FAC ≥4 were considered to have a “good” outcome. Results:

Artificial intelligence · Machine learning · Deep neural
network · Stroke · Motor recovery · Prediction
Abstract
Background: Machine learning (ML) is an artificial intelli-
gence technique in which a system learns patterns and rules
from a given data. Objectives: The objective of the study was
to investigate the potential of ML for predicting motor re-
covery in stroke patients. Methods: We analyzed data from
833 consecutive stroke patients using 3 ML algorithms: deep
neural network (DNN), random forest, and logistic regres-
sion. We created a practical ML model using the most com-
mon data measured in almost all rehabilitation hospitals as
input data. Demographic and clinical data, including modi-
fied Brunnstrom classification (MBC) and functional ambula-
tion classification (FAC), were collected when patients were
transferred to the rehabilitation unit (8–30 days) and 6
months after stroke onset and were used as input data. Mo-
tor outcomes at 6 months after stroke onset of the affected
upper and lower extremities were classified according to
MBC and FAC, respectively. Patients with an MBC of <5 and
an FAC of <4 at 6 months after stroke onset were considered
to have a “poor” outcome, whereas those with MBC ≥5 and
The area under the curve (AUC) for the DNN model for pre-
dicting motor function was 0.836 for the upper and lower
limb motor functions. For the random forest and logistic re-
gression models, the AUCs were 0.736 and 0.790 for the up-
per and lower limb motor functions, respectively. The AUCs
for the random forest and logistic regression models were
0.741 and 0.795 for the upper and lower limb motor func-
tions, respectively. Conclusion: Although we used simple
and common data that can be obtained in clinical practice
as variables, our DNN algorithm was useful for predicting
motor recovery of the upper and lower extremities in stroke
patients during the recovery phase. © 2022 S. Karger AG, Basel
Introduction
Stroke is the second leading cause of death in the el-
derly in high-income countries, and it is one of the lead-
ing causes of serious long-term disability in the adult pop-
ulation [1]. Many post-stroke patients continue to have a
Jeoung Kun Kim and Zhihan Lv equally contributed to this work as
first authors.

Karger@karger.com © 2022 S. Karger AG, Basel Correspondence to:

www.karger.com/ene Donghwi Park, bdome @ hanmail.net
Min Cheol Chang, wheel633 @ gmail.com
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Data of 1,328 stroke patients

Data of 486 stroke patients were

excluded after applying inclusion
and exclusion criteria
A total of data of 842 patients
were analyzed

Training set Validation Test set

set

429 patients (MBC) 129 patients (MBC) 56 patients (MBC)

583 patients (FAC) 175 patients (FAC) 75 patients (FAC)

Feature extraction Feature extraction Feature extraction

Trained model Best model Model performance

Training
performance validation re-validation

Hyper-parameter tuning and training refinement Final ML model

Fig. 1. The overall process of analysis of data with ML. MBC, modified Brunnstrom classification; FAC, func-
tional ambulation score; ML, machine learning.

residual disability even after acute stroke management [2,
3]. Appropriate rehabilitative treatment can improve
functional recovery and reduce post-stroke disability [4,
5]. Knowledge of motor function prognosis is useful for
clinicians in determining the most appropriate and effec-
tive rehabilitation strategy [4].
To date, several prognostic scoring systems, such as
Acute ASTRAL, DRAGON, and SEDAN scores, have
been developed for this purpose [6, 7]. In addition, trans-
cranial magnetic stimulation and diffusion tensor trac-
tography studies have been used for predicting motor
outcome after stroke [8, 9]. However, in clinical practice,
the aforementioned methods frequently fail to predict the
actual results [10]. Furthermore, because each hospital
has a variety of tests and uses different evaluation tools, it
is often difficult to apply the abovementioned predicting
systems or tools. Therefore, efforts to improve the predic-
tion accuracy and the use of commonly used are required.
Machine learning (ML) is an artificial intelligence
technique in which a system learns patterns and rules
from a given data [11–13]. It has the advantage of detect-
ing potential interactions between many attributes/vari-
ables. The application of this technology in the medical
field has produced promising results. In particular, the
complex and unpredictable nature of human physiology
has proven to be better explained by ML algorithms in
many circumstances [13]. Previous studies in the field of
stroke rehabilitation demonstrated the potential of ML to
be used in motor function prediction [13–15]. However,
because the input data used in previous ML studies were
diverse and the data forms used by hospitals in actual
clinical practice differed, it is difficult to uniformly use it
in many hospitals. In this study, we created a practical ML
model using the most common data measured in almost
all rehabilitation hospitals as input data.
Materials and Methods
This study was approved by the Institutional Review Board of
Yeungnam University Hospital, and informed consent was waived
because of the retrospective nature of the study and because the
analysis involved anonymous clinical data. This study included
stroke patients who were admitted to the physical medicine and
rehabilitation department of a single university hospital for stroke
rehabilitation between January 2009 and March 2021. The steps
of the modeling process applied in this study are shown in Figure
1.

274 Eur Neurol 2022;85:273–279 Kim/Lv/Park/Chang

DOI: 10.1159/000522254

Table 1. Performances comparison for random forest, logistic regression, DNN models
ML model MBC prediction model
Sample size (patients) 429 for training, 129 for validation, 56 for test, total 614
Sample zero ratio Train 50.12%, validation 50.45%, test 50.00%
DNN 3 layers with 256-256-256 neurons, learning rate 4e−06
SGD optimizer, ELU activation, batch size 16, drop out rate 0.2
Training accuracy: 78.09%
Validation accuracy: 83.72%
Test accuracy: 80.36%
Validation AUC 0.836 with CI (0.774–0.898)
Test AUC 0.804 with CI (0.703–0.904)
Logistic regression Training accuracy: 75.99%
Validation accuracy: 79.07%
Test accuracy: 76.79%
Validation AUC 0.790 with CI (0.722–0.858)
Test AUC 0.768 with CI (0.664–0.872)
Random forest 500 estimators
Out-of-bag score estimate: 72.73%
Mean validation accuracy score: 73.64%
Mean test accuracy score: 75.00%
Validation AUC 0.736 with CI (0.660–0.813)
Test AUC 0.750 with CI (0.636–0.864)
ML, machine learning; MBC, modified Brunnstrom classification; FAC, functional ambulation category; DNN, deep neural network; SGD, stochastic gradient
descent; AUC, area under the curve; CI, confidence interval.
Data Collection
The inclusion criteria were as follows: (1) first-ever stroke, (2)
age over 20 years, (3) hemiplegia or hemiparesis following stroke,
(4) clinical data collected within 7–30 days (early stage, day of
transfer, or day of admission to the rehabilitation department) af-
ter onset, and (5) absence of serious medical complications, such
as pneumonia or cardiac problems (acute coronary syndromes [4
patients] and cardiomyopathy [2 patients]) from onset to final
evaluation. The exclusion criteria were as follows: (1) other preex-
isting brain or spinal cord lesions and (2) presence of other periph-
eral neuropathies that could affect ankle dorsiflexion strength,
such as peripheral polyneuropathy.
The following demographic and clinical data were collected
when patients were transferred to the rehabilitation unit (8–30
days after stroke onset): age, sex, type of stroke (ischemic/hemor-
rhagic), modified Brunnstrom classification (MBC), functional
ambulation score (FAC), and Medical Research Council (MRC)
score for muscle strength of shoulder abductor, elbow flexor, fin-
ger flexor, finger extensor, hip flexor, knee extensor, and ankle
dorsiflexor of the affected side [16, 17]. We selected these input
variables because they are most commonly and easily collected
when stroke patients are admitted or visit the hospital for reha-
bilitation.
We used three ML algorithms: deep neural network (DNN),
random forest, and logistic regression [18]. The DNN algorithm
consists of layers of interconnected artificial neurons [19]. An ar-
tificial neuron is designed based on the biological neuron and re-
ceives multiple inputs multiplied by weights and outputs the sum
Artificial Intelligence for Stroke
Rehabilitation
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FAC prediction model
583 for training, 175 for validation, 75 for test, total 833
Train 45.97%, validation 46.0%, test 46.0%
3 layers with 256-512-1024 neurons, learning rate 5e−06
SGD optimizer, ReLU activation, batch size 32, drop out rate 0.6
Training accuracy: 90.22%
Validation accuracy: 83.43%
Test accuracy: 78.67%
Validation AUC 0.836 with CI (0.782–0.891)
Test AUC 0.782 with CI (0.687–0.877)
Training accuracy: 71.87%
Validation accuracy: 78.86%
Test accuracy: 69.33%
Validation AUC 0.795 with CI (0.736–0.853)
Test AUC 0.692 with CI (0.585–0.798)
500 estimators
Out-of-bag score estimate: 67.75%
Mean validation accuracy score: 74.29%
Mean test accuracy score: 69.33%
Validation AUC 0.741 with CI (0.675–0.806)
Test AUC 0.684 with CI (0.579–0.790)
of the inputs [20]. The random forest algorithm comprises several
decision trees that consist of multiple true or false conditions using
input variables [21]. The final classification is based on the sum of
the decisions made by the decision trees [22]. Logistic regression
is a statistical technique for estimating the causal relationship be-
tween a dependent variable with only two values and the indepen-
dent variables using a logistic function [23].
Two DNN models were trained for FAC and MBC predictions
with all variables as inputs to classify the patients’ motor outcomes.
For the DNN, three layers with 256-256-256 neurons (MBC predic-
tion) and 256-512-1024 neurons (FAC prediction) were used. For
the random forest model, 500 decision trees were used (Table 1).
To understand the effects of two demographic variables – sex
and age, we evaluated performance change for each model which
does not use sex or age as input data. The evaluation result shows
that the DNN model with all data outperformed the other two
models (without sex or age) on both validation and test datasets.
Logistic regression and random forest model show only minor dif-
ferences or no difference without sex or age. The details are shown
in Tables 2 and 3.
We categorized the output variables as “good” and “poor” in
the upper and lower extremities. In the lower extremity, patients
with an FAC of <4 at 6 months after stroke onset were considered
to have a “poor” outcome, while those with scores ≥4 were consid-
ered to have a “good” outcome. In the upper extremity, patients
with an MBC score of <5 at 6 months after stroke onset were con-
sidered to have a “poor” outcome, while those with scores ≥5 were
considered to have a “good” outcome.
Eur Neurol 2022;85:273–279 275
DOI: 10.1159/000522254
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Table 2. Modified Brunnstrom classification prediction model performance change comparison

ML model Base model with all variables Model without sex Diff Model without age Diff

DNN Training accuracy: 78.09% Training accuracy: 80.89% Training accuracy: 85.08%
Validation accuracy: 83.72% Validation accuracy: 83.72% 0% Validation accuracy: 80.62% −3.1%
Test accuracy: 80.36% Test accuracy: 78.57% −1.79% Test accuracy: 78.57% −1.79%

Logistic Training accuracy: 75.99% Training accuracy: 76.22% Training accuracy: 75.52%
regression Validation accuracy: 79.07% Validation accuracy: 77.52% −1.55% Validation accuracy: 78.79% −0.28%
Test accuracy: 76.79% Test accuracy: 75.00% −1.79% Test accuracy: 78.57% +1.78%

Random Out-of-bag score estimate: 72.73% Out-of-bag score estimate: 70.16% Out-of-bag score estimate: 72.49%
forest Mean validation accuracy score: 73.64% Mean validation accuracy score: 73.64% 0% Mean validation accuracy score: 75.19% +1.55%
Mean test accuracy score: 75.00% Mean test accuracy score: 75.00% 0% Mean test accuracy score: 76.79% +1.79%

ML, machine learning; DNN, deep neural network.

Table 3. Functional ambulation category prediction model performance change comparison

ML model Base model with all variables Model without sex Diff Model without age Diff

DNN Training accuracy: 90.22% Training accuracy: 79.93%% Training accuracy: 79.07%
Validation accuracy: 83.43% Validation accuracy: 81.17% −2.26% Validation accuracy: 80.00% −3.43%
Test accuracy: 78.67% Test accuracy: 69.33% −9.33% Test accuracy: 72.00% −6.67%

Logistic Training accuracy: 71.87% Training accuracy: 71.87% Training accuracy: 69.98%
regression Validation accuracy: 78.86% Validation accuracy: 78.86% 0% Validation accuracy: 77.71% −1.15%
Test accuracy: 69.33% Test accuracy: 69.33% 0% Test accuracy: 70.67% +1.34%

Random Out-of-bag score estimate: 67.75% Out-of-bag score estimate: 66.90% Out-of-bag score estimate: 67.41%
forest Mean validation accuracy score: 74.29% Mean validation accuracy score: 73.14% −1.15% Mean validation accuracy score: 77.14% +2.85%
Mean test accuracy score: 69.33% Mean test accuracy score: 66.67% −2.66% Mean test accuracy score: 68.00% +1.33%

ML, machine learning; DNN, deep neural network.

For this study, data from 842 patients (mean age: 60.8 ± 13.2
years; 480 males, 353 females; stroke onset: 16.3 ± 6.6 days) were
analyzed. To develop a model for predicting motor outcome of upper
extremity, 614 patients’ data (mean age 61.0 ± 13.0 years; 349 males,
265 females; stroke onset: 16.4 ± 6.5 days) were used. To prevent
overfitting of the models, 70% (n = 429, poor: good = 50.1%: 49.9%),
21% (n = 129, poor: good = 50.5%: 49.7%), and 9% (n = 56, poor: good
= 50.0%: 50.0%) of these data were included in the training, valida-
tion, and test sets, respectively. To develop a model for predicting
motor outcome of lower extremity, 833 patients’ data (mean age: 60.8
± 13.2 years; 480 males, 353 females; stroke onset: 16.3 ± 6.6 days)
were used: 70% (n = 583, poor : good = 46.0%: 54.0%) for training set,
21% (n = 175, poor: good = 46.3%: 53.7%) for validation set, and 9%
(n = 75, poor: good = 45.3%: 54.7%) for test sets. TensorFlow version
2.4.1 (Google, Mountain View, CA, USA) and the scikit-learn toolkit
version 0.24.1 were used to train the ML models.
Statistical Analysis
Statistical analyses were performed using Python 3.8.8 and
scikit-learn version 0.24.1. Receiver operating characteristic curve
analysis was employed, and area under the curve (AUC) was cal-
culated. The confidence interval (CI) for AUC was calculated using
the approach used by DeLong et al. [24].
Results
In the prediction of the motor outcome of the upper
extremity, the AUC of the validation dataset for the DNN
model was 0.836 (95% CI, 0.774–0.898). For the random
forest and logistic regression models, the AUC of the val-
idation dataset was 0.736 (95% CI, 0.660–0.813) and 0.790
(95% CI, 0.722–0.858), respectively (Table 1; Fig. 2).
As for the motor outcome of the lower extremity, the
AUC of the validation dataset for the DNN model was
0.836 (95% CI, 0.782–0.891). For the random forest and
logistic regression models, the AUC was 0.741 (95% CI,
0.675–0.806) and 0.795 (95% CI, 0.736–0.853), respec-
tively (Table 1; Fig. 2).

276 Eur Neurol 2022;85:273–279 Kim/Lv/Park/Chang

DOI: 10.1159/000522254

MBC validation receiver operating characteristic curve
1.0
0.8
True positive rate
0.6
0.4
0.2 Deep neural network, AUC = 0.836
Logistic regression, AUC = 0.790
Random forest, AUC = 0.736
0 0
0 0.2 0.4 0.6 0.8
False positive rate
Fig. 2. Receiver operating characteristic curves for validation data. AUC, area under the curve.
Discussion
In predicting both motor outcomes of the upper and
lower extremities in stroke patients, the DNN model
showed the highest AUC, followed by the logistic regres-
sion model and random forest. The AUC for the DNN
model for predicting motor function was 0.836 for the
upper and lower limb motor functions. For the random
forest and logistic regression models, the AUCs were un-
der 0.8.
The most noticeable improvements usually occur
within the first few weeks of stroke onset, after which the
rate of improvement slows and reaches a relatively stable
state after 3 months [25, 26]. Within 3 months after stroke
onset, 70% recovery in motor function is known to occur.
After 6 months, recovery usually reaches its limit and en-
ters a chronic phase [25, 26]. Therefore, in this study, we
used the FAC and MBC score at 6 months after stroke
onset as indicators of recovery of the upper and lower ex-
tremities.
In previous studies, ML models were used to predict
functional improvement in stroke patients. For example,
Heo et al. [13] predicted the modified Rankin scale (mRS)
score using the DNN with 2,604 acute ischemic stroke
subjects and reported an AUC of 0.888. The researchers
used six variables to calculate the ASTRAL score as input
data to predict the outcome. Lin et al. [14] investigated
whether ML models can predict the recovery of activities
Artificial Intelligence for Stroke
Rehabilitation
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Color version available online
FAC validation receiver operating characteristic curve
1.0
0.8
True positive rate
0.6
0.4
0.2 Deep neural network, AUC = 0.836
Logistic regression, AUC = 0.795
Random forest, AUC = 0.741
1.0 0 0.2 0.4 0.6 0.8 1.0
False positive rate
of daily living in acute stroke patients. The researchers
used data from 313 patients to predict the Bathel index
score at discharge using ML methods, such as support
vector machine, and they obtained an AUC of 0.777. Lin
et al. [14] used several data, such as mRS, BI, functional
oral intake scale, mini nutrition assessment, European
quality of life five dimensions questionnaire, instrumen-
tal activities of daily living scale, Berg balance test, gait
speed, 6-min walk test, Fugl-Meyer upper extremity as-
sessment, modified Fugl-Meyer sensory assessment,
mini-mental state examination, motor activity log amount
of use, and concise Chinese aphasia test as input data [14].
Wang et al. [15] developed a prognostic model of func-
tional outcome using data from 333 patients with prima-
ry ICH. They utilized Auto-WEKA 2.0, which uses a se-
quential model-based algorithm configuration to deter-
mine the class with the best performance on the given
data. Functional scores at 1 and 6 months after onset,
evaluated with the mRS, were used as the outcome data,
and an AUC of 0.899 at 1 month and 0.917 at 6 months
was obtained. To predict the outcome, they used demo-
graphic attributes (age, medical history of hypertension
and diabetes, blood pressure, and level of consciousness),
radiologic attributes (volume and location of hematoma,
presence of intraventricular hemorrhage, ventricle com-
pression, and midline structure shift), and laboratory at-
tributes (serum glucose level, aspartate aminotransferase,
alanine aminotransferase, blood urea nitrogen, creati-
Eur Neurol 2022;85:273–279 277
DOI: 10.1159/000522254

nine, the blood urea nitrogen/creatinine ratio, glycosyl-
ated hemoglobin, the complete blood count, triglyceride,
total cholesterol, C-reactive protein, uric acid, prothrom-
bin time, activated partial thrombin time, and hypersen-
sitive C-reactive protein) as input data.
Unlike the abovementioned previous studies, we at-
tempted to develop a practical ML model using the most
commonly and easily measured clinical data. The MRCs
in each muscle group were measured in almost all reha-
bilitation hospitals. MBC and FAC are easily checked by
physiatrists and physical therapists [27]. Furthermore, in
a previous Delphi study that evaluated what medical in-
formation is essential for physicians to improve the effi-
ciency of transferring medical records for stroke patients
undergoing interhospital transfer, variables such as age,
sex, type of stroke (ischemic/hemorrhagic), MRC scores,
MBC, and FAC, which were used in our study, were re-
ported to be indispensable information [28]. Therefore,
we used these variables as input data to develop a practical
ML algorithm for predicting post-stroke motor out-
comes. Previously developed ML algorithms for predict-
ing post-stroke functional or motor outcomes used vari-
ous measurements as input data, which could increase the
prediction accuracy of the ML algorithm. However, neu-
rology and rehabilitation departments of hospitals evalu-
ate stroke patients’ states using different tools and collect
different clinical data. Accordingly, it is practically inap-
propriate to use several various data as input data for pre-
viously developed algorithm. In addition, there are time
constraints for clinicians to collect all input data used in
previous studies, making it less effective. Since our ML
algorithm used only essential data that can be easily
checked as inputs, its use by clinicians is convenient and
practical.
Although we used simple and common data that can
be obtained much more easily than previous studies as
variables [13–15], the current study demonstrated that
ML models could be useful for predicting the recovery of
upper and lower extremities in acute stroke patients.
Considering that AUCs of 0.7–0.8, 0.8–0.9, and >0.9 are
generally considered acceptable, excellent, and outstand-
ing, the ability of the ML models used in this study to pre-
dict the recovery of the upper extremity and lower ex-
tremity were excellent, with the DNN model outperform-
ing the other models (random forest and logistic
regression models).
In conclusion, our results showed that DNN using
simple and common data as input variables is an excellent
predictor of motor outcomes after stroke. The DNN was
found to be better than decision tree forest and logistic
278 Eur Neurol 2022;85:273–279
DOI: 10.1159/000522254
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regression. Multiple layers of complex networks in DNN
would be efficient for representing the complex charac-
teristics of the clinical outcomes of a stroke patient. Our
study is limited in that it is a single-center study and
should be validated with data from more sources from
other hospitals. Also, we did not use data on comorbidi-
ties as input data, their addition is expected to increase the
prediction accuracy.
Statement of Ethics
This study protocol was reviewed and approved by the Institu-
tional Review Board of Yeungnam University Hospital, approval
number (2019-10-008). Informed consent was waived by the Insti-
tutional Review Board of Yeungnam University Hospital because
of the retrospective nature of the study and because the analysis
involved anonymous clinical data.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
The present study was supported by a National Research Foun-
dation of Korea grant funded by the Korean government (grant
No. NRF-2019M3E5D1A02068106).
Author Contributions
J.K.K., Z.L., D.P., and M.C.C. collected the data, designed the
study, performed the statistical analysis, and drafted the manu-
script.
Data Availability Statement
The corresponding author will provide the data on reasonable
request.
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