Fatigue

Evidence Reviewed as of before: 28-08-2019
Author(s): Tatiana Ogourtsova, PhD OT; Annabel McDermott, OT
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Fatigue is a multidimensional, motor-perceptive, cognitive and emotional experience. It is described as “a feeling of early exhaustion with weariness, lack of energy and aversion to effort that develops during physical or mental activity and is usually not ameliorated by rest” (Staub & Bogousslavsky, 2001). Post-stroke fatigue can be distinguished into three types:

1) Physical fatigue (i.e. inability to perform activities at physical lengths and intensities);
2) Cognitive fatigue (i.e. inability to perform activities at concentration, multitasking and/or cognitive load stressors lengths and intensities); and
3) Emotional fatigue (i.e. getting tired when facing demanding interactions or relationships) (Terrill, Schwartz & Belagaje, 2018).

Post-stroke fatigue is a prevalent stroke consequence, affecting more than 50% of stroke survivors (Cumming et al. 2016). Prevalence cannot be explained by type of stroke, side of stroke or lesion location. Prevalence is also not associated to stroke severity, meaning that prevalence is the same in mild stroke as compared to severe stroke (Acciarresi et al., 2014). Fatigue is associated with depressive symptoms but can be present without depression. Its association to cognitive deficits and gender remains unclear. However, higher levels of fatigue are found to be associated with female sex, depression, longer post-stroke time period and greater disability (Cumming et al., 2018).

A documentary (lasting 40 minutes) presenting how fatigue impacts daily life of five individuals and what strategies they use to effectively cope with fatigue was produced in March 2019. The documentary (in French) can be viewed by clicking here.

References:
Acciarresi, M., Bogousslavsky, J., & Paciaroni. M. (2014). Post-stroke fatigue: epidemiology, clinical characteristics and treatment. European Neurology, 72, 255-61.
Carlsson, G.E., Möller, A., & Blomstrand, C. (2003). Consequences of mild stroke in persons. Cerebrovascular Diseases16(4), 383-388.
Cumming, T.B., Packer, M., Kramer, S.F., & English, C. (2016). The prevalence of fatigue after stroke: a systematic review and meta-analysis. International Journal of Stroke, 11, 968-77.
Cumming, T.B., Yeo, A.B., Marquez, J., Churilov, L., Annoni, J.M., Badaru, U., … & Mills, R. (2018). Investigating post-stroke fatigue: An individual participant data meta-analysisJournal of Psychosomatic Research113, 107-112.
Glader, E.L., Stegmayr, B., & Asplund, K. (2002). Poststroke fatigue: a 2-year follow-up study of stroke patients in Sweden. Stroke33(5), 1327-1333.
Schepers, V.P., Visser-Meily, A.M., Ketelaar, M., & Lindeman, E. (2006). Poststroke fatigue: course and its relation to personal and stroke-related factors. Archives of Physical Medicine and Rehabilitation87(2), 184-188.
Staub, F. & Bogousslavsky, J. (2001). Fatigue after stroke: a major but neglected issue. Cerebrovascular Diseases12(2), 75-81.
Terrill, A.L., Schwartz, J.K., & Belagaje, S.R. (2018). Best Practices for The Interdisciplinary Rehabilitation Team: A Review of Mental Health Issues in Mild Stroke Survivors. Stroke Research and Treatment, Volume 2018, Article ID 6187328.

Patient/Family Information

Author: Tatiana Ogourtsova, PhD OT; Annabel McDermott, OT

Since my stroke I feel tired. Am I normal?

Fatigue is common in patients with stroke. Approximately 50% of stroke survivors will experience fatigue after having a stroke, no matter what the severity of the stroke is.

What is fatigue after stroke?

Fatigue is a feeling of early tiredness, lack of energy and aversion to effort. Fatigue occurs during or after activity that is physically demanding, mentally demanding (i.e. requiring attention and concentration) or emotionally demanding (e.g. conflict with another person). The main difference with regular fatigue is that post-stroke fatigue usually does not get better as fast with rest.

Are there different types of fatigue?

Fatigue after stroke is usually distinguished into three types: 1) physical, 2) mental or cognitive, and 3) emotional.

Physical fatigue is when a person is unusually tired after physical activity, or is unable to perform a physical activity that requires more effort or strength (e.g. walking, going up the stairs) or for a long period of time.

Mental or cognitive fatigue is when a person is unusually tired after or unable to perform an activity that requires attention, concentration or multitasking (e.g. reading, following a movie).

Emotional fatigue is when a person is unusually tired after difficult interactions or conflicts with close ones (e.g. marital conflict, being uncomfortable with someone, difficulty managing emotions).

When would fatigue appear after a stroke?

Fatigue after stroke can appear at different times. Some people experience fatigue shortly after the stroke. Others experience fatigue much later after stroke, even 1 year after stroke.

Is fatigue caused by my stroke?

It is possible that the fatigue you are experiencing is an effect of your stroke. Here is one possible explanation:

Injury to your brain

There are debates on whether the site of the lesion (stroke location) is related to symptoms of fatigue. Some research shows that people who have a stroke in specific parts of the brain (basal ganglia, internal capsule, brain stem, thalamus) are more likely to experience post-stroke fatigue. Other research argues that it is the number of strokes that matter, where fatigue is more common in people who have had several strokes rather than in those who had a stroke for the first time.

How do I know if I have post-stroke fatigue? What are the common signs of fatigue after a stroke?

People who have fatigue after stroke share some common traits such as:

  • Low energy
  • Feeling weary soon after starting a physical activity (e.g. walking, exercise), an activity that is mentally demanding (e.g. reading, social event) or an activity that is emotionally demanding (e.g. conflict with another person).
  • Feeling a loss of self-control
  • Feeling emotional instability
  • Feeling of tiredness that becomes greater during physical exercise, during activities that require concentration and/or with stress.

Is it easy to detect fatigue after a stroke?

It is often easy to detect fatigue in a person that has had a stroke. However, it can be difficult to identify the type of fatigue you are experiencing and what causes you to feel tired. Your rehabilitation therapist may often ask about your level of fatigue. However, sometimes people who had a stroke have problems speaking or understanding words; this makes it more difficult to share information about fatigue symptoms.

How is the diagnosis of fatigue after a stroke made?

Your therapist may ask you a series of questions or have you or your caregiver fill out a questionnaire. This will help to identify presence of fatigue.

Are there different kinds of therapies for fatigue?

There are many different therapies available for fatigue after stroke. This module includes the following interventions:

  • Mindfulness-based stress reduction (MBSR): a program that helps you to calm you mind and body to help cope with illness, pain, and stress.
  • Inspiratory muscle training (IMT): breathing exercises using a breathing device.
  • Game-based team therapy: playing games in groups that are competitive in nature (e.g. playing ball with scores).
  • Multimodal interventions: rehabilitation that combines physical exercises and cognitive exercises together.
  • Psychoeducation: education, advice, recommendations, and strategies to help change your thoughts and behavior.

There is no known ‘cure’ for post-stroke fatigue. However, when we asked individuals who have had a stroke for their key strategies to cope with fatigue post-stroke, they told us:

  • To accept that you may need to reduce the frequency or intensity of an activity;
  • To plan rest periods into your daily routine;
  • To organise your environment and routine;
  • To conserve your energy when doing everyday activities by making a task simpler;
  • To identify the type of fatigue you are prone to and the activities that trigger your fatigue;
  • To prioritise activities that are meaningful to you and your well-being;
  • To communicate with your close-ones about your level of fatigue;
  • To engage in planned exercise such as aerobics to increase endurance;
  • To practice good sleep patterns.

What fatigue therapies work for stroke?

Fatigue therapies have been examined using high and fair quality research studies. Some therapies were shown to improve mental fatigue and other important domains such as independence in self-care activities, depression, sleep, endurance and respiratory function in some patients after stroke.

In particular, for patients with chronic stroke (more than 6 months after stroke), mindfulness-based stress reduction therapy has been shown to be useful to improve mental fatigue, depression, anxiety, and cognitive abilities (e.g. attention).

For patients with stroke across the recovery continuum (acute, subacute and/or chronic), inspiratory muscle training, game-based team therapy, and multimodal interventions have been shown to be useful to improve fatigue, independence in everyday activities (e.g. dressing, walking), respiratory function (e.g. inspiration and expiration lung capacities), depression, and sleep.

What can I expect in terms of therapy for fatigue?

Your therapist will discuss with you what fatigue therapy is most suitable for you. How often and for how long the therapy is provided for depends on the nature of therapy.

Who provides the treatment?

Different health-care providers can administer fatigue therapies: occupational therapists, physiotherapists, psychologists, neuropsychologists and nurses.

Are there any side effects or risks?

Fatigue therapies are usually administered by a trained health professional at a rehabilitation clinic or at home. Your therapist will monitor your reactions to the therapy closely. It is important to report to your therapist any changes in your state (e.g. more or less fatigue, sleep quality, independence for daily tasks). Your therapist will adjust the nature, intensity and the duration of therapy according to your ability, endurance and progress.

Is it possible to speak to someone who had a stroke?

Support groups are available in some regions for people who have had a stroke. You can also find stories about people who have had problems similar to yours. Consult your National Stroke Association.

How does my fatigue impact on my recovery?

Fatigue after stroke may make you feel less motivated, more tired, and also may cause you to have trouble concentrating. All these symptoms of fatigue will slow down your recovery. Studies have shown that people who have fatigue after stroke do not get better as quickly as people who do not have fatigue.

I would like to know more about fatigue and stroke?

Understanding how fatigue and stroke happen can reassure you. There are many resources online. Your health care provider can help answer your specific questions.

A documentary (lasting 40 minutes) presenting how fatigue impacts daily life of five individuals and what strategies they use to effectively cope with fatigue was produced in March 2019. The documentary (in French) can be viewed by clicking here.

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The current module includes studies examining interventions specific for post-stroke fatigue. Studies were excluded based on the following exclusion criteria: i) fatigue is a secondary outcome and intervention is not fatigue-specific; and ii) the type of intervention is represented by an existing Stroke Engine module. Please see the following Stroke Engine modules for more information on the effects of these intervention on fatigue: Cognitive Rehabilitation, Robotics, Aerobic Exercise, Transcranial Direct Current Stimulation/Transcranial Magnetic Stimulation, Task-Oriented Upper Extremity, Video Games, Balance Training, and Task-Oriented Lower Extremities. The current module includes 8 studies: 2 high quality RCTs, 3 fair quality RCTs and 3 non-RCTs design studies. Of these, 7 studies included patients with stroke not defined to one specific post-stroke time period (e.g. participants in the subacute or chronic stage of stroke recovery). The following 5 types of interventions for post-stroke fatigue emerged and are included in the present module: Mindfulness-based stress reduction, Inspiratory muscle training, Group sports, Multimodal intervention (cognitive and physical training), and Fatigue management psychoeducation.

No studies on interventions for post-stroke fatigue were found for patients specifically in the acute and subacute phase of stroke recovery.

Outcomes

Chronic phase - Mindfulness

Anxiety
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on anxiety in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Anxiety was measured by the Comprehensive Psychopathological Rating Scale (CPRS: Anxiety) at post-treatment (8 weeks). No significant between-group difference was found. Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in reducing anxiety in patients with chronic stroke.

Depression
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on depression in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Depression was measured by the Comprehensive Psychopathological Rating Scale (CPRS: Depression) at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in reducing depression in patients with chronic stroke.

Executive function
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on executive functions in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Executive function was measured by the Trail Making Test (TMT: A, B, C, D) and the Wechsler Adult Intelligence Scale-III: Digit Symbol-Coding Test at post-treatment (8 weeks). A significant between-group difference was found on only one measure of executive function (TMT – A) in favour of MBSR treatment vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving executive function in patients with chronic stroke.
Note: Significant between-group differences in TMT-A were also found at baseline, favoring MBSR vs. no treatment. Significant between-group differences in TMT-B and TMT-C scores were found at post-treatment, but differences did not remain significant when adjusted with TMT-A scores.

Mental fatigue
Effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on mental fatigue in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Mental fatigue was measured by the Self-Evaluation Questionnaire for Mental Fatigue at post-treatment (8 weeks). A significant between-group difference was found in favour of MBSR treatment vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is more effective than no treatment in reducing mental fatigue in patients with chronic stroke.

Reading speed
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on reading speed in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Reading speed was measured by a Reading Speed Dyslexia Screening test at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving reading speed in patients with chronic stroke.

Verbal fluency
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on verbal fluency in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Verbal fluency was measured by the FAS Verbal Fluency Test at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving verbal fluency in patients with chronic stroke.

Working memory
Not effective
2a

One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on working memory in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Working memory was measured by the Wechsler Adult Intelligence Scale-III: Digit Span Test at post-treatment (8 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving working memory in patients with chronic stroke.

Phase not specific to one period - Fatigue management education

Activities of daily living
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on activities of daily living (ADLs) in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. ADLs were measured by the Barthel Index and the modified Rankin Scale at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found on any measure at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in improving activities of daily living in patients with stroke.

Anxiety
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on anxiety in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing anxiety in patients with stroke.

Depression
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) and one non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on anxiety in patients with stroke.

The fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Depression was measured by the Hospital Anxiety and Depression Scale (HADS: Depression) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

The non-randomized pre-post design study (Wu et al., 2017) allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Depression was measured by the Patient Health Questionnaire (PHQ-9) at post-treatment (6 sessions) and follow-up (1 month, 3 months). A significant improvement was found at one follow-up time point only (1 month).

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing depression in patients with stroke. Similarly, a pre-post design study found no significant immediate or long-term benefits from a psychoeducation program.

Fatigue
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012), and two non-randomized studies (Wu et al., 2017; Boehm, Muehlberg & Stube, 2015) investigated the effect aof fatigue management education on fatigue in patients with stroke.

The fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Fatigue was measured by the Fatigue Severity Scale, a Visual Analogue Scale for Fatigue (Fatigue, Vigor), and the Checklist of Individual Strength at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found on any measure at either time point.

A non-randomized pre-post design study (Wu et al., 2017) allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (6 sessions) and follow-up (1 month, 3 months). A significant improvement was found at one follow-up time point only (3 months).

A case report (Boehm, Muehlberg & Stube, 2015) allocated one patient with stroke and post-stroke fatigue (time since stroke not specified) to receive a fatigue management course. Fatigue was measured by the Fatigue Impact Scale (FIS: Physical Fatigue, Cognitive Fatigue, Social Fatigue) at post-treatment (5 weeks). Improvements were noted on all measures of fatigue, however no statistical results were provided. This study is not used in the conclusion below.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing fatigue in patients with stroke. A non-randomized also reported no significant improvements in fatigue immediately following a psychoeducation program.

Health-related quality of life
Not effective
2a

One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on health-related quality of life in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Health-related quality of life was measured by the Short Form-36 (SF-36: Physical functioning, Role physical, Role emotional, Energy/Fatigue, Emotional wellbeing, Social functioning, Pain, General Health) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in improving health-related quality of life in patients with stroke.

Instrumental activities of daily living
Insufficient evidence
5

One non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on instrumental activities of daily living (IADLs) in patients with stroke. This pre-post design study allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. IADLs were measured by the Nottingham Extended Activities of Daily Living at post-treatment (6 sessions) and follow-up (1 month, 3 months). No significant improvements were found at any time point.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on instrumental activities of daily living in patients with stroke. However, one pre-post design study found no significant improvements in instrumental activities of daily living following an psychoeducation program.

Occupational performance
Insufficient evidence
5

One case-report (Boehm, Muehlberg & Stube, 2015) investigated the effect of fatigue management education on occupational performance in a patient with stroke. This case-reported allocated one patient with stroke and post-stroke fatigue (time since stroke not specified) to receive a fatigue management course. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM: Perceived performance, Satisfaction) at post-treatment (5 weeks). No improvements were noted and no statistical results were provided.

Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on occupational performance in patients with stroke. However, one case report found no improvement in occupational performance following a fatigue management course.

Stroke outcomes
Insufficient evidence
5

One non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on stroke outcomes in patients with stroke. This pre-post design study allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Stroke outcomes were measured by the Stroke Impact Scale (SIS: General recovery, Physical strength, Memory and thinking, Emotion, Communication, Daily activities, Mobility, Hand function, Social activity) at post-treatment (6 sessions) and follow-up (1 month, 3 months). Significant improvements were noted in some stroke outcomes at post-treatment (SIS: Mobility, Social activity), 1-month follow-up (SIS: Mobility, Social activity), and 3-month follow-up (SIS: General recovery, Memory and thinking, Emotion, Mobility, Social activity).

Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on stroke outcomes in patients with stroke. However, one pre-post design study found significant improvements in some stroke outcomes following a psychoeducation program.

Phase not specific to one period - Group sports

Depression
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on depression in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Depression was measured by the Korean version of the State Depression Scale at post-treatment (2 weeks). A significant between-group differences was found, favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in reducing depression in patients with stroke.

Fatigue
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on fatigue in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Fatigue was measured by the Brief Fatigue Inventory at post-treatment (2 weeks). A significant between-group difference was found, favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in reducing fatigue in patients with stroke.

Functional independence
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on functional independence in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM: Motor, Cognition, Total scores) at post-treatment (2 weeks). Significant between-group differences were found in two measures of functional independence (FIM: Motor, Total scores), favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving functional independence in patients with stroke.

Sleep quality
Effective
2b

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on sleep quality in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Sleep quality was measured by the Pittsburgh Sleep Quality Index at post-treatment (2 weeks). A significant between-group difference was found, favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving sleep quality in patients with stroke.

One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on functional independence in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM: Motor, Cognition, Total scores) at post-treatment (2 weeks). Significant between-group differences were found in two measures of functional independence (FIM: Motor, Total scores), favoring group sports vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving functional independence in patients with stroke.

Phase not specific to one period - Inspiratory muscle training

Activities of daily living
Effective
2a

One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on activities of daily living (ADLs) in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. ADLs were measured by the Barthel Index at post-treatment (10 weeks). A significant between-group difference was found, favoring IMT vs. no treatment. Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is more effective than no treatment in improving activities of daily living in patients with stroke.

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on walking endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (3 months) and follow-up (6 months). A significant between-group difference was found at post-treatment, favoring cognitive therapy with graded activity vs. cognitive therapy alone. This between-group difference remained significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is more effective than a comparison intervention (cognitive therapy alone) in improving walking endurance in patients with stroke.

Fatigue
Not effective
1b

One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on fatigue in patients with stroke. The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Fatigue was measured by the Fatigue Severity Scale at post-treatment (6 weeks). No significant between-group difference was found. The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (10 weeks). No significant between-group difference was found. Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that inspiratory muscle training is not more effective than no treatment in reducing fatigue in patients with stroke.

Perceived exertion
Not effective
2a

One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on perceived exertion in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Perceived exertion was measured by the modified Borg Scale at post-treatment (10 weeks). No significant between-group difference was found. Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is not more effective than no treatment in improving perceived exertion in patients with stroke.

Respiratory function
Effective
1b

One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on respiratory function in patients with stroke. The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Respiratory function (MIP, IME, affected/non-affected DT at rest/contraction, affected/non-affected DT thickness ratio) was measured by the inspiratory muscle training device PowerBreath K5 (2010, HaB International LtD, UK) at post-treatment (6 weeks). Significant between-group differences were found in some measures of respiratory function (MIP, IME, affected DT at contraction, affected DT thickness ratio), favoring IMT vs. no treatment. The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Respiratory function (FVC, FEV1, ratio FEV1/FVC, MIP, MEP, MMEF, SpO2) was measured by standard spirometer and a finger pulse oximeter at post-treatment (10 weeks). A significant between-group difference was found in one measure of respiratory function (MIP), favoring IMT vs. no treatment. Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is more effective than no treatment in improving respiratory function in patients with stroke. In addition, one fair quality RCT found a significant between-group difference in one measure of respiratory function, favoring inspiratory muscle training compared to no treatment. DT: Diaphragm thickness IME: Inspiratory muscle endurance FVC: Forced Vital Capacity FEV1: Forced Expiratory Volume in 1 sec MIP: Maximal inspiratory pressure MEP: Maximal expiratory pressure MMEF: Maximal mid-expiratory flow SpO2: Resting oxyhemoglobin saturation.

One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on perceived exertion in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Perceived exertion was measured by the modified Borg Scale at post-treatment (10 weeks). No significant between-group difference was found. Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is not more effective than no treatment in improving perceived exertion in patients with stroke.

Walking endurance
Not effective
1b

One high quality RCT (Cho et al., 2018) investigated the effect of inspiratory muscle training (IMT) on endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Walking endurance was measured by the 6-Minute Walk Test at post-treatment (6 weeks). No significant between-group difference was found. Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is not more effective than no treatment in improving walking endurance in patients with stroke.

One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on respiratory function in patients with stroke. The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Respiratory function (MIP, IME, affected/non-affected DT at rest/contraction, affected/non-affected DT thickness ratio) was measured by the inspiratory muscle training device PowerBreath K5 (2010, HaB International LtD, UK) at post-treatment (6 weeks). Significant between-group differences were found in some measures of respiratory function (MIP, IME, affected DT at contraction, affected DT thickness ratio), favoring IMT vs. no treatment. The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Respiratory function (FVC, FEV1, ratio FEV1/FVC, MIP, MEP, MMEF, SpO2) was measured by standard spirometer and a finger pulse oximeter at post-treatment (10 weeks). A significant between-group difference was found in one measure of respiratory function (MIP), favoring IMT vs. no treatment. Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is more effective than no treatment in improving respiratory function in patients with stroke. In addition, one fair quality RCT found a significant between-group difference in one measure of respiratory function, favoring inspiratory muscle training compared to no treatment. DT: Diaphragm thickness IME: Inspiratory muscle endurance FVC: Forced Vital Capacity FEV1: Forced Expiratory Volume in 1 sec MIP: Maximal inspiratory pressure MEP: Maximal expiratory pressure MMEF: Maximal mid-expiratory flow SpO2: Resting oxyhemoglobin saturation.

Phase not specific to one period - Multimodal intervention

Fatigue
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Fatigue was measured by the Checklist Individual Strength (CIS: Fatigue) and the Fatigue Self-Observation List at post-treatment (3 months) and follow-up (6 months). There were no significant between-group differences on either measure at either time point.
Note: The authors noted a significant clinically relevant improvement in CIS: Fatigue scores at follow-up, for the cognitive therapy group with graded activity training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in reducing fatigue in patients with stroke.

Health-related quality of life
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on health-related quality of life (HRQoL) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. HRQoL was measured by the Stroke-Adapted Sickness Impact Profile at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving health-related quality of life in patients with stroke.

Mood and affect
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on mood and affect in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Mood and affect were measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety, Depression) at post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving mood and affect in patients with stroke.

Pain
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on pain in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Pain was measured by the Pain Self-Observation List at post-treatment (3 months) and follow-up (6 months). No significant between-group difference found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in reducing pain in patients with stroke.

Sleep quality
Not effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on sleep quality in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Sleep quality was measured by the Sleep Quality Self-Observation List at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving sleep quality in patients with stroke.

Walking endurance
Effective
1b

One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on walking endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (3 months) and follow-up (6 months). A significant between-group difference was found at post-treatment, favoring cognitive therapy with graded activity vs. cognitive therapy alone. This between-group difference remained significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is more effective than a comparison intervention (cognitive therapy alone) in improving walking endurance in patients with stroke.

References

Boehm, N., Muehlberg, H., & Stube, J.E. (2015). Managing poststroke fatigue using telehealth: a case report. American Journal of Occupational Therapy69(6), 6906350020p1-6906350020p7.
https://ajot.aota.org/article.aspx?articleid=2465091

Chen PC, Liaw MY, Wang LY, Tsai YC, Hsin YJ, Chen YC, Chen SM, Lin MC. (2016). Inspiratory muscle training in stroke patients with congestive heart failure: A CONSORT-compliant prospective randomized single-blind controlled trial. Medicine (Baltimore). Sep;95(37):e4856. doi: 10.1097/MD.0000000000004856.
https://www.ncbi.nlm.nih.gov/pubmed/27631248

Cho JE, Lee HJ, Kim MK, Lee WH. (2018). The improvement in respiratory function by inspiratory muscle training is due to structural muscle changes in patients with stroke: a randomized controlled pilot trial.Top Stroke Rehabil. Jan;25(1):37-43. doi: 10.1080/10749357.2017.1383681.
https://www.ncbi.nlm.nih.gov/pubmed/29061084

Clarke, A., Barker-Collo, S.L., & Feigin, V.L. (2012). Poststroke fatigue: does group education make a difference? A randomized pilot trial. Topics in Stroke Rehabilitation19(1), 32-39.
https://www.tandfonline.com/doi/abs/10.1310/tsr1901-32

Johansson, B., Bjuhr, H., & Rönnbäck, L. (2012). Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury. Brain Injury26(13-14), 1621-1628.
https://www.tandfonline.com/doi/abs/10.3109/02699052.2012.700082

Kim, I. (2012). Effects of an enjoyable nurse-led intervention to promote movement in poststroke inpatients. Clinical Nursing Research21(4), 390-405.
https://journals.sagepub.com/doi/abs/10.1177/1054773812439204

Paul, L., Wyke, S., Brewster, S., Sattar, N., Gill, J. M., Alexander, G., … & Dybus, A. (2016). Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study. Topics in Stroke Rehabilitation23(3), 170-177.
https://www.tandfonline.com/doi/abs/10.1080/10749357.2015.1122266

Wu, S., Chalder, T., Anderson, K.E., Gillespie, D., Macleod, M.R., & Mead, G.E. (2017). Development of a psychological intervention for fatigue after stroke. PloS One12(8), e0183286.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183286

Zedlitz, A.M., Rietveld, T.C., Geurts, A.C., & Fasotti, L. (2012). Cognitive and graded activity training can alleviate persistent fatigue after stroke: a randomized, controlled trial. Stroke, STROKEAHA-111.
https://repository.ubn.ru.nl//bitstream/handle/2066/102380/M_346855.pdf?sequence=1

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