Post-stroke fatigue has been described by people with stroke as ‘a fatigue like no other’ (Thomas et al, 2019a). It is characterised by a disproportionate sense of tiredness, a lack of energy, and a need to rest that is greater than usual, although rest may not be effective in alleviating it (Lanctot et al, 2020). There is no consensus on how to define post-stroke fatigue, but case definitions have been proposed (Lynch et al, 2007). Post-stroke fatigue needs to be differentiated from post-stroke apathy (see Section 4.40 Apathy). [2023]
Post-stroke fatigue can profoundly impact the lives of people with stroke, particularly their return to work, mobility, physical activity, mood, cognitive function, functional ADL (e.g. shopping) and social activities (Worthington et al, 2017). Post-stroke fatigue can also impact on a person’s ability to engage in rehabilitation, requiring therapists to adopt strategies to manage it during therapy (Riley, 2017). Post-stroke fatigue often affects the lives of families and carers, as it may limit their social life and result in increased loneliness and isolation (Ablewhite et al, 2022b). As family members or carers are often involved in overseeing the implementation of post-stroke fatigue management strategies, fatigue may add considerably to the burden of care. [2023]
Post-stroke fatigue is common and may be the sole residual problem in people who have made an otherwise good recovery (Stroke Association, 2022). Between 35 and 92% of people with stroke are estimated to have post-stroke fatigue (Duncan et al, 2012), with estimates varying by the type of measure, the point at which it is measured during recovery, and the type of stroke (Alghamdi et al, 2021). Post-stroke fatigue may present early or later after stroke, whilst early-onset fatigue persists in a proportion of cases (Wu et al, 2015). Persistent fatigue may continue to impact on functioning and participation several years after stroke (Elf et al, 2016). [2023]
The causes of post-stroke fatigue are not fully understood. It needs to be considered in a holistic manner (Thomas et al, 2019a) and a biopsychosocial model has been proposed (Wu et al, 2015). Post-stroke fatigue appears to be multi-factorial (Wu et al, 2015; Aarnes et al, 2020), and may fluctuate over the course of the day and vary in severity. It is commonly associated with pre-stroke fatigue (Wu et al, 2015), demographic (older age, female gender), clinical (stroke site, immune response characteristics, pain, sleep disturbance), physical (disability severity), emotional (depression, anxiety, avoidant or confrontational coping styles), cognitive (impaired information processing), and social factors (lack of social support) (Aarnes et al, 2020). It is plausible that different factors are associated with early compared to late-onset post-stroke fatigue, while psychological factors play a role in both (Wu et al, 2015; Chen & Marsh, 2018). There is overlap between post-stroke fatigue and depression, but post-stroke fatigue should be considered a condition in its own right (Aarnes et al, 2020). Potential triggers include physical or cognitive exertion, emotional experiences and sedentary behaviour, but in a proportion of cases there are no known triggers, rendering it unpredictable (Worthington et al, 2017). [2023]
The multifactorial nature of post-stroke fatigue should be captured in tools used to assess it, but a systematic review showed that the most commonly used outcome measures do not address potentially relevant aspects of post-stroke fatigue (Skogestad et al, 2021). Measures for post-stroke fatigue have been reviewed by Mead et al (2007) and Skogestad et al (2021). [2023]
People with stroke indicate that their fatigue is often not understood by healthcare professionals (Thomas et al, 2019a), that they are rarely provided with information or advice on how to manage it (Worthington et al, 2017; Thomas et al, 2019a; Drummond et al, 2021) and that recommended approaches may be conflicting (Thomas et al, 2019a). People with post-stroke fatigue indicate that this lack of awareness by healthcare professionals can cause anxiety (Drummond et al, 2021). Healthcare professionals’ understanding of post-stroke fatigue varies widely (Thomas et al, 2019b), and in the absence of clear evidence, their management of it largely relies on their own clinical experience (Riley, 2017). [2023]