Keywords
Nursing
Stroke
Depression
Pain
Fatigue
Anxiety
How to Cite
Abstract
Introduction. Depression, anxiety, fatigue, and pain are four pathological conditions and symptoms very common in stroke patients that often occur simultaneously, affecting each other. This mutual influence seems little studied, as literature tends to study them separately.
Method. This study aims to analyze the literature on the co-presence and mutual influence of anxiety, depression, fatigue, and pain in stroke patients during neurorehabilitative hospitalization. Scopus, Pubmed, Embase, and Cinahl databases were searched from 01/2017 to 12/2023.
Results. Out of the 24 included studies, 11 investigated fatigue and depression, 10 depression and pain, 6 fatigue and anxiety, and 3 anxiety and pain. In the anxiety and fatigue domains, the observational studies reported a direct association between the two variables, while the intervention studies showed the covariation over time. In anxiety and pain, all the studies reported a direct correlation. In the depression and fatigue, the observational studies showed a positive correlation of variable degree, while the RCTs didn't indicate correlations. No clear association emerged between depression and pain.
Discussion. In conclusion, post-stroke pain and anxiety are less frequently assessed and addressed than fatigue and depression. Current assessment tools appear limited in their adequacy for stroke patients, highlighting important methodological gaps. Further research is needed to develop more appropriate instruments and improve psychological support and pain management in this population.
References
Alghamdi, I., Ariti, C., Williams, A., Wood, E., & Hewitt, J. (2021). Prevalence of fatigue after stroke: a systematic review and meta-analysis. European stroke journal, 6(4), 319-332. https://doi-org.bibliosan.idm.oclc.org/10.1177/23969873211047681
Appelros P. (2006). Prevalence and predictors of pain and fatigue after stroke: a population-based study. International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation, 29(4), 329–333. https://doi.org/10.1097/MRR.0b013e328010c7b8
Aydın Y, Aşkın A, Aghazada N, Şengül İ. (2023) High frequency neuronavigated repetitive transcranial magnetic stimulation in post-stroke shoulder pain: A double-blinded, randomized controlled study. J Stroke Cerebrovasc Dis. Mar;33(3):107562. doi: 10.1016/j.jstrokecerebrovasdis.2024.107562
Babkair, L. A., Safhi, R. A., Balshram, R., Safhei, R., Almahamdy, A., Hakami, F. H., & Alsaleh, A. M. (2023). Nursing Care for Stroke Patients: Current Practice and Future Needs. Nursing Reports, 13(3), 1236-1250. https://doi.org/10.3390/nursrep13030106
Baik JS, Yang JH, Ko SH, Lee SJ, Shin YI. (2023) Exploring the Potential of Transcranial Direct Current Stimulation for Relieving Central Post-Stroke Pain: A Randomized Controlled Pilot Study. Life (Basel). May 12;13(5):1172. doi: 10.3390/life13051172.
Barbay, M., Taillia, H., Nédélec-Ciceri, C., Bompaire, F., Bonnin, C., Varvat, J., ... & Godefroy, O. (2018). Prevalence of poststroke neurocognitive disorders using National Institute of Neurological Disorders and Stroke-Canadian Stroke Network, VASCOG criteria (vascular behavioral and cognitive disorders), and optimized criteria of cognitive deficit. Stroke, 49(5), 1141-1147. https://doi.org/10.1161/STROKEAHA.117.018889
Barker TH, Hasanoff S, Aromataris E, Stone JC, Leonardi-Bee J, Sears K, et al. The revised JBI critical appraisal tool for the assessment of risk of bias for analytical cross-sectional studies. JBI Evid Synth. 2026;24(3):401-8.
Barker, Timothy H.1,2; Hasanoff, Sabira2; Aromataris, Edoardo1; Stone, Jennifer C.1; Leonardi-Bee, Jo3; Sears, Kim4; Habibi, Nahal1; Klugar, Miloslav5,6; Tufanaru, Catalin7; Moola, Sandeep8; Liu, Xian-Liang9; Munn, Zachary2. The revised JBI critical appraisal tool for the assessment of risk of bias for cohort studies. JBI Evidence Synthesis 23(3):p 441-453, March 2025. | DOI: 10.11124/JBIES-24-00103
Barker TH, Habibi N, Aromataris E, Stone JC, Leonardi-Bee J, Sears K, et al. The revised JBI critical appraisal tool for the assessment of risk of bias quasi-experimental studies. JBI Evid Synth. 2024;22(3):378-88.
Barritt, A. W., & Smithard, D. G. (2011). Targeting fatigue in stroke patients. International Scholarly Research Notices, 2011. https://doi.org/10.5402/2011/805646
Batur, E. B., Ozyemisçi-Taskiran, O., Yuksel, S., Cengiz, M., & Karatas, G. K. (2022). Validity and reliability of the fatigue impact scale in stroke. Topics in Stroke Rehabilitation, 29(7), 526–537. https://doi.org/10.1080/10749357.2021.1978629
Beblo, T., & Driessen, M. (2002). No melancholia in poststroke depression? A phenomenologic comparison of primary and poststroke depression. Journal of geriatric psychiatry and neurology, 15(1), 44-49. https://doi-org.bibliosan.idm.oclc.org/10.1177/089198870201500109
Benaim, C., Froger, J., Cazottes, C., Gueben, D., Porte, M., Desnuelle, C., & Pelissier, J. Y. (2007). Use of the Faces Pain Scale by left and right hemispheric stroke patients. Pain, 128(1-2), 52-58. https://doi-org.bibliosan.idm.oclc.org/10.1016/j.pain.2006.08.029
Berg, A., Lönnqvist, J., Palomäki, H., & Kaste, M. (2009). Assessment of depression after stroke: a comparison of different screening instruments. Stroke, 40(2), 523-529 .https://doi-org.bibliosan.idm.oclc.org/10.1161/strokeaha.108.527705
Burton, L. J., & Tyson, S. (2015). Screening for mood disorders after stroke: a systematic review of psychometric properties and clinical utility. Psychological medicine, 45(1), 29-49. https://doi-org.bibliosan.idm.oclc.org/10.1017/s0033291714000336
Carrozzino, D., Patierno, C., Fava, G. A., & Guidi, J. (2020). The Hamilton rating scales for depression: a critical review of clinimetric properties of different versions. Psychotherapy and psychosomatics, 89(3), 133-150. https://doi-org.bibliosan.idm.oclc.org/10.1159/000506879
Chapman, B., & Bogle, V. (2014). Adherence to medication and self-management in stroke patients. British Journal of Nursing, 23(3), 158-166. https://doi-org.bibliosan.idm.oclc.org/10.12968/bjon.2014.23.3.158
Chen, C. H., Hung, K. S., Chung, Y. C., & Yeh, M. L. (2019). Mind–body interactive qigong improves physical and mental aspects of quality of life in inpatients with stroke: A randomized control study. European Journal of Cardiovascular Nursing, 18(8), 658–666. https://doi.org/10.1177/1474515119860232
Chen YC, Chou W, Hong RB, Lee JH, Chang JH. (2023) Home-based rehabilitation versus hospital-based rehabilitation for stroke patients in post-acute care stage: Comparison on the quality of life. J Formos Med Assoc. 2023 Sep;122(9):862-871. doi: 10.1016/j.jfma.2023.05.007
Chun, H. Y. Y., Ford, A., Kutlubaev, M. A., Almeida, O. P., & Mead, G. E. (2022). Depression, anxiety, and suicide after stroke: a narrative review of the best available evidence. Stroke, 53(4), 1402-1410. https://doi.org/10.1161/STROKEAHA.121.035499
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(9), 968-977. https://doi-org.bibliosan.idm.oclc.org/10.1177/1747493016669861
de Vries, N. J., Sloot, P. H., & Achterberg, W. P. (2017). Pain and pain assessment in stroke patients with aphasia: a systematic review. Aphasiology, 31(6), 703-719. https://doi.org/10.1080/02687038.2016.1254150
Dornonville de la Cour FL, Schow T, Andersen TE, Petersen AH, Zornhagen G, Visser-Keizer AC, Norup A. (2023) Measurement Properties of the Dutch Multifactor Fatigue Scale in Early and Late Rehabilitation of Acquired Brain Injury in Denmark. J Clin Med. Mar 29;12(7):2587. doi: 10.3390/jcm12072587
Feigin, V. L., Brainin, M., Norrving, B., Martins, S., Sacco, R. L., Hacke, W., ... & Lindsay, P. (2022). World Stroke Organization (WSO): global stroke fact sheet 2022. International Journal of Stroke, 17(1), 18-29. https://doi.org/10.1177/17474930211065917
Ferro, J. M., Caeiro, L., & Figueira, M. L. (2016). Neuropsychiatric sequelae of stroke. Nature reviews. Neurology, 12(5), 269–280. https://doi.org/10.1038/nrneurol.2016.46
Gillham, S., Carpenter, M., & Leathley, M. (2012). Psychological care after stroke: economic modelling of a clinical psychology led team approach. London: Department of Health. Available on: https://www.nice.org.uk/media/default/sharedlearning/531_strokepsychologicalsupportfinal.pdf Last accessed 22/10/2023
Guidetti, S., Gustavsson, M., Tham, K., Andersson, M., Fors, U., & Ytterberg, C. (2020). F@ce: a team-based, person-centred intervention for rehabilitation after stroke supported by information and communication technology – a feasibility study. BMC Neurology, 20(1). https://doi.org/10.1186/s12883-020-01968-x
Harrison, R. A., & Field, T. S. (2015). Post stroke pain: identification, assessment, and therapy. Cerebrovascular diseases, 39(3-4), 190-201. https://doi-org.bibliosan.idm.oclc.org/10.1159/000375397
Hartley, T., Burger, M., & Inglis-Jassiem, G. (2022). Post stroke health-related quality of life, stroke severity and function: A longitudinal cohort study African Journal of Disability. https://doi.org/10.4102/ajod
Hawker, G., Mian, S., Kendzerska, T & French, M. (2011). Measures of adult pain. Arthritis Care Res., 63, S240-S252. https://doi-org.bibliosan.idm.oclc.org/10.1002/acr.20543
Honoré, H., Skovbjerg, F., Pedersen, A. R., Mechlenburg, I., & Nielsen, J. F. (2023). Exploring Physical Activity During the Discharge Transition Phase in People With Acquired Brain Injury—An Observational Study. Archives of Rehabilitation Research and Clinical Translation, 5(1), 100247. https://doi.org/10.1016%2Fj.arrct.2022.100247
Kahl, C., & Cleland, J. A. (2005). Visual analogue scale, numeric pain rating scale and the McGill pain Questionnaire: an overview of psychometric properties. Physical therapy reviews, 10(2), 123-128.
Kautzky-Willer, A., Harreiter, J., Thomas, A., Burger, J., Schneeweiß, U., Deischinger, C., Klein, W., & Moser, H. (2021). Women With Cerebral Infarction Feature Worse Clinical Profiles at Admission but Comparable Success to Men During Long-Term Inpatient Neurorehabilitation. Frontiers in Aging Neuroscience, 13. https://doi.org/10.3389/fnagi.2021.663215
Kim, J. S. (2009). Post-stroke pain. Expert review of neurotherapeutics, 9(5), 711-721. https://doi.org/10.1586/ern.09.19
Kim, W. H., Joa, K. L., Kim, C. B., Lee, H. S., Kang, S. G., Jung, H. Y., & Bae, J. N. (2022). The Effect of Bright Light Therapy on Sleep and Quality of Life in Patients with Poststroke Insomnia. Psychosomatic Medicine, 84(1), 123–130. https://doi.org/10.1097/PSY.0000000000001014
Kjeverud, A., Østlie, K., Schanke, A. K., Gay, C., Thoresen, M., & Lerdal, A. (2020). Trajectories of fatigue among stroke patients from the acute phase to 18 months post-injury: A latent class analysis. PLoS ONE, 15(4). https://doi.org/10.1371/journal.pone.0231709
Kobylańska, M., Kowalska, J., Neustein, J., Mazurek, J., Wójcik, B., Bełza, M., Cichosz, M., & Szczepańska-Gieracha, J. (2019). The role of biopsychosocial factors in the rehabilitation process of individuals with a stroke. Work, 61(4), 523–535. https://doi.org/10.3233/WOR-162823
Lan Nguyen Hoang, C., Salle, J. Y., Mandigout, S., Hamonet, J., Macian-Montoro, F., & Daviet, J. C. (2012). Physical factors associated with fatigue after stroke: an exploratory study. Topics in Stroke Rehabilitation, 19(5), 369-376. https://doi-org.bibliosan.idm.oclc.org/10.1310/tsr1905-369
Liampas, A., Velidakis, N., Georgiou, T., Vadalouca, A., Varrassi, G., Hadjigeorgiou, G. M., ... & Zis, P. (2020). Prevalence and management challenges in central post-stroke neuropathic pain: a systematic review and meta-analysis. Advances in therapy, 37, 3278-3291.
Lin, F., Su, Y., Weng, Y., Lin, X., Weng, H., Cai, G., & Cai, G. (2021). The effects of bright light therapy on depression and sleep disturbances in patients with Parkinson's disease: a systematic review and meta-analysis of randomized controlled trials. Sleep medicine, 83, 280-289. https://doi.org/10.1016/j.sleep.2021.03.035
Lincoln, N. B., Kneebone, I. I., Macniven, J. A., & Morris, R. C. (2011). Psychological management of stroke. John Wiley & Sons.New Jersey. USA
Luker, J., Lynch, E., Bernhardsson, S., Bennett, L., & Bernhardt, J. (2015). Stroke survivors' experiences of physical rehabilitation: a systematic review of qualitative studies. Archives of physical medicine and rehabilitation, 96(9), 1698-1708. https://doi-org.bibliosan.idm.oclc.org/10.1016/j.apmr.2015.03.017
Lundström, E., Smits, A., Terént, A., & Borg, J. (2009). Risk factors for stroke‐related pain 1 year after first‐ever stroke. European Journal of Neurology, 16(2), 188-193. https://doi-org.bibliosan.idm.oclc.org/10.1111/j.1468-1331.2008.02378.x
Mahadevan, S., Chan, M. F., Moghadas, M., Shetty, M., Burke, D. T., Al-Rasadi, K., & Al-Adawi, S. (2021). Post-stroke psychiatric and cognitive symptoms in west asia, south asia and africa: A systematic review and meta-analysis. Journal of Clinical Medicine, 10(16), 3655. https://doi.org/10.3390%2Fjcm10163655
Mandysova, P., Klugarová, J., Matějková, I., de Vries, N. J. C., & Klugar, M. (2022). Assessment instruments used for self-report of pain in hospitalized stroke patients with communication problems: a scoping review. JBI Evidence Synthesis, 20(6), 1511-1536. https://doi-org.bibliosan.idm.oclc.org/10.11124/jbies-21-00047
McKevitt, C., Fudge, N., Redfern, J., Sheldenkar, A., Crichton, S., Rudd, A. R., ... & Wolfe, C. D. (2011). Self-reported long-term needs after stroke. Stroke, 42(5), 1398-1403.https://doi.org/10.1161/STROKEAHA.110.598839
Mackenzie, A., & Greenwood, N. (2012). Positive experiences of caregiving in stroke: a systematic review. Disability and rehabilitation, 34(17), 1413-1422. https://doi-org.bibliosan.idm.oclc.org/10.3109/09638288.2011.650307
Meader, N., Moe-Byrne, T., Llewellyn, A., & Mitchell, A. J. (2014). Screening for poststroke major depression: a meta-analysis of diagnostic validity studies. Journal of Neurology, Neurosurgery & Psychiatry, 85(2), 198-206. https://doi-org.bibliosan.idm.oclc.org/10.1136/jnnp-2012-304194
Murray, J., Young, J., Forster, A., & Ashworth, R. (2003). Developing a primary care-based stroke model: the prevalence of longer-term problems experienced by patients and carers. British Journal of General Practice, 53(495), 803-807.
Naess, H., Lunde, L., Brogger, J., & Waje-Andreassen, U. (2010). Post-stroke pain on long-term follow-up: the Bergen stroke study. Journal of neurology, 257, 1446-1452. https://doi-org.bibliosan.idm.oclc.org/10.1007/s00415-010-5539-y
O’’Donnell, M. J., Diener, H. C., Sacco, R. L., Panju, A. A., Vinisko, R., & Yusuf, S. (2013). Chronic pain syndromes after ischemic stroke: PRoFESS trial. Stroke, 44(5), 1238-1243. https://doi-org.bibliosan.idm.oclc.org/10.1161/strokeaha.111.671008
Ozyemisci-Taskiran, O., Batur, E. B., Yuksel, S., Cengiz, M., & Karatas, G. K. (2019). Validity and reliability of fatigue severity scale in stroke. Topics in stroke rehabilitation, 26(2), 122-127. https://doi.org/10.1080/10749357.2018.1550957
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., ... & Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. International journal of surgery, 88, 105906. https://doi-org.bibliosan.idm.oclc.org/10.1136/bmj.n71
Payton, H., & Soundy, A. (2020). The experience of post-stroke pain and the impact on quality of life: an integrative review. Behavioral Sciences, 10(8), 128. https://doi-org.bibliosan.idm.oclc.org/10.3390/bs10080128
Paudel, S. K., Rolls, K., Green, H., & Fernandez, R. (2023). Prevalence and Impact of Poststroke Fatigue on Patient Outcomes in the First 6 Months After Stroke: A Systematic Review and Meta-analysis. Journal of Neuroscience Nursing, 55(5), 178-185. https://doi-org.bibliosan.idm.oclc.org/10.1097/jnn.0000000000000716
Prisnie, J. C., Fiest, K. M., Coutts, S. B., Patten, S. B., Atta, C. A., Blaikie, L., ... & Jetté, N. (2016). Validating screening tools for depression in stroke and transient ischemic attack patients. The International Journal of Psychiatry in Medicine, 51(3), 262-277.https://doi-org.bibliosan.idm.oclc.org/10.1177/0091217416652616
Rahamatali, M., De Bont, N., Valet, M., Halkin, V., Hanson, P., Deltombe, T., ... & Selves, C. (2021). Post-stroke fatigue: how it relates to motor fatigability and other modifiable factors in people with chronic stroke. Acta Neurologica Belgica, 121, 181-189. https://doi.org/10.1007/s13760-020-01453-9
Rhudy, L. M., Wells-Pittman, J., & Flemming, K. D. (2020). Psychosocial Sequelae of Stroke in Working-Age Adults: A Pilot Study. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses, 52(4), 192–199. https://doi.org/10.1097/JNN.0000000000000523
Rhudy LM, Hines EA, Farr EM, Esterov D, Chesak SS. (2023) Feasibility and acceptability of the Resilient Living program among persons with stroke or brain tumor and their family caregivers. NeuroRehabilitation. 52(1):123-135. doi: 10.3233/NRE-220127
Rivas, J. J., del Carmen Lara, M., Castrejon, L., Hernández-Franco, J., Orihuela-Espina, F., Palafox, L., ... & Sucar, L. E. (2021). Multi-label and multimodal classifier for affective states recognition in virtual rehabilitation. IEEE Transactions on Affective Computing, 13(3), 1183-1194. doi: 10.1109/TAFFC.2021.3055790
Rutkowski, N. A., Sabri, E., & Yang, C. (2021). Post-stroke fatigue: A factor associated with inability to return to work in patients <60 years—A 1-year follow-up. PLoS ONE, 16(8 August). https://doi.org/10.1371/journal.pone.0255538
Spalletta, G., Ripa, A., & Caltagirone, C. (2005). Symptom profile of DSM-IV major and minor depressive disorders in first-ever stroke patients. The American Journal of Geriatric Psychiatry, 13(2), 108-115. https://doi-org.bibliosan.idm.oclc.org/10.1176/appi.ajgp.13.2.108
Sterne, J. A., Savović, J., Page, M. J., Elbers, R. G., Blencowe, N. S., Boutron, I., ... & Higgins, J. P. (2019). RoB 2: a revised tool for assessing risk of bias in randomised trials. bmj, 366. https://doi-org.bibliosan.idm.oclc.org/10.1136/bmj.l489
Szczepańska-Gieracha, J., & Mazurek, J. (2020). The role of self-efficacy in the recovery process of stroke survivors. Psychology Research and Behavior Management, 13, 897–906. https://doi.org/10.2147/PRBM.S273009
Tyson, S. F., & Brown, P. (2014). How to measure fatigue in neurological conditions? A systematic review of psychometric properties and clinical utility of measures used so far. Clinical rehabilitation, 28(8), 804-816. https://doi-org.bibliosan.idm.oclc.org/10.1177/0269215514521043
Urimubenshi, G., Langhorne, P., Cadilhac, D. A., Kagwiza, J. N., & Wu, O. (2017). Association between patient outcomes and key performance indicators of stroke care quality: a systematic review and meta-analysis. European stroke journal, 2(4), 287-307. https://doi.org/10.1177/2396987317735426
van Meijeren-Pont, W., Volker, G., Vliet Vlieland, T., & Goossens, P. (2019). Comparison of the responsiveness of the Utrecht Scale for Evaluation of Rehabilitation (USER) and the Barthel Index in stroke patients. Clinical Rehabilitation, 33(10), 1672-1681. https://doi.org/10.1177/0269215519852130
van Nimwegen, D., Hjelle, E. G., Bragstad, L. K., Kirkevold, M., Sveen, U., Hafsteinsdóttir, T., ... & de Man-van Ginkel, J. (2023). Interventions for improving psychosocial well-being after stroke: A systematic review. International Journal of Nursing Studies, 104492.
Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007 Oct 20;370(9596):1453-7. PMID: 18064739. https://doi-org.bibliosan.idm.oclc.org/10.1016/s0140-6736(07)61602-x
West, R., Hill, K., Hewison, J., Knapp, P., & House, A. (2010). Psychological disorders after stroke are an important influence on functional outcomes: a prospective cohort study. Stroke, 41(8), 1723-1727. https://doi.org/10.1161/STROKEAHA.110.583351
West, A., Simonsen, S. A., Jennum, P., Cyril Hansen, N., Schønsted, M., Zielinski, A., ... & Iversen, H. K. (2019). An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial. NeuroRehabilitation, 45(2), 187-200. https://doi.org/10.3233/NRE-192752.
Wong, H. J., Lua, P. L., Harith, S., & Ibrahim, K. A. (2021). Health-related quality of life profiles and their dimension-specific associated factors among Malaysian stroke survivors: a cross sectional study. Health and quality of life outcomes, 19, 1-14. https://doi-org.bibliosan.idm.oclc.org/10.1186/s12955-021-01847-0
Wu, S., Kutlubaev, M. A., Chun, H. Y. Y., Cowey, E., Pollock, A., Macleod, M. R., ... & Mead, G. E. (2015). Interventions for post‐stroke fatigue. Cochrane Database of Systematic Reviews, (7). https://doi-org.bibliosan.idm.oclc.org/10.1002/14651858.cd007030.pub3
Zhang, S., Xu, M., Liu, Z. J., Feng, J., & Ma, Y. Neuropsychiatric issues after stroke: clinical significance and therapeutic implications. World J Psychiatry. 2020; 10 (6): 125–38. http://dx.doi.org/10.5498/wjp.v10.i6.125
Zhao, C. G., Sun, W., Ju, F., Jiang, S., Wang, H., Sun, X. L., ... & Yuan, H. (2021). Analgesic effects of navigated repetitive transcranial magnetic stimulation in patients with acute central poststroke pain. Pain and Therapy, 10, 1085-1100. https://doi.org/10.1007/s40122-021-00261-0
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