Post-stroke sleep disturbances and rehabilitation outcomes: a prospective cohort study

Factors Affecting Functional Improvement in the Initial Months of Recovery After Stroke: A Pilot Study

ABSTRACT

BACKGROUND: The purpose of this study is to examine factors affecting functional improvement among survivors of stroke during the initial months of stroke recovery. METHODS: A 1-group repeated measures sequential mixed methods design was used. Quantitative longitudinal data were collected on admission, discharge, and postdischarge from the inpatient rehabilitation unit to evaluate the change in patient engagement and the relationship between environmental, personal, and behavioral factors, and functional independence. Semistructured interviews were conducted up to 6 months postdischarge. RESULTS: The sample included 27 participants with a mean age of 64.67 (SD = 13.56). There was a significant increase in patient engagement from admission to discharge ( P < .0001), followed by a nonsignificant decrease from discharge to follow-up ( P = .36). The change in functional improvement from admission to discharge was significant ( P < .0001). Stroke severity was the only significant predictor of functional improvement ( P = .008). There was a significant but weak negative correlation between Patient Health Engagement scale (PHE-s®) total score and sleep disturbance ( r = -0.344, P = .008) and sleep disturbance and self-efficacy ( r = -0.362, P = .005). There was a moderate positive correlation between PHE-s total score and self-efficacy ( r = 0.662, P < .001). Five participants participated in follow-up interviews. The 5 main themes that emerged from interview data were (1) feeling happy to be home, (2) wishing recovery was quicker, (3) living with disability, (4) overcoming obstacles, and (5) social support. CONCLUSION: This pilot study provides insight into the experiences of survivors of stroke during rehabilitation and recovery. The results of this study indicate a need for additional support (eg, transportation, social/emotional) for survivors of stroke after discharge from the rehabilitation unit. Further research to investigate the barriers and facilitators of recovery for survivors of stroke after discharge and the development of interventions aimed at improving sustainable recovery outcomes is needed.

Sleep regularity index as a novel indicator of sleep disturbance in stroke survivors: a secondary data analysis

Sleep disturbance is common but often overlooked after stroke. Regular sleep is increasingly recognised as important for overall health, yet little is known about how sleep regularity changes after stroke. This study examined differences in the Sleep Regularity Index (SRI) between stroke survivors and healthy controls using actigraphy data from an existing dataset (~ 1 week per participant). Data were analysed for 162 stroke survivors (mean age 61 ± 14 years, 5 ± 5 years post-stroke, 89 males) and 60 controls (mean age 57 ± 17 years, 32 males). Stroke survivors had significantly lower SRI scores than controls (p = 0.001), indicating less regular sleep. In the stroke group, higher SRI correlated with longer total sleep time (p = 0.003) and better self-reported sleep quality (p = 0.001) but not with other sleep metrics. Lower SRI was associated with worse depressive symptoms (p = 0.006) and lower quality of life (p = 0.001) but not with disability (p = 0.886) or time since stroke (p = 0.646). These findings suggest that sleep regularity is disrupted post-stroke and may influence well-being. Future research should explore interventions to improve sleep regularity and related health outcomes in stroke survivors.

The 24-Hour Physical Activities in Adults With Cerebral Palsy and Their Adherence to the 24-Hour Movement Guideline

OBJECTIVE

To describe 24-hour physical activities (sleep and physical activity) in adults with cerebral palsy (CP), explore potential influencing factors, and compare 24-hour physical activities with controls.

DESIGN

Cross-sectional, observational internet study involving adults with CP and a convenience sample of adults without CP.

SETTING

Individuals residing in the Netherlands.

PARTICIPANTS

A total of 110 adults with CP (median age: 42, range: 28-77 years; 64 [58%] ambulant; 40% men) and 89 adult controls (median age; 43, range: 18-78 years; 29% men).

MAIN OUTCOME MEASURES

Sleep quantity and quality measured by the Pittsburgh Sleep Quality Index, physical activity measured using the International Physical Activity Questionnaire- Short Form, and health status using the 5-level EuroQol-5D.

RESULTS

Most recurrent sleep problems for adults with CP included falling asleep, waking up, needing the toilet, having nightmares, and experiencing pain during the night. Sleep quality was significantly worse for adults with CP than controls. A total of 64% of adults with CP met the physical activity guidelines. Total physical activity was similar between adults with CP who are ambulatory and controls. A total of 44% of adults with CP, compared with 51% controls, met both sleep and physical activity guidelines. No factors influencing the 24-hour activities were found for level of severity, age, sex, pain/discomfort, and anxiety/depression.

CONCLUSIONS

Given the prevalence of worse sleep quality and modest adherence to the 24-hour movement guideline, this study emphasizes the importance for clinicians to assess problems in physical activities during clinical encounters with adults with CP.

Prevalence of poor sleep quality among stroke survivors: A meta-analysis and systematic review

BACKGROUND

Poor sleep quality is common among stroke survivors, but the prevalence rates vary between studies. This meta-analysis examined the global prevalence of poor sleep quality and its moderating factors among stroke survivors.

METHOD

Relevant publications were systematically searched in PubMed, Web of Science, Embase, PsycINFO, CNKI and WanFang. The pooled prevalence of poor sleep quality and the sleep quality component scores with 95 % confidence intervals (CIs) were calculated using a random-effects model.

RESULT

Totally, 68 studies comprising 14,845 participants who fulfilled study entry criteria were included for analyses. All included studies used the Pittsburgh sleep quality index (PSQI) to assess sleep quality. The global prevalence of poor sleep quality in stroke survivors was 50.26 % (95%CI: 46.69%-53.82 %). Stroke location in left hemisphere was associated with a lower risk of poor sleep quality, while stroke type (i.e., cerebral infarction) and lower-middle-income countries were associated with higher risk of poor sleep quality in stroke survivors.

CONCLUSION

In this meta-analysis, poor sleep quality was common among stroke survivors and was moderated by stroke location, type, and countries income. To address the adverse impacts of poor sleep quality in stroke survivors, regular screening and appropriate intervention should be provided in a timely fashion.

Poor sleep quality and its determinants among stroke survivors in Northwest Ethiopia

Sleep disorders are highly prevalent and linked bidirectionally to stroke as risk factors for stroke to worsen the outcomes. To date, most of the studies on post-stroke sleep were conducted in Western countries. Quality of sleep among stroke patients is masked by other physical and medical complications and limited attention is given in Ethiopia. To address this gap the current study aims to estimate the incidence of poor sleep quality and its determinants among stroke survivors in Northwest Ethiopia. A prospective cohort study was conducted in three public referral hospitals from June 2022 to December 2022. The study included 403 stroke survivors at the three-month follow-up. We conducted analyses of bivariable and multivariable logistic regression to look into the relationship between the outcome and the explanatory variables. Statistics were given as odds ratios and 95% confidence intervals, with a significance level of p < 0.05. The overall incidence of poor sleep quality was 50.1%, with a mean Global Sleep Quality (GSQ score) of 5.15 (SD ± 0.16). According to Pittsburgh Sleep Quality Index (PSQI) data, the mean sleep hour was 6.15. History of alcohol consumption, complications during admission, and time between the onset of symptoms and hospital arrival were predictors of sleep quality. Sleep quality was observed in half of stroke survivors. The study's findings point to the significance of screening for sleep quality following a stroke and further research is needed including admitted and non-admitted stroke patients.

Impact of Ward Noise Management Combined with Bobath Concept-Based Rehabilitation Training on Patients with Cerebral Arteriovenous Malformations: A Retrospective Study

OBJECTIVE

The aim of this study was to investigate the effect of Bobath concept-based rehabilitation training combined with noise management on the rehabilitation outcomes of patients with cerebral arteriovenous malformation (CAVM).

METHODS

The clinical data of CAVM patients who underwent rehabilitation treatment after microsurgical resection from January 2019 to December 2023 in the Fourth Hospital of Hebei Medical University were collected in this retrospective study. A total of 119 patients were divided into a control group (56 individuals, Bobath concept-based rehabilitation training) and an observation group (63 individuals, Bobath concept-based rehabilitation training + noise management) according to the treatment plan. The baseline characteristics of the patients, noise levels, motor function, activities of daily living, neurological function and anxiety and depression levels were analysed.

RESULTS

The noise level in the observation group was significantly lower than that in the control group (P < 0.001). The Fugl-Meyer assessment score (68.67 ± 3.62 vs. 72.53 ± 3.91, P < 0.001) and modified Barthel index score (71.21 ± 4.06 vs. 75.42 ± 4.12, P < 0.001) of the observation group after rehabilitation were significantly higher than those of the control group, whereas the Hospital Anxiety and Depression Scale-Depression score (P = 0.034) and Hospital Anxiety and Depression Scale-Anxiety score (P < 0.001) were significantly lower than those of the control group.

CONCLUSION

Bobath concept-based rehabilitation training combined with noise management can significantly improve the rehabilitation outcomes of CAVM patients, including improvements in motor function, activities of daily living and reductions in anxiety and depression levels. Theoretical and practical guidance for clinical practice, emphasising the importance of environmental management in rehabilitation treatment, is provided in this study. Future rehabilitation interventions should be personalised and comprehensive to enhance the rehabilitation level and quality of life of patients.

Effect of Increasing or Decreasing Use of Polypharmacy on Recovery of Activities of Daily Living in Patients With Stroke in the Recovery-Phase Rehabilitation Ward: A Retrospective Cohort Study Using Propensity Score Matching

Background: Polypharmacy is a predictor of adverse outcomes, making its management crucial for improving patient health and recovery. Managing polypharmacy is particularly challenging in patients with stroke with many comorbidities and sequelae. Although reducing inappropriate prescribing is necessary, the number of medications may increase to effectively implement secondary prevention, potentially offsetting any changes in medication count. For patients with stroke undergoing recovery-phase rehabilitation, balancing secondary prevention and optimizing drug use early without hindering recovery of activities of daily living are crucial. This study is aimed at examining the effect of increasing or decreasing the use of polypharmacy on recovery of motor and cognitive function during recovery-phase rehabilitation in patients with stroke. Methods: The study was conducted from July 2010 to June 2019 among patients with stroke discharged from the convalescent rehabilitation ward during the study period. Patients who were using more than five drugs on admission and had either an increase or decrease in the number of drugs used on discharge were compared. Propensity score matching (PSM) was used to control for background variables such as patient demographics, laboratory values, and functional independence measure (FIM) scores at baseline. The primary outcomes were motor, cognition, and total FIM gain. Results: Of the 226 patients initially enrolled, 156 were matched on propensity score. The total motor FIM gain, total cognitive FIM gain, and total FIM gain were significantly higher in the decreased group than in the increased group (p = 0.0139, p = 0.0377, and p = 0.0077, respectively). Conclusion: In patients with stroke, reducing rather than increasing the number of drugs administered during recovery-phase rehabilitation could improve rehabilitation outcomes. Therefore, it is important to consider whether the drugs are essential for the patient and proactively revise the drug regimen to ensure rapid rehabilitation of patients with stroke.

Assessing sleep metrics in stroke survivors: a comparison between objective and subjective measures

INTRODUCTION

Stroke survivors are at risk of sleep disturbance, which can be reflected in discrepancies between objective and subjective sleep measures. Given there are limited studies on this phenomenon and using portable monitoring devices is more convenient for stroke survivors to monitor their sleep, this study aimed to compare objectively measured (Belun Ring) and subjectively reported (sleep diary) sleep metrics (total sleep time (TST) and wakefulness after sleep onset (WASO)) in stroke survivors.

METHODS

In this cross-sectional study, thirty-five participants wore a ring-shaped pulse oximeter (Belun Ring) and kept a sleep diary for three consecutive nights in one week. The effects of various factors on TST and WASO were analyzed by linear mixed models. Systematic bias between two measures was examined by the Bland-Altman analysis.

RESULTS

TST and WASO were significantly affected by measures (p <.001), but not night. TST was significantly lower and WASO was significantly higher in the Belun Ring than in the sleep diary (p <.05). Age was the only covariate that had a significant effect on WASO (p <.05). The Bland-Altman analysis demonstrated positive bias in TST (29.55%; 95% CI [16.57%, 42.53%]) and negative bias in WASO (-117.35%; 95% CI [-137.65%, -97.06%]). Proportional bias was exhibited in WASO only (r =.31, p <.05).

CONCLUSION

The findings revealed discrepancies between objective and subjective sleep measures in stroke survivors. It is recommended that objective measures be included when assessing and monitoring their sleep conditions.

Sex differences in the risk of excessive daytime sleepiness in mild and moderate ischaemic stroke patients: a retrospective database study

BACKGROUND

Excessive daytime sleepiness (EDS) is a common complication of stroke that has a detrimental effect on patients' daily life and functional recovery. The clinical characteristics and risk factors for poststroke EDS may differ between males and females.

METHODS

A retrospective study based on hospital medical records was conducted on patients with a diagnosis of stroke who participated in polysomnographic monitoring at the Affiliated Hospital of Yangzhou University from February 2022 to May 2024. Baseline data, laboratory test data, polysomnographic data, and related scale scores were retrospectively collected. The Epworth Sleepiness Scale (ESS) score was used to assess EDS after stroke. Binary logistic regression was used to determine the risk factors for daytime sleepiness. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Statistical analysis was performed via IBM SPSS 26.0.

RESULTS

ESS scores were higher in males than in females, whereas females had higher Pittsburgh Sleep Quality Index (PSQI) scores and Hospital Anxiety and Depression Scale (HADS) scores. Male sex and higher depression scores were risk factors for EDS; among male patients, higher anxiety scores were a risk factor for EDS, whereas smoking was a protective factor. Depression, a higher arousal index and a reduced proportion of N3 sleep periods were risk factors for EDS in females.

CONCLUSIONS

The characteristics and influencing factors of EDS differ between the sexes in patients with mild and moderate ischaemic stroke. Our study may provide evidence and guidance for clinical diagnosis and treatment. Interventional studies are needed to assess the impact of treating these risk factors in the future.

Presence of Self-Reported Sleep Alterations After Stroke and Their Relationship With Disability: A Longitudinal Study

BACKGROUND

Sleep disorders have a prevalence of 30% to 70% in post-stroke individuals. The presence of sleep disorders and poor sleep quality after stroke can affect important functions and lead to worse outcomes. However, most studies are restricted to the acute post-stroke stage only.

OBJECTIVE

To investigate the frequency of self-reported sleep alterations in a sample of chronic stroke individuals and to identify which self-reported sleep alterations were associated with disability.

METHODS

Prospective exploratory study. Self-reported sleep alterations were measured by the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale, and STOP-Bang Questionnaire. The dependent variable was measured 3 years after the first contact by the Modified Rankin Scale (mRS). Step-wise multiple linear regression analysis was employed to identify which sleep alterations were associated with disability.

RESULTS

Sixty-five individuals with stroke participated. About 67.7% of participants had poor sleep quality, 52.4% reported insomnia symptoms, 33.9% reported excessive daytime sleepiness, and 80.0% were classified as intermediate or high risk for obstructive sleep apnea. Only risk for obstructive sleep apnea was significantly associated with disability and explained 5% of the variance in the mRS scores.

CONCLUSION

Self-reported sleep alterations had a considerable frequency in a sample of chronic stroke individuals. The risk of obstructive sleep apnea was associated with disability in the chronic stage of stroke. Sleep alterations must be considered and evaluated in the rehabilitation process even after a long period since the stroke onset.

Association Between Lifestyle Behaviors and Obesity Among Stroke Survivors

AIM

The aim was to investigate factors influencing obesity among stroke survivors based on demographics and lifestyle behaviors.

BACKGROUND

Stroke survivors are more likely to experience stroke recurrence within a few years. As obesity is a traditional risk factor for stroke, obesity should be managed in stroke survivors to prevent stroke recurrence.

METHODS

A cross-sectional secondary data analysis analyzed data from the 2017 United States Behavioral Risk Factor Surveillance System (BRFSS) survey. Demographics, frequency of vegetable and fruit intake, smoking, alcohol use, physical activity, and sleep were examined.

RESULTS

Among 1032 stroke survivors, 57.8% were obese. Advanced age, female sex, veteran status, at least once-daily fruit intake, current smoking, and lack of physical activity were associated with obesity.

CONCLUSION

Stroke survivors should be encouraged to pursue healthy behaviors to manage obesity. Appropriate transitional care, including diet education and tailored exercise, can be an effective strategy.

Improving physical movement during stroke rehabilitation: investigating associations between sleep measured by wearable actigraphy technology, fatigue, and key biomarkers

BACKGROUND

Sleep disturbance and fatigue are common in individuals undergoing inpatient rehabilitation following stroke. Understanding the relationships between sleep, fatigue, motor performance, and key biomarkers of inflammation and neuroplasticity could provide valuable insight into stroke recovery, possibly leading to personalized rehabilitation strategies. This study aimed to investigate the influence of sleep quality on motor function following stroke utilizing wearable technology to obtain objective sleep measurements. Additionally, we aimed to determine if there were relationships between sleep, fatigue, and motor function. Lastly, the study aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with motor function or fatigue post-stroke.

METHODS

Eighteen individuals who experienced a stroke and were undergoing inpatient rehabilitation participated in a cross-sectional observational study. Following consent, participants completed questionnaires to assess sleep patterns, fatigue, and quality of life. Objective sleep was measured throughout one night using the wearable Philips Actiwatch. Upper limb motor performance was assessed on the following day and saliva was collected for biomarker analysis. Correlation analyses were performed to assess the relationships between variables.

RESULTS

Participants reported poor sleep quality, frequent awakenings, and difficulties falling asleep following stroke. We identified a significant negative relationship between fatigue severity and both sleep quality (r=-0.539, p = 0.021) and participants experience of awakening from sleep (r=-0.656, p = 0.003). A significant positive relationship was found between grip strength on the non-hemiplegic limb and salivary gene expression of Brain-derived Neurotrophic Factor (r = 0.606, p = 0.028), as well as a significant negative relationship between grip strength on the hemiplegic side and salivary gene expression of C-reactive Protein (r=-0.556, p = 0.048).

CONCLUSION

The findings of this study emphasize the importance of considering sleep quality, fatigue, and biomarkers in stroke rehabilitation to optimize recovery and that interventions may need to be tailored to the individual. Future longitudinal studies are required to explore these relationships over time. Integrating wearable technology for sleep and biomarker analysis can enhance monitoring and prediction of outcomes following stroke, ultimately improving rehabilitation strategies and patient outcomes.

Development of insomnia in patients with stroke: A systematic review and meta-analysis

BACKGROUND AND AIM

Stroke is a serious threat to human life and health, and post-stroke insomnia is one of the common complications severely impairing patients' quality of life and delaying recovery. Early understanding of the relationship between stroke and post-stroke insomnia can provide clinical evidence for preventing and treating post-stroke insomnia. This study was to investigate the prevalence of insomnia in patients with stroke.

METHODS

The Web of Science, PubMed, Embase, and Cochrane Library databases were used to obtain the eligible studies until June 2023. The quality assessment was performed to extract valid data for meta-analysis. The prevalence rates were used a random-efect. I2 statistics were used to assess the heterogeneity of the studies.

RESULTS

Twenty-six studies met the inclusion criteria for meta-analysis, with 1,193,659 participants, of which 497,124 were patients with stroke.The meta-analysis indicated that 150,181 patients with stroke developed insomnia during follow-up [46.98%, 95% confidence interval (CI): 36.91-57.18] and 1806 patients with ischemic stroke (IS) or transient ischemic attack (TIA) developed insomnia (47.21%, 95% CI: 34.26-60.36). Notably, 41.51% of patients with the prevalence of nonclassified stroke developed insomnia (95% CI: 28.86-54.75). The incidence of insomnia was significantly higher in patients with acute strokes than in patients with nonacute strokes (59.16% vs 44.07%, P < 0.0001).Similarly, the incidence of insomnia was significantly higher in the patients with stroke at a mean age of ≥65 than patients with stroke at a mean age of <65 years (47.18% vs 40.50%, P < 0.05). Fifteen studies reported the follow-up time. The incidence of insomnia was significantly higher in the follow-up for ≥3 years than follow-up for <3 years (58.06% vs 43.83%, P < 0.05). Twenty-one studies used the Insomnia Assessment Diagnostic Tool, and the rate of insomnia in patients with stroke was 49.31% (95% CI: 38.59-60.06). Five studies used self-reporting, that the rate of insomnia in patients with stroke was 37.58% (95% CI: 13.44-65.63).

CONCLUSIONS

Stroke may be a predisposing factor for insomnia. Insomnia is more likely to occur in acute-phase stroke, and the prevalence of insomnia increases with patient age and follow-up time. Further, the rate of insomnia is higher in patients with stroke who use the Insomnia Assessment Diagnostic Tool.

Sleep and motor learning in stroke (SMiLES): a longitudinal study investigating sleep-dependent consolidation of motor sequence learning in the context of recovery after stroke

INTRODUCTION

There is growing evidence that sleep is disrupted after stroke, with worse sleep relating to poorer motor outcomes. It is also widely acknowledged that consolidation of motor learning, a critical component of poststroke recovery, is sleep-dependent. However, whether the relationship between disrupted sleep and poor outcomes after stroke is related to direct interference of sleep-dependent motor consolidation processes, is currently unknown. Therefore, the aim of the present study is to understand whether measures of motor consolidation mediate the relationship between sleep and clinical motor outcomes post stroke.

METHODS AND ANALYSIS

We will conduct a longitudinal observational study of up to 150 participants diagnosed with stroke affecting the upper limb. Participants will be recruited and assessed within 7 days of their stroke and followed up at approximately 1 and 6 months. The primary objective of the study is to determine whether sleep in the subacute phase of recovery explains the variability in upper limb motor outcomes after stroke (over and above predicted recovery potential from the Predict Recovery Potential algorithm) and whether this relationship is dependent on consolidation of motor learning. We will also test whether motor consolidation mediates the relationship between sleep and whole-body clinical motor outcomes, whether motor consolidation is associated with specific electrophysiological sleep signals and sleep alterations during subacute recovery.

ETHICS AND DISSEMINATION

This trial has received both Health Research Authority, Health and Care Research Wales and National Research Ethics Service approval (IRAS: 304135; REC: 22/LO/0353). The results of this trial will help to enhance our understanding of the role of sleep in recovery of motor function after stroke and will be disseminated via presentations at scientific conferences, peer-reviewed publication, public engagement events, stakeholder organisations and other forms of media where appropriate.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05746260, registered on 27 February 2023.

The Life After Stroke In Northern Sweden Study (LASINS): Methodology, cohort demographics and initial results

BACKGROUND

To advance rehabilitation we need a comprehensive understanding of functioning and disability of people after stroke.

OBJECTIVE

To present an overview of the methodology of the Life After Stroke In Northern Sweden Study, compare participants and non-participants regarding gender and age, and describe baseline sociodemographics, stroke characteristics and the participants' self-rated degree of recovery.

METHODS

Data were collected through a study specific questionnaire, from the participants' medical records and with internationally established self-assessment tools focusing on sleep disturbances, depressive symptoms, fatigue, physical activity, and remaining physical and cognitive impairments, activity limitations, participation restrictions and life satisfaction.

RESULTS

Of 301 potential participants, 160 comprise the final sample (response rate 53%; 86 men and 74 women, mean age 73 years±11, mean time since stroke onset 35 months±11; 18- 61). Most participants had an ischemic stroke (87%), were retired (84%), cohabitant (63%) and walked independently (71%). The mean self-rated degree of recovery was 75 (SD±24; 0- 100).

CONCLUSIONS

These baseline data together with forthcoming studies will describe stroke-related impairments, activity limitations, participation restrictions and life satisfaction more than one year after stroke, and deepen our understanding of factors of importance for a healthy and successful life after stroke.

Prevalence and determinants of post-stroke sleep disorders: a cross-sectional hospital-based study

INTRODUCTION

Post-stroke sleep disorders (PSSD) are an important part of post-stroke disability. PSSD is neglected as a part of stroke rehabilitation. We aimed to study the prevalence and determinants of PSSD in a hospital based, single center setting.

METHODS

In a cross-sectional study, adult patients (≥ 18 years) with stroke (one month to one year after the onset), were enrolled in the study. Demographic, clinical, radiological, and motor and functional disabilities were assessed. Sleep quality was assessed with Pittsburg Sleep Quality Index (PSQI) and STOP BANG questionnaire (for obstructive sleep apnea [OSA]). Patients with poor sleep quality (PSQI > 5) were analyzed for risk factors.

RESULTS

A total of 103 patients were recruited in the study period (January 2021 to June 2022). The self-reported prevalence of PSSD was 16% which increased to 72% when the PSQI was administered. High risk of OSA was present in 33%. In bivariate analysis, factors associated with PSQI > 5 were involvement of ≥ 2 lobes, lower body mass index (BMI), worse modified Rankin Scale (mRS), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A) and Stroke Specific Quality of Life (SSQoL). In multivariate analysis, only depression was associated with PSQI > 5 (OR: 1.3 (1.0; 1.7); p-value = 0.03).

CONCLUSION

PSSD had a prevalence of 72%. In multivariate analysis, the factor associated with PSQI > 5 was worse HAM-D score.

High total bilirubin-to-uric acid ratio predicts poor sleep quality after acute ischemic stroke: a prospective nested case-control study

BACKGROUND

Sleep disorders are prevalent after stroke, resulting in high recurrence rates and mortality. But the biomarkers of sleep disorders in stroke patients remain to be elucidated. This study aimed to explore the relationship between total bilirubin-to-uric acid ratio (TUR) and sleep quality after acute ischemic stroke (AIS).

METHODS

Three hundred twenty-six AIS patients were recruited and followed up 1 month after stroke in our study. Serum total bilirubin and uric acid levels were obtained within 24 h after admission. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality 1 month after stroke. We conducted receiver operating characteristic (ROC) curve analysis and screened the optimal biomarker to differentiate sleep disorders after stroke. Then the TUR was stratified according to the best cut-off value (0.036) of the ROC and further analysed by binary logistic regression analysis. Additionally, the interaction was used to explore the difference in its effect on post-stroke sleep quality in different subgroups.

RESULTS

Three hundred thirty-one patients (40.2%) were considered as having poor sleep quality during the one-month follow-up. Compared to patients with good sleep, patients with poor sleep were more likely to have higher TUR (IQR), 0.05 (0.03-0.06) versus 0.03 (0.02-0.04), P < 0.001. After adjusting for confounding factors, binary regression analysis demonstrated that a high TUR (≥0.036) was independently related to post-stroke poor sleep quality (OR = 3.75, 95% CI = 2.02-6.96, P < 0.001).

CONCLUSIONS

High TUR is associated with an increased risk of poor sleep quality in AIS patients, especially in females, diabetics, and patients with hyperlipidaemia.

Impact of site, size and severity of ischemic cerebrovascular stroke on sleep in a sample of Egyptian patients a polysomnographic study

BACKGROUND

Sleep difficulties following a cerebrovascular stroke are an interesting topic in the scientific community. Following a brain ischemic insult, a variety of sleep problems can occur.

AIM OF WORK

To study the sleep architecture following stroke and to identify the impact of site, size and severity of ischemic cerebrovascular troke on sleep microstructure.

SUBJECTS AND METHODS

this was a case control study; polysomnogram was done for 93 patients admitted to the stroke unit at El- Hadara university hospital with the first ever ischemic stroke. NIHSS was calculated immediately and 1 month after stroke onset. 50 age matched control subjects with no evidence of central nervous system or major psychiatric disorder by history or clinical examination.

RESULTS

Total sleep time, sleep efficiency were lower in ischemic cerebrovascular stroke patients than in control group and this was statistically significant (p = .001* p = .0001* respectively). Arousal index limb movement index and snoring index were all higher among the ischemic cerebrovascular stroke group in comparison to the control group and this was statistically significant (p = .0001*p = .05*p = .0001). Both the REM(rapid eye movement) and REM latency were highest among brain stem stroke, and this was statistically significant p = .043*, p = .0.001*.cortical infarcts showed higher AHI (apnea hypopnea index)and this was statistically significant p = 0.002* Limb movement index was higher among sizable size stroke and this was statistically significant (p = 0.038). NIHSS National Institutes of Health Stroke Scale after 1 month follow up showed a significant indirect correlation with the lowest oxygen saturation during sleep (p = 0.047). Lowest oxygen saturation was lowest among sizable stokes and desaturation index was highest among sizable size strokes both were statistically significant p = 0.006. NIHSS2 had a significant negative correlation with the lowest oxygen saturation during sleep p = 0.047.

CONCLUSION

The microstructure of sleep is significantly impacted by cerebrovascular stroke. Brain stem strokes had the highest REM and REM latency, while cortical strokes had the highest moderate-to-severe AHI. Sizable strokes displayed increased indices of limb movement, desaturation, and oxygen saturation.

Modified Suanzaoren decoction in treating post-stroke cognitive impairment with comorbid insomnia symptoms: A clinical trial

BACKGROUND

Cognitive impairment and insomnia are common complications for stroke patients, and often coexist without effective therapy. Modified Suanzaoren decoction (M-SZRD), derived from a famous classic prescription, has been used as an alternative treatment for these patients. The objective of this study is to investigate the effectiveness of M-SZRD in treating post-stroke cognitive impairment with comorbid insomnia symptoms.

METHODS

A total of 80 participants were randomly assigned into 2 groups to 40 cases in the treatment group (treated with modified Suanzaoren decoction) and 40 cases in the control group (treated with zolpidem). The intervention period was 4 weeks. Cognitive function, sleep quality, depression, and anxiety disorders were evaluated in both groups before and after treatment. Clinical assessment of patients with stroke included National Institutes of Health Stroke Scale and Barthel Index evaluations. Hormone levels of the hypothalamic-pituitary-adrenal and hypothalamus-pituitary-thyroid axis were also measured.

RESULTS

Out of the total 80 participants, 5 withdrew during the experiment and did not complete the study, leaving 75 patients for analysis to 38 in the treatment group and 37 in the control group. The findings showed that M-SZRD was more effective than the control group in improving cognitive function (P = .006). However, both groups were found to have a similar effect in improving insomnia (P = .323). There was no significant difference between the 2 groups in terms of activities of daily living and National Institutes of Health Stroke Scale improvement. M-SZRD was superior to the control group in improving depression state (P = .034), but when including dropouts in the intention-to-treat analysis, the difference was not statistically significant (P = .150). Furthermore, the M-SZRD group was better than the control group in reducing cortisol levels (P = .036), and the improvement in serum-free triiodothyronine (FT3) levels was also more significant in the M-SZRD group than in the control group (P = .0007).

CONCLUSION

M-SZRD is a more effective treatment for improving cognitive function in patients with post-stroke cognitive impairment and comorbid insomnia symptoms, possibly by regulating the cortisol levels of the hypothalamic-pituitary-adrenal axis and FT3 levels of the hypothalamus-pituitary-thyroid axis.

Psychometric properties of Indonesian version of sleep condition indicator for screening poststroke insomnia

BACKGROUND

No study has examined the psychometric properties of the sleep condition indicator (SCI) for screening poststroke insomnia in the Indonesian population. We aimed to develop the Indonesian version of the sleep condition indicator (ISCI) and to examine its psychometric properties for screening adult patients in late sub-acute and chronic periods after stroke.

METHODS

This was a cross-sectional study with two stages. In the first stage, the English version of the SCI was translated into the ISCI using standard procedures. The psychometric properties of the ISCI were tested in the second stage. Internal consistency and test-retest reliability of ISCI were used to evaluate reliability. A confirmatory factor analysis (CFA) was performed to test construct validity. To test concurrent and convergent validity, the Indonesian version of the insomnia severity index (ISI-INA), generalized anxiety disorder questionnaire (IGAD-7), and patient health questionnaire (IPHQ-9) were used. A receiver operating characteristic (ROC) analysis was conducted to calculate the optimal cutoff score of the ISCI on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for insomnia.

RESULTS

A total of 160 adults with a diagnosis of stroke for more than 3 months were included (median age of 58.5 years, 31% met the DSM-5 criteria for insomnia). The ISCI had a satisfactory Cronbach's alpha of 0.89 and test-retest reliability of 0.78. The CFA revealed that the ISCI exhibited a satisfactory model fit and was associated with the ISI-INA, IGAD-7, and IPHQ-9 (r = -0.81, -0.32, and -0.52, respectively; all P < .001). The ROC test revealed that the optimal cutoff point of ≤23 yielded the highest sensitivity (94%) and specificity (97%).

CONCLUSION

The study results revealed that the 8-item ISCI is a reliable and valid screening tool for detecting insomnia symptoms according to the DSM-5 criteria in the chronic period after stroke.

The Diagnostic Value of Gut Microbiota Analysis for Post-Stroke Sleep Disorders

BACKGROUND

Gut microbiota have been associated with many psychiatric disorders. However, the changes in the composition of gut microbiota in patients with post-stroke sleep disorders (PSSDs) remain unclear. Here, we determined the gut microbial signature of PSSD patients.

METHODS

Fecal samples of 205 patients with ischemic stroke were collected within 24 h of admission and were further analyzed using 16 s RNA gene sequencing followed by bioinformatic analysis. The diversity, community composition, and differential microbes of gut microbiota were assessed. The outcome of sleep disorders was determined by the Pittsburgh Sleep Quality Index (PSQI) at 3 months after admission. The diagnostic performance of microbial characteristics in predicting PSSDs was assessed by receiver operating characteristic (ROC) curves.

RESULTS

Our results showed that the composition and structure of microbiota in patients with PSSDs were different from those without sleep disorders (PSNSDs). Moreover, the linear discriminant analysis effect size (LEfSe) showed significant differences in gut-associated bacteria, such as species of Streptococcus, Granulicatella, Dielma, Blautia, Paeniclostridium, and Sutterella. We further managed to identify the optimal microbiota signature and revealed that the predictive model with eight operational-taxonomic-unit-based biomarkers achieved a high accuracy in PSSD prediction (AUC = 0.768). Blautia and Streptococcus were considered to be the key microbiome signatures for patients with PSSD.

CONCLUSIONS

These findings indicated that a specific gut microbial signature was an important predictor of PSSDs, which highlighted the potential of microbiota as a promising biomarker for detecting PSSD patients.

"The Days Are Long But the Nights Are Even Longer": A Mixed-Method Study of Sleep Disturbances Among Patients in an Inpatient Rehabilitation Program

Objective

To assess sleep quality of patients on a rehabilitation ward and to identify staff practices and beliefs about management of sleep disturbance.

Design

Mixed-methods design including patient surveys and staff interviews.

Setting

Inpatient rehabilitation ward in a tertiary teaching hospital in Adelaide, Australia.

Participants

Of the 345 screened inpatients who had been in a mixed post-acute rehabilitation ward for at least 5 days, 120 (43% women) were included. The mean age was 67.7 years and the main admission reason was functional decline (40%). Patients with stroke or traumatic brain injury were excluded. Eleven (n = 11) staff (a mix of doctors, nurses, and allied health) were interviewed.

Main Outcome Measures

The surveys comprised of the Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale, the Flinders Fatigue Scale, and the Sleep Inertia Questionnaire. The survey results were compared with functional outcomes using the functional independence measure (FIM). Staff interviews delved into barriers to good sleep, ward practices, and knowledge about sleep hygiene.

Results

43% of the surveyed patients reported having healthy amount of sleep. Sleep quality was not significantly correlated with rehabilitation outcomes (assessed using FIM). Staff reported having a good awareness of sleep hygiene; however, acknowledged limitations about the environment and routine which were not conducive to healthy sleep. They identified several actions which could be taken to improve patients' sleep hygiene.

Conclusions

Sleep disturbance is common for patients in rehabilitation. Rehabilitation wards should address this often-neglected critical component of rehabilitation to improve patient experience and potential participation in therapy. Introducing a systematic approach for assessing sleep during admission, establishing clear roles regarding sleep assessment and intervention among staff, and ensuring that patients and staff are aware of good sleep hygiene practices may promote better sleep during inpatient rehabilitation.

Sleep disturbances and associated factors amongst stroke survivors in North Central, Nigeria

Introduction

Sleep disturbance is common in persons with stroke and when unrecognised and untreated may hinder rehabilitation efforts and lead to poor functional outcome. It may also result in increased risk for stroke recurrence.

Aim

We investigated the frequency and associated factors of sleep disturbances amongst stroke survivors.

Methodology

One hundred and ten stroke survivors attending the neurology outpatient clinics of two tertiary hospitals, from February 2021 to January 2022, were interviewed after obtaining ethical approval and informed consent. We used a structured questionnaire to obtain their socio-demographic, clinical characteristics and sleep disturbances. Excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Data were analysed with statistical significance set at P < 0.05.

Results

Eighty (72.7%) patients were males with a mean age of 61.4 ± 11.8, slightly older than the females (30, 27.3%) with a mean age of 60.9 ± 2.9. Their median follow-up duration was 7.5 months. Majority (84, 76.4%) had ischaemic stroke, and the frequency of sleep disturbances was 37 (33.6%) consisting of insomnia (19, 17.3%), hypersomnia (10, 9.0%), sleep-disordered breathing (5, 4.5%) and sleep-related movement disorder (3, 2.7%), respectively. Using the ESS score, 22 (20.0%) had mild, 10 (9.0%) had moderate and 7 (6.4%) had severe ESS scores, respectively. Univariate analysis showed depression to be significantly associated with ESS (P = 0.006) whereas multivariate analysis revealed age and sex as significant associated factors (P = 0.008 and P = 0.009) of ESS.

Conclusion

More than one-third of participants reported sleep disturbances with depression, age and gender as associated factors.

Behavioral and biologic characteristics of cancer-related cognitive impairment biotypes

Psychiatric diagnosis is moving away from symptom-based classification and towards multi-dimensional, biologically-based characterization, or biotyping. We previously identified three biotypes of chemotherapy-related cognitive impairment based on functional brain connectivity. In this follow-up study of 80 chemotherapy-treated breast cancer survivors and 80 non-cancer controls, we evaluated additional factors to help explain biotype expression: neurofunctional stability, brain age, apolipoprotein (APOE) genotype, and psychoneurologic symptoms. We also compared the discriminative ability of a traditional, symptom-based cognitive impairment definition with that of biotypes. We found significant differences in cortical brain age (F = 10.50, p < 0.001), neurofunctional stability (F = 2.83, p = 0.041), APOE e4 genotype (X2 = 7.68, p = 0.050), and psychoneurological symptoms (Pillai = 0.378, p < 0.001) across the three biotypes. The more resilient Biotype 2 demonstrated significantly higher neurofunctional stability compared to the other biotypes. Symptom-based classification of cognitive impairment did not differentiate biologic or other behavioral variables, suggesting that traditional categorization of cancer-related cognitive effects may miss important characteristics which could inform targeted treatment strategies. Additionally, biotyping, but not symptom-typing, was able to distinguish survivors with cognitive versus psychological effects. Our results suggest that Biotype 1 survivors might benefit from first addressing symptoms of anxiety and fatigue, Biotype 3 might benefit from a treatment plan which includes sleep hygiene, and Biotype 2 might benefit most from cognitive skills training or rehabilitation. Future research should include additional demographic and clinical information to further investigate biotype expression related to risk and resilience and examine integration of more clinically feasible imaging approaches.

Improving sleep and learning in rehabilitation after stroke, part 2 (INSPIRES2): study protocol for a home-based randomised control trial of digital cognitive behavioural therapy (dCBT) for insomnia

INTRODUCTION

Consolidation of motor skill learning, a key component of rehabilitation post-stroke, is known to be sleep dependent. However, disrupted sleep is highly prevalent after stroke and is often associated with poor motor recovery and quality of life. Previous research has shown that digital cognitive behavioural therapy (dCBT) for insomnia can be effective at improving sleep quality after stroke. Therefore, the aim of this trial is to evaluate the potential for sleep improvement using a dCBT programme, to improve rehabilitation outcomes after stroke.

METHODS AND ANALYSIS

We will conduct a parallel-arm randomised controlled trial of dCBT (Sleepio) versus treatment as usual among individuals following stroke affecting the upper limb. Up to 100 participants will be randomly allocated (2:1) into either the intervention (6-8 week dCBT) or control (continued treatment as usual) group. The primary outcome of the study will be change in insomnia symptoms pre to post intervention compared with treatment as usual. Secondary outcomes include improvement in overnight motor memory consolidation and sleep measures between intervention groups, correlations between changes in sleep behaviour and overnight motor memory consolidation in the dCBT group and changes in symptoms of depression and fatigue between the dCBT and control groups. Analysis of covariance models and correlations will be used to analyse data from the primary and secondary outcomes.

ETHICS AND DISSEMINATION

The study has received approval from the National Research Ethics Service (22/EM/0080), Health Research Authority (HRA) and Health and Care Research Wales (HCRW), IRAS ID: 306 291. The results of this trial will be disseminated via presentations at scientific conferences, peer-reviewed publication, public engagement events, stakeholder organisations and other forms of media where appropriate.

TRIAL REGISTRATION NUMBER

NCT05511285.

Psychometric properties of the post-stroke depression scale in the sequelae stage

Aim

To evaluate the psychometric properties of the Post-Stroke Depression Scale in the Sequelae Stage (PSDS-SS).

Background

The incidence of the sequelae stage Post-Stroke Depression (PSD) is high, and the best screening tools are still lacking. Under this circumstances, our research team developed the PSDS-SS by Delphi method, but its psychometric properties need to be further verified.

Method

This was a cross-sectional study. Seven hundred and sixteen stroke patients in the sequelae stage were enrolled by purpose sampling from May 2022 to September 2022. The exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to verify the factor structure of the scale. The reliability of the scale was tested by Cronbach’s α coefficient, test–retest reliability and composite reliability. The validity of the scale was tested by criterion-related validity, convergent and discriminant validity.

Result

Eight items were deleted through item analysis. The EFA ended up with a 5-factor scale including 24 items after removing one item with low factor loading. Finally, a 21-item model was established by confirmatory factor analysis, and all the fit indexes were acceptable. The reliability and validity of the total scale and each factor are acceptable.

Conclusion

The PSDS-SS has a stable factor structure, and demonstrated good reliability and validity. And it would be an effective tool to assess PSD in the sequelae stage.

Sleep Quantity and Quality During Inpatient Rehabilitation After Stroke

OBJECTIVE

To identify sleep patterns and their association with recovery after stroke during inpatient rehabilitation, and to determine if clinical outcomes are different between participants demonstrating abnormal sleep patterns as compared to those with normal sleep patterns.

METHODS

Cohort study in which participants were undergoing inpatient rehabilitation after a stroke. Sleep quantity and quality was measured using an actigraph that participants wore for up to 7 nights during the first week of inpatient rehabilitation. Medicare Quality Indicators (GG code), Barthel Index, gait speed, and Berg balance scale were collected at admission and discharge. Participants were categorized into groups based on meeting or not meeting recommended sleep quantity and quality guidelines. Association between sleep patterns and outcomes were assessed using Pearson correlation and differences in outcomes and length of stay between participants who met or did not meet sleep quantity and quality guidelines were determined using independent sample t-test.

RESULTS

69 participants were in the study. Sleep quantity and quality was poor for all the participants. None of the participants met all the sleep quantity and quality guidelines. There were moderate to small associations (-0.42 to 0.22) between some sleep quantity and quality parameters and clinical outcomes. Participants who's sleep efficiency (SE) was <85% had a significantly longer length of stay compared to those who's SE was >=85% (17.4 vs. 21.5 days, p<0.05).

CONCLUSIONS

People with stroke undergoing inpatient rehabilitation have poor sleep quantity and quality. There is a small to moderate association between sleep patterns and clinical outcomes and participants with poor sleep quality had longer length of stay compared to those with good sleep quality. Further research is necessary to better understand the complex relationship between sleep and recovery after stroke.

IMPACT

Sleep is associated with functional recovery during inpatient rehabilitation after stroke.

Measuring Sleep Quality in the Hospital Environment with Wearable and Non-Wearable Devices in Adults with Stroke Undergoing Inpatient Rehabilitation

Sleep disturbances are common after stroke and may affect recovery and rehabilitation outcomes. Sleep monitoring in the hospital environment is not routine practice yet may offer insight into how the hospital environment influences post-stroke sleep quality while also enabling us to investigate the relationships between sleep quality and neuroplasticity, physical activity, fatigue levels, and recovery of functional independence while undergoing rehabilitation. Commonly used sleep monitoring devices can be expensive, which limits their use in clinical settings. Therefore, there is a need for low-cost methods to monitor sleep quality in hospital settings. This study compared a commonly used actigraphy sleep monitoring device with a low-cost commercial device. Eighteen adults with stroke wore the Philips Actiwatch to monitor sleep latency, sleep time, number of awakenings, time spent awake, and sleep efficiency. A sub-sample (n = 6) slept with the Withings Sleep Analyzer in situ, recording the same sleep parameters. Intraclass correlation coefficients and Bland-Altman plots indicated poor agreement between the devices. Usability issues and inconsistencies were reported between the objectively measured sleep parameters recorded by the Withings device compared with the Philips Actiwatch. While these findings suggest that low-cost devices are not suitable for use in a hospital environment, further investigations in larger cohorts of adults with stroke are needed to examine the utility and accuracy of off-the-shelf low-cost devices to monitor sleep quality in the hospital environment.

Reliability and validity of the Turkish version of general sleep disturbance scale (GSDS-T) in stroke

BACKGROUND

Stroke is a life-threatening condition with many complications. Sleep disturbances is one of them. Sleep disturbances effect quality of life, recovery and rehabilitation process. It is crucial to reveal sleep disturbances objectively in stroke patients. The aim of the study is to determine reliability and validity of the Turkish version of General Sleep Disturbance Scale (GSDS-T) in stroke patients.

METHODS

After translation and culture validation of the scale was done, Pittsburgh Sleep Quality Index (PSQI) and the Turkish version of the GSDS was applied at admission and at 24 h to the 58 patients with stroke.

RESULTS

Cronbach alpha coefficient of total score was found as 0.850 and test re-test reliability-related Cronbach alpha coefficient was 0.785.

CONCLUSION

GSDS-T is a reliable and valid tool to assess sleep disturbance in stroke patients.

Repetitive transcranial magnetic stimulation (rTMS) for post-stroke sleep disorders: a systematic review of randomized controlled trials

OBJECTIVE

Survivors of stroke often experience post-stroke sleep disorders (PSSDs), but pharmacotherapy risks adverse side effects. Transcranial magnetic stimulation (TMS) is potentially a nonpharmacotherapeutic option. This meta-analysis investigated the effects of rTMS to treat PSSD.

METHODS

Databases were searched for randomized controlled trials (RCTs) of rTMS to treat PSSD, conducted in accordance with the PRISMA 2020 guidelines. Risk-of-bias assessments were performed using the Cochrane risk-of-bias tool. A meta-analysis of the following indexes was performed using RevMan 5.4 software: Pittsburgh sleep quality index; effective rate of sleep improvement; Hamilton Anxiety Rating Scale (for mood); and National Institute of Health Stroke Scale (NIHSS, stroke severity). Mean differences (MDs) and confidence intervals (CIs) were calculated.

RESULTS

The meta-analysis included 17 RCTs, with 1411 patients overall. The indexes indicated that rTMS could improve the sleep quality, mood, and stroke severity of patients with PSSD: Pittsburgh sleep quality index (12 studies; MD =  - 2.51, 95% CI [- 3.24, - 1.79], P < 0.00001); effective rate of sleep improvement (7 studies; MD = 4.03, 95% CI [2.43, 6.68], P < 0.0001); Hamilton Anxiety Rating Scale (2 studies; MD =  - 4.05, 95% CI [- 4.77, - 3.32], P < 0.00001); and NIHSS (2 studies; MD = -2.71, 95% CI [- 3.36, - 2.06], P < 0.00001).

CONCLUSION

The results suggest that rTMS may have positive effects on the sleep quality, mood, and stroke severity of patients with PSSD.

The Effect of Physical Activity on Sleep Quality among Older Stroke Survivors: Secondary Analysis from a Randomized Controlled Trial

Poor sleep quality constitutes one of the most common difficulties faced by stroke survivors. Physical activity has been shown to improve sleep quality among healthy adults. The study objective was to examine the effect of physical activity on sleep outcomes in community-dwelling stroke survivors previously enrolled in a randomized clinical trial (RCT). Secondary analysis of data collected in the RCT was used to examine the effects of physical activity (PA) on sleep outcomes using the Pittsburgh Sleep Quality Index (PSQI), compared to usual care (controls). Unadjusted and adjusted mixed effects models were used to model changes in sleep quality between groups. At baseline, poor sleep quality (PSQI > 5) was reported by about half of the participants (PA group = 48.5%, n = 47/97; controls = 56.3%, n = 27/48). Results from the unadjusted and adjusted models for sleep quality were similar and showed no statistically significant differences between groups (p > 0.05). In the unadjusted model, the difference between groups (change from baseline to 24 weeks) showed that the PA group had better sleep quality than the controls (difference= -1.02 points, 95% CI -2.12, 0.07, p = 0.07). In the model adjusted for age, social support, and marital status, the difference between groups (change from baseline to 24 weeks) showed that the PA group had better sleep quality than the controls (difference= -1.07 points, 95% CI -2.19, 0.05, p = 0.06). PA did not significantly improve sleep quality in older community-dwelling stroke survivors. Further research is needed to confirm or refute these findings.

Impact of Persistent Poor Sleep Quality on Post-Stroke Anxiety and Depression: A National Prospective Clinical Registry Study

PURPOSE

The impact of poor sleep quality after stroke, especially persistent poor sleep quality, on poststroke anxiety and depression is unclear. We seek to investigate the impact of baseline and persistent poor sleep quality on short-term poststroke anxiety and depression.

PATIENTS AND METHODS

Data were analyzed for 1619 patients with acute ischemic stroke from the Impairment of Cognition and Sleep after Acute Ischemic Stroke or Transient Ischemic Attack in Chinese Patients study (ICONS). The sleep quality was assessed at 2 weeks and 3 months using the Pittsburgh Sleep Quality Index scale (PSQI). Poor sleep quality was defined as a PSQI score of >5, and persistent poor sleep quality was defined as a PSQI score of >5 at each time point. Patients were divided into three groups according to the quality of sleep: good sleep quality, baseline poor sleep quality and persistent poor sleep quality. Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 scale (GAD-7), and Modified Rankin Scale (mRS) at 3 months after stroke were taken as the study outcomes.

RESULTS

Persistent poor sleep quality was present in 70.2% of patients after stroke. Compared to those with good sleep quality, patients with baseline poor sleep quality did not show significant differences in disability, anxiety and depression. However, patients with persistent poor sleep were at increased risk of depression (odds ratio, OR 3.04, 95% confidence interval, CI 1.66-5.57, P < 0.01) and anxiety (OR 3.20, 95% CI 1.42-7.19, P < 0.01) at 3 months after stroke. Persistent poor sleep quality was not identified as a risk factor for functional disability at 3 months.

CONCLUSION

Patients with persistent poor sleep quality are at added risks for depression and anxiety after stroke.

Association Between Sleep Duration and Functional Disability in Inpatient Stroke Rehabilitation: A Pilot Observational Study

Objective

To describe the change in sleep duration during inpatient rehabilitation and to determine if sleep quality and sleep duration is associated with functional disability for individuals after stroke. It was hypothesized that participants who experienced optimal sleep during inpatient rehabilitation would have greater functional ability at discharge.

Design

Longitudinal observation study.

Setting

Inpatient rehabilitation unit at a large, urban hospital.

Participants

Thirty-seven individuals with acute stroke (N=37; mean age, 62.5±11.8y, male=20, female=17) were recruited from September 2018 to September 2019. Participants were invited to participate in the study by clinical personnel associated with their usual care as they were admitted to inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Participants were asked to wear an actigraph for the duration of their rehabilitation program to assess sleep. The first 3 nights of actigraphy data were averaged to obtain total sleep time (TST) and sleep efficiency (SE) at admission, and the last 3 nights were averaged for TST and SE at discharge. Functional disability (primary outcome was FIM) at admission and discharge was gathered from the participants’ medical records. One-way analysis of variance and chi-square analyses assessed for group differences, and regression modeling was used to determine if sleep was associated with functional ability at discharge.

Results

Sixteen participants (43%) were categorized as “good sleepers” and 21 (57%) were “poor sleepers” based on their TST at admission. Of the poor sleepers, 14 participants (66%) remained short duration sleepers (<7h at admission and discharge). Sleep outcomes did not significantly predict FIM score at discharge.

Conclusions

Most participants had less than optimal sleep duration during inpatient rehabilitation. Efforts may be warranted to optimize sleep during inpatient rehabilitation.

Physical Therapy Exercises for Sleep Disorders in a Rehabilitation Setting for Neurological Patients: A Systematic Review and Meta-Analysis

Background: Sleep occupies one-third of human life and is essential for health and for emotional, physical, and cognitive well-being. Poor or insufficient sleep is associated with a wide range of dysfunctions that involve different body systems, such as the endocrine, metabolic, and immune systems, thus compromising the higher cortical functions, cognitive performance, mood, and post-physical activity recovery. The present systematic review and meta-analysis aimed to explore the effectiveness of physical therapy exercises on sleep disorders in patients with neurological disorders. Our systematic review identified 10 articles that investigated the effects of physical therapy on sleep disorders in patients with neurological disorders, 6 of which were included in the meta-analysis. Results suggest that physical therapy exercises are a safe and useful strategy for managing sleep disorders in neurorehabilitation.

Social support and sleep quality in patients with stroke: The mediating roles of depression and anxiety symptoms

BACKGROUND

Research has demonstrated that higher social support is associated with better psychological health, quality of life, cognition, activities of daily living and social participation, but the relationship between social support and sleep quality remains unknown.

AIMS

This study aimed to assess the incidence of poor sleep quality, clarify the relationship between social support and sleep quality amongst stroke patients and determine whether anxiety and depression symptoms mediate this relationship.

METHODS

We conducted a quantitative, cross-sectional study involving 238 patients with stroke (median age of 61 [range 29-87] years, 68.1% male) recruited from a comprehensive tertiary care hospital between September 2019 and January 2020. A self-administered, structured questionnaire was used for the survey. The mediating effect of anxiety and depression symptoms was assessed using the bootstrap method via Model 4 (parallel mediation) of the SPSS PROCESS macro.

RESULTS

Results showed that the incidence of poor sleep quality amongst stroke patients was 65%. Mediation analysis showed that social support exerted significant direct effects on sleep quality, and anxiety and depression symptoms mediated the relationship between social support and sleep quality.

CONCLUSION

Measures should be taken to enhance social support to improve the sleep quality of stroke patients.

SUMMARY STATEMENT

What is already known about this topic? Patients with stroke have a high rate of sleep disorders, anxiety and depression symptoms. Anxiety and depression symptoms have a negative effect on sleep quality. Social support may be an effective intervention to reduce anxiety and depression symptoms and improve sleep quality amongst stroke patients. What this paper adds? The incidence of poor sleep was high amongst stroke patients. Social support had a direct positive effect on sleep quality. Anxiety and depression symptoms played multiple mediating roles in the relationship between social support and sleep quality. The implications of this paper: Our study adds to the existing literature by clarifying how social support impacts the sleep quality of stroke patients. We suggested improving the sleep quality of stroke patients through enhancing social support and reducing anxiety and depression symptoms, especially in patients with low levels of social support.

Sleep Disorders in Stroke: An Update on Management

Stroke is a leading cause of disability and mortality all over the world. Due to an aging population, the incidence of stroke is rising significantly, which has led to devastating consequences for patients. In addition to traditional risk factors such as age, hypertension, hyperlipidemia, diabetes and atrial fibrillation, sleep disorders, as independent modifiable risk factors for stroke, have been highlighted increasingly. In this review, we provide an overview of common types of current sleep disturbances in cerebrovascular diseases, including insomnia, hypersomnia, breathing-related sleep disorders, and parasomnias. Moreover, evidence-based clinical therapeutic strategies and pitfalls of specific sleep disorders after stroke are discussed. We also review the neurobiological mechanisms of these treatments as well as their effects on stroke. Since depression after stroke is so prevalent and closely related to sleep disorders, treatments of post-stroke depression are also briefly mentioned in this review article.

Sleep Disturbance and Disorders within Adult Inpatient Rehabilitation Settings: A Systematic Review to Identify Both the Prevalence of Disorders and the Efficacy of Existing Interventions

OBJECTIVES

Older people who are admitted to inpatient rehabilitation settings often experience sleep disturbance or disorders. Both intrinsic and environmental factors may contribute to reduced sleep quality. Poor sleep quality has been reported to be associated with poorer rehabilitation outcomes. The aim of this review was (1) to describe the prevalence of sleep disturbance or disorder among older people participating in inpatient rehabilitation, and (2) to describe interventions that have been trialed to increase sleep quality and/or quantity in older people in rehabilitation settings and report on their efficacy.

DESIGN

Systematic review involving search of 3 electronic databases and gray literature. Two authors independently reviewed citations and reviewed full text and agreed on included studies. Data were extracted and synthesized and risk of bias was assessed.

SETTING AND PARTICIPANTS

Studies were included if they provided quantitative data about the prevalence of sleep disturbance or disorder in older people in a rehabilitation setting or if they reported the results of a randomized trial evaluating an intervention to improve sleep quality in older people in a rehabilitation setting.

MEASURES

Studies were included if they reported data from monitoring (such as polysomnography or actigraphy), clinical assessments, or questionnaires.

RESULTS

16 studies reporting prevalence data and 3 studies reporting evaluations of interventions were included in this review. Studies reported data from stroke and mixed population rehabilitation settings. The prevalence of obstructive sleep apnea was high and ranged from 12% to 92% in stroke rehabilitation settings. Other types of sleep disturbance, such as difficulty initiating sleep, were also common.

CONCLUSIONS AND IMPLICATIONS

Many older people participating in inpatient rehabilitation have sleep disturbance or sleep disorders. Poor sleep quality is associated with poorer health status and recovery; therefore, it is important that rehabilitation settings take steps to enhance sleep quality for inpatients drawing on the principles of good sleep hygiene.

Impact of a Sleep Enhancement Protocol on Nighttime Room Entries in an Inpatient Rehabilitation Facility

PURPOSE

This study examined whether a sleep enhancement protocol (SEP) could reduce nighttime room entries (NREs) for patients with orthopedic injury (OI) or acquired brain injury (ABI) in an inpatient rehabilitation facility.

DESIGN

A two-wave prospective study assessing standard of care (SOC) versus SEP.

METHODS

Sixty-five participants completed baseline and follow-up questionnaires and wore an actigraph for approximately 7 days. In the SEP, nighttime care was "bundled."

FINDINGS

In SOC, NREs were associated with less efficient sleep and greater daytime fatigue. Nighttime room entries were approximately 50% lower in the SEP than SOC. Participants in the OI SOC had more room entries than any other group. There were no significant changes in room entries in the ABI SEP group.

CONCLUSIONS

There was a relationship between NREs and sleep. The SEP was effective at reducing NREs for patients with OI, but not ABI.

CLINICAL RELEVANCE

Sleep enhancement protocols in inpatient rehabilitation facilities may be effective at improving sleep. Future research may focus on developing individualized protocols to improve sleep across patients with a variety of presenting diagnoses.

Sleep Disruption After Brain Injury Is Associated With Worse Motor Outcomes and Slower Functional Recovery

Background. Sleep is important for consolidation of motor learning, but brain injury may affect sleep continuity and therefore rehabilitation outcomes. Objective. This study aims to assess the relationship between sleep quality and motor recovery in brain injury patients receiving inpatient rehabilitation. Methods. Fifty-nine patients with brain injury were recruited from 2 specialist inpatient rehabilitation units. Sleep quality was assessed (up to 3 times) objectively using actigraphy (7 nights) and subjectively using the Sleep Condition Indicator. Motor outcome assessments included Action Research Arm test (upper limb function), Fugl-Meyer Assessment (motor impairment), and the Rivermead Mobility Index. The Functional Independence Measure (FIM) was assessed at admission and discharge by the clinical team. Fifty-five age- and gender-matched healthy controls completed one assessment. Results. Inpatients demonstrated lower self-reported sleep quality (P < .001) and more fragmented sleep (P < .001) than controls. For inpatients, sleep fragmentation explained significant additional variance in motor outcomes, over and above that explained by admission FIM score (P < .017), such that more disrupted sleep was associated with poorer motor outcomes. Using stepwise linear regression, sleep fragmentation was the only variable found to explain variance in rate of change in FIM (R²_adj = 0.12, P = .027), whereby more disrupted sleep was associated with slower recovery. Conclusions. Inpatients with brain injury demonstrate impaired sleep quality, and this is associated with poorer motor outcomes and slower functional recovery. Further investigation is needed to determine how sleep quality can be improved and whether this affects outcome.