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

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.

Sleep Following a Stroke: Multimodal Evaluation of Sleep Health and Disruptions and Impact on Recovery During Acute Inpatient Rehabilitation

BackgroundOur understanding of sleep during early stroke care and its impact on rehabilitation outcomes remains limited. The objectives of this work were to (1) evaluate multidimensional sleep health and disruptions during acute inpatient rehabilitation for individuals with stroke, and (2) explore the relationship between sleep health/disruptions and functional recovery.MethodsData from 103 individuals with stroke were analyzed during acute inpatient rehabilitation. Sleep health/disruptions were assessed via patient reports, actigraphy, and biometric sensors. Functional outcomes were measured at admission and discharge. Generalized Linear Models (GLMs) were used to describe changes in sleep health over time, and multivariate regressions analyzed sleep disruptions and sleep-related predictors of functional recovery.ResultsOver inpatient stays, sleep improved with a 23% reduction in wake after sleep onset and 15% fewer multiple overnight disruptions. GLMs revealed that improved sleep quality was associated with reduced overnight activity and increased heart rate over time. Poor initial sleep quality and cognitive status were associated with more overnight disruptions. Lastly, minimal associations were found between sleep health and functional recovery.ConclusionsSleep health during inpatient stroke rehabilitation is generally poor, though improves over time. Sleep is affected by neurological recovery and hospital environment. Overnight activity and autonomic biomarkers were associated with perceived sleep health, and both physiological and environmental factors triggered disruptions. The association between functional recovery and indirect indicators of sleep health requires further investigation. These findings reveal new insights about inpatient sleep which can inform early, targeted sleep interventions to optimize post-stroke outcomes.SIESTA, ClinicalTrials.gov (NCT04254484).

Are we ready to cure post-stroke cognitive impairment? Many key prerequisites can be achieved quickly and easily

PURPOSE

Post-stroke (PS) cognitive impairment (CI) is frequent and its devastating functional and vital consequences are well known. Despite recent guidelines, they are still largely neglected. A large number of recent studies have re-examined the epidemiology, diagnosis, imaging determinants and management of PSCI. The aim of this update is to determine whether these new data answer the questions that are essential to reducing PSCI, the unmet needs, and steps still to be taken.

METHODS

Literature review of stroke unit-era studies examining key steps in the management of PSCI: epidemiology and risk factors, diagnosis (cognitive profile and assessments), imaging determinants (quantitative measures, voxelwise localization, the disconnectome and associated Alzheimer's disease [AD]) and treatment (secondary prevention, symptomatic drugs, rehabilitation and noninvasive brain stimulation) of PSCI.

FINDINGS

(1) the prevalence of PSCI of approximately 50% is probably underestimated; (2) the sensitivity of screening tests should be improved to detect mild PSCI; (3) comprehensive assessment is now well-defined and should include apathy; (4) easily available factors can identify patients at high risk of PSCI; (5) key imaging determinants are the location and volume of the lesion and the resulting disconnection, associated AD and brain atrophy; WMH, ePVS, microhemorrhages, hemosiderosis, and cortical microinfarcts may contribute to cognitive impairment but are more likely to be markers of brain vulnerability or associated AD that reduce PS recovery; (6) remote and online assessment is a promising approach for selected patients; (7) secondary stroke prevention has not been proven to prevent PSCI; (8) symptomatic drugs are ineffective in treating PSCI and apathy; (9) in addition to cognitive rehabilitation, the benefits of training platforms and computerized training are yet to be documented; (10) the results and the magnitude of improvement of noninvasive brain stimulation, while very promising, need to be substantiated by large, high-quality, sham-controlled RCTs.

DISCUSSION AND CONCLUSION

These major advances pave the way for the reduction of PSCI. They include (1) the development of more sensitive screening tests applicable to all patients and (2) online remote assessment; crossvalidation of (3) clinical and (4) imaging factors to (5) identify patients at risk, as well as (6) factors that prompt a search for associated AD; (7) the inclusion of cognitive outcome as a secondary endpoint in acute and secondary stroke prevention trials; and (8) the validation of the benefit of noninvasive brain stimulation through high-quality, randomized, sham-controlled trials. Many of these objectives can be rapidly and easily attained.

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.