Poststroke Fatigue: An Overlooked Barrier to Functional Recovery 2026 Tiwari et al

[Andy]

Poststroke fatigue (PSF) is one of the most prevalent and debilitating consequences of a stroke,1, 2 yet it remains underprioritized in both clinical care and scientific investigations. Broadly, PSF is defined as a persistent subjective feeling of tiredness, lack of energy, low motivation, and difficulty concentrating that is disproportionate to exertion and not relieved by rest.3 PSF affects nearly 3 out of 4 individuals with stroke,4 severely diminishes individuals' quality of life, and often persists for years after the insult.1 Despite the significance of PSF, poststroke rehabilitation strategies continue to focus on conspicuous impairments, such as sensory, motor, cognitive, and speech deficits, while overlooking fatigue and its detrimental impact on recovery.5, 6 In this commentary, we assert that PSF must be recognized and prioritized as a core component of poststroke rehabilitation. To build this argument, we highlight emerging evidence on the impact of PSF on recovery, examine the reasons for its continued neglect, and advocate for its integration into rehabilitation frameworks as a crucial step toward improving functional recovery after stroke.

Open access

 

[Trish]

I have only read the abstract. I notice the assumption that any sort of fatigue can be treated effectively by 'rehabilitation'. Yet we have no evidence from any fatiguing condition that any rehab strategy makes any difference to fatigue, apart from training people to fill in questionnaires differently.

 

[Utsikt]

Historically, rehabilitation models have prioritized hemiparesis, cognitive decline, or aphasia. In contrast, fatigue is dismissed as a vague, subjective, and secondary complaint that should be endured rather than treated.34This perception has led to stigma, making it difficult for patients to convey the severity of their fatigue and for clinicians to view it as anything other than inevitable or peripheral to recovery.10 Similarly, in research settings, fatigue is often dismissed as noise or a confound to be controlled for.

I looks like they’ve overlooked a lot of the research on non-stroke fatigue.

Here, we propose to operationalize PSF along 4 distinguishable features that can co‐occur but need not covary16, 35(Figure): (1) perceived effort (ie, how one perceives a previously exerted action; retrospective), (2) subjective feelings of tiredness (ie, how tired one feels), (3) reduced likelihood to exert effort (ie, an individual's decision to engage in effortful actions; prospective), and (4) decrements in performance (ie, fatigability3).

(…)

Specifically, we hypothesize that (1) a sensorimotor network, involving the posterior insula, primary motor and sensory cortices, as well as the cerebellum, underpins perceived effort; (2) an affective network, involving the ventral anterior insula and other limbic regions, underpins subjective feelings of tiredness; (3) a decision‐making/valuation network, involving the ventral striatum and the ventromedial prefrontal cortex, underpins effort‐based decision‐making; and (4) task‐specific networks, in either the cognitive or physical domains, will underpin performance.

(…)

Crucially, each phenotype could imply distinct intervention strategies. For example, sensorimotor recalibration and feedback optimization for elevated perceived effort, autonomic regulation strategies for pronounced tiredness, contingency‐based scheduling for effort‐averse decision profiles, and targeted strengthening/aerobic conditioning for predominant fatigability.

(…)

Lastly, we may not accomplish these priorities without a multidisciplinary approach to PSF. Collaboration among neurologists, rehabilitation specialists, psychologists, researchers, and, importantly, patients will accelerate understanding, facilitate the development of validated assessment tools, and lead to the establishment of effective, evidence‐based treatments.

Rehab truly lives in their own world, where anything can be rehabilitated.

 

[Andy]

As well as the noted issues that rehab believe that they can simply rehabilite fatigue away, I thought it was worth posting on the basis that post-stroke fatigue is (presumed to be) caused by the insult to the brain, and can be seriously debilitating and long lasting, so potentially of interest to us here.

 

[rvallee]

The paper is interesting in that it aptly lists many of the reasons for why fatigue is not taken seriously, and it's quite simple: medicine does not take it seriously. Their solutions involve the same "not taking it seriously" ideas that have always failed, hence repeating the exact same mistake of treating is as noise that can be brushed aside with a stroke (pun intended) of rehabilitation.

The angle of how brain injury causes fatigue has some interest to us, but there really isn't much of a basis to set it apart from similar fatigue following a heart attack or cancer, where there is no such injury.

This is more clarity on the problem than usual, though still lacking in their obvious attachment to frame it as similar to depression, but it fails in the same standardized way on how to solve it: the same way that has always failed. It's odd how I appreciate that they keep using rating and assessment rather than measure. It's such a low bar to see people use the correct word for this: if you're not counting a quantity, you're not measuring.

Frankly, the idea that you can rehabilitate fatigue is plain silly. I have no idea how something this obviously implausible ever took place, but it seems there is no moving away from it. All this paper does it set the stage for literal decades of the same old stuff that always fails, presented throughout as 'promising' and novel/holistic/biopsychosocial/multidisciplinary, right up the last minute when a chance finding makes all of this go away by figuring out the cause.

The sad truth is that modern medicine doesn't know a single thing about fatigue more than people in antiquity did. All by choice, because it's noise, somehow. Also it's very hard, but that's not something that refusing to do the work will fix. And it's still noise in recommendations like this. The needle will remain unmoved, but the needle that randomly jumps around at the thought that the real needle might move will definitely be jittering around as long as it takes. Papers will be written and applause will be given, and so on. No one will actually be helped by this, but it will so great for them while they achieve nothing.