Review

European Stroke Journal

2021, Vol. 6(4) 319–332
Prevalence of fatigue after stroke: © European Stroke Organisation 2021
Article reuse guidelines:
A systematic review and meta-analysis sagepub.com/journals-permissions
DOI: 10.1177/23969873211047681
journals.sagepub.com/home/eso

Ibraheem Alghamdi1 , Cono Ariti2, Adam Williams2 ,

Emma Wood3  and Jonathan Hewitt4

Abstract
Background and Purpose: Post-stroke fatigue is a debilitating and long-lasting condition. However, there are un-
certainties regarding its prevalence and variability between studies. This review aims to estimate the prevalence of fatigue
and determine the factors responsible for its variation in the literature.
Methods: A systematic review was conducted for all published studies (search to November 2020) using AMED, CINAHL,
EMBASE, MEDLINE, PsycINFO, SCOPUS and Web of Science. Papers were included if they recruited participants with
stroke, used a validated scale to measure fatigue and were in English. Two reviewers screened and assessed the relevant
studies for eligibility (n = 96). The included papers were appraised using the Joanna Briggs Institute (JBI) tool for prevalence
studies, and data were extracted by one reviewer. To understand the variation in PSF prevalence between papers, data
were pooled and analysed based on relevant methodological (e.g. time of assessment) or clinical factors (e.g. depression)
using Review Manager 5.4 software.
Results: While 48 studies were included and summarised (N = 9004), only 35 were appropriate for the meta-analysis (N =
6851). The most frequently used tool to measure fatigue was the Fatigue Severity Scale (FSS) (n = 31). The prevalence was
calculated with a cut-off point of four or more using FSS and resulted in an estimate of 48% (95% CI 42–53%). Time of
assessment (<6 vs ≥6 months), stroke type (ischaemic vs haemorrhagic/subarachnoid haemorrhage) and geographical
location (East Asia vs Europe) could explain the prevalence variation between studies.
Conclusions: Fatigue is prevalent among stroke survivors. This condition varies in terms of occurrence between studies;
however, time of assessment, stroke type and geographical location might explain this variation. As this review estimates
the overall burden of fatigue after stroke, it provides a useful indicator to inform policy, planning and healthcare pro-
fessionals. Further efforts are required to investigate the mechanisms that lead to PSF, particularly in the groups that show
high prevalence, in order to prevent or alleviate it.

Keywords
fatigue, frequency, review, stroke

Date received: 24 May 2021; accepted: 1 September 2021

Introduction
Stroke has many complications, one of which is fatigue. A
1
recent scoping review reported that fatigue is one of the Department of Family and Community Medicine, School of Medicine, King
commonest secondary conditions among stroke survivors.1 Saud University, Riyadh, Saudi Arabia
2
Centre for Trials Research, School of Medicine, Cardiff University, Cardiff,
It has also been ranked as one of the top research priorities in
UK
the United Kingdom.2 Although there is no consensus on its 3
School of Medicine, Cardiff University, Cardiff, UK
definition, a practical one is ‘a sensation of exhaustion 4
Division of Population Medicine, School of Medicine, Cardiff University,
during or after usual activities, or a feeling of inadequate Cardiff, UK
energy to begin these activities’.3,4 Since defining the
Corresponding author:
condition is open to personal interpretations, this has re- Ibraheem Alghamdi, King Saud University, Flat 205, Aby Almaqdisi St,
flected on the methods that are been used to measure it. Tuwaiq 14928, Riyadh, Kingdom of Saudi Arabia.
These methods are usually subjective and consist of a Email: alghamdiims@gmail.com
320
self-reported questionnaire. Some of the frequently em-
ployed tools are the Fatigue Severity Scale (FSS) and Multi-
dimensional Fatigue Inventory (MFI).5,6
Post-stroke fatigue has a negative impact on patients’
quality of life and independence, and the evidence of its
association with high morbidity and mortality rates is well-
established.7–10 This condition has been reported to affect
around 29–68% of stroke survivors.11 However, there is a
noticeable variability in this range. This variation has been
suggested to be due to multiple reasons, broadly the
methodological and clinical differences between studies.
One factor that has been claimed to play a role is the se-
lection of a scale to measure fatigue, which might be
influenced by the fact that there is neither a clear definition
of PSF nor a standardised tool to assess it.12 Nevertheless,
even in studies that used the same scale and cut-off point,
there was still a considerable variation between their esti-
mates. Moreover, it has been proposed that the time of
assessment might affect the occurrence, resulting in more
patients reporting fatigue in later months as they start re-
suming their normal activities. But the evidence around this
factor was conflicting for some cohorts showed an in-
creasing trend in PSF prevalence, while others a downward
or stable one.4 Finally, it has been proposed that other
methodological factors such as geographical locations or
eligibility criteria, specifically related to depression, dis-
ability or cognitive impairment, are somehow related.
However, there is still a lack of comprehensive, systematic
evidence to support that.13–16
Post-stroke fatigue has increasingly drawn researchers’
attention, particularly for the last decade, but there is still a
scarcity of extensive evidence to estimate its prevalence and
determine the factors of its variability. Since this condition
has multiple implications on stroke survivors and their
families’ lives, and there is a need for evidence synthesis
regarding its occurrence and the causes of its variation
between studies, we aim to address this gap by conducting a
systematic review of the literature.
Methods
The data that support the findings of this study are available
from the corresponding author upon reasonable requests.
This review is complied with the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines, and it is registered with the International Pro-
spective Register of Systematic Reviews (PROSPERO)
(CRD42020201168).17,18
Eligibility criteria
Studies were eligible if they recruited adults (≥18) with
stroke, used a validated fatigue measurement scale with a
cut-off point, were published in a peer-reviewed journal and
European Stroke Journal 6(4)
in English. Studies were excluded if they recruited partic-
ipants with other brain injuries (e.g. transient ischaemic
stroke, traumatic brain injury), were non–peer-reviewed
publications (e.g. conference abstracts) or did not use a
structured and validated tool to measure fatigue.
Search strategy
An extensive literature search was conducted between
October and November 2020. Search terms were developed
based on three key words, namely, stroke, fatigue and
prevalence. Databases included AMED (inception to Oc-
tober 2020), CINAHL (1937 to November 2020), EM-
BASE (1947 to October 2020), MEDLINE (1865 to
November 2020), PsycINFO (1806 to October 2020),
SCOPUS (1960 to November 2020) and Web of Science
(1900 to November 2020). The search was also com-
plemented by scrutinising key papers’ reference lists (i.e.
snowballing). A full search strategy of one of the databases
is in the online supplementary materials.
Procedure
Two authors (IA and AW) conducted the search and initially
screened results’ titles and abstracts. Once the irrelevant
papers were excluded, full texts were obtained for the re-
maining studies to be assessed for eligibility. Any exclusion
occurred at this stage was recorded and presented on the
PRISMA flow chart (Figure 1). Due to time restrictions, the
methodological quality of the included studies was ap-
praised by one reviewer (IA) using the Joanna Briggs In-
stitute (JBI) checklist which is designed for systematic
reviews of prevalence data.19 This tool has nine anchoring
statements ranging from the appropriateness of the sample
frame to the validity of the methods used to identify the
condition. The checklist is explained in depth in the JBI
reviewers’ manual.20
Data extraction
Data were extracted by (IA) using an adapted JBI form
which included descriptive and analytic details such as
study design; setting and location; eligibility criteria;
population demographics; number of participants; number
of fatigued participants; fatigue scale and data analysis (e.g.
measures of associations). Any further data or clarifications
needed were requested directly from the authors via emails.
The extraction form can be found in the online supple-
mentary materials.
Statistical analysis
Prevalence data were recorded, and standard errors wereffi
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
calculated using the following formula: p∗ð1  pÞ =n,
Alghamdi et al.
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMAs) flow diagram.
where p = proportion and n = sample size. A random
effects model using the generic inverse variance method
was applied to estimate the pooled fatigue proportion
and heterogeneity. This model was used for its flexibility
as it assumes that different factors affect the data var-
iability other than a mere error or chance. Studies that
used the same fatigue assessment scale (FAS) and cut-
off point were combined, and a common metric was
calculated using Review Manager 5.4 software. Using
the same approach, pre-specified subgroup analyses
were performed to compare fatigue proportions between
studies based on different factors such as location and
stroke type (ischaemic vs haemorrhagic/subarachnoid
haemorrhage) (for the full list see the protocol). Based
on a post-hoc decision, one study that reported a very
high fatigue proportion (i.e. an outlier) due to its ex-
treme eligibility criteria was excluded from the meta-
analysis.21 A funnel plot was produced to assess the risk
of publication bias and was also included in the sup-
plementary materials.
321
Results
The initial search produced 5032 results. After excluding
irrelevant studies and duplicates, 96 articles remained, and
their full texts were obtained to be assessed for eligibility.
Ultimately, 48 studies were included in this review
(Figure 1).
Several tools were used by researchers to measure fa-
tigue, namely, FSS (n = 31), MFI (n = 5), Checklist Indi-
vidual Strength (CIS) (n = 3), FAS (n = 2), Chalder Fatigue
Scale (n = 2), Emotional State Questionnaire (n = 1), Fatigue
Impact Scale (n = 1), Mental Fatigue Scale (n = 1), Profile
of Mood States (n = 1) and the 36-Item Short Form Survey
(n = 1) (Table 1).5,6,16,22–28
Authors who used FSS mostly selected the nine-item
version (n = 29), whereas only two authors preferred the
seven-item scale.29,30 Most studies had a pre-specified aim
to estimate fatigue prevalence except seven papers that
focused on assessing the contributing factors of the
condition.21,31–36 In terms of quality, the majority of studies
 322

Table 1. Summary of the included studies.

Fatigue
measurement Fatigue prevalence
Study (Country) N Stroke type Agea Male % tool Time of assessment %

Boerboom et al.48 (Netherland) 48 aSAH 53 (11) 32 FSS Within the first year after stroke 70
Broussy et al.54 (France) 141 Ischaemic (86%) 69 (14) 62 FSS 1 year after stroke 59
Haemorrhagic (14%)
Chen et al.32 (China) 218 Ischaemic 61 (11) 73 FSS 3 months 32
Choi-Kwon et al.60 (South Korea) 220 Ischaemic (90%) 60 (N/R) 72 FSS Within 2 years 57
Haemorrhagic (10%)
Choi-Kwon et al.33 (South Korea) 373 Ischaemic 61 (N/R) 63 FSS 3 months 43
Christensen et al.61 (Denmark) 165 Ischaemic (N/R) 64 (N/R) 56 MFI 10 days 59
3 months
Haemorrhagic (N/R) 1 year 44
2 years 38
40
Crosby et al.55 (United Kingdom) 64 Ischaemicb (56%) 73 (14) 33 FSS Within 2 years 48
Haemorrhagic (20%)
Damsbo et al.39 (Denmark) 919 Ischaemic Median 68 61 MFI Upon admission 40
1 month 56
6 months 46
Duncanc et al.62 (Scotland) 86 Ischaemic (93%) Median 71 62 FAS 1 month 28
haemorrhagic (7%) 6 months 23
IQR 63– 1 year 21
79
Egerton et al.30 (Norway) 199 Ischaemic 74 (11) 53 FSS 3 months 34
Elf et al.29 (Sweden) 102 Ischaemic (86%) 62 (14) 56 FSS 6 years 37
haemorrhagic (14%)
Feiginc et al.40 (New Zealand) 613 Ischaemic 69 (13) 53 SF-36 6 months 29
Galliganc et al.63 (Ireland) 98 Ischaemic (93%) 65 (11) 71 FAS Within 2 years 47
haemorrhagic (7%)
Harbison et al.34 (Ireland) 100 N/R 69 (11.3) 49 FSS Within 6 months 42
Hoang et al.56 (France) 32 Ischaemic (≈66%) 64 (11) 66 FSS Within 7 years 66
Haemorrhagic (≈33%)
Holmqvistc et al.64 (Sweden) 33 Ischaemic and aSAH Median 53 67 MFS Within 2 years 51
IQR 21–
65
Hubacher et al.57 (Germany and 31 Ischaemic (90%) 59 (10) 81 FSS Within 3 months 16
Switzerland Haemorrhagic (10%)

(continued)
European Stroke Journal 6(4)
Table 1. (continued)

Fatigue
measurement Fatigue prevalence
Study (Country) N Stroke type Agea Male % tool Time of assessment %
Alghamdi et al.

Khajeh et al.44 (Netherland) 84 aSAH 55 (11) 33 FSS Before discharge 76

6 months 50
14 months 60
Lerdal et al.58 (Norway) 115 N/R 68 (13) 59 FSS Within 2 weeks 57
Maaijweec et al.41 (Netherland) 325 Ischaemic 40 (7) 44 CIS Participants who had stroke 41
between 1980 and 2010 were followed up in
2009/12
Mahon et al.37 (New Zealand) 256 Ischaemic (87%) 73 (13) 54 FSS 4 years 55
aSAH (7%)
Intracerebral
haemorrhage (6%)
Michael et al.65 (United States) 48 Ischaemic 66 (N/R) 58 FSS Within (≈13 years) 45
Miller et al.66 (United States) 77 Ischaemic (44%) 64 (N/R) 75 FSS 6 months or more 66
Haemorrhagic (56%)
Morsund et al.45 (Norway) 324 Ischaemic 58 (10) 63 FSS 3 months 25
1 year 29
Muina-Lopez and Guidon67 (Ireland) 55 N/R 68 (9) 63 MFI Within 1–42 years 49
Mutai et al.68 (Japan) 101 Ischaemic (77%) 74 (11) 66 MFI Within 2 weeks 56
haemorrhagic (23%)
Naess et al.59 (Norway) 192 Ischaemic 47 (N/R) 57 FSS Within 1–12 years 51
Naess et al.35 (Norway) 333 Ischaemic (92%) 67 (N/R) 63 FSS Within (≈1 year) 43
Haemorrhagic (8%)
Park et al.69 (South Korea) 40 Ischaemic (62%) 59 (11) 65 FSS Within 6 months to 5 years 30
Haemorrhagic (38%)
Parksc et al.70 (Canada) 228 Ischaemic 68 (13) 53 FIS 1 year 36
Passier et al.47 (Netherlands) 108 aSAH 53 (12) 18 FSS 1 year 71
Pihlajac et al.71 (Finland) 133 Ischaemic 54 (9) 64 POMS 3 months 24
6 months 25
2 years 18
Ponchelc et al.72 (France) 153 Ischaemic 64 (13) 60 CFS 6 months 52
Rahamatali et al.53 (Belgium) 62 Ischaemic (77%) 59 (11) 60 FSS More than 6 months 71
haemorrhagic (23%)
Sarfo et al.38 (Ghana) 60 Ischaemic (77%) 55 (12) 65 FSS Within 1 month 58
haemorrhagic (23%) 9 months 23
Snaphaanc et al.73 (Netherlands) 108 Ischaemic 65 (12) 64 CIS 2 months 35
18 months 33
Stokes et al.74 (Ireland) 100 Haemorrhagic N/R 72 (9) 55 MFI Within 3 years 58

(continued)
323
Table 1. (continued)
324

Fatigue
measurement Fatigue prevalence
Study (Country) N Stroke type Agea Male % tool Time of assessment %

Suh et al.51 (South Korea) 282 Ischaemic 62 (12) 58 FSS Within a week 24
Tang et al.50 (China) 500 Ischaemic 65 (10) 64 FSS 3 months 25
Van de Port et al.36 (France) 223 Ischaemic (72%) 57 (11) 59 FSS 6 months 68
(28%) 12 months 74
36 months 58
Van der Werfc et al.75 (Netherlands) 90 Ischaemicb (64%) 62 (N/R) 72 CIS Within 1–6 years 50
Haemorrhagic (4%)
Van Eijsden et al.43 (Netherlands) 242 Ischaemic (81%) 57 (10) 64 FSS Before discharge 58
Haemorrhagic (19%) 6 months 55
Vetkasc et al.76 (Estonia) 125 aSAH 58 (12) 30 EST-Q Participants who had stroke 45
between 2001 and 2013
were followed up
Wang et al.52 (China) 265 Ischaemic 63 (12) 57 FSS Within 2 weeks 40
Western et al.49 (Norway) 356 aSAH 55 (12) 32 FSS 1–2 years 74
2–3 years 74
3–4 years 61
4–5 years 77
5–6 years 65
6–7 years 60
Winwardc et al.77 (United Kingdom) 73 Ischaemic (91%) Median 74 58 CFS 6 months 56
Haemorrhagic (9%) IQR 64–
80
Wu et al.31 (China) 312 Ischaemic 66 (11) 56 FSS Within 2 weeks 40
Zedlitzc et al.21 (Netherlands) 88 Ischaemicb (72%) 54 (8) 52 FSS 4 months or more 92
Haemorrhagic (6%)
Subarachnoid
haemorrhage (10%)
CIS: Checklist Individual Strength; CFS: Chalder Fatigue Scale; EST-Q: Emotional State Questionnaire; FIS: Fatigue Impact Scale; FSS: Fatigue Severity Scale; MFI: Multi-dimensional Fatigue Inventory; MFS:
Mental Fatigue Scale; POMS: Profile of Mood States; SF-36: 36-Item Short Form Survey.
aSAH, aneurysmal Subarachnoid Haemorrhage; CFS, Chalder Fatigue Scale; CIS, Checklist Individual Strength; EST-Q, Emotional State Questionnaire; FAS, Fatigue Assessment Scale; FIS, Fatigue Impact
Scale; FSS, Fatigue Severity Scale; MFI, Multi-dimensional Fatigue Inventory; MFS, Mental Fatigue Scale; N, Sample size; N/A, Not Applicable; N/R, Not Reported; POMS, Profile of Mood States; SF-36, 36-Item
Short Form Survey.
a
Mean age in years (standard deviation) unless otherwise specified.
b
Missing data reported.
c
Study was not included in meta-analysis.
European Stroke Journal 6(4)
Alghamdi et al. 325

Figure 2. Critical appraisal of the included studies.

326
Figure 3. Random effects meta-analysis of post-stroke fatigue prevalence in studies that used FSS and MFI to measure fatigue. FSS:
Fatigue Severity Scale; MFI: Multi-dimensional Fatigue Inventory.
had a medium to high-quality score of five or above out of
nine (n = 20) (Figure 2). The most failed criterion was
appropriate sampling as only two papers had a represen-
tative sample, with either a population-based or randomised
sample, whereas the majority had a consecutive
sampling.37,38 All studies reported a cut-off point of four or
more to identify fatigued participants. There was only one
study that exclusively included participants with severe
fatigue and reported a PSF prevalence of 92%, as a result, it
was not included in the final quantitative synthesis.21 Data
were pooled for 30 studies (N = 5511) to estimate PSF
prevalence and resulted in a figure of 48% (95% CI 42–53),
European Stroke Journal 6(4)
with high heterogeneity (I2 = 95%) (Figure 3). A sensitivity
analysis was performed based on the quality of included
studies where low-quality papers were excluded showed a
similar result 47% (95% CI 40–54) (I2 = 96%).
Five studies employed the general fatigue subscale of
MFI, with a cut-off point of 12 or more to measure PSF, and
three of which had a medium to high-quality score. All
studies aimed to estimate fatigue prevalence in stroke
survivors except one that aimed to investigate the deter-
minants of the condition.39 Furthermore, all papers lacked
an appropriate sampling method and only one report had a
detailed description of the setting and participants. The
Alghamdi et al. 327

combined PSF estimate was 52% (95% CI 43–62%) (N =

1199), with high heterogeneity (I2 = 87%) (Figure 3). Other
fatigue scales were not utilised frequently enough to
be included in the meta-analysis. Their PSF proportions
ranged from 18% to 56%. Once more, all reports had an
inappropriate sampling method except one that was a
population-based study.40 Moreover, the majority had an
insufficient description of the data ascertainment procedure
except two studies.40,41 A summary of all the included
studies’ characteristics and their critical appraisal are pre-
sented on Table 1 and Figure 2.
As estimates varied across the studies, stratified analyses
were carried out. Based on the time of assessment, patients
who were interviewed within the first 6 months had a
prevalence of 36% (95% CI 30–42%), whereas those who
were assessed after that had a higher proportion of 56%
(95% CI 50–63%) (p < 0.001). Moreover, while participants
with ischaemic stroke had a prevalence of 36% (95% CI 30–
42%), those who suffered from haemorrhagic stroke had
nearly double that figure 66% (95% CI 59–74%) (p < 0.001).
Additionally, studies that were conducted in Asia had a lower
estimate 37% (95% CI 29–45) than those carried out in
Europe 51% (95% CI 42–59%) (p = 0.02) (Figure 4).
Based on other eligibility criteria and methodological
factors, stratified analyses were performed to further un-
derstand the variation. There was little to no evidence of a
difference between PSF estimate in studies with sample size
of 100 or more 45% (95% CI 38–52%) and those with less
than that number 52% (95% CI 41–64%) (p = 0.30), though
the confidence interval was narrower in the first group.
Moreover, studies that excluded patients with depression had
a lower proportion 41% (95% CI 32–50%) than those that did
not 51% (95% CI 43–58%); however, there was very weak
evidence of difference between them (p = 0.10). Other eli-
gibility criteria, such as disability, cognitive impairment and
cancer, demonstrated no evidence of a difference between
prevalence data in studies that included affected participants
and those that did not with (p = 0.47), (p = 0.42) and (p =
0.69), respectively (see Supplemental material).

Discussion
This review demonstrates that almost half of adults complain
from fatigue at some point after stroke, though this estimate
should be treated with caution due to high heterogeneity.
Time of assessment, stroke type and geographical location Figure 4. Random effects meta-analysis of post-stroke fatigue
prevalence stratified according to time of assessment, stroke
could explain the prevalence variation between studies. type and location.
Consistent with a previous review, PSF prevalence in this
study ranges between 42 and 53% in studies that used FSS,
whereas 43–62% in those that employed MFI, but in each The first methodological factor investigated was the time
group the heterogeneity is high, with I2 = 95% and 87%, of assessment. Interestingly, this review finds that PSF
respectively.42 Thus, the results should be interpreted with proportion is lower within the first 6 months following a
caution. Because the variation in our estimate was expected, stroke than later on (36% vs 56%). This is in contrast to what
subgroup analyses were planned a priori to explain it. has been stated in the literature that the course of the
328
condition is generally persistent over time. However, when
we individually examine the included longitudinal studies,
two papers report a decrease of fatigue levels over time,38,43
while another two show a fluctuation,36,44 and only one
study demonstrates an increase.45 Notably, the studies that
demonstrate a decline in fatigue scores followed the same
cohort whereas the others do not report if that is the case. It is
also worth considering that the two studies that followed the
same patients one of them has a relatively small sample size
(N = 60),38 while the other shows that 66% of its cohort has
remained either fatigued or non-fatigued during the follow-up
period. Factors which influence the time course of fatigue are
complex and can be biological or psycho-social, nonetheless,
a few have been proposed, namely, post-stroke depression
and stroke severity, though the temporal relationship between
the former and fatigue lacks sufficient evidence.13,38
One unexpected outcome is the stark difference in PSF
proportion between patients with ischaemic stroke and those
with haemorrhagic stroke (36% vs 66%). To our knowledge,
this area has insufficiently been investigated in the literature.
One review that examines this subject at length discusses a
few determinants that play a role.46 One factor that has been
reported is the female sex. Consistently in this review, the
studies that exclusively recruited patients with haemorrhagic
stroke at least two-thirds of their participants were
women.44,47–49 Other determinants reported are mood dis-
orders that follow ictus; however, there are not sufficient data
to firmly conclude the association. Since this phenomenon is
not fully understood, there is still abundant room for further
studies to better understand the mechanisms behind those
associations and support the proposed contributing factors.
Consistent with the literature, this review finds that
studies conducted in Europe have higher PSF proportions
than those in East Asia. In one review, this is attributed to
cultural differences in psychosocial factors rather than
epidemiological determinants such as stroke type, though
this review has found it to be a factor.42 This is evident as
our results show that most of the included studies in Asia
have participants with only ischaemic stroke (n =
6),31–33,50–52 whereas those in the Europe include patients
with either both types of stroke (n = 11) or only haemor-
rhagic stroke (n = 4).34–36,43,44,47–49,53–58 A post-hoc sen-
sitivity analysis supporting this demonstrates that studies in
Europe that only included patients with ischaemic stroke
have a similar PSF proportion to the ones conducted in Asia
(37% vs 37%).29,30,45,59 To develop a comprehensive pic-
ture of why PSF is more prevalent in Europe than in East
Asia, and to test our theory, further investigations are
recommended.
We further investigated other methodological factors by
using some of the eligibility criteria. Despite the narrower
range that PSF estimate has in studies with sample size of
100 or more than those with less than that, there is no
evidence of a significant difference between the two groups
European Stroke Journal 6(4)
(p = 0.30). This could be explained by the fact that the
condition is prevalent unlike other rare illnesses that require
larger sample size to identify it. Furthermore, although the
proportion is higher in studies that have included participants
with depression than those that have not (51% vs 41%), there
is still very weak evidence of a significant difference between
the two categories (p = 0.10). This is also evident in another
review which concludes that depression is not likely to
explain the variability in PSF proportions between studies as
a considerable number of stroke patients without depressive
symptoms suffer from weariness.42
Although the majority of the included studies have a
medium to high quality of evidence, there is no consensus
on one validated tool to assess fatigue after stroke. This area
requires further research to standardise the method of
identifying the condition. Despite this variety, PSF is still
common, even if we accept the lower end of its occurrence
range among stroke survivors. Therefore, healthcare pro-
fessionals who care for this specific population should be
aware of it. As this review concerns a prevalence of a
condition, it will be the first step to inform policy and
planning for future care services targeting stroke survivors
who are at risk or experience fatigue.
This review has several limitations on both the review
and included studies levels. Although it was planned a
priori, the search was limited to the published and English
literature. This, in theory, could have led to missing out on
relevant articles. However, we scrutinised the key refer-
ences’ lists and this has expanded the comprehensiveness of
this review. In addition, SCOPUS had a limited number of
keywords per set which affected the number of synonyms
searched per key term. Furthermore, although a validated
tool was used to appraise the included studies, it was
conducted by one reviewer, as a result, this might have
introduced a subjective assessment and risk of bias during
the critiquing process. Additionally, due to the insufficient
number of studies or difficulty in retrieving data, some
eligibility criteria were not dissected in the subgroup ana-
lyses, such as age and sampling methods. On the study
level, fatigue was assessed at separate time points, in dif-
ferent geographical locations or settings and with distinct
assessment tools and ascertainment methods, which theo-
retically might have led to methodological and clinical
heterogeneity, though some of these factors were considered
in the stratified analyses.
Summary/conclusions
This review demonstrates that fatigue is prevalent among
stroke survivors. This condition varies in terms of occur-
rence between studies; however, time of assessment, stroke
type and geographical location might explain this variation.
As this review estimates the overall burden of fatigue after
stroke, it provides a useful indicator to inform policy,
Alghamdi et al.
planning and healthcare professionals. Continued efforts are
needed to investigate the mechanisms that lead to PSF,
particularly in the groups that show high prevalence, in
order to prevent or alleviate it.
Acknowledgements
We thank Mari-Ann Hilliar, a librarian at Cardiff University, for her
support in developing the protocol. We also thank the authors who
replied to our emails.
Contributorship
The authors have contributed equally to the preparation and
writing of this review.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with re-
spect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, au-
thorship, and/or publication of this article.
Guarantor
IA
ORCID iDs
Ibraheem Alghamdi  https://orcid.org/0000-0003-3192-8816
Adam Williams  https://orcid.org/0000-0002-4825-8997
Emma Wood  https://orcid.org/0000-0003-1147-1572
Supplemental material
Supplemental material for this article is available online.
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