Role of non-motor disorders in patients with stroke

Cardiovascular diseases are the leading cause of mortality in most countries of the world, while cerebral stroke ranks second in this indicator and third among the causes of disability. The relevance of the study of non-motor disorders in post-stroke patients is due to their significant impact on the recovery process and quality of life of patients. The aim of the study was to analyse modern research that highlights the relevance and various manifestations of non-motor impairments in stroke patients, as well as to improve the effective rehabilitation and quality of life of such patients. The article analyses the current scientific data on the prevalence, pathophysiological mechanisms and clinical significance of the main non-motor disorders in post-stroke patients. Particular attention is paid to cognitive disorders, emotional and behavioural disorders, sleep disorders, chronic post-stroke pain and autonomic dysfunction, and their impact on functional recovery, social adaptation and overall prognosis of the disease is considered. Based on the analysis of the current literature, the relationship between different types of non-motor disorders and their cumulative impact on the rehabilitation potential of patients is highlighted. Data on the frequency of certain non-motor symptoms, their dynamics in the acute and recovery periods of stroke, and their prognostic value for long-term treatment outcomes are presented. The results of the analysis indicate the need for further research to study the pathogenetic mechanisms of non-motor disorders and develop effective methods of their correction, which will allow optimising existing rehabilitation protocols and improving long-term treatment outcomes in post-stroke patients.

Introduction

Stroke is a major cause of disability and mortality, which places a significant burden on the global healthcare system. According to the World Health Organisation, nearly 15 million new stroke cases are registered each year, of which approximately 5 million result in permanent disability [1]. In Ukraine, more than 100,000 stroke cases are recorded annually, which is 280–290 cases per 100,000 people [2]. According to the Ministry of Health of Ukraine, in 2023, more than 87,000 patients were diagnosed with acute cerebral stroke, of which 91.0% were ischaemic and 9.0% were haemorrhagic [3]. Even though the burden of stroke has decreased globally over the past three decades, morbidity and mortality rates are increasing in countries with a critical lack of healthcare resources [4].

The main focus of rehabilitation for post-stroke patients is on restoring motor function. However, recent studies on non-motor impairment following stroke have shown that it has a significant impact on patient’s quality of life and rehabilitation outcomes. According to modern neuroimaging studies, stroke-related motor impairment is associated not only with localised brain tissue damage but also with impaired functional connectivity between different parts of the brain. The problem of non-motor impairment is particularly relevant in the context of increasing stroke survival rates through improved emergency medical care. The economic impact of non-motor impairment after stroke is also worthy of attention, as the presence of cognitive and emotional disorders in post-stroke patients is associated with more extended hospitalisation, higher medical costs and a lower rate of return to work. Non-motor complications are often overlooked because the focus of treatment is on motor disorders. However, treating neuropsychological complications can significantly ensure optimal recovery outcomes and improve the patient’s quality of life [5–9].

Neuroplastic processes that begin to occur in the brain after a stroke can either accelerate recovery or lead to unexpected changes in behaviour, mental disorders and further complications, including an increased risk of relapse, difficulties with rehabilitation, and suicidal behaviour [10–11]. Psychopathological disorders after stroke are manifested in various variants of the psycho-organic syndrome, the main clinical manifestations of which are memory loss, emotional instability and difficulties with understanding [12–17].

The development of neuropsychopathological conditions that occur after stroke is complex and poorly understood, which can be associated with the individual’s reaction to the disease and damage to certain brain structures with an imbalance of transmitter systems [18–21]. Anxiety in combination with depression is more common in left hemisphere lesions, isolated anxiety disorder in the right hemisphere, and neuropsychopathological disorders are associated with the size of the stroke focus [22]. The functional specialisation of the hemispheres is related to emotion control: the left hemisphere is involved in processing positive emotional stimuli. In contrast, the right hemisphere processes negative ones [23].

The main unresolved problems of non-motor disorders in patients after stroke are their pathogenesis, insufficient attention to a multidisciplinary approach, the effectiveness of pharmacological support and psychosocial aspects [24–27]. Further development of scientific research on non-motor disorders in patients with stroke is associated with studying innovative diagnostic technologies, personalised approaches to rehabilitation and expanding clinical trials [28–30].

Object and methods of the research

The purpose of the study is to analyse current research that highlights the relevance and various manifestations of non-motor disorders in patients who have suffered a stroke in order to identify effective methods of rehabilitation and improve the quality of life of such patients.

The purpose of the article is to conduct a systematic analysis of modern scientific publications on the prevalence and nature of non-motor impairments in post-stroke patients, to identify the main types and manifestations of non-motor impairments in patients after stroke, and to analyse the relationship between non-motor impairments and the quality of their lives.

The object of the study is non-motor disorders (non-motor symptoms) in patients who have suffered an ischaemic or haemorrhagic stroke, their clinical manifestations, prevalence and impact on functional recovery and quality of life.

Research methods: bibliosemantic and systematic analysis.

Results and discussion

Understanding the mechanisms of development and consequences of non-motor disorders is relevant for the development of effective strategies for rehabilitation and improvement of the quality of life of patients after stroke. Post-stroke psychopathological disorders are an important problem of modern neurology and psychiatry, as they significantly affect the quality of life of patients and complicate the rehabilitation process. The most common of these disorders are depression, anxiety disorders, post-traumatic stress disorder, cognitive impairment, and emotional lability [31–35].

Post-stroke depression (PSD), which is often underdiagnosed and untreated, has only recently been recognised as a serious long-term problem in post-stroke patients. PSD occurs in almost 33% of patients, and in 40% of patients, symptoms persist for at least a year after the stroke. It has a negative impact on life expectancy after the disease and is directly related to the presence of physical disabilities [36–39]. PSD can be diagnosed with damage to either hemisphere of the brain, although it usually occurs with a stroke in the left hemisphere [40]. Some studies have shown that damage to the cortico-lymphatic system and changes in neural activity between the prefrontal cortex and basal ganglia may contribute to the development of depression after stroke [41–43]. Affective disorders are observed in 24–30% of patients after stroke and are the most common mental disorders, but they receive less attention than PSD [44–47]. Poststroke anxiety disorder develops during the acute phase of stroke in 25–50% of patients, especially young people with a history of anxiety or depression [48, 49]. According to the results of studies, post-ischemic tissue damage can last for several years and not only leads to a restriction of patients’ social activity and is accompanied by difficulties in their adaptation to everyday life but is also complicated by symptoms of intellectual disability that correspond to the development of cortical atrophy [50–51]. The formation of post-ischemic tissue repair occurs in the context of residual neurological deficits and is complicated by the presence of a stroke-related psycho traumatic situation, which is characterised by the unexpectedness of the onset and uncertainty of the timing of recovery of dysfunction, as well as the fear of recurrent strokes [52].

Patients after stroke show the following symptoms of anxiety: physiological arousal with increased heart rate, cognitive decline, increased sensitivity to possible threatening signals and expectation of adverse events, avoidance of crowded places, sexual intercourse, being alone at home, walking alone and travelling by public transport, limitation of activity due to fear of recurrent stroke, and headaches [53]. Pseudo-neurological symptoms are also characteristic: dizziness, blurred vision, tingling and numbness in the hands and feet, fine tremors, etc [54].

Another common consequence of stroke is post-stroke apathy (PSA), which is characterised by a deficit in goal-directed behaviour with a weakening of both its emotional and cognitive components [55, 56]. PSA is more common in less educated subjects, women with cognitive impairment, and in cases of recurrent stroke [57]. In approximately 40% of cases, PSA and depression co-occur and contribute to further development of depression and poorer functional recovery [58, 59].

Asthenia is a relatively common symptom of many diseases; in particular, it occurs in 25–85% of patients with stroke [60]. There is no unified definition of post-stroke asthenia. It is most often described as a lack of mental and physical energy that interferes with a person’s daily activities and correlates with old age, neurological deficits, diabetes mellitus, hypertension, heart failure, kidney disease, as well as pain, anxiety, depression, sleep disturbances, fatigue, and cognitive impairment [61]. The pathophysiological mechanisms of asthenia remain poorly understood. It is assessed subjectively, based on the patient’s feeling of fatigue or unwillingness to perform tasks, and objectively, based on a measurable decrease in performance during repetitive physical or mental tasks [62].

Factors contributing to the onset of asthenia include physical disabilities, disability, sleep disorders, and depression [63]. The high incidence of asthenia is associated with low motor excitability of the cortex in the affected hemisphere due to changes in corticomotor control on the affected side [64]. Stroke also causes pituitary dysfunction, resulting in post-stroke fatigue [65].

Sleep disorders characterise stroke in the form of breathing disorders and insomnia, which can be risk factors for stroke and its symptoms. Sleep apnoea manifests in snoring, as well as obstructive and central apnoea. They most often occur in patients with repeated stroke. Central apnoea is usually characterised by damage to central autonomic networks, such as the insular cortex and thalamus. Although no correlation has been found between sleep apnoea and stroke severity, topography, or presumed aetiology, it has been linked to depression, anxiety, and cognitive impairment, which hurts the rehabilitation and quality of life of these patients. Timely diagnosis and treatment of post-stroke sleep disorders are helpful in the context of improving rehabilitation after stroke [66–69].

Another common psychological condition is emotionality, which occurs in 8–32% of cases after stroke, impedes recovery and is manifested by an increase in the frequency of crying or laughing in a social situation in response to unemotional or inappropriate stimuli [70, 71].

Post-stroke psychosis, which has a prevalence of about 5%, usually manifests itself within the first week after stroke but can also occur several weeks later and is characterised by delirium, hallucinations, psychomotor agitation, irrelevant and incoherent speech, catatonic symptoms, and sleep cycle disturbances [72, 73].

Post-traumatic stress disorder (PTSD) develops after an event that poses a real or perceived threat to a person’s physical and psychological integrity, and stroke is, without exaggeration, a catastrophe that dramatically changes patients’ lives. Symptoms of PTSD include intrusive memories, autonomic arousal, emotional numbness, and avoidant behaviour. Post-stroke PTSD is often associated with PSD and poststroke anxiety, and its prevalence is 4–37% [74, 75]. In addition, patients with PTSD have a higher risk of developing stroke [76].

Among the psychopathological disorders following a stroke is post-stroke mania, the prevalence of which is quite low (<2%), which in most patients develops in the period from one day to one year after the disease and is more common in right-sided lesions [77–79].

After a stroke, personality disorders may occur, which are more common in the case of frontal lobe damage — the patient becomes irritable or aggressive, disinhibited and/or impulsive. Studies have shown that the prevalence of irritability and disinhibition is 12–53% and 6–76%, respectively [80]. Spatial neglect is one of the most common syndromes that develops after stroke and traumatic brain injury, mainly in this hemisphere [81–84].

The analysis of the current state of research on movement disorders in post-stroke patients reveals a number of promising areas for further study, in particular, the role of neurobiological mechanisms in the formation of movement disorders after stroke, identification of biomarkers and neuroimaging predictors of movement disorders; individualised approaches to the prevention and treatment of movement disorders, taking into account and conducting large-scale, long-term studies to study the natural course of movement disorders; evaluation of the effectiveness of various therapeutic interventions. The introduction of new methods of neuroimaging and functional diagnostics is also promising. In particular, the use of functional magnetic resonance imaging can provide new information about the mechanisms of formation of non-motor disorders in post-stroke patients.

Conclusions

Motor impairment in post-stroke patients is an important medical and social problem that significantly affects the quality of life of patients and the effectiveness of their rehabilitation.

Among the central non-motor disorders in post-stroke patients, the most important are post-stroke cognitive impairment of varying severity, emotional and volitional disorders, in particular, PSD, sleep disorders and insomnia, autonomic dysfunction and pain syndromes of various localisations.

Timely diagnosis and correction of non-motor disorders are strategically important for improving patients’ functional recovery, reducing the risk of recurrent vascular events, increasing adherence to rehabilitation measures, and optimising their quality of life.

A promising area for further research is the development of specific diagnostic tools and therapeutic strategies to correct non-motor disorders in post-stroke patients, considering their pathophysiological mechanisms and individual characteristics of the disease. The standardisation of approaches to assessing non-motor disorders and including appropriate diagnostic procedures in the routine examination of post-stroke patients at all stages of medical care remains relevant.

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Information about the authors:

Vostrotin Oleksandr V. — postgraduate student, Department of Neurology and Child Neurology, Educational and Scientific Institute of Postgraduate Education, Kharkiv National Medical University, Kharkiv, Ukraine. E-mail: vostr1k94@gmail.com. orcid.org/0000-0003-2847-6601

Shmatko Yuliia V. — PhD in Medical Sciences, Associate Professor, Department of Neurology and Child Neurology, Educational and Research Institute of Postgraduate Education, Kharkiv National Medical University, Kharkiv, Ukraine. orcid.org/0000-0003-0009-3123

Відомості про авторів:

Востротін Олександр Вячеславович — аспірант кафедри неврології та дитячої неврології Навчально-наукового інституту післядипломної освіти Харківського національного медичного університету, Харків, Україна. E-mail: vostr1k94@gmail.com. orcid.org/0000-0003-2847-6601

Шматько Юлія Вікторівна — кандидатка медичних наук, доцентка кафедри неврології та дитячої неврології Навчально-наукового інституту післядипломної освіти Харківського національного медичного університету, Харків, Україна. orcid.org/0000-0003-0009-3123

Надійшла до редакції/Received: 31.01.2025
Прийнято до друку/Accepted: 06.02.2025