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Sleep disorders in stroke rehabilitation: mechanisms, impacts, and multidisciplinary management - a narrative review
Guojin Hu1, Xiuli Sun1, Cheng Xie1
1Department of Geriatric Rehabilitation, Shanghai Second Rehabilitation Hospital, Shanghai, China.
Background:
Sleep disorders and stroke share a bidirectional relationship. Sleep disturbances are independent stroke risk factors and frequent post-stroke complications. Obstructive sleep apnea (OSA), through intermittent hypoxia, systemic inflammation, endothelial dysfunction, and autonomic dysregulation, increases stroke risk by approximately 2- to 3-fold. Post-stroke sleep disorders affect up to 59.9% of patients, impeding neurological recovery.
Objectives:
To examine the epidemiology, pathophysiology, and clinical impacts of sleep disorders on stroke recovery, and to summarize evidence-based management strategies.
Methods:
A narrative review was guided by a writing outline developed from clinical observations and preliminary synthesis. A theme-driven literature search was conducted in PubMed, Embase, Cochrane, Web of Science, CNKI, and Wanfang (March 10-13, 2026) using targeted keywords (e.g., "sleep disorders," "obstructive sleep apnea," "rehabilitation," "stroke"), limited to 2000-2026 publications in English or verified Chinese translations. Reference lists were also screened.
Results:
Post-stroke sleep disorder prevalence ranges from 25 to 84%; OSA affects 40-78% of stroke patients. Sleep disorders correlate with worse functional outcomes, prolonged hospitalization, cognitive decline, and elevated stroke recurrence. Mechanistically, intermittent hypoxia, oxidative stress, systemic inflammation, glymphatic dysfunction, autonomic dysregulation, and impaired neuroplasticity are implicated. Management: CPAP is first-line for OSA; CBT-I improves insomnia symptoms; rTMS has been shown to improve sleep quality in clinical studies; exercise, melatonin, and light therapy show emerging evidence. Pharmacotherapy for RLS/PLMD requires caution regarding fall risk and cognitive side effects.
Conclusion:
Sleep disorders are highly prevalent and negatively impact stroke recovery. Evidence-based strategies-CPAP, CBT-I, and rTMS-improve sleep and functional outcomes, though evidence heterogeneity exists. High-quality RCTs are needed to optimize individualized protocols.