Psychological outcomes and changes in health-related quality of life in young and middle-aged patients with first-onset stroke after rehabilitation training

Objectives: The primary objective of this study is to determine the changes in psychological well-being and health-related quality of life (HRQOL) among young and middle-aged individuals who have experienced their first stroke and undergone structured rehabilitation training.

Methods: This prospective analysis included 203 young and middle-aged individuals who had experienced their first stroke and took part in a comprehensive rehabilitation program conducted in China. Patients were classified into “Unremarkable” or “Impaired” groups based on their pre-rehabilitation scores in each scale of the SF-36, SCL-90, and BDI-II scales using established cut-off values from prior research. The rehabilitation program consisted of physical therapy, occupational therapy, and psychological counseling. The rehabilitation program began at least 4 weeks after stroke onset and was carried out over a period of 6 to 8 weeks, with participants attending five sessions per week. Neuropsychological assessments, including the SF-36, SCL-90, and BDI-II scales, were conducted before and after rehabilitation to measure changes in HRQOL, psychological outcomes, and depressive symptoms.

Results: In terms of HRQOL, notable improvements were observed, particularly in the “impaired” group. Following rehabilitation, key indicators, including physical function, overall health, bodily pain, and vitality, showed considerable enhancement (P < 0.001). Regarding psychological outcomes, the “impaired” group demonstrated substantial reductions in symptoms such as aggression, anxiety, obsessive-compulsive behaviors, and paranoid ideation (P < 0.001). Furthermore, assessments using the BDI-II and SCL-90 depression scales indicated a significant decrease in depressive symptoms within the “impaired” group (P < 0.001), whereas no meaningful changes were noted in the “no significant abnormalities” group. These results demonstrate the effectiveness of rehabilitation in improving both psychological well-being and HRQOL in patients with more severe pre-rehabilitation impairments.

Conclusion: Rehabilitation training significantly improves psychological outcomes and HRQOL in young and middle-aged individuals with first-onset stroke, particularly those with more severe baseline impairments. These findings support the integration of multidisciplinary rehabilitation programs in the management of stroke recovery, with significant benefits for both physical and psychological recovery.

1 Background

Stroke is a significant contributor to long-term disability and mortality across the globe, affecting both individuals and healthcare systems (1). It is the second leading cause of death worldwide, representing about 11.6% of all deaths in 2019 (2). Additionally, stroke is a major cause of disability, with an estimated 80 million people around the world living with its long-term consequences (3). While stroke traditionally has been considered a disease primarily affecting older individuals, recent epidemiological trends have highlighted an increasing incidence among younger populations (4, 5). Recent research suggests that strokes affect approximately 10% to 15% of individuals within the age range of 18 to 50 years (4, 5). This younger age group faces unique challenges, including long-term disability, reduced productivity, and difficulties with social and family reintegration. In China, stroke rates among young and middle-aged adults have been steadily rising, becoming an increasing cause of disability and death (6). This trend is attributed to factors such as the growing prevalence of hypertension, diabetes, smoking, and sedentary lifestyles (7, 8). An analysis of ischemic stroke in young adults (20-49) in China from 1990 to 2019 revealed a decrease in mortality and DALYs, but an increase in burden from risk factors like high body mass index, red meat intake, and air pollution (9). Males showed a faster rise in disease burden compared to females (9). This underscores the need for focused stroke prevention and rehabilitation strategies tailored to the unique challenges faced by younger individuals.

Despite advancements in acute stroke treatment and survival rates, many stroke survivors experience enduring physical, psychological, and cognitive impairments that significantly affect their quality of life (10). While much of the focus in stroke rehabilitation has been on physical recovery, mental health and emotional well-being are increasingly recognized as critical components of recovery. Psychological conditions such as depression, anxiety, and post-stroke stress are prevalent among stroke survivors, with studies showing that up to 30-50% of stroke patients experience depression (11, 12). Depression, in particular, is associated with worse functional recovery, increased disability, and poorer long-term outcomes (13). Additionally, cognitive impairments, emotional dysregulation, and reduced social engagement further compound the challenges faced by stroke survivors, making it essential to consider psychological recovery as an integral part of rehabilitation.

Health-related quality of life (HRQOL) acts as a key multidimensional indicator, reflecting various aspects such as physical health, psychological well-being, and social functioning (14). Although numerous studies have focused on physical rehabilitation post-stroke, fewer have addressed the full spectrum of HRQOL, particularly in terms of psychological outcomes. Stroke survivors frequently encounter challenges such as decreased life satisfaction, social withdrawal, and difficulties with emotional regulation, which may contribute to a further decline in their overall quality of life (15, 16). In younger individuals, these challenges may be even more pronounced due to their unique roles in family, employment, and social life. Addressing these issues through structured rehabilitation programs is critical to improving both psychological well-being and functional recovery. There is an increasing awareness of the important role that comprehensive rehabilitation programs may have in supporting both physical and psychological recovery (17). However, most studies have focused on older stroke survivors or have provided limited insights into how rehabilitation programs impact psychological outcomes and HRQOL across different age groups (18–20). To date, research on the psychological recovery of young and middle-aged stroke survivors, particularly in the context of rehabilitation, remains limited. This study seeks to contribute to the existing literature by examining the effects of structured rehabilitation programs on psychological outcomes and HRQOL in young and middle-aged individuals following their first stroke. To evaluate changes in psychological well-being and overall life quality, standardized neuropsychological tools, such as the SF-36, SCL-90, and BDI-II scales, were employed.

2 Methods

2.1 Participants enrollment

This prospective study included young and middle-aged individuals with first-onset stroke who underwent structured rehabilitation at Department of Rehabilitation Medicine, Zibo First Hospital between February 2022 and March 2025. The inclusion criteria were: (1) age ranging from 18 to 65 years; (2) first-onset stroke diagnosed by clinical and neuroimaging findings; (3) at least 4 weeks post-stroke; (4) no prior psychiatric or neurological disorders; (5) ability to provide informed consent and engage in rehabilitation. Exclusion criteria: (1) severe cognitive impairment, assessed using the Mini-Mental State Examination (MMSE) with a cutoff score of 24, which resulted in the exclusion of participants with significant cognitive deficits; (2) Physical disabilities hindering rehabilitation participation; (3) active psychiatric disorders requiring intervention; (3) concurrent rehabilitative or psychotherapeutic treatments. A total of 203 patients were enrolled and underwent comprehensive rehabilitation. Post-rehabilitation assessments were performed to evaluate changes in HRQOL, psychological outcomes, and depressive symptoms. The study was approved by the institutional review board. Informed consent was signed by all participants.

2.2 Procedures of comprehensive rehabilitation

All participants took part in a comprehensive and personalized rehabilitation program designed to support both physical and psychological recovery. This program encompassed three primary components: physical therapy, occupational therapy, and psychological counseling. (1) Physical therapy was conducted by licensed physical therapists and aimed to improve motor skills, strength, and coordination. The training included exercises to increase muscle strength, enhance joint flexibility, improve balance, and support gait retraining, with a focus on restoring functional movement. Each patient’s treatment plan was customized to meet their specific physical condition and rehabilitation requirements, typically consisting of five sessions per week over a period of 6 to 8 weeks. Each session lasted approximately one hour. (2) Occupational therapy was led by certified occupational therapists and focused on helping patients improve their ability to perform essential daily activities, such as dressing, eating, bathing, and grooming. Therapists used adaptive techniques and tools, such as specialized utensils, dressing aids, and mobility aids, to assist patients in regaining independence in these tasks. Therapists tailored the therapy to each patient’s specific functional impairments and provided individualized strategies for improving daily living skills. Occupational therapy sessions were conducted five times per week, with each session lasting approximately one hour. This frequency and duration allowed for consistent progress and the effective implementation of the therapeutic techniques. (3) Psychological counseling was provided by licensed clinical psychologists and focused on managing the mental and emotional challenges associated with stroke recovery. This component involved both individual and group therapy, with sessions tailored to the specific needs of each participant. Cognitive behavioral techniques (CBT), including cognitive restructuring, behavioral activation, relaxation training, and problem-solving strategies, were employed to address issues such as anxiety, depression, and post-stroke stress. For individual counseling, participants were scheduled for one-on-one sessions with licensed clinical psychologists. Group counseling sessions, involving multiple participants with similar psychological needs, were also offered to foster peer support and shared coping strategies. Psychoeducation, which was conducted in person, was integrated into both individual and group sessions. These approaches ensured that all participants received appropriate psychological support throughout their rehabilitation process. Sessions were structured to enhance coping strategies, improve emotional well-being, and provide long-term tools for managing psychological difficulties. Each session typically lasted one hour, and the structure included psychoeducation, guided practice, and real-life application of techniques. Counseling, including psychoeducation, was provided five times per week throughout the rehabilitation program. Rehabilitation training was carried out by a team of professionals, including physical therapists, occupational therapists, and clinical psychologists. Treatment plans were periodically modified in accordance with each patient’s rehabilitation progress.

2.3 Neuropsychological assessments and clinical data collection

Trained neuropsychologists evaluated the psychological health, depressive symptoms, and HRQOL of the participants. Psychological outcomes were assessed using the SCL-90, with depressive symptoms measured through the BDI-II. HRQOL was examined using the SF-36) The criteria for functional impairment were established based on prior research findings (21, 22). The SF-36 is a Likert scale with 36 items assessing eight domains, including physical and emotional health. It has a reliability range of 0.70 to 0.90 (Cronbach’s alpha) as previously reported (23) and was translated into Chinese using standard back-translation procedures. Results were considered abnormal if the z-score was less than −1 SD. The SCL-90, with 90 items, measures nine psychological symptoms and has a reliability range of 0.85 to 0.95. It was also translated using a rigorous back-translation process, and abnormal results were defined by a t-score > 60, with a t-score > 63 on the Global Severity Index indicating significant distress. The BDI-II is a 21-item Likert scale assessing depressive symptoms, with a reliability coefficient of 0.90. The cut-off scores for depression severity were: mild depression (≥ 14), moderate depression (≥ 20), and major depression (≥ 29). All tools were used with permission from the original developers, and translations were reviewed for cultural and linguistic accuracy. These assessments were performed both pre- and post-rehabilitation to evaluate changes in psychological functioning and quality of life. Pre-rehabilitation measurements served to establish baseline psychological states, while post-rehabilitation evaluations assessed the effectiveness of the rehabilitation program. The post-rehabilitation assessments were conducted within one week of completing the program to capture the immediate effects and assess short-term benefits before external factors could influence the outcomes. In addition to these neuropsychological tools, demographic information, medical history, and stroke severity were considered to account for confounding variables in the analysis.

Participants were classified into “impaired” and “unremarkable” groups based on their post-rehabilitation scores from the SF-36, SCL-90, and BDI-II, compared to established cut-off values. Those with scores below the cut-offs were categorized as “impaired”, while those with scores meeting or exceeding the cut-offs were classified as “non-impaired”, reflecting better rehabilitation outcomes. This classification allowed for a clear distinction between participants based on their rehabilitation progress.

2.4 Statistical analysis

Data analysis was conducted using SPSS version 26.0 (IBM Corp., Armonk, NY). Descriptive statistics were used to summarize baseline characteristics, with categorical variables expressed as frequencies and percentages, and continuous variables reported as means with standard deviations (SD). To compare SF-36, SCL-90, and BDI-II scores before and after rehabilitation, paired t-tests were used for normally distributed data, and the Wilcoxon signed-rank test was applied for data that did not follow a normal distribution, as determined by normality tests such as the Shapiro-Wilk test. Effect sizes were also calculated to assess the magnitude of the changes. A p-value of less than 0.05 was considered statistically significant for all analyses.

3 Results

3.1 Baseline characteristics

The baseline characteristics of the study cohort revealed that 64.53% of the participants were male, with a mean age of 50.54 years and a SD of 14.15. The mean BMI was 25.13 kg/m² (SD = 1.52), with 26.1% categorized as overweight, and 23.7% as obese. In terms of educational attainment, 26.1% of patients had no formal education, 23.7% had completed primary school, and 50.3% had received education at or above the middle school level. Employment status indicated that 77.3% of patients were employed, while 22.7% were unemployed. Smoking history was prevalent, with 32.0% being current smokers, 29.1% former smokers, and 38.9% never having smoked. Approximately 17.2% of the patients reported consuming alcohol regularly, 35.0% consumed it occasionally, and 47.8% did not drink alcohol at all. Regarding physical activity, 58.1% of patients reported sedentary behavior, while 41.9% were physically active. Comorbidities included hypertension (68.97%), diabetes mellitus (33.0%), hyperlipidemia (38.4%), and coronary artery disease (23.2%). Detailed information regarding these characteristics is presented in Table 1.

Table 1

Table 1. Baseline characteristics.

3.2 Post-rehabilitation changes in HRQOL

After rehabilitation, young and middle-aged individuals with first-onset stroke showed noticeable improvements in HRQOL across several domains of the SF-36 scale. Among those initially classified as impaired, 31.0% experienced meaningful gains in physical function, with scores improving from -3.12 ± 0.40 to -1.18 ± 0.25 (P < 0.001). Furthermore, 49.3% of patients reported significant improvements in overall health, with scores increasing from -2.96 ± 0.47 to -1.06 ± 0.79 (P < 0.001). In the bodily pain domain, 26.1% of patients showed substantial improvement, with scores rising from -2.12 ± 0.36 to -0.33 ± 0.32 (P < 0.001). Additionally, 43.4% of patients demonstrated significant progress in physical role function, with scores increasing from -2.64 ± 0.44 to -0.99 ± 0.47 (P < 0.001). Regarding psychological health, 36.9% of those initially impaired exhibited substantial improvement, with scores rising from -2.54 ± 0.35 to -0.56 ± 0.38 (P < 0.001). Emotional role function was enhanced in 37.9% of patients, with scores increasing from -3.50 ± 0.48 to -1.35 ± 0.74 (P < 0.001). Social function also showed improvement in 31.0% of patients, with scores rising from -2.97 ± 0.32 to -1.00 ± 0.43 (P < 0.001). The most pronounced improvement was observed in vitality, with 41.9% of patients showing a notable increase in scores from -1.70 ± 0.29 to -0.69 ± 0.44 (P < 0.001). In contrast, patients initially classified as having no significant abnormalities showed minimal changes across most domains. For example, improvements in physical function and overall health were modest (P = 0.065 and P = 0.236, respectively), and there was little to no change in psychological health and emotional role function (P = 0.905). Detailed information on these changes can be found in Table 2.

Table 2

Table 2. Post-rehabilitation changes in HRQOL in young and middle-aged patients with first-onset stroke, evaluated by the SF-36 scale.

3.3 Post-rehabilitation improvements in psychological outcomes

Following rehabilitation training, notable improvements in psychological outcomes were observed in SCL-90 scale. Among patients initially categorized as impaired, 21.2% showed a significant reduction in aggression, with scores decreasing from 67.68 ± 1.78 to 63.93 ± 1.86 (P < 0.001). Similarly, 33.0% of impaired patients exhibited a substantial decrease in anxiety, with scores dropping from 70.80 ± 2.34 to 63.22 ± 2.51 (P < 0.001). Significant improvements were also noted in obsessive-compulsive symptoms and paranoid thoughts. Specifically, 41.9% of impaired patients demonstrated improvements in the obsessive-compulsive dimension, with scores falling from 68.51 ± 2.57 to 62.93 ± 2.52 (P < 0.001). For paranoid thoughts, 11.8% of patients showed a significant reduction in scores, from 63.79 ± 0.87 to 58.74 ± 0.89 (P < 0.001). Insecurity was reduced in 8.9% of patients, with scores decreasing from 69.94 ± 0.94 to 63.74 ± 0.94 (P < 0.001), while somatization symptoms improved significantly in 30.1% of patients, with scores dropping from 64.68 ± 1.80 to 56.00 ± 1.89 (P < 0.001). Psychotic and phobic symptoms also showed noticeable improvements after rehabilitation. Specifically, 35.9% of impaired patients demonstrated improvements in psychotic symptoms, with scores decreasing from 63.82 ± 1.31 to 53.95 ± 1.45 (P < 0.001). Phobic symptoms improved in 25.1% of patients, with scores falling from 65.57 ± 1.86 to 61.95 ± 1.77 (P < 0.001). In contrast, no significant changes were observed in the psychological domains for patients who were initially classified as having no significant abnormalities. Detailed information regarding these changes is available in Table 3.

Table 3

Table 3. Post-rehabilitation changes in psychological outcomes in young and middle-aged patients with first-onset stroke, evaluated by the SCL-90 scale.

3.4 Post-rehabilitation changes in depression

After rehabilitation, notable reductions in depressive symptoms were observed in young and middle-aged patients with first-onset stroke, as measured by the depressive dimension of the BDI-II and SCL-90 scales. Among the 38.92% of patients initially classified as impaired (n = 79), BDI-II scores decreased substantially from 20.80 ± 1.88 to 11.94 ± 1.88 (P < 0.001). In contrast, among the 61.08% of patients initially classified as having no significant abnormalities (n = 124), changes in depressive scores were relatively modest (P = 0.055). Similarly, significant improvement was noted in the depressive dimension of the SCL-90 scale in the impaired group, with scores dropping from 64.76 ± 1.87 to 58.05 ± 1.86 (P < 0.001). In the group without significant abnormalities, depressive scores showed only a slight decrease, from 13.81 ± 1.85 to 13.35 ± 1.89 (P = 0.056). These results suggest that rehabilitation training had a more pronounced effect in alleviating depression among patients with more severe baseline depressive symptoms, while the improvement in those with milder symptoms was relatively limited. Further details can be found in Table 4.

Table 4

Table 4. Post-rehabilitation changes in depressive symptoms in young and middle-aged patients with first-onset stroke, evaluated by the BDI-II and SCL-90 scales.

4 Discussion

This study seeks to explore the effects of structured rehabilitation programs on psychological outcomes and HRQOL in young and middle-aged individuals with first-onset stroke. The findings suggest that comprehensive rehabilitation, which includes physical therapy, occupational therapy, and psychological counseling, offers significant improvements in both psychological well-being and HRQOL, especially for those with more severe impairments prior to rehabilitation. These results underscore the value of an integrated rehabilitation approach that not only focuses on physical recovery but also emphasizes psychological recovery. The study is particularly noteworthy for its focus on the often underrepresented group of young and middle-aged stroke patients in rehabilitation research, highlighting the positive impact of holistic rehabilitation strategies on improving both their psychological health and quality of life.

This study observed improvements in HRQOL, especially in the “impaired” group, as measured by the SF-36 scale. After rehabilitation, patients showed noticeable gains in physical function, overall health, bodily pain, and vitality. These findings align with previous research, which has also suggested that stroke patients tend to recover some aspects of physical function following rehabilitation (24, 25). Stroke rehabilitation is a multifaceted process designed to restore functional abilities and enhance overall quality of life (26–29). It involves a combination of therapeutic interventions, including physical, occupational, and psychological therapies, that target both the physical impairments and the psychological and emotional challenges resulting from stroke (26–29). A key goal of rehabilitation is to enhance HRQOL, which encompasses an individual’s overall well-being in multiple areas, such as physical, psychological, and social functioning (30, 31). HRQOL is a multifaceted concept that aims to capture how an individual’s health condition influences different areas of daily living (32, 33). For stroke survivors, HRQOL includes aspects such as physical functioning, pain, social interaction, psychological well-being, and independence in daily activities (34, 35). Improvements in HRQOL following stroke rehabilitation have been consistently observed across various studies. For instance, research by Gao et al. (36) suggested that non-pharmacological interventions, including exercise training, constraint-induced movement therapy, and music therapy, were associated with improvements in various aspects of HRQOL in stroke survivors, affecting physical, psychological, and social dimensions. Similarly, Visser et al. (37) found that integrating problem-solving therapy into stroke outpatient rehabilitation led to improvements in task-oriented coping strategies and overall HRQOL. However, this intervention did not show a significant effect on psychosocial quality of life specific to stroke. In a separate study, Brouns et al. (38) observed that eRehabilitation, which integrates cognitive and physical training, activity monitoring, and psychological education, resulted in noticeable improvements in communication abilities and physical strength when combined with traditional rehabilitation methods. While the improvements were relatively modest, this approach appeared to support the long-term enhancement of HRQOL. Together, these studies highlight the diverse approaches in stroke rehabilitation that can contribute to improvements in different aspects of HRQOL. Psychological rehabilitation is an important factor in enhancing HRQOL after a stroke. Stroke survivors frequently face challenges such as depression, anxiety, and cognitive impairments, which can considerably affect their overall HRQOL (39, 40). Psychological counseling and cognitive-behavioral therapies have been shown to reduce depression and anxiety while enhancing emotional regulation and coping skills, thus contributing to improved psychological well-being. For instance, Zhao et al. (41) found that psychological interventions, when incorporated into rehabilitation therapy, can assist stroke patients with anxiety and depression in improving their ability to carry out daily tasks, enhancing overall quality of life, and alleviating symptoms of both anxiety and depression. Additionally, rehabilitation’s impact on HRQOL can vary depending on the stroke severity and the timing of rehabilitation. Early intervention tends to yield more favorable outcomes, as patients can regain more function when rehabilitation is initiated sooner (42, 43). However, even patients with more severe impairments can show significant improvements in HRQOL with long-term rehabilitation, although these improvements may be more gradual and less pronounced compared to those with mild impairments. In this study, the “Unremarkable” group showed minimal improvements, suggesting that patients with milder impairments may benefit less from rehabilitation, possibly due to a ceiling effect in domains like physical functioning and general health. This highlights the need for creating personalized rehabilitation plans that cater to the physical and psychological requirements of stroke patients.

Furthermore, after rehabilitation, significant improvements were observed in both psychological outcomes and depressive symptoms, particularly in the “Impaired” group. Psychological outcomes, as assessed by the SCL-90 scale, showed notable reductions in aggressiveness, anxiety, obsessiveness, and paranoid thinking, reflecting the effectiveness of the psychological counseling component of the rehabilitation program. Additionally, following the evaluation with the BDI-II and SCL-90 depression scales, a notable decrease in depressive symptoms was observed in the “impaired” group. The minimal changes observed in the “Unremarkable” group suggest that patients with milder depressive symptoms may not benefit as much from psychological interventions, reinforcing the need for early and comprehensive interventions in patients with more severe psychological impairments. Stroke frequently results in a range of psychological challenges, including depression, anxiety, and mood fluctuations, all of which can adversely affect the rehabilitation process and overall quality of life for patients (41, 44–46). Zheng et al. (40) found that depression and cognitive impairment are relatively common among elderly stroke survivors in China, with a notable relationship between the two conditions. The severity of these symptoms appears to be linked to a considerable decline in the patients’ quality of life. Psychological distress in stroke survivors not only hinders rehabilitation progress but also exacerbates physical impairments, leading to worse long-term outcomes (12, 47, 48). Rehabilitation programs that integrate psychological counseling, cognitive behavioral therapy, and psychoeducation have shown to effectively alleviate these psychological symptoms, thus enhancing both emotional well-being and physical recovery. Multiple studies have shown that rehabilitation can help reduce symptoms of depression and anxiety following a stroke, underscoring the value of using a comprehensive, multidisciplinary approach to manage both the physical and psychological challenges faced by patients (49–51). Lei et al.’s review (52) suggested that psychological interventions, including cognitive-behavioral therapy and supportive psychotherapy, may contribute to improvements in the psychological well-being, cognitive function, and physical recovery of stroke patients dealing with anxiety and depression. Similarly, Nungulo et al. (53) found that psychological education interventions can contribute to improvements in self-care abilities, functional independence, and the ability to manage depression and anxiety in stroke patients, ultimately supporting overall health and quality of life. Psychological challenges are especially notable in younger stroke patients. Young stroke survivors face unique psychological experiences and challenges, including premature disability, emotional adjustment, and the impact of their condition on family and social roles (54, 55). In their meta-analysis on post-traumatic growth in young and middle-aged stroke patients, Liu et al. (56) outlined a three-phase framework, which includes trauma and stress, adaptation and reconstruction, and growth. This framework underscores the importance of recovery across physical, psychological, and social domains throughout the rehabilitation process. The psychological symptoms in this group, including anxiety, depression, and post-traumatic stress, can be more pronounced due to their unexpected and life-altering nature (57, 58). This younger demographic often struggles with issues such as career disruption, reduced social engagement, and changes in family dynamics, further exacerbating their mental health concerns (57, 58). The urgency of addressing these issues is heightened by the long-term nature of psychological recovery and the significant impact it has on functional outcomes. Addressing the psychological needs of young stroke survivors through effective rehabilitation is essential. This approach not only supports emotional recovery but also aids in their successful reintegration into society. This study is valuable in contributing to the existing literature by focusing on the psychological outcomes of young and middle-aged stroke survivors, a group that is often underrepresented in current rehabilitation research. The findings highlight the effectiveness of a comprehensive rehabilitation approach in improving psychological well-being and reducing depressive symptoms, especially for those with more severe impairments.

Interestingly, the study observed that the “impaired” group showed greater improvements in psychological outcomes and HRQOL following rehabilitation compared to the “non-impaired” group. Several interrelated mechanisms may explain this difference. First, individuals with greater baseline deficits may have more “room for improvement,” as they have a larger margin for measurable change (59, 60). This could result in more substantial absolute improvements in the impaired group. Second, neuroplastic and behavioral adaptation processes may be more readily triggered when impairments are more severe. The higher intensity of rehabilitation demands may stimulate greater cognitive and emotional re-engagement, motivation, and therapeutic responsiveness. Previous research suggests that individuals with functional impairments are more vulnerable to psychological distress, which may drive stronger motivation for rehabilitation in the impaired group (61–63). Lastly, the non-impaired group may already function at or near normative levels in many domains at baseline, which limits the potential for change during the short rehabilitation period, thus reducing the measurable improvements achievable. These findings suggest that a one-size-fits-all approach to rehabilitation may not be optimal for the non-impaired group. For these individuals, the focus could shift from remediation to enhancement, maintenance, and participation-oriented interventions. Strategies might include strengthening resilience, promoting social reintegration, and providing preventive psychological education. The criteria for tailoring rehabilitation could involve baseline psychological scores, the presence of sub-clinical symptoms, and functional or social role participation status (64, 65). For example, non-impaired participants with high baseline scores but concerns about social reintegration might benefit more from group-based psychosocial programs or goal-setting interventions rather than the standard therapies applied to impaired individuals. Future studies should stratify participants by impairment status and potential for change, testing adaptive rehabilitation approaches tailored to individual needs. Longitudinal follow-up is needed to determine if the smaller improvements in the non-impaired group reflect a true plateau or require longer or different interventions. Further research on motivational, psychological, and neurobiological factors in non-impaired stroke survivors could help optimize rehabilitation strategies for this subgroup.

Comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, and coronary artery disease can significantly influence both psychological functioning and HRQOL in stroke patients. These conditions often exacerbate physical disability, increase psychological distress, and reduce the overall effectiveness of rehabilitation programs (66, 67). Previous studies have shown that individuals with comorbidities tend to experience more severe psychological symptoms, such as depression and anxiety, which can impede recovery and worsen HRQOL outcomes (68–70). In particular, conditions like diabetes and hypertension are associated with increased levels of stress, reduced mobility, and poorer physical functioning, all of which can negatively impact rehabilitation outcomes (71, 72). Additionally, comorbidities often contribute to a higher burden of symptoms, which may limit the capacity for meaningful improvement in both psychological well-being and physical function. The cumulative effect of multiple comorbid conditions can result in a more complex rehabilitation process, requiring tailored interventions that address both the physical and psychological challenges these patients face. Future research should explore how comorbidities affect rehabilitation effectiveness and recovery, focusing on their impact on psychological well-being and HRQOL. This understanding can help develop more effective, individualized rehabilitation strategies for these patients.

While this study offers important insights into the effects of rehabilitation on psychological outcomes and HRQOL, there are some limitations. First, the study relied on self-reported psychological outcomes, which may introduce potential biases. The use of more objective methods, such as clinical evaluations or neuroimaging data, could provide a more thorough assessment of psychological and neurobiological changes following rehabilitation. Second, the study focused primarily on a homogeneous group of participants, limiting the generalizability of the findings to more diverse populations with varying types and severities of stroke. Finally, future studies should examine the long-term impact of rehabilitation on psychological health and HRQOL, as the current research focused solely on short-term outcomes.

5 Conclusion

In summary, this study demonstrates that rehabilitation is associated with meaningful improvements in psychological outcomes and HRQOL among young and middle-aged stroke patients, with the greatest benefits observed in those who had more severe impairments before starting rehabilitation. The findings stress the importance of combining both physical and psychological interventions in post-stroke rehabilitation to promote comprehensive recovery. Early implementation of tailored psychological rehabilitation strategies can not only enhance emotional adjustment but also support functional recovery and lead to broader improvements in quality of life for stroke survivors.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The study was approved by the institutional review board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

CH: Writing – original draft. DY: Writing – original draft. XS: Writing – original draft. ZL: Conceptualization, Writing – review & editing, Supervision.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that Generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1. Pu L, Wang L, Zhang R, Zhao T, Jiang Y, and Han L. Projected global trends in ischemic stroke incidence, deaths and disability-adjusted life years from 2020 to 2030. Stroke. (2023) 54:1330–9. doi: 10.1161/STROKEAHA.122.040073

PubMed Abstract | Crossref Full Text | Google Scholar

2. Feigin VL, Brainin M, Norrving B, Martins SO, Pandian J, Lindsay P, et al. World stroke organization: global stroke fact sheet 2025. Int J Stroke. (2025) 20:132–44. doi: 10.1177/17474930241308142

PubMed Abstract | Crossref Full Text | Google Scholar

3. Diseases GBD and Injuries C. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. (2024) 403:2133–61. doi: 10.1016/S0140-6736(24)00757-8

PubMed Abstract | Crossref Full Text | Google Scholar

4. Yahya T, Jilani MH, Khan SU, Mszar R, Hassan SZ, Blaha MJ, et al. Stroke in young adults: Current trends, opportunities for prevention and pathways forward. Am J Prev Cardiol. (2020) 3:100085. doi: 10.1016/j.ajpc.2020.100085

PubMed Abstract | Crossref Full Text | Google Scholar

5. Hathidara MY, Saini V, and Malik AM. Stroke in the young: a global update. Curr Neurol Neurosci Rep. (2019) 19:91. doi: 10.1007/s11910-019-1004-1

PubMed Abstract | Crossref Full Text | Google Scholar

6. Li Y, Wang Y, Wang S, and Zhu H. Global, regional, and national burden and trends of of stroke in adolescents and young adults from 1992 to 2021. J Stroke Cerebrovasc Dis. (2025) 34:108414. doi: 10.1016/j.jstrokecerebrovasdis.2025.108414

PubMed Abstract | Crossref Full Text | Google Scholar

7. Collaborators GBDS. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. (2021) 20:795–820. doi: 10.1016/S1474-4422(21)00252-0

PubMed Abstract | Crossref Full Text | Google Scholar

8. Ma Q, Li R, Wang L, Yin P, Wang Y, Yan C, et al. Temporal trend and attributable risk factors of stroke burden in China, 1990-2019: an analysis for the Global Burden of Disease Study 2019. Lancet Public Health. (2021) 6:e897–906. doi: 10.1016/S2468-2667(21)00228-0

PubMed Abstract | Crossref Full Text | Google Scholar

9. Gao Y, Liu K, and Fang S. Analysis and projections of disease burden for different risk factors and sexes of ischemic stroke in young adults in China. Sci Rep. (2024) 14:13339. doi: 10.1038/s41598-024-63920-0

PubMed Abstract | Crossref Full Text | Google Scholar

10. Ramos-Lima MJM, Brasileiro IC, Lima TL, and Braga-Neto P. Quality of life after stroke: impact of clinical and sociodemographic factors. Clinics (Sao Paulo). (2018) 73:e418. doi: 10.6061/clinics/2017/e418

PubMed Abstract | Crossref Full Text | Google Scholar

11. Zhang S, Yuan Y, Zhuang W, Xiong T, Xu Y, Zhang J, et al. Contributing factors and induced outcomes of psychological stress response in stroke survivors: A systematic review. Front Neurol. (2022) 13:843055. doi: 10.3389/fneur.2022.843055

PubMed Abstract | Crossref Full Text | Google Scholar

12. Kusec A, Milosevich E, Williams OA, Chiu EG, Watson P, Carrick C, et al. Long-term psychological outcomes following stroke: the OX-CHRONIC study. BMC Neurol. (2023) 23:426. doi: 10.1186/s12883-023-03463-5

PubMed Abstract | Crossref Full Text | Google Scholar

13. Paolucci S, Iosa M, Coiro P, Venturiero V, Savo A, De Angelis D, et al. Post-stroke depression increases disability more than 15% in ischemic stroke survivors: A case-control study. Front Neurol. (2019) 10:926. doi: 10.3389/fneur.2019.00926

PubMed Abstract | Crossref Full Text | Google Scholar

14. Flokstra-de Blok BM, Oude Elberink JN, Vlieg-Boerstra BJ, Duiverman EJ, and Dubois AE. Measuring health-related quality of life: fundamental methodological issues. Clin Exp Allergy. (2009) 39:1774. doi: 10.1111/j.1365-2222.2009.03376.x

PubMed Abstract | Crossref Full Text | Google Scholar

15. Cooper CL, Phillips LH, Johnston M, Whyte M, and MacLeod MJ. The role of emotion regulation on social participation following stroke. Br J Clin Psychol. (2015) 54:181–99. doi: 10.1111/bjc.12068

PubMed Abstract | Crossref Full Text | Google Scholar

16. Mukherjee D, Levin RL, and Heller W. The cognitive, emotional, and social sequelae of stroke: psychological and ethical concerns in post-stroke adaptation. Top Stroke Rehabil. (2006) 13:26–35. doi: 10.1310/tsr1304-26

PubMed Abstract | Crossref Full Text | Google Scholar

17. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, et al. Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the american heart association/american stroke association. Stroke. (2016) 47:e98–e169. doi: 10.1161/STR.0000000000000098

PubMed Abstract | Crossref Full Text | Google Scholar

18. Schindel D, Schneider A, Grittner U, Jobges M, and Schenk L. Quality of life after stroke rehabilitation discharge: a 12-month longitudinal study. Disabil Rehabil. (2021) 43:2332–41. doi: 10.1080/09638288.2019.1699173

PubMed Abstract | Crossref Full Text | Google Scholar

19. De Wit L, Theuns P, Dejaeger E, Devos S, Gantenbein AR, Kerckhofs E, et al. Long-term impact of stroke on patients’ health-related quality of life. Disabil Rehabil. (2017) 39:1435–40. doi: 10.1080/09638288.2016.1200676

PubMed Abstract | Crossref Full Text | Google Scholar

20. Gurkova E, Sturekova L, Mandysova P, and Sanak D. Factors affecting the quality of life after ischemic stroke in young adults: a scoping review. Health Qual Life Outcomes. (2023) 21:4. doi: 10.1186/s12955-023-02090-5

PubMed Abstract | Crossref Full Text | Google Scholar

21. Haas P, Fudali M, Wang SS, Hurth H, Hauser TK, Ernemann U, et al. Quality of life impairment in adult Moyamoya patients-preoperative neuropsychological assessment and correlation to MRI and H(2)(15)O PET findings. Neurosurg Rev. (2022) 45:1533–41. doi: 10.1007/s10143-021-01660-9

PubMed Abstract | Crossref Full Text | Google Scholar

22. Roder C, Haas P, Fudali M, Milian M, Ernemann U, Meyer PT, et al. Neuropsychological impairment in adults with moyamoya angiopathy: preoperative assessment and correlation to MRI and H(2)(15)O PET. Neurosurg Rev. (2020) 43:1615–22. doi: 10.1007/s10143-019-01192-3

PubMed Abstract | Crossref Full Text | Google Scholar

23. Lin Y, Yu Y, Zeng J, Zhao X, and Wan C. Comparing the reliability and validity of the SF-36 and SF-12 in measuring quality of life among adolescents in China: a large sample cross-sectional study. Health Qual Life Outcomes. (2020) 18:360. doi: 10.1186/s12955-020-01605-8

PubMed Abstract | Crossref Full Text | Google Scholar

24. Lee KE, Choi M, and Jeoung B. Effectiveness of rehabilitation exercise in improving physical function of stroke patients: A systematic review. Int J Environ Res Public Health. (2022) 19. doi: 10.3390/ijerph191912739

PubMed Abstract | Crossref Full Text | Google Scholar

25. Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev. (2014) 2014:Cd001920. doi: 10.1002/14651858.CD001920.pub3

PubMed Abstract | Crossref Full Text | Google Scholar

26. Shahid J, Kashif A, and Shahid MK. A comprehensive review of physical therapy interventions for stroke rehabilitation: impairment-based approaches and functional goals. Brain Sci. (2023) 13. doi: 10.3390/brainsci13050717

PubMed Abstract | Crossref Full Text | Google Scholar

27. Belagaje SR. Stroke rehabilitation. Continuum (Minneap Minn). (2017) 23:238–53. doi: 10.1212/CON.0000000000000423

PubMed Abstract | Crossref Full Text | Google Scholar

28. Langhorne P, Bernhardt J, and Kwakkel G. Stroke rehabilitation. Lancet. (2011) 377:1693–702. doi: 10.1016/S0140-6736(11)60325-5

PubMed Abstract | Crossref Full Text | Google Scholar

29. Li X, He Y, Wang D, and Rezaei MJ. Stroke rehabilitation: from diagnosis to therapy. Front Neurol. (2024) 15:1402729. doi: 10.3389/fneur.2024.1402729

PubMed Abstract | Crossref Full Text | Google Scholar

30. Gigantesco A and Giuliani M. Quality of life in mental health services with a focus on psychiatric rehabilitation practice. Ann Ist Super Sanita. (2011) 47:363–72. doi: 10.4415/ANN_11_04_07

PubMed Abstract | Crossref Full Text | Google Scholar

31. Parsons JT and Snyder AR. Health-related quality of life as a primary clinical outcome in sport rehabilitation. J Sport Rehabil. (2011) 20:17–36. doi: 10.1123/jsr.20.1.17

PubMed Abstract | Crossref Full Text | Google Scholar

32. Karimi M and Brazier J. Health, health-related quality of life, and quality of life: what is the difference? Pharmacoeconomics. (2016) 34:645–9. doi: 10.1007/s40273-016-0389-9

PubMed Abstract | Crossref Full Text | Google Scholar

33. Kaplan RM and Hays RD. Health-related quality of life measurement in public health. Annu Rev Public Health. (2022) 43:355–73. doi: 10.1146/annurev-publhealth-052120-012811

PubMed Abstract | Crossref Full Text | Google Scholar

34. Kranciukaite D and Rastenyte D. Measurement of quality of life in stroke patients. Med (Kaunas). (2006) 42:709–16.

Google Scholar

35. Gandolfi M, Donisi V, Battista S, Picelli A, Vale N, Del Piccolo L, et al. Health-related quality of life and psychological features in post-stroke patients with chronic pain: A cross-sectional study in the neuro-rehabilitation context of care. Int J Environ Res Public Health. (2021) 18. doi: 10.3390/ijerph18063089

PubMed Abstract | Crossref Full Text | Google Scholar

36. Gao C, Li X, Li F, Li J, and Zhang J. Non-pharmacological interventions on quality of life in stroke survivors: A systematic review and meta-analysis. Worldviews Evid Based Nurs. (2024) 21:158–82. doi: 10.1111/wvn.12714

PubMed Abstract | Crossref Full Text | Google Scholar

37. Visser MM, Heijenbrok-Kal MH, Van't Spijker A, Lannoo E, Busschbach JJ, and Ribbers GM. Problem-solving therapy during outpatient stroke rehabilitation improves coping and health-related quality of life: randomized controlled trial. Stroke. (2016) 47:135–42. doi: 10.1161/STROKEAHA.115.010961

PubMed Abstract | Crossref Full Text | Google Scholar

38. Brouns B, van Bodegom-Vos L, de Kloet AJ, Tamminga SJ, Volker G, Berger MAM, et al. Effect of a comprehensive eRehabilitation intervention alongside conventional stroke rehabilitation on disability and health-related quality of life: A pre-post comparison. J Rehabil Med. (2021) 53:jrm00161. doi: 10.2340/16501977-2785

PubMed Abstract | Crossref Full Text | Google Scholar

39. Tang WK, Lau CG, Mok V, Ungvari GS, and Wong KS. Impact of anxiety on health-related quality of life after stroke: a cross-sectional study. Arch Phys Med Rehabil. (2013) 94:2535–41. doi: 10.1016/j.apmr.2013.07.012

PubMed Abstract | Crossref Full Text | Google Scholar

40. Zheng MR, Chen P, Feng Y, Zhang Q, Su Z, Cheung T, et al. Prevalence of depression and cognitive impairment and their inter-relationship and association with quality of life among older stroke survivors: the findings of a national survey in China. Stroke Vasc Neurol. (2025). doi: 10.1136/svn-2024-003623

PubMed Abstract | Crossref Full Text | Google Scholar

41. Zhao B, Yao Y, and Gao T. The effect of psychological intervention on the quality of life and rehabilitation outcome of stroke patients with anxiety and depression: A systematic review. Med (Baltimore). (2024) 103:e40439. doi: 10.1097/MD.0000000000040439

PubMed Abstract | Crossref Full Text | Google Scholar

42. Novak I and Morgan C. High-risk follow-up: Early intervention and rehabilitation. Handb Clin Neurol. (2019) 162:483–510. doi: 10.1016/B978-0-444-64029-1.00023-0

PubMed Abstract | Crossref Full Text | Google Scholar

43. Stucki G, Stier-Jarmer M, Grill E, and Melvin J. Rationale and principles of early rehabilitation care after an acute injury or illness. Disabil Rehabil. (2005) 27:353–9. doi: 10.1080/09638280400014105

PubMed Abstract | Crossref Full Text | Google Scholar

44. van Mierlo ML, Schroder C, van Heugten CM, Post MW, de Kort PL, and Visser-Meily JM. The influence of psychological factors on health-related quality of life after stroke: a systematic review. Int J Stroke. (2014) 9:341–8. doi: 10.1111/ijs.12149

PubMed Abstract | Crossref Full Text | Google Scholar

45. Atigossou OLG, Ouedraogo F, Honado AS, Alagnide E, Kpadonou TG, and Batcho CS. Association between post-stroke psychological disorders, activity limitations and health-related quality of life in chronic stroke survivors in Benin. Disabil Rehabil. (2023) 45:2087–94. doi: 10.1080/09638288.2022.2083703

PubMed Abstract | Crossref Full Text | Google Scholar

46. Ferro JM, Caeiro L, and Figueira ML. Neuropsychiatric sequelae of stroke. Nat Rev Neurol. (2016) 12:269–80. doi: 10.1038/nrneurol.2016.46

PubMed Abstract | Crossref Full Text | Google Scholar

47. Hreha K, Wong J, Molton I, Nelson IK, and Lee D. The impact of stroke on psychological and physical function outcomes in people with long-term physical disability. Disabil Health J. (2020) 13:100919. doi: 10.1016/j.dhjo.2020.100919

PubMed Abstract | Crossref Full Text | Google Scholar

48. Crichton SL, Bray BD, McKevitt C, Rudd AG, and Wolfe CD. Patient outcomes up to 15 years after stroke: survival, disability, quality of life, cognition and mental health. J Neurol Neurosurg Psychiatry. (2016) 87:1091–8. doi: 10.1136/jnnp-2016-313361

PubMed Abstract | Crossref Full Text | Google Scholar

49. Terrill AL, Schwartz JK, and Belagaje SR. Best practices for the interdisciplinary rehabilitation team: A review of mental health issues in mild stroke survivors. Stroke Res Treat. (2018) 2018:6187328. doi: 10.1155/2018/6187328

PubMed Abstract | Crossref Full Text | Google Scholar

50. Clarke DJ and Forster A. Improving post-stroke recovery: the role of the multidisciplinary health care team. J Multidiscip Healthc. (2015) 8:433–42. doi: 10.2147/JMDH.S68764

PubMed Abstract | Crossref Full Text | Google Scholar

51. Baker C, Worrall L, Rose M, and Ryan B. Stroke health professionals’ management of depression after post-stroke aphasia: a qualitative study. Disabil Rehabil. (2021) 43:217–28. doi: 10.1080/09638288.2019.1621394

PubMed Abstract | Crossref Full Text | Google Scholar

52. Lei XY, Chen LH, Qian LQ, and Lu XD. Psychological interventions for post-stroke anxiety and depression: Current approaches and future perspectives. World J Psychiatry. (2025) 15:103270. doi: 10.5498/wjp.v15.i6.103270

PubMed Abstract | Crossref Full Text | Google Scholar

53. Nungulo VN, Goncalves M, Henriques MA, and Baixinho CL. Effectiveness of psychoeducational intervention in promoting post-stroke self-care: a systematic literature review. Front Rehabil Sci. (2025) 6:1569526. doi: 10.3389/fresc.2025.1569526

PubMed Abstract | Crossref Full Text | Google Scholar

54. Buschenfeld K, Morris R, and Lockwood S. The experience of partners of young stroke survivors. Disabil Rehabil. (2009) 31:1643–51. doi: 10.1080/09638280902736338

PubMed Abstract | Crossref Full Text | Google Scholar

55. Morris R. The psychology of stroke in young adults: the roles of service provision and return to work. Stroke Res Treat. (2011) 2011:534812. doi: 10.4061/2011/534812

PubMed Abstract | Crossref Full Text | Google Scholar

56. Liu S, Zhou W, Wu X, Ding J, Liu Y, Shao H, et al. Post-traumatic growth in young and middle-aged patients with stroke: a qualitative systematic review and meta-synthesis. BMC Psychol. (2025) 13:967. doi: 10.1186/s40359-025-03321-8

PubMed Abstract | Crossref Full Text | Google Scholar

57. Shipley J, Luker J, Thijs V, and Bernhardt J. The personal and social experiences of community-dwelling younger adults after stroke in Australia: a qualitative interview study. BMJ Open. (2018) 8:e023525. doi: 10.1136/bmjopen-2018-023525

PubMed Abstract | Crossref Full Text | Google Scholar

58. Chalmers C, Leathem J, Bennett S, McNaughton H, and Mahawish K. The efficacy of problem solving therapy to reduce post stroke emotional distress in younger (18-65) stroke survivors. Disabil Rehabil. (2019) 41:753–62. doi: 10.1080/09638288.2017.1408707

PubMed Abstract | Crossref Full Text | Google Scholar

59. Bruce JM, Echemendia RJ, Meeuwisse W, Hutchison MG, Aubry M, and Comper P. Measuring cognitive change with ImPACT: the aggregate baseline approach. Clin Neuropsychol. (2017) 31:1329–40. doi: 10.1080/13854046.2017.1311375

PubMed Abstract | Crossref Full Text | Google Scholar

60. Stein J, Luppa M, Brahler E, Konig HH, and Riedel-Heller SG. The assessment of changes in cognitive functioning: reliable change indices for neuropsychological instruments in the elderly - a systematic review. Dement Geriatr Cognit Disord. (2010) 29:275–86. doi: 10.1159/000289779

PubMed Abstract | Crossref Full Text | Google Scholar

61. Fan AZ, Strine TW, Jiles R, Berry JT, and Mokdad AH. Psychological distress, use of rehabilitation services, and disability status among noninstitutionalized US adults aged 35 years and older, who have cardiovascular conditions, 2007. Int J Public Health. (2009) 54 Suppl 1:100–5. doi: 10.1007/s00038-009-1313-2

PubMed Abstract | Crossref Full Text | Google Scholar

62. Spindler H, Leerskov K, Joensson K, Nielsen G, Andreasen JJ, and Dinesen B. Conventional rehabilitation therapy versus telerehabilitation in cardiac patients: A comparison of motivation, psychological distress, and quality of life. Int J Environ Res Public Health. (2019) 16. doi: 10.3390/ijerph16030512

PubMed Abstract | Crossref Full Text | Google Scholar

63. Pozzato I, Kifley A, Craig A, Gopinath B, Tran Y, Jagnoor J, et al. Effects of seeking compensation on the psychological health and recovery of injured patients: the role of stress vulnerability and injury-related disability. Psychol Med. (2022) 52:68–79. doi: 10.1017/S003329172000166X

PubMed Abstract | Crossref Full Text | Google Scholar

64. Vriezekolk JE, Eijsbouts AM, van Lankveld WG, Beenackers H, Geenen R, and van den Ende CH. An acceptance-oriented cognitive-behavioral therapy in multimodal rehabilitation: a pre-post test evaluation in highly distressed patients with rheumatic diseases. Patient Educ Couns. (2013) 91:357–63. doi: 10.1016/j.pec.2013.01.018

PubMed Abstract | Crossref Full Text | Google Scholar

65. Brinkhof LP, Ridderinkhof KR, Murre JMJ, Krugers HJ, and de Wit S. Improving goal striving and resilience in older adults through a personalized metacognitive self-help intervention: a protocol paper. BMC Psychol. (2023) 11:223. doi: 10.1186/s40359-023-01259-3

PubMed Abstract | Crossref Full Text | Google Scholar

66. Rai D, Kosidou K, Lundberg M, Araya R, Lewis G, and Magnusson C. Psychological distress and risk of long-term disability: population-based longitudinal study. J Epidemiol Community Health. (2012) 66:586–92. doi: 10.1136/jech.2010.119644

PubMed Abstract | Crossref Full Text | Google Scholar

67. Byles JE, Robinson I, Banks E, Gibson R, Leigh L, Rodgers B, et al. Psychological distress and comorbid physical conditions: disease or disability? Depress Anxiety. (2014) 31:524–32. doi: 10.1002/da.22162

PubMed Abstract | Crossref Full Text | Google Scholar

68. Liao W, Luo Z, Dong X, Wu X, Mei Y, Cui N, et al. Associations between depressive symptoms, anxiety symptoms, their comorbidity and health-related quality of life: a large-scale cross-sectional study. BMC Public Health. (2021) 21:1911. doi: 10.1186/s12889-021-11969-1

PubMed Abstract | Crossref Full Text | Google Scholar

69. Pham TTM, Vu MT, Luong TC, Pham KM, Nguyen LTK, Nguyen MH, et al. Negative impact of comorbidity on health-related quality of life among patients with stroke as modified by good diet quality. Front Med (Lausanne). (2022) 9:836027. doi: 10.3389/fmed.2022.836027

PubMed Abstract | Crossref Full Text | Google Scholar

70. Pati S, Pati S, Akker MVD, Schellevis FFG, Jena S, and Burgers JS. Impact of comorbidity on health-related quality of life among type 2 diabetic patients in primary care. Prim Health Care Res Dev. (2020) 21:e9. doi: 10.1017/S1463423620000055

PubMed Abstract | Crossref Full Text | Google Scholar

71. Bruce DG, Davis WA, and Davis TM. Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes: the Fremantle Diabetes Study. Diabetes Care. (2005) 28:2441–7. doi: 10.2337/diacare.28.10.2441

PubMed Abstract | Crossref Full Text | Google Scholar

72. Murray EM, Whellan DJ, Chen H, Bertoni AG, Duncan P, Pastva AM, et al. Physical rehabilitation in older patients hospitalized with acute heart failure and diabetes: insights from REHAB-HF. Am J Med. (2022) 135:82–90. doi: 10.1016/j.amjmed.2021.08.001

PubMed Abstract | Crossref Full Text | Google Scholar