On the importance of effort perception in stroke care: From evidence to an ideal care pathway – An opinion paper

Post-stroke rehabilitation has traditionally relied on objective assessments of motor and cognitive abilities. However, one crucial factor remains largely overlooked in current practice: the perception of effort, that is, the conscious experience of task intensity and difficulty. Effort perception is strongly influenced by internal states such as fatigue and pain, two symptoms frequently reported after stroke, even in the absence of major neurological deficits. While these symptoms are often treated separately, they converge into a shared experience: that of heightened perceived effort. Here, we propose a model in which fatigue and pain reduce physical and cognitive capacity, requiring greater effort to compensate; this increased effort is in turn perceived and feeds back onto fatigue and pain, creating a self-sustaining loop. Recent literature suggests that both physical and mental fatigue, along with pain, increase perceived effort by impacting available resources and the motivation to engage and persist in cognitive and physical tasks. This modulation can have direct consequences on patient engagement and adherence to rehabilitation. When effort is perceived as disproportionate, even for an objectively simple task, it may lead to reduced participation or even withdrawal from rehabilitation. Conversely, a better understanding of the perception of effort could pave the way for personalized interventions that consider not only patients' actual capacities but also their subjective experiences. It is therefore urgent to consider the perception of effort as a clinical indicator in its own right, one that sits at the intersection of body, brain and lived experience. By integrating this dimension, research could better explain why some patients disengage from post-stroke care despite good recovery potential, and clinical practice could refine its motivational strategies and therapeutic adherence models. The stakes are twofold: to improve understanding of the mechanisms underlying effort perception, and to harness it as a lever for optimizing post-stroke care trajectories.