2015: Post Stroke Fatigue - Why Live With It?-Giap

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Post Stroke FatigueWhy Live with It?

Benton Giap, MD MBA

© 2008 Santa Clara Valley Health & Hospital System

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Today’s Overview

Increase awareness of manifestations and common factors in developing of PSF

Review the evidence for assessment and treatment of fatigue after stroke

Management –outline practical non-pharmacological tools for managing this condition

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Disclosure

Off-labeled uses of medications for post stroke fatigue.

Employer Anthem Blue Cross, Commercial Health Plan

Lots of cute baby pictures

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In Their own words

“my head is foggy”

“life is too overwhelming!”

hit a “brick wall”

“exhausted” and failing to meet the

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Definition of Fatigue

“a subjective experience of extreme and persistent tiredness, weakness or exhaustion after stroke, which can present itself mentally, physically or both and is unrelated to previous exertion levels.

[Lerdal and colleagues]

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Scope of the Problem

Prevalence – 38 - 73 % PSF often does not diminish even years after stroke can be present within weeks and persist for many months or even years

afterwards identified by 40% as amongst their worst symptoms impacting function, QOL,

safety

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Fatigue following Stroke: Frequency, characteristics and associated factors

Not associated with lesion size Location-fatigue associated lacunar infarcts located within the

basal ganglia, internal capsule, and infra-tentorial areas greater fatigue was related consistently to a poorer physical

function and symptoms of depression Pre-morbid level of functioning Multiple medications effect?

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Fatigue is well appreciated in other conditions

multiple sclerosis post-polio syndrome traumatic brain injury cardiovascular disease pulmonary disease (COPD) depression thyroid disease obesity HIV/AIDs diabetes mellitus

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Depression Sleep problems, such as

sleep apnea Lack of physical exercise Vitamin deficiency/poor

nutrition Anemia Pain Infection-acute , chronic

Physical impairments from stroke

Medications -anti-hypertensive, spasmolytics, antidepressants, pain medication

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Differentiating fatigue from sleepiness

Subjective feeling of weariness, depleted energy

Multidimensional(e.g. mental, physical)

No real objective measure

Physiological drive to sleep

Measurable signs: Yawning

Eyes drooping Reduced alertness Can be measured in a

sleep laboratory(MSLT)

FATIGUE EXCESSIVE DAYTIME SLEEPINESS

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Mechanisms

Activation of an inflammatory response with secretion of various cytokines necessary for immune signaling including interleukin-6 (IL-6) interleukin-1 beta (IL-

1β) tumor necrosis factor

alpha (TNF α)

the exact mechanisms of origin and persistence of PSF are still elusive

Contribution by hypothalamic-pituitary-adrenal (HPA) axis modulated by cytokines Hypo-activity of the HPA axis owing to

decreased corticotrophin releasing hormone has been accordingly found in CFS and in chronic autoimmune conditions

Hyperactivity results in a blunting of the normal diurnal cortisol secretion curve with reduced gluco-corticoid production and onset of fatigue and depressive symptoms

© 2008 Santa Clara Valley Health & Hospital System

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“Sickness Behavior”mediated throughneural, immune, and endocrine mechanisms following stroke

“neurovegetative “ syndrome (early)

poor appetite sleep disturbances psychomotor slowing fatigue

[Rothwell and colleagues]

“mood and cognitive” syndrome (later)

depression anxiety impairment of memory, attn lowered libido

© 2008 Santa Clara Valley Health & Hospital System

13© 2008 Santa Clara Valley Health & Hospital System

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7-step approach toward a diagnosis

Characterize the fatigue Assess presence of complaints suggesting organic

illness associated with fatigue Evaluate medicines used and/or substances abused Perform psychiatric screening Ask questions on sleep quantity and/or quality Perform a physical examination Undertake investigations

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Fatigue Severity Scale (FSS)

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Fatigue Pictogram

© 2008 Santa Clara Valley Health & Hospital System

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Management

No effective pharmacological option has been identified

insufficient evidence existed to recommend any single treatment for PSF

no evidence-based treatments are currently available to alleviate fatigue.

© 2008 Santa Clara Valley Health & Hospital System

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Fatigue: pharmacological options ?

Anecdotal reports with : amantadine, methylphenidate, modafinil, Fluoxetine

Randomized DB controlled trials: One N=83, consecutive outpatient stroke survivors (average 14

months post stroke) randomly assigned to either fluoxetine 20 mg/day (n=40)

or placebo (n=43) given over 3 months. Follow-up evaluations at 3 and 6 months after the

beginning of the treatment, included the Visual Analogue Scale (mean score 5.4±2 at baseline) and Fatigue Severity Scale (mean score 4.4±1.2 at baseline).

© 2008 Santa Clara Valley Health & Hospital System

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IS EXERCISE THE SOLUTION? Design- multicenter, randomized, controlled trial , 8 rehabilitation centers. Participants – 83 participants with stroke (4 months after stroke) were

randomly assigned to 12 weeks of cognitive therapy (CO) or cognitive therapy and graded activity training (COGRAT) after qualification.

Aim - to compare the effectiveness of a combined intervention (COGRAT) with that of CO alone on fatigue and associated psychological and physical variables.

Graded Activity Training (GRAT) consisted of walking on a treadmill, strength training, and physical fitness home work assignments.

Outcomes -Seventy-three patients completed treatment and 68 were available at follow-up. Primary outcomes (Checklist Individual Strength–subscale Fatigue (CIS-f); self-

observation list–fatigue (SOL-f)) Findings - Group cognitive therapy combined with graded activity training

during a 12-week period reduces persistent PSF

[Zedlitz and colleagues, 2012]

© 2008 Santa Clara Valley Health & Hospital System

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Intervention

Cognitive Behavioral Intervention

Sleep Management Sleep Hygiene Caffeine Intake Alcohol Intake Medication Use

Energy Conservation Plan Prioritize Pacing Elimination

Cardiovascular Conditioning

© 2008 Santa Clara Valley Health & Hospital System

21© 2008 Santa Clara Valley Health & Hospital System

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Key points Stroke patients often present with complex needs. Fatigue can truly be disabling Fatigue can be challenging to quantify because of its multi-dimensionality

(physical, mental and psychological). Comprehensive intervention includes physical, informational, emotional,

cognitive, communication and practical aspects to support. Cardiovascular exercise is an important tool and highly recommended

intervention. Exercise offers one of the most effective interventions to enhance neurocognitive functioning. It also may decrease depression and improve sleep.

Modafinil is not effective in treating fatigue but has shown to be effective in treating excessive daytime sleepiness post TBI.

Practicing energy conservation principles and by prioritizing, planning, pacing for those important tasks of the day is very often helpful.

© 2008 Santa Clara Valley Health & Hospital System

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Reference Lerdal A, Bakken L, Kouwenhoven S, Pedersen G, Kirkevold M, Finset A, et al. Poststroke fatigue: a review. J

Pain Symptom Manage. 2009;38:928–949. Ouellet M, Morin C. Fatigue following traumatic brain injury: frequency, characteristics, and associated factors.

Rehabil Psychol. 2006; 51:140–9. Barritt AW, Smithard DG. Review Article: Targeting Fatigue in Stroke Patients. International Scholarly

Research Network ISRN Neurology, Volume 2011, Article ID Levine J, Greenwald B; Fatigue in Parkinson disease, stroke and TBI. Phys Med Rehabil clin N Am 2009; 20;

347-61 Rothwell NJ, Luheshi G, Toulmond S. Cytokines and their receptors in the central nervous system: physiology,

pharmacology, and pathology,” Pharmacology and Therapeutics, vol. 69, no. 2, pp. 85–95, 1996. Zedlitz AMEE, Rietveld TCM, Geurts AC, Fasotti L. Randomized, Controlled Trial Cognitive and Graded Activity

Training Can Alleviate Persistent Fatigue After Stroke: Stroke. 2012;43:1046-1051; originally published online February 2, 2012

Mathiowetz V, Matuska K, Murphey M. Efficacy of an energy conservation course for patients with multiple sclerosis. Arch Phys Med Rehabil. 2001;82:449.

Harbison JA, Walsh S , Kenny RA. Hypertension and daytime hypotension found on ambulatory blood pressure is associated with fatigue following stroke and TIA. Q J Med 2009; 102:109–115

Barker-Collo S, Feigin VL, Dudley M. Post-stroke fatigue—where is the evidence to guide practice? Journal of the New Zealand Medical Association, 26-October-2007, Vol 120 No 1264

© 2008 Santa Clara Valley Health & Hospital System

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Zedlitz and colleagues Stroke. 2012;43:1046-1051

© 2008 Santa Clara Valley Health & Hospital System

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