POST STROKEPOST STROKEFATIGUE, DEPRESSION AND FATIGUE, DEPRESSION AND

SHOULDER PAINSHOULDER PAIN

Hillary Spiro Hawkins, M.D.Hillary Spiro Hawkins, M.D.Attending PhysiatristAttending PhysiatristSheltering Arms Rehabilitation HospitalSheltering Arms Rehabilitation Hospital

POST STROKE POST STROKE FATIGUEFATIGUE

(PSF)(PSF)

Definition of FatigueDefinition of Fatigue

•• Normal Fatigue Normal Fatigue --temporary loss of strength and energy resulting temporary loss of strength and energy resulting from hard physical or mental work from hard physical or mental work

•• Pathological fatiguePathological fatigue-- loss of strength and energy without hard loss of strength and energy without hard physical or mental workphysical or mental work

•• General state of lethargy General state of lethargy •• A condition marked by extreme tiredness and inability to A condition marked by extreme tiredness and inability to

function due lack of energy.function due lack of energy.•• Fatigue may be acute or chronic.Fatigue may be acute or chronic.•• Incapacitating mental or physical tirednessIncapacitating mental or physical tiredness•• Do You Feel Tired?Do You Feel Tired?

–– How Swedish researchers characterized fatigue in their 2002 StroHow Swedish researchers characterized fatigue in their 2002 Stroke studyke study

Post Stroke Fatigue ScalesPost Stroke Fatigue Scales

•• Stroke.Stroke. 2007 Jul;38(7):20902007 Jul;38(7):2090--5. 5. •• 4 valid and feasible scales found4 valid and feasible scales found

–– SFSF--36v2 (vitality component)36v2 (vitality component)–– Fatigue subscale of the Profile of Mood StatesFatigue subscale of the Profile of Mood States–– Fatigue Assessment ScaleFatigue Assessment Scale–– General subscale of the Multidimensional Fatigue General subscale of the Multidimensional Fatigue

Symptom InventorySymptom Inventory

Prevalence of Post Stroke FatiguePrevalence of Post Stroke Fatigue

•• IntInt J J RehabilRehabil Res.Res. 2006 Dec;29(4):3292006 Dec;29(4):329--3333•• Prevalence and predictors of pain and Prevalence and predictors of pain and

fatigue after stroke: a populationfatigue after stroke: a population--based based studystudy–– patients with firstpatients with first--ever stroke (n=377) were ever stroke (n=377) were

examined at baseline and after 1 yearexamined at baseline and after 1 year–– TwentyTwenty--eight patients (11%) had strokeeight patients (11%) had stroke--associated associated

pain and 135 pain and 135 (53%)(53%) had strokehad stroke--associated fatigueassociated fatigue–– Fatigue was more associated with physical disability Fatigue was more associated with physical disability

and with sleep disturbancesand with sleep disturbances

Prevalence of PSFPrevalence of PSF

•• Arch Phys Med Arch Phys Med RehabilRehabil 2006;87:1842006;87:184--8 8 •• Main Outcome Measure: Main Outcome Measure: The Fatigue Severity Scale The Fatigue Severity Scale •• Results: Results:

–– At admission, 6 months and 1 year At admission, 6 months and 1 year poststrokepoststroke,,–– fatigue was present in 51.5%, 64.1%, and 69.5% of the patients, fatigue was present in 51.5%, 64.1%, and 69.5% of the patients,

respectivelyrespectively–– Fatigue impact 1 year Fatigue impact 1 year poststrokepoststroke was greater among patients with was greater among patients with

more depressive symptoms, higher age, women, and patients with amore depressive symptoms, higher age, women, and patients with alocus of control more directed to powerful others.locus of control more directed to powerful others.

•• Conclusions: Conclusions: –– Because fatigue impact is an increasing problem during the firstBecause fatigue impact is an increasing problem during the first

year year poststrokepoststroke, it deserves more attention in clinical practice and , it deserves more attention in clinical practice and scientific researchscientific research

–– Locus of control and depression are related to Locus of control and depression are related to poststrokepoststroke fatigue fatigue and might be important foci for future interventions.and might be important foci for future interventions.

Poststroke FatiguePoststroke FatigueA 2A 2--Year FollowYear Follow--Up Study of Stroke Patients in Up Study of Stroke Patients in

SwedenSweden

•• StrokeStroke. 2002;33:1327. 2002;33:1327--13331333

•• Of the 3667 patients who did not always feel Of the 3667 patients who did not always feel depressed at the 2depressed at the 2--year followyear follow--upup–– 366 (366 (10.0%)10.0%) always felt tiredalways felt tired–– 1070 (1070 (29.2%)29.2%) often felt tired often felt tired

Evidence based treatments?Evidence based treatments?SSRISSRI’’ss ((FluoxetineFluoxetine))

•• CerebrovascCerebrovasc Dis.Dis. 2007;23(22007;23(2--3):1033):103--8. 8. •• METHODS: METHODS:

–– 83 consecutive outpatients with 83 consecutive outpatients with PoSFPoSF at an average of 14 months after the onset of at an average of 14 months after the onset of strokestroke

–– The visual analogue scale (VAS) and Fatigue Severity Score (FSS)The visual analogue scale (VAS) and Fatigue Severity Score (FSS) were used to were used to assess assess PoSFPoSF

–– The subjects were given either 20 mg/day of The subjects were given either 20 mg/day of fluoxetinefluoxetine (n = 40) or placebo (n = 43) (n = 40) or placebo (n = 43) for 3 monthsfor 3 months

–– FollowFollow--up evaluations were done 3 and 6 months after the beginning of tup evaluations were done 3 and 6 months after the beginning of the he treatment. treatment.

•• RESULTS: RESULTS: –– There were no differences in the number of patients with There were no differences in the number of patients with PoSFPoSF between the between the

fluoxetinefluoxetine group and the placebo group at 3 and 6 months after the treatmegroup and the placebo group at 3 and 6 months after the treatmentnt•• However, However, fluoxetinefluoxetine significantly improved postsignificantly improved post--stroke emotional incontinence (p < 0.05) stroke emotional incontinence (p < 0.05)

and postand post--stroke depression (p = 0.05) in the patients with stroke depression (p = 0.05) in the patients with PoSFPoSF

•• CONCLUSIONS: CONCLUSIONS: FluoxetineFluoxetine does not improve does not improve PoSFPoSF, although some , although some concomitant emotional disturbances improved significantly. concomitant emotional disturbances improved significantly.

Evidence based TreatmentsEvidence based TreatmentsCVA & CVA & NeurostimulantsNeurostimulants

•• The PostThe Post--Stroke Rehabilitation Outcomes Project (PSROP) Stroke Rehabilitation Outcomes Project (PSROP) databasedatabase

•• NeurostimulantsNeurostimulants usedused–– methylphenidate, methylphenidate, modafinilmodafinil, , levodopalevodopa, , amantadineamantadine, or , or

bromocriptinebromocriptine•• Patients who received Patients who received neurostimulantneurostimulant medications did not have medications did not have

any more significant changes in length of stay, motor recovery, any more significant changes in length of stay, motor recovery, cognitive recovery, or discharge destination than patients who cognitive recovery, or discharge destination than patients who did not receive did not receive neurostimulantneurostimulant medicationsmedications–– No difference in outcomesNo difference in outcomes

•• Did not look at Did not look at neurostimulantneurostimulant effects on fatigueeffects on fatigue

CVA and Neuro stimulantsCVA and Neuro stimulants

•• VAH GuidelinesVAH Guidelines-- consider in selected patients consider in selected patients to to improve participationimprove participation or enhance motor or enhance motor recoveryrecovery

•• DextroamphetamineDextroamphetamine-- 10mg per day10mg per day

Methylphenidate in early Methylphenidate in early poststrokepoststrokerecoveryrecovery

•• Arch Phys Med Arch Phys Med RehabilRehabil.. 1998 Sep;79(9):10471998 Sep;79(9):1047--5050•• doubledouble--blind, placeboblind, placebo--controlled studycontrolled study•• 21 stroke patients consecutively admitted to a community21 stroke patients consecutively admitted to a community--based rehabilitation unitbased rehabilitation unit•• 3 wk of methylphenidate (or placebo) in conjunction with physica3 wk of methylphenidate (or placebo) in conjunction with physical therapyl therapy

–– Methylphenidate was started at 5mg and increased gradually to 30Methylphenidate was started at 5mg and increased gradually to 30mg (15mg at 8:00AM and mg (15mg at 8:00AM and 15mg at 12:00 noon), and discontinued before discharge15mg at 12:00 noon), and discontinued before discharge

•• MAIN OUTCOME MEASURESMAIN OUTCOME MEASURES–– Mood measures included the Hamilton Depression Rating Scale (HAMMood measures included the Hamilton Depression Rating Scale (HAM--D) and D) and ZungZung SelfSelf--

Rating Depression Scale (ZDS)Rating Depression Scale (ZDS)–– Cognitive status was evaluated using the MiniCognitive status was evaluated using the Mini--Mental State Exam (MMSE)Mental State Exam (MMSE)–– Motor functioning was assessed using the Motor functioning was assessed using the FuglFugl--Meyer Scale (FMS) and a modified version of Meyer Scale (FMS) and a modified version of

the Functional Independence Measure (Mthe Functional Independence Measure (M--FIM)FIM)•• RESULTS RESULTS --Patients receiving methylphenidate treatment scored Patients receiving methylphenidate treatment scored

–– lower on the HAMlower on the HAM--D (F(1,18)=5.714, p=.028)D (F(1,18)=5.714, p=.028)–– lower on the ZDS (F(1,18)=4.206, p=.055)lower on the ZDS (F(1,18)=4.206, p=.055)–– higher on the Mhigher on the M--FIM (F(1,18)=5.374, p=.032)FIM (F(1,18)=5.374, p=.032)–– higher on the FMS (F(1,9)=4.060, p=.075) higher on the FMS (F(1,9)=4.060, p=.075)

•• CONCLUSION: Methylphenidate appears to be a safe and effective iCONCLUSION: Methylphenidate appears to be a safe and effective intervention in ntervention in early early poststrokepoststroke rehabilitation that may expedite recovery. rehabilitation that may expedite recovery.

Factors Contributing to Poststroke Factors Contributing to Poststroke FatigueFatigue

•• Physiologic factorsPhysiologic factors–– Altered nutritional statusAltered nutritional status–– MalnutritionMalnutrition–– HypovolemiaHypovolemia/dehydration/dehydration–– Biochemical abnormalitiesBiochemical abnormalities–– Electrolyte imbalanceElectrolyte imbalance–– HypoglycemiaHypoglycemia

•• Systemic states or disordersSystemic states or disorders–– HypothyroidismHypothyroidism–– Infection/feverInfection/fever–– AnemiaAnemia–– Renal failureRenal failure–– DiabetesDiabetes–– Chronic painChronic pain–– Congestive heart failureCongestive heart failure–– Inflammatory disordersInflammatory disorders

•• Medication side effectsMedication side effects–– Hypnotics/tranquilizersHypnotics/tranquilizers

•• Immobility/inactivityImmobility/inactivity–– DisuseDisuse–– Physical Physical deconditioningdeconditioning–– Excessive restExcessive rest–– Physical impairmentPhysical impairment

•• Medication side effectsMedication side effects–– Hypnotics/tranquilizersHypnotics/tranquilizers–– AnticonvulsantsAnticonvulsants–– CorticosteroidsCorticosteroids–– AntihypertensivesAntihypertensives–– AntihistaminesAntihistamines–– OpiatesOpiates–– BB--blockersblockers

•• Sleep disordersSleep disorders–– Chronic sleep disturbance because ofChronic sleep disturbance because of–– HospitalizationHospitalization–– Pain/discomfortPain/discomfort–– IllnessIllness--related stressrelated stress–– Sleep apnea or other sleepSleep apnea or other sleep--disordered breathingdisordered breathing

•• PsychologicPsychologic factorsfactors–– Levels of perceived effortLevels of perceived effort–– Perceived increase in:Perceived increase in:

•• Mental effort or strainMental effort or strain•• Physical effort or strainPhysical effort or strain

–– IllnessIllness--related stressrelated stress–– Comorbid mood disordersComorbid mood disorders

•• Anxiety disorderAnxiety disorder•• Depression or other mood disorderDepression or other mood disorder•• StressStress--related disorderrelated disorder

CVA and NeuroCVA and Neuro--StimulantsStimulants

•• AtomoxetineAtomoxetine ((StratteraStrattera))--Selective NESelective NE•• ConcertaConcerta•• MethylphenidateMethylphenidate•• DexedrineDexedrine•• ProvigilProvigil•• MetadateMetadate, , FocalinFocalin, , AdderallAdderall

POST STROKE POST STROKE DEPRESSIONDEPRESSION

(PSD)(PSD)

Epidemiology of post stroke Epidemiology of post stroke depression (PSD)depression (PSD)

•• Depression after stroke is Depression after stroke is commoncommon•• 20% of women and 8.2% of men (Adherence 20% of women and 8.2% of men (Adherence

Evaluation After Ischemic Stroke Longitudinal Evaluation After Ischemic Stroke Longitudinal Registry Registry –– AVAIL)AVAIL)

•• 625,00 new ischemic strokes/year625,00 new ischemic strokes/year…….185,000 per .185,000 per year develop depression year develop depression

Risk Factors for PSDRisk Factors for PSD

•• Location of ischemic lesionLocation of ischemic lesion•• Severity of deficitSeverity of deficit•• PrePre--morbid depressionmorbid depression

Screening and diagnosisScreening and diagnosis

•• PsychometricsPsychometrics•• Vegetative symptomsVegetative symptoms•• Awareness of staff and family and treating Awareness of staff and family and treating

physicianphysician

Impact of PSDImpact of PSD

Increased mortalityIncreased mortalityPoor med compliancePoor med compliancePoor rehab progressPoor rehab progressReduced functional outcomesReduced functional outcomesIncreased caregiver burdenIncreased caregiver burden

Prevention of PSDPrevention of PSD

•• Prophylactic Prophylactic mirtazapinemirtazapine may help to prevent may help to prevent postpost--stroke depressionstroke depression…… WeenWeen EvidEvid Based Based MentMentHealth.Health.2005; 8: 74 2005; 8: 74

Treatment of PSDTreatment of PSD

•• Watchful waitingWatchful waiting……indicated only if mild indicated only if mild impaimentimpaiment, pt preference or no prior history, pt preference or no prior history

•• Antidepressant medicationAntidepressant medication•• Referral to mental health servicesReferral to mental health services

Available AntidepressantsAvailable Antidepressants

•• Selective Selective seratoninseratonin reuptake inhibitors (reuptake inhibitors (SSRIsSSRIs) ) ––fluoxetinefluoxetine (Prozac), (Prozac), paroxetineparoxetine ((PaxilPaxil), ), sertralinesertraline(Zoloft), (Zoloft), citalopramcitalopram ((CelexaCelexa), ), escitalopramescitalopram ((LexaproLexapro))

•• Serotonin Serotonin norepinephrinenorepinephrine reuptake inhibitorsreuptake inhibitors((SNRIsSNRIs) ) -- venlafaxinevenlafaxine ((EffexorEffexor), ), duloxetineduloxetine ((CymbaltaCymbalta))

•• OthersOthers: buproprion (: buproprion (WellbutrinWellbutrin), ), mirtazapinemirtazapine((RemeronRemeron), ), trazadonetrazadone ((DesyrelDesyrel))

•• TricyclicsTricyclics: : nortryptilinenortryptiline ((PamelorPamelor), ), amitryptilineamitryptiline((ElavilElavil))

•• MAO inhibitorsMAO inhibitors

Rationale in choosing antidepressantRationale in choosing antidepressant

•• Cost Cost •• Half lifeHalf life•• Side effect profileSide effect profile•• Drug interactions (P450, protein binding)Drug interactions (P450, protein binding)•• Formulary restrictionsFormulary restrictions•• PatientPatient’’s biass bias

““The effectiveness of antidepressant medications is generally The effectiveness of antidepressant medications is generally comparable between classes and within the classes of comparable between classes and within the classes of

medications. Therefore, the initial selection of an medications. Therefore, the initial selection of an antidepressant medication will largely be based on the antidepressant medication will largely be based on the

anticipated side effects, the safety or tolerability of these sianticipated side effects, the safety or tolerability of these side de effects for individual patients, patient preference, quantity aneffects for individual patients, patient preference, quantity and d quality of clinical trial data regarding the medication, and itsquality of clinical trial data regarding the medication, and its

cost.cost.””

--APA Practice Guideline for the APA Practice Guideline for the Treatment of Patients with Major Treatment of Patients with Major

Depressive Disorder (2000)Depressive Disorder (2000)

Matching by Side EffectsMatching by Side Effects

------------------------------TCA SNRITCA SNRIChronic Chronic Pain/Central PainPain/Central Pain

TCA TCA MirtazipineMirtazipinetrazadonetrazadone

BupropionBupropion>SSRI >SSRI Ritalin (CVA) Ritalin (CVA)

ObesityObesity

SSRI TCASSRI TCABupropionBupropion or or MirtazipineMirtazipine

Sexual Sexual dysfxndysfxn

Sedating ADSedating ADStimulating ADStimulating ADSleepy, LethargicSleepy, Lethargic

Stimulating AD Stimulating AD ((wellbutrinwellbutrin))

Sedating AD Sedating AD ((remeronremeron))

Insomnia, Insomnia, agitationagitation

Avoid:Avoid:Preferred:Preferred:Depression Depression andand

Matching by Side Effects (2)Matching by Side Effects (2)

TCA TCA SSRISSRIIBS IBS (constipation)(constipation)

SSRISSRITCATCAIrritable Bowel Irritable Bowel Syndrome Syndrome (diarrhea, spasm)(diarrhea, spasm)

BupropionBupropion--------------------------------SeizuresSeizures

TCA (MS TCA (MS changes)changes)

----------------------------CirrhosisCirrhosis

TCATCASSRI (SSRI (zoloftzoloft or or CelexaCelexa))

CADCAD

Avoid:Avoid:Preferred:Preferred:Depression Depression andand

What is an adequate trial of What is an adequate trial of antidepressantantidepressant

•• At least 4At least 4--6 weeks6 weeks•• Adequate dosageAdequate dosage•• Compliant patient and familyCompliant patient and family

Evaluating Poor ResponseEvaluating Poor Response

•• Adequate dose and duration?Adequate dose and duration?•• Is pt compliant? Cost?Is pt compliant? Cost?•• Medical Medical comorbiditycomorbidity: OSA, anemia, : OSA, anemia,

hypothyroid, hypothyroid, vitvit D defD def•• Social Social comorbiditiescomorbidities: poverty, abuse: poverty, abuse

Strategy for Poor RespondersStrategy for Poor Responders

Optimize current drug (dose increase)

Switch Add Psychotherapy

Augmentation(non AD)

..Lithium, T3, Ritalin

Combination(drug 1 + drug 2)

POST STROKE SHOULDER PAINPOST STROKE SHOULDER PAIN

Physical Therapists Better Than Physical Therapists Better Than Robots in Helping Stroke Survivors Robots in Helping Stroke Survivors

Regain MobilityRegain Mobility

Stroke 2008;39.Stroke 2008;39.

Epidemiology of Post Stroke Epidemiology of Post Stroke Shoulder PainShoulder Pain

•• 72% of patients experience > 1 episode of shoulder 72% of patients experience > 1 episode of shoulder pain during the 12 months following strokepain during the 12 months following stroke

•• Risks: severe upper limb motor deficit Risks: severe upper limb motor deficit ClinClin RehabilRehabil..2003 May;17(3):3042003 May;17(3):304--11 11

•• Statistically significant association with Statistically significant association with ipsilateralipsilateralsensory impairment (p < 0.005), abnormal sensory impairment (p < 0.005), abnormal rheumatologicalrheumatological examination (p < 0.001) and examination (p < 0.001) and depression score (p < 0.005). depression score (p < 0.005). EurEur J Pain.J Pain. 2000;4(3):3132000;4(3):313--5. 5.

Etiology of Post Stroke Shoulder Etiology of Post Stroke Shoulder PainPain

•• Adhesive Adhesive capsulitiscapsulitis is the main cause of shoulder pain is the main cause of shoulder pain (50% of patients). Patients with adhesive (50% of patients). Patients with adhesive capsulitiscapsulitisshowed significant restriction of passive shoulder showed significant restriction of passive shoulder external rotation and abduction and have a higher external rotation and abduction and have a higher incidence of shoulderincidence of shoulder--hand syndrome .hand syndrome .44% 44% …… glenogleno--humeral humeral subluxationsubluxation, ,

•• 22% 22% …….rotator cuff tears and .rotator cuff tears and tendonopathytendonopathy•• 16%..... CRPS/RSD/shoulder16%..... CRPS/RSD/shoulder--hand syndrome.hand syndrome.•• Other: Other: spasticityspasticity, central/neuropathic pain (thalamic , central/neuropathic pain (thalamic

CVAsCVAs) ) •• Arch Phys Med Arch Phys Med RehabilRehabil.. 2003 Dec;84(12):17862003 Dec;84(12):1786--91 91

Prevention of Shoulder Pain in the Prevention of Shoulder Pain in the Post Stroke PeriodPost Stroke Period

•• Proper physical therapy and Proper physical therapy and cautious handlingcautious handling of of stroke patients to preserve shoulder mobility and stroke patients to preserve shoulder mobility and function during early rehabilitation are function during early rehabilitation are important for a good outcome. important for a good outcome.

•• Most patients who develop shoulder problems Most patients who develop shoulder problems had onset of had onset of hemiplegichemiplegic shoulder pain less than shoulder pain less than 2 months after stroke2 months after stroke……....

Predictability of simple clinical tests Predictability of simple clinical tests to identify shoulder pain after stroke. to identify shoulder pain after stroke.

•• Simple tests can be performed during a bedside Simple tests can be performed during a bedside evaluation to help predict evaluation to help predict hemiplegichemiplegic shoulder shoulder pain after an acute stroke. pain after an acute stroke.

•• Positive Positive NeerNeer test and a difference of more than test and a difference of more than 10 degrees of passive range of external rotation 10 degrees of passive range of external rotation between shoulders had a 98% probability of between shoulders had a 98% probability of predicting the presence of predicting the presence of hemiplegichemiplegic shoulder shoulder pain pain

Interventions (prevention)Interventions (prevention)

•• E E stimstim to increase shoulder external rotation and to increase shoulder external rotation and increase blood flow and decrease increase blood flow and decrease subluxationsubluxation

•• Shoulder slings, taping, lap tray or arm trough Shoulder slings, taping, lap tray or arm trough on wheelchair to decrease on wheelchair to decrease subluxationsubluxation (begin in (begin in acute care)acute care)

•• Staff and family education to decrease trauma to Staff and family education to decrease trauma to joint and soft tissues during transfers and joint and soft tissues during transfers and ADLsADLs

•• NO PULLEYS EVER!!!!NO PULLEYS EVER!!!!

Interventions (treatment)Interventions (treatment)

•• Corticosteroid injections Corticosteroid injections Am J Phys Med Am J Phys Med RehabilRehabil..1997 Jan1997 Jan--Feb;76(1):43Feb;76(1):43--8 8

•• BotoxBotox injections into injections into subscapularissubscapularis (decreased pain and (decreased pain and increased ROM) increased ROM) Stroke.Stroke. 2008 Jan;39(1):1262008 Jan;39(1):126--31. 31. EpubEpub2007 Nov 29 2007 Nov 29

•• Taping, slings (picture)Taping, slings (picture)•• AROM, PROM, AAROMAROM, PROM, AAROM•• Modalities: e. Modalities: e. stimstim, ultrasound, ice, heat, soft tissue , ultrasound, ice, heat, soft tissue

massagemassage•• Medication: Medication: antiinflammatoriesantiinflammatories, , ACDsACDs

BotulinumBotulinum Toxin A Injection Toxin A Injection Relieves Shoulder Pain in Spastic Relieves Shoulder Pain in Spastic

HemiplegicHemiplegic PatientsPatients

BotoxBotox was injected into affected side was injected into affected side subscapularissubscapularis in 10 pts and sham in 10 pts and sham injection into 10 pts.injection into 10 pts.

•• J J NeurolNeurol NeurosurgNeurosurg Psychiatry 2007;78:789,845Psychiatry 2007;78:789,845--848.848.

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