Transcript Fatigue Post Stroke

Moira Keating MSc, BSc(Hons), PGCertCBT, RGN.
Aims
 Definition and Outline of current knowledge of causes
 Impact of fatigue post stroke
 Meaning of Fatigue to patients
 What can help
 Professionals role in supporting patients with post
stroke fatigue
 Overview
What is it
A feeling of lack of energy and weariness
and an aversion of effort.
Mead et al (2007)
It may not be caused by activity
It may not improve with rest
How common is it
 Reports vary
 Estimated prevalence rates between 16-70 % even in stroke
patients who seem to recover well. (Glader 2002, Carllson
2003; Leegard 1983)
 Can go on for years without improvement (Naess et al 2005,
Christensen et al 2008, Schepers et al 2006, van der Werf
2001)
 Prevalence rates on the chronic phase that show no natural
improvement are as high as 38-73% (Lerdal et al 2009)
A Cochrane review found
 Some association with depression (Naess 2005; Schepers 2006; van der Werf
2001),
 One small study found a relationship with brain stem lesions (Staub 2001),
 Others did not (Ingles 1999; Morley 2005; Naess 2005).
 Possible underlying biological mechanism;
 one small study of 38 participants found a relationship with plasma
glutamate/glutamine ratio (Syed 2007).
 In cancer patients, fatigue may be related to cortisol dysregulation (Bower
2005).
 The relationship between cortisol dysregulation and fatigue after stroke has not
been studied.
 Another interesting hypothesis is that fatigue may be associated with physical
deconditioning, which is common after stroke (Saunders 2004),
 but the single study which has investigated the relationship between fatigue
and fitness found no association (Michael 2006).
Put simply
 Number of factors involved in having a greater risk of stroke
 Type of stroke
 Size of stroke
 Location of stroke
 Number of strokes
 Other factors associated with fatigue
 Depression
 Anxiety
 Reduced functional health
 Disrupted Sleep
 Pain
 Reduced physical fitness
(Lerdal et al 2009, Naess et al 2005, Tang, et al 2009, Snaphaan, et
al 2011)
Put simply
 The Cause of fatigue after stroke is still unclear
 Diagnosis is typically based on exclusion of other
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conditions,
There are often frequent comorbidities
No known neuropathological basis
No established single cause or pathogenesis
No recognised treatment
How bad is it
 Outcome tools
 Fatigue Severity Scale (Krupp 1989);
 Visual analogue scale for fatigue severity;
 Fatigue self-reported questionnaire;
 Energy/fatigue scale from the Medical Outcomes Study.
 Quality of life scales
 Short form 36
 Disability
 Barthel
 Dependence
 MRS
Barbour & Mead (2012)
Kelly The onset of Stroke
Kelly The problems after the stroke
Kelly What was the fatigue like
Kelly Managing it
Kelly Medication managment
Kelly Getting back to work
What do the National Guidelines say?
 There is no evidence that
medication improves outcomes in
fatigue (McGeough et al 2009).
 6.37.1 Recommendations
 A Fatigue in medically stable
patients should be assessed
particularly where engagement
with rehabilitation, or quality
of life is affected.
 B Patients with fatigue and
their families should be given
information and reassurance
that the symptom is likely to
improve with time.
What do patients say
 Lots of patients said it started at the time of their
stroke.
 Different factors were reported to improve fatigue,
 exercise,
 good sleep
 rehabilitation and rest.
 Fatigue influences patients’ sense of “control” after their
stroke
 Small mixed study Barbour & Mead (2012)
Barbour & Mead (2012)
Barbour & Mead (2012)
Cognitive and Graded Activity Training Can Alleviate
Persistent Fatigue After Stroke
A Randomized, Controlled Trial Aglaia et al (2013)
 This randomized, controlled, assessor-blind clinical
trial was conducted in 8 rehabilitation centers.
 83 stroke patients randomly assigned (4 months after
stroke) to 12 weeks of
 Cognitive Therapy (CO)
 or
 CO with Graded Activity Training (GRAT) after
qualification.
 73 patients completed treatment and 68 were available
at follow-up.
Results
 Both treatment showed benefits on fatigue but not on
pain or anxiety
 COGRAT group better than Co group on physical
endurance
 Conclusions
A 12-week cognitive therapy program can alleviate
persistent fatigue after stroke. The best results are
obtained when cognitive therapy is augmented with
graded activity training. Aglaia et al (2013)
Summary
 Fatigue after stroke is common and can cause a high impact
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on the function and quality of life into the long-term.
Causes are still unclear
No specific medication to treat it
Cognitive therapy and Graded Activity Training program
may help
Patient report benefits from
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Activity and rest
Keeping occupied
Not overdoing it
A good sleep pattern
Modify medication regimes
Aglaia M.E.E. Zedlitz, Toni C.M. Rietveld, Alexander C. Geurts, and Luciano Fasotti (2013)Cognitive and Graded Activity Training Can
Alleviate Persistent Fatigue After Stroke: A Randomized, Controlled Trial Stroke. 2012;43:1046-1051, published online before print
February 2 2012, doi:10.1161/STROKEAHA.111.632117
McGeough E, Pollock A, Smith LN, Dennis M, Sharpe M, Lewis S, Mead GE
Interventions for post-stroke fatigue (Review) The Cochrane Library 2009, Issue 3
G.Mead, J. Lynch, C. Greig, A. Young, S. Lewis, and M. Sharpe, “Evaluation of fatigue scales in stroke patients,” Stroke, vol. 38, no. 7,
pp. 2090–2095, 2007
Lerdal, A. Bakken, L Kouwenhoven, S. Pedersen, G. Kirkvold, M. Finset, a et al. Poststroke fatigue: a review. Journal of Pain Symptom
Management. 2009; 38:928-949
Krupp (1989)Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale . Archives of Neurology 1989;46: 1121–3.
Barbour1 V, Mead, G. Fatigue after Stroke: The Patient’s Perspective Stroke Research and Treatment . Volume 2012, Article ID 863031, 6
pages doi:10.1155/2012/863031
Naess H, Nyland HI, Thomassen L, Aarseth J, Myhr KM. (2005)Fatigue at long-term follow-up in young adults with cerebral infarction.
Cerebrovasc Dis. 2005;20:245–250.
Christensen D, Johnsen SP, Watt T, Harder I, Kirkevold M, Andersen G. (2008)Dimensions of post-stroke fatigue: a two-year follow-up
study.Cerebrovasc Dis. 2008;26:134 –141.
Schepers V, Visser-Meily A, Ketelaar M, Lindeman E. (2006) Post-stroke fatigue: course and its relation to personal and stroke-related
factors. Arch Phys Med Rehabil. 2006;87:184 –188.
van der Werf SP, van den Broek HL, Anten HW, Bleijenberg G. (2001) Experience of severe fatigue long after stroke and its relation to
depressive symptoms and disease characteristics. Eur Neurol. 2001;45:28 –33.
Tang WK, Chen YK, Mok V, Chu WCW, Ungvari GS, Ahuja AT, et al. (2009)Acute basal ganglia infarcts in poststroke fatigue: an MRI
study. J Neurol. 2009;257:178 –182.
Snaphaan L, van der Werf S, de Leeuw FE. (2011)Time course and risk factors of post-stroke fatigue: a prospective cohort study. Eur J
Neurol. 2011; 18:611– 617.