Fatigue Post StrokeMoira Keating MSc, BSc(Hons), PGCertCBT,

RGN.

AimsDefinition and Outline of current knowledge

of causes Impact of fatigue post strokeMeaning of Fatigue to patients What can help Professionals role in supporting patients with

post stroke fatigue Overview

What is itA 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 itReports 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

unclearDiagnosis is typically based on exclusion of

other conditions, There are often frequent comorbiditiesNo known neuropathological basisNo established single cause or pathogenesis No recognised treatment

How bad is itOutcome 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

DependenceMRS

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 RecommendationsA 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 sayLots of patients said it started at the time of

their stroke. Different factors were reported to improve

fatigue,exercise, good sleeprehabilitation 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 AlleviatePersistent 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 anxietyCOGRAT 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 on the function and quality of life into the long-term.

Causes are still unclearNo specific medication to treat itCognitive therapy and Graded Activity Training program

may helpPatient report benefits from

Activity and rest Keeping occupiedNot 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 GEInterventions 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.