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Fatigue Post Stroke

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.

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Fatigue Post Stroke

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  1. Fatigue Post Stroke Moira Keating MSc, BSc(Hons), PGCertCBT, RGN.

  2. 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

  3. 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

  4. How common is it • Reports vary • Estimated prevalence rates between 16-70 % even in stroke patients who seem to recover well. (Glader2002, Carllson2003; Leegard 1983) • Can go on for years without improvement (Naess et al 2005, Christensen et al 2008, Schepers et al 2006, van der Werf2001) • Prevalence rates on the chronic phase that show no natural improvement are as high as 38-73% (Lerdal et al 2009)

  5. A Cochrane review found • Some association with depression (Naess2005; 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).

  6. 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 (Lerdalet al 2009, Naess et al 2005, Tang, et al 2009, Snaphaan, et al 2011)

  7. Put simply • The Cause of fatigue after stroke is still unclear • Diagnosis is typically based on exclusion of other conditions, • There are often frequent comorbidities • No known neuropathologicalbasis • No established single cause or pathogenesis • No recognised treatment

  8. 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

  9. Barbour & Mead (2012)

  10. Kelly The onset of Stroke

  11. Kelly The problems after the stroke

  12. Kelly What was the fatigue like

  13. Kelly Managing it

  14. Kelly Medication managment

  15. Kelly Getting back to work

  16. What do the National Guidelines say? • There is no evidence that medication improves outcomes in fatigue (McGeoughet 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.

  17. 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)

  18. Barbour & Mead (2012)

  19. Barbour & Mead (2012)

  20. Cognitive and Graded Activity Training Can AlleviatePersistent Fatigue After StrokeA 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.

  21. 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)

  22. 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 unclear • No specific medication to treat it • Cognitive therapy and Graded Activity Training program may help • Patient report benefits from • Activity and rest • Keeping occupied • Not overdoing it • A good sleep pattern • Modify medication regimes

  23. AglaiaM.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.CerebrovascDis. 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 PhysMed 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. SnaphaanL, 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.

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