POST STROKE

FATIGUE, DEPRESSION AND

SHOULDER PAIN

Hillary Spiro Hawkins, M.D.

Attending Physiatrist
Sheltering Arms Rehabilitation Hospital
POST STROKE
FATIGUE
(PSF)
 Definition of Fatigue
• Normal Fatigue -temporary loss of strength and energy resulting
from hard physical or mental work
• Pathological fatigue- loss of strength and energy without hard
physical or mental work
• General state of lethargy
• A condition marked by extreme tiredness and inability to
function due lack of energy.
• Fatigue may be acute or chronic.
• Incapacitating mental or physical tiredness
• Do You Feel Tired?
– How Swedish researchers characterized fatigue in their 2002 Stroke study
 Post Stroke Fatigue Scales
• Stroke. 2007 Jul;38(7):2090-5.
• 4 valid and feasible scales found
– SF-36v2 (vitality component)
– Fatigue subscale of the Profile of Mood States
– Fatigue Assessment Scale
– General subscale of the Multidimensional Fatigue
Symptom Inventory
Prevalence of Post Stroke Fatigue
• Int J Rehabil Res. 2006 Dec;29(4):329-33
• Prevalence and predictors of pain and
fatigue after stroke: a population-based
study
– patients with first-ever stroke (n=377) were
examined at baseline and after 1 year
– Twenty-eight patients (11%) had stroke-associated
pain and 135 (53%) had stroke-associated fatigue
– Fatigue was more associated with physical disability
and with sleep disturbances
 Prevalence of PSF
• Arch Phys Med Rehabil 2006;87:184-8
• Main Outcome Measure: The Fatigue Severity Scale
• Results:
– At admission, 6 months and 1 year poststroke,
– fatigue was present in 51.5%, 64.1%, and 69.5% of the patients,
respectively
– Fatigue impact 1 year poststroke was greater among patients with
more depressive symptoms, higher age, women, and patients with a
locus of control more directed to powerful others.
• Conclusions:
– Because fatigue impact is an increasing problem during the first
year poststroke, it deserves more attention in clinical practice and
scientific research
– Locus of control and depression are related to poststroke fatigue
and might be important foci for future interventions.
 Poststroke Fatigue
A 2-Year Follow-Up Study of Stroke Patients in
Sweden
• Stroke. 2002;33:1327-1333
• Of the 3667 patients who did not always feel
depressed at the 2-year follow-up
– 366 (10.0%) always felt tired
– 1070 (29.2%) often felt tired
 Evidence based treatments?
SSRI’s (Fluoxetine)
• Cerebrovasc Dis. 2007;23(2-3):103-8.
• METHODS:
– 83 consecutive outpatients with PoSF at an average of 14 months after the onset of
stroke
– The visual analogue scale (VAS) and Fatigue Severity Score (FSS) were used to
assess PoSF
– The subjects were given either 20 mg/day of fluoxetine (n = 40) or placebo (n = 43)
for 3 months
– Follow-up evaluations were done 3 and 6 months after the beginning of the
treatment.
• RESULTS:
– There were no differences in the number of patients with PoSF between the
fluoxetine group and the placebo group at 3 and 6 months after the treatment
• However, fluoxetine significantly improved post-stroke emotional incontinence (p < 0.05)
and post-stroke depression (p = 0.05) in the patients with PoSF
• CONCLUSIONS: Fluoxetine does not improve PoSF, although some
concomitant emotional disturbances improved significantly.
 Evidence based Treatments
CVA & Neurostimulants
• The Post-Stroke Rehabilitation Outcomes Project (PSROP)
database
• Neurostimulants used
– methylphenidate, modafinil, levodopa, amantadine, or
bromocriptine
• Patients who received neurostimulant medications did not have
any more significant changes in length of stay, motor recovery,
cognitive recovery, or discharge destination than patients who
did not receive neurostimulant medications
– No difference in outcomes
• Did not look at neurostimulant effects on fatigue
 CVA and Neuro stimulants
• VAH Guidelines- consider in selected patients
to improve participation or enhance motor
recovery
• Dextroamphetamine- 10mg per day
 Methylphenidate in early poststroke
recovery
• Arch Phys Med Rehabil. 1998 Sep;79(9):1047-50
• double-blind, placebo-controlled study
• 21 stroke patients consecutively admitted to a community-based rehabilitation unit
• 3 wk of methylphenidate (or placebo) in conjunction with physical therapy
– Methylphenidate was started at 5mg and increased gradually to 30mg (15mg at 8:00AM and
15mg at 12:00 noon), and discontinued before discharge
• MAIN OUTCOME MEASURES
– Mood measures included the Hamilton Depression Rating Scale (HAM-D) and Zung Self-
Rating Depression Scale (ZDS)
– Cognitive status was evaluated using the Mini-Mental State Exam (MMSE)
– Motor functioning was assessed using the Fugl-Meyer Scale (FMS) and a modified version of
the Functional Independence Measure (M-FIM)
• RESULTS -Patients receiving methylphenidate treatment scored
– lower on the HAM-D (F(1,18)=5.714, p=.028)
– lower on the ZDS (F(1,18)=4.206, p=.055)
– higher on the M-FIM (F(1,18)=5.374, p=.032)
– higher on the FMS (F(1,9)=4.060, p=.075)
• CONCLUSION: Methylphenidate appears to be a safe and effective intervention in
early poststroke rehabilitation that may expedite recovery.
 Factors Contributing to Poststroke
Fatigue
• Physiologic factors
– Altered nutritional status
– Malnutrition
– Hypovolemia/dehydration
Hypovolemia/dehydration
– Biochemical abnormalities
– Electrolyte imbalance
– Hypoglycemia
• Systemic states or disorders
– Hypothyroidism
– Infection/fever
– Anemia
– Renal failure
– Diabetes
– Chronic pain
– Congestive heart failure
– Inflammatory disorders
• Medication side effects
– Hypnotics/tranquilizers
• Immobility/inactivity
– Disuse
– Physical deconditioning
– Excessive rest
– Physical impairment
• Medication side effects
– Hypnotics/tranquilizers
– Anticonvulsants
– Corticosteroids
– Antihypertensives
– Antihistamines
– Opiates
– B-blockers
• Sleep disorders
– Chronic sleep disturbance because of
– Hospitalization
– Pain/discomfort
– Illness-
Illness-related stress
– Sleep apnea or other sleep-
sleep-disordered breathing
• Psychologic factors
– Levels of perceived effort
– Perceived increase in:
• Mental effort or strain
• Physical effort or strain
– Illness-
Illness-related stress
– Comorbid mood disorders
• Anxiety disorder
• Depression or other mood disorder
• Stress-
Stress-related disorder
 CVA and Neuro-Stimulants
• Atomoxetine (Strattera)-Selective NE
• Concerta
• Methylphenidate
• Dexedrine
• Provigil
• Metadate, Focalin, Adderall
POST STROKE
DEPRESSION
(PSD)
 Epidemiology of post stroke
depression (PSD)
• Depression after stroke is common
• 20% of women and 8.2% of men (Adherence
Evaluation After Ischemic Stroke Longitudinal
Registry – AVAIL)
• 625,00 new ischemic strokes/year….185,000 per
year develop depression
 Risk Factors for PSD
• Location of ischemic lesion
• Severity of deficit
• Pre-morbid depression
 Screening and diagnosis
• Psychometrics
• Vegetative symptoms
• Awareness of staff and family and treating
physician
 Impact of PSD

Increased mortality
Poor med compliance
Poor rehab progress
Reduced functional outcomes
Increased caregiver burden
 Prevention of PSD
• Prophylactic mirtazapine may help to prevent
post-stroke depression… Ween Evid Based Ment
Health.2005; 8: 74
 Treatment of PSD
• Watchful waiting…indicated only if mild
impaiment, pt preference or no prior history
• Antidepressant medication
• Referral to mental health services
 Available Antidepressants
• Selective seratonin reuptake inhibitors (SSRIs) –
fluoxetine (Prozac), paroxetine (Paxil), sertraline
(Zoloft), citalopram (Celexa), escitalopram (Lexapro)
• Serotonin norepinephrine reuptake inhibitors
(SNRIs) - venlafaxine (Effexor), duloxetine (Cymbalta)
• Others: buproprion (Wellbutrin), mirtazapine
(Remeron), trazadone (Desyrel)
• Tricyclics: nortryptiline (Pamelor), amitryptiline
(Elavil)
• MAO inhibitors
Rationale in choosing antidepressant
• Cost
• Half life
• Side effect profile
• Drug interactions (P450, protein binding)
• Formulary restrictions
• Patient’s bias
 “The effectiveness of antidepressant medications is generally
comparable between classes and within the classes of
medications. Therefore, the initial selection of an
antidepressant medication will largely be based on the
anticipated side effects, the safety or tolerability of these side
effects for individual patients, patient preference, quantity and
quality of clinical trial data regarding the medication, and its
cost.”

-APA Practice Guideline for the

Treatment of Patients with Major
Depressive Disorder (2000)
 Matching by Side Effects
Depression and Preferred: Avoid:

Insomnia, Sedating AD Stimulating AD

agitation (remeron) (wellbutrin)
Sleepy, Lethargic Stimulating AD Sedating AD

Sexual dysfxn Bupropion or SSRI TCA

Mirtazipine
Obesity Bupropion>SSRI TCA Mirtazipine
Ritalin (CVA) trazadone
Chronic TCA SNRI ---------------
Pain/Central Pain
 Matching by Side Effects (2)
Depression and Preferred: Avoid:

CAD SSRI (zoloft or TCA

Celexa)
Cirrhosis -------------- TCA (MS
changes)
Seizures ---------------- Bupropion

Irritable Bowel TCA SSRI

Syndrome
(diarrhea, spasm)
IBS SSRI TCA
(constipation)
 What is an adequate trial of
antidepressant
• At least 4-6 weeks
• Adequate dosage
• Compliant patient and family
 Evaluating Poor Response
• Adequate dose and duration?
• Is pt compliant? Cost?
• Medical comorbidity: OSA, anemia,
hypothyroid, vit D def
• Social comorbidities: poverty, abuse
Strategy for Poor Responders
Optimize current drug
(dose increase)

Switch Add Psychotherapy

Augmentation
Combination
(non AD)
(drug 1 + drug 2)
..Lithium, T3, Ritalin
POST STROKE SHOULDER PAIN
 Physical Therapists Better Than
Robots in Helping Stroke Survivors
Regain Mobility

Stroke 2008;39.
 Epidemiology of Post Stroke
Shoulder Pain
• 72% of patients experience > 1 episode of shoulder
pain during the 12 months following stroke
• Risks: severe upper limb motor deficit Clin Rehabil.
2003 May;17(3):304-11
• Statistically significant association with ipsilateral
sensory impairment (p < 0.005), abnormal
rheumatological examination (p < 0.001) and
depression score (p < 0.005). Eur J Pain. 2000;4(3):313-
5.
 Etiology of Post Stroke Shoulder
Pain
• Adhesive capsulitis is the main cause of shoulder pain
(50% of patients). Patients with adhesive capsulitis
showed significant restriction of passive shoulder
external rotation and abduction and have a higher
incidence of shoulder-hand syndrome .
44% … gleno-humeral subluxation,
• 22% ….rotator cuff tears and tendonopathy
• 16%..... CRPS/RSD/shoulder-hand syndrome.
• Other: spasticity, central/neuropathic pain (thalamic
CVAs)
• Arch Phys Med Rehabil. 2003 Dec;84(12):1786-91
 Prevention of Shoulder Pain in the
Post Stroke Period
• Proper physical therapy and cautious handling of
stroke patients to preserve shoulder mobility and
function during early rehabilitation are
important for a good outcome.
• Most patients who develop shoulder problems
had onset of hemiplegic shoulder pain less than
2 months after stroke…..
Predictability of simple clinical tests
to identify shoulder pain after stroke.
• Simple tests can be performed during a bedside
evaluation to help predict hemiplegic shoulder
pain after an acute stroke.
• Positive Neer test and a difference of more than
10 degrees of passive range of external rotation
between shoulders had a 98% probability of
predicting the presence of hemiplegic shoulder
pain
 Interventions (prevention)
• E stim to increase shoulder external rotation and
increase blood flow and decrease subluxation
• Shoulder slings, taping, lap tray or arm trough
on wheelchair to decrease subluxation (begin in
acute care)
• Staff and family education to decrease trauma to
joint and soft tissues during transfers and ADLs
• NO PULLEYS EVER!!!!
 Interventions (treatment)
• Corticosteroid injections Am J Phys Med Rehabil.
1997 Jan-Feb;76(1):43-8
• Botox injections into subscapularis (decreased pain and
increased ROM) Stroke. 2008 Jan;39(1):126-31. Epub
2007 Nov 29
• Taping, slings (picture)
• AROM, PROM, AAROM
• Modalities: e. stim, ultrasound, ice, heat, soft tissue
massage
• Medication: antiinflammatories, ACDs
 Botulinum Toxin A Injection
Relieves Shoulder Pain in Spastic
Hemiplegic Patients

Botox was injected into affected side subscapularis in 10 pts and sham
injection into 10 pts.

• J Neurol Neurosurg Psychiatry 2007;78:789,845-

848.
THANK YOU