Article

Prevalence and predictors of pain and fatigue after stroke: A population-based study

January 2007
International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation 29(4):329-33

Source
PubMed

Authors:

Pain and fatigue are two often overlooked symptoms after stroke. Their prevalence and determinants are not well understood. In this study patients with first-ever stroke (n=377) were examined at baseline and after 1 year. General characteristics of the patients, as well as stroke type, stroke severity and risk factors were registered at baseline. After 1 year survivors (n=253) were examined with respect to residual impairment, disability, cognition and depression. They were asked whether they had experienced pain and/or fatigue which had started after the stroke, and which the patient felt to be stroke related. Twenty-eight patients (11%) had stroke-associated pain and 135 (53%) had stroke-associated fatigue. Pain was associated with depression and different manifestations of stroke severity, especially degree of paresis at baseline. Fatigue was more associated with physical disability. In univariate analysis, fatigue was also associated with sleep disturbances. In conclusion, it is important to be aware of the occurrence of pain and fatigue after stroke, because these symptoms are common, they impair quality of life and they are potentially treatable. Post-stroke depression may coexist with pain and fatigue. The detection of one symptom should lead to consideration of the others. Follow-up and individual assessment of stroke patients is crucial.

Post-stroke fatigue is linked to resting state posterior hypoactivity and prefrontal hyperactivity

Preprint

Full-text available

Mar 2021

Background and Purpose. Fatigue is associated with poor functional outcomes and increased mortality following stroke. Survivors identify fatigue as one of their key unmet needs. Despite the growing body of research into post-stroke fatigue, the specific neural mechanisms remain largely unknown. Methods. This observational study included 63 stroke survivors (22 women; age 30-89 years; mean 67.5 years) from the Cognition And Neocortical Volume After Stroke (CANVAS) study, a cohort study examining cognition, mood, and brain volume in stroke survivors following ischaemic stroke. Participants underwent brain imaging 3 months post-stroke, including a 7-minute resting state fMRI echoplanar sequence. We calculated the fractional amplitude of low-frequency fluctuations, a measure of resting state brain activity at the whole-brain level. Results. Forty-five participants reported experiencing post-stroke fatigue as measured by an item on the Patient Health Questionnaire-9. A generalised linear regression model analysis with age, sex, and stroke severity covariates was conducted to compare resting state brain activity in the 0.01-0.08 Hz range, as well as its subcomponents - slow-5 (0.01-0.027 Hz), and slow-4 (0.027-0.073 Hz) frequency bands between fatigued and non-fatigued participants. We found no significant associations between post-stroke fatigue and ischaemic stroke lesion location or stroke volume. However, in the overall 0.01-0.08 Hz band, participants with post-stroke fatigue demonstrated significantly lower resting-state activity in the calcarine cortex (p<0.001, cluster-corrected pFDR=0.009, k=63) and lingual gyrus (p<0.001, cluster-corrected pFDR=0.025, k=42) and significantly higher activity in the medial prefrontal cortex (p<0.001, cluster-corrected pFDR=0.03, k=45), attributed to slow-4 and slow-5 oscillations, respectively. Conclusions. Post-stroke fatigue is associated with posterior hypoactivity and prefrontal hyperactivity, reflecting dysfunction within large-scale brain systems such as fronto-striatal-thalamic and frontal-occipital networks. These systems in turn might reflect a relationship between post-stroke fatigue and abnormalities in executive and visual functioning. This first whole-brain resting-state study provides new targets for further investigation of post-stroke fatigue beyond the lesion approach.

Fatigue and activity after stroke. Secondary results from the Life After Stroke study

Article

Full-text available

May 2020

Objectives The aim of this study was to describe how the prevalence of fatigue changed from the subacute phase to the chronic phase after stroke, and to investigate how activity was associated with fatigue among participants included in the randomized controlled multicentre‐study Life After STroke (LAST). Methods The present study represents secondary analysis based on data from the LAST study. One‐hundred‐and‐forty‐five patients with mild and moderate stroke (mean (SD) age: 71.5 (10.5) years, 57.2% males) recruited from St. Olav's University Hospital were included. Fatigue was assessed by the Fatigue Severity Scale (FSS‐7) at inclusion, 3 months after stroke, and at follow‐up 18 months later. activPAL was used to measure activity at follow‐up. Results A total of 46 (31.7%) participants reported fatigue at inclusion and 43 (29.7%) at follow‐up (p = .736). In the univariable regression analysis, sedentary behaviour, walking and sedentary bouts were significantly associated with fatigue (p ≤ .015), whereas only time spent walking was significantly associated with fatigue in the multivariable regression analysis (p = .017). Conclusions The present study showed that fatigue is a common symptom after stroke and that the prevalence of fatigue remained unchanged from the subacute to the chronic phase. The study also showed that increased time spent walking was strongly related to lower fatigue, while no such associations were found between the other activity categories and fatigue.

Experienced pain after stroke: a cross-sectional 5-year follow-up study

Article

Full-text available

Jan 2020
BMC NEUROL

Background: Stroke is one of the most common cause of disability worldwide. Pain is common in both stroke survivors and in the general population. Consequences of post-stroke pain (PSP) include reduced quality of life and are important to consider. The aim of the current study was to explore the experience of pain 5 years after stroke, and factors associated with the experience of pain. Methods: Inclusion criteria were: First ever stroke, treated at Sahlgrenska University Hospital, Sweden, during an 18 months period in 2009-2010, aged 18 years or older. Furthermore, the participants had to respond to a set of questionnaires 5 years post-stroke. Baseline data were collected from medical records and follow-up data from the set of questionnaires. The primary outcome was based on the question Do you experience pain? Predictors and explanatory factors for experiencing more frequent pain were analysed with logistic regression. Results: A total of 281 participants were included. Almost 40% experienced pain to some degree 5 years post-stroke (15% reported pain frequently), and 25% felt that their needs for pain treatment were not met. The participants experiencing more frequent pain reported poorer quality of life, self-perceived health status and recovery post-stroke. Functional dependency at discharge from hospital, experiencing depression at follow up and restricted mobility at follow up were all associated with more frequent pain. Conclusion: Pain is common 5 years post-stroke and the treatment is not perceived as optimal. The persons experiencing more frequent pain seem to rate their health and recovery worse than the persons experiencing less frequent pain. Most of the factors associated with more frequent pain were treatable and this emphasize the importance of standardised follow-up care that takes pain into consideration.

Article

Oct 2018
J Stroke Cerebrovasc Dis

Background: Studies suggest that fatigue and cognitive impairment may be present after transient ischemic attack (TIA) or minor stroke, but little is known about consequences in daily life. The main aim was to explore the presence of fatigue, cognitive impairment, and consequences in daily life after minor stroke-TIA. Methods. Patients (n=92) were consecutively recruited from the Stroke Unit and were assessed within 2 weeks of hospital admission for first-ever and 3 months later. Control participants (n=89) were recruited from the same population as the patients. Measures included the Fatigue Assessment Scale (FAS), Montreal Cognitive Assessment (MoCA) and The European Quality of Life index (EQ-5D-5L). Results: The prevalence of substantial fatigue was 65.2%(CI95%: 54.6-74.8%) and extreme fatigue was 20.7% (CI95%: 12.9-30.4%) in minor stroke-TIA patients. The prevalence of substantial fatigue in controls was 23.5%(CI95%: 15.0-34.0%) and extreme fatigue was 4.5% (CI95%: 1.8-11.0%). The mean (SD) score on the MoCA was 24.1 (3.2) for the patients group and 27.3 (2.4) for controls (p<0.001). FAS showed the strongest negative correlation score with the EQ-5D-5L index (r=-0.480; p<0,0001), higher levels of mental and physical fatigue are associated with lower EQ-5D-5L index (r=-0.376; p<0.001 and r=-0.497; p<0.001, respectively). The correlations between the FAS and the MoCA measures were no significant. MoCA was not significantly correlated with EQ-5D-5L. Conclusions: Fatigue was a very common symptom in TIA /minor stroke patients. The fatigue had a significant impact on the health-related quality of life construct in its entirety, even after accounting for the influence of several factors.

Investigating post-stroke fatigue: An individual participant data meta-analysis

Article

Aug 2018
J PSYCHOSOM RES

Objective: The prevalence of post-stroke fatigue differs widely across studies, and reasons for such divergence are unclear. We aimed to collate individual data on post-stroke fatigue from multiple studies to facilitate high-powered meta-analysis, thus increasing our understanding of this complex phenomenon. Methods: We conducted an Individual Participant Data (IPD) meta-analysis on post-stroke fatigue and its associated factors. The starting point was our 2016 systematic review and meta-analysis of post-stroke fatigue prevalence, which included 24 studies that used the Fatigue Severity Scale (FSS). Study authors were asked to provide anonymised raw data on the following pre-identified variables: (i) FSS score, (ii) age, (iii) sex, (iv) time post-stroke, (v) depressive symptoms, (vi) stroke severity, (vii) disability, and (viii) stroke type. Linear regression analyses with FSS total score as the dependent variable, clustered by study, were conducted. Results: We obtained data from 14 of the 24 studies, and 12 datasets were suitable for IPD meta-analysis (total n = 2102). Higher levels of fatigue were independently associated with female sex (coeff. = 2.13, 95% CI 0.44-3.82, p = 0.023), depressive symptoms (coeff. = 7.90, 95% CI 1.76-14.04, p = 0.021), longer time since stroke (coeff. = 10.38, 95% CI 4.35-16.41, p = 0.007) and greater disability (coeff. = 4.16, 95% CI 1.52-6.81, p = 0.010). While there was no linear association between fatigue and age, a cubic relationship was identified (p < 0.001), with fatigue peaks in mid-life and the oldest old. Conclusion: Use of IPD meta-analysis gave us the power to identify novel factors associated with fatigue, such as longer time since stroke, as well as a non-linear relationship with age.

Sensorimotor Processing in Post-Stroke Fatigue

Conference Paper

Oct 2021

William De Doncker

Chronic pathological fatigue is a highly debilitating symptom with a significant impact on quality of life of stroke survivors. Despite its high prevalence, research into the mechanisms that underlie post-stroke fatigue is lacking. This thesis outlines how changes in cortical neurophysiology results in alterations in sensorimotor processing associated with the perception of effort and how prolonged experience of high effort can subsequently result in chronic pathological fatigue. I show that the perception of effort for what are usually low effort activities is altered in non-depressed, chronic stroke survivors with minimal physical impairment. Low effort voluntary contractions are perceived as more effortful in stroke survivors with high fatigue compared to those with low fatigue. Sensory attenuation, the ability to attend away from predictable sensory input, is thought to underlie altered effort perception. If one is unable to attend away from predictable sensory input associated with a voluntary movement, this will give rise to the perception of higher effort afforded to the movement. I show that stroke survivors with high fatigue do not show reduced sensory attenuation of sensory input arising from mechanoreceptors as quantified using a force matching task and suggest that high effort afforded to simple voluntary movements may be a result of reduced sensory attenuation of information arising from within the body, namely proprioceptive afferent information from the contracting muscle. Using TMS, I show that cortical excitability both at rest and during movement preparation is altered in stroke survivors with high fatigue and propose that cortical excitability reflects the degree of sensory attenuation at the level of the sensorimotor cortex. Finally, I show that neuromodulatory techniques such as transcranial direct current stimulation, are potential tools that can be used to reduce fatigue severity by potentially resetting cortical neurophysiology and reducing perceived effort. Overall, the data provides some evidence in support of the sensory attenuation model of fatigue and provides a novel insight into the mechanisms implicated in post- stroke fatigue.

Influence of mobility restrictions on post-stroke pain

Article

Full-text available

May 2021

Objectives: The objective of this study was to investigate the role of mobility limitations and vitality, as well as additional factors such as comorbidities, to predict post-stroke pain. Materials & methods: This study included cross-sectional data from 214 participants living in varied settings in different parts of Sweden. Participants were asked to complete the Stroke Impact Scale, Medical Outcomes Study Short Form 36, and Self-administered Comorbidity Questionnaire to evaluate mobility, vitality, comorbidities, and pain. Descriptive statistics were used for demographic and clinical characteristics. Binary logistic regression analysis was performed to predict the pain domain score on Medical Outcomes Study Short Form 36. Results: The mean age of all participants in the sample was 66 years (SD 14); 43.4% of the study population were women. After analyses, "standing without losing balance and vitality'' were found to be significant predictors in the model which explained the pain score on Medical Outcomes Study Short Form 36. Conclusions: In conclusion, the results suggest that restrictions in mobility and low vitality have an important role on the occurrence of post-stroke pain. Having post-stroke pain could be due to not able to stand without losing balance and low vitality. Thus, rehabilitation professionals may consider the importance of these factors, especially mobility restrictions, in preventing post-stroke pain.

Predictors and short-term outcomes of post-stroke fatigue in initial phase of transition from hospital to home: A prospective observational stud

Article

Full-text available

Apr 2021
J ADV NURS

Aim: To analyse the interactions of associated factors with post stroke fatigue (PSF) after discharge home and determine the predictors of PSF and their impact on stroke survivors. Design: A prospective observational study. Methods: A total of 94 patients with acute stroke were recruited between May 2019 -July 2020. The main outcomes were fatigue, depression, insomnia, sarcope- nia, and health-related quality of life (HRQOL) and were assessed at admission and 1 month after discharge. Fatigue was measured using the Fatigue Assessment Scale. Depression and Insomnia were assessed using the Hospital Anxiety and Depression Scale-Depression and Insomnia Severity Index, respectively. Sarcopenia was meas- ured using the SARC-F questionnaire, and HRQOL was assessed using the Short Form-8. Results: Acute phase PSF was an independent predictor of PSF after discharge home. Moreover the path analysis revealed that this effect is mediated through both the direct effect of acute-phase PSF on PSF after discharge home and through the indi- rect effect of interaction with pre-stroke SARC-F, acute phase depression, and acute phase insomnia, which remains a separate predictor of acute-phase PSF. In total, 17% of the survivors had persistent PSF. Persistent PSF was significantly associated with depression, insomnia, sarcopenia, and a lower quality of life scores. Conclusions: Post-stroke fatigue may occur in the acute phase and persists after discharge, it will not only affect later depression, insomnia, and quality of life, but also sarcopenia. Impact: Acute phase PSF was found to be an independent predictor of PSF after discharge home. In addition, the interaction with pre-stroke SARC-F, acute phase depression and insomnia had an indirect connection with PSF after discharge home, which remains a separate predictor of acute-phase PSF. Thus, early assessment and management of mental status, sleep problems, and sarcopenia during hospitalization might be an important step in post-stroke rehabilitation and home transition.

Implementing a pain assessment survey and team-approached method to effectively assess and treat pain in post-stroke patients.

Article

Full-text available

May 2020

Objective To monitor and treat pain effectively in stroke patients in an inpatient rehabilitation facility (IRF) using an efficient Pain Assessment Survey (PAS). Design The study was conducted as a two-part project; part one was a pre-intervention study conducted to assess the prevalence of pain in post-stroke patients using a PAS. Factors such as central/peripheral mechanisms, psychological factors, as well as autonomic input were utilized to study the surveyed population. Other potential risk factors such as age and gender were also incorporated into statistical gathering[61]. The correlation between the presence of pain and post-stroke patients was assessed, and an enhanced pain assessment was created and implemented in the admission process of post-stroke patients; this helped comprise part of the second portion of the study called the post-intervention study. Setting Participants were chosen from an Inpatient Rehabilitation Facility (IRF); each part of the project was conducted over a six-month period. Participants 184 patients were randomly selected; 82 for the pre-intervention survey and 102 for the post-intervention survey. Those who had pain prior to stroke, which remained unchanged or if the pain was secondary to another diagnosis, were excluded from the study. Intervention Those with complaints of PSP were intervened immediately upon admission using a team approach; this included all personnel involved in the patient’s care to resolve pain before discharge. Different types of medications and non-medical modalities were used for pain control. Main Outcome Measure The prevalence of PSP in post-stroke patients. Results The pre-intervention survey revealed a pain prevalence of 31.7%, while the post-intervention study showed a prevalence of 11.8% in post-stroke patients on admission. The odds that a post-stroke patient would be discharged without pain and with a proper pain assessment and management was 96.2, with a statistically significant p-value of 0.0015. Conclusion The team approach to pain management resulted in all patients being successfully treated and discharged pain free. This further proves the importance of using both a pain assessment survey and team approach to assess PSP in post-stroke patients.

Poststroke Fatigue

Article

Jun 2019

Inflammatory Signaling in Post-Stroke Fatigue and Depression

Article

Nov 2018

b> Background: In the United States, stroke continues to be the cause for long-term disability. Of the patients with a first stroke, up to 75% will experience post-stroke fatigue (PSF) in the first year following stroke. PSF is one of the most disabling symptoms in stroke survivors; it decreases quality of life, increases mortality, and is a barrier to stroke rehabilitation. Given the incidence of stroke and the prevalence and detrimental impact of PSF on quality of life, independent living, and overall survival, efficient management of PSF must be a priority in stroke rehabilitation. The cause of PSF remains unknown. The burden of fatigue in stroke survivors is influenced by other stroke-related symptoms, most notably post-stroke depression (PSD). It is well known that stroke induces a systemic inflammatory response that is the trigger for sickness behavior, of which fatigue and depression are predominant symptoms. Summary: To date, only a handful of studies have sought to explore the relationship between stroke-induced inflammation and PSF and PSD. In this review, we describe this evidence, highlight the strengths and weaknesses of these existing studies, and suggest further experiments that may further support the association between stroke-related inflammatory processes and stroke-related symptoms. Key Messages: The current concept and further research are important for a more specific therapeutic intervention for PSF and PSD.

Interhemispheric Asymmetries in Intracortical Facilitation Correlate With Fatigue Severity in Individuals With Poststroke Fatigue

Article

Mar 2023
J CLIN NEUROPHYSIOL

Purpose: Poststroke fatigue (PSF) contributes to increased mortality and reduces participation in rehabilitative therapy. Although PSF's negative influences are well known, there are currently no effective evidence-based treatments for PSF. The lack of treatments is in part because of a dearth of PSF pathophysiological knowledge. Increasing our understanding of PSF's causes may facilitate and aid the development of effective therapies. Methods: Twenty individuals, >6 months post stroke, participated in this cross-sectional study. Fourteen participants had clinically relevant pathological PSF, based on fatigue severity scale (FSS) scores (total score ≥36). Single-pulse and paired-pulse transcranial magnetic stimulation were used to measure hemispheric asymmetries in resting motor threshold, motor evoked potential amplitude, and intracortical facilitation (ICF). Asymmetry scores were calculated as the ratios between lesioned and nonlesioned hemispheres. The asymmetries were then correlated (Spearman rho) to FSS scores. Results: In individuals with pathological PSF (N = 14, range of total FSS scores 39-63), a strong positive correlation (rs = 0.77, P = 0.001) between FSS scores and ICF asymmetries was calculated. Conclusions: As the ratio of ICF between the lesioned and nonlesioned hemispheres increased so did self-reported fatigue severity in individuals with clinically relevant pathological PSF. This finding may implicate adaptive/maladaptive plasticity of the glutamatergic system/tone as a contributor to PSF. This finding also suggests that future PSF studies should incorporate measuring facilitatory activity and behavior in addition to the more commonly studied inhibitory mechanisms. Further investigations are required to replicate this finding and identify the causes of ICF asymmetries.

The association between functional status and physical pain with depressive symptoms after a stroke event: A cross-sectional analysis of the China Health and Retirement Longitudinal Study 2018

Article

Full-text available

Sep 2022

Background Stroke is a major cause of mortality and long-term physical and cognitive impairment. This study aims to: (1) examine the prevalence of depressive symptoms, disability and pain among Chinese adults with stroke; (2) test the associations of functional limitations and body pain with occurrence of depressive symptoms; (3) investigate gender and urban-rural disparities in these associations. Methods This study utilized the data from the China Health and Retirement Longitudinal Study in 2018, involving 969 patients with stroke among 17,970 participants aged ≥ 45 years. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression (CES-D) Scale. We performed multivariable logistic regression models to estimate the associations between activities of daily life (ADL), instrumental activities of daily life (IADL) and pain with depressive symptoms. Results Depressive symptoms were found among 40.2% of stroke patients, with a higher prevalence in females (48.2%) than males (32.7%). Prevalence of ADL limitations, IADL limitations and pain among stroke patients were 39.2, 49.8 and 14.0%, respectively. ADL and IADL limitations and pain were more prevalent among females and residents in rural areas. Multivariable regression analyses showed a significant association between ADL limitation (OR = 1.535, 95% CI = 1.168, 2.018), IADL limitation (OR = 1.666, 95% CI = 1.260, 2.203) and pain (OR = 2.122, 95% CI = 1.466, 3.073) with depressive symptoms. Stratified analyses revealed stronger associations among urban residents. Females had a higher association of ADL and IADL with depressive symptoms but similar in that of pain to the males. The impact of ADL and IADL in male patients is higher than in females, but the impact of pain on depressive symptoms is higher in female patients. Conclusion Depressive symptoms are common amongst post-stroke patients in China and are significantly associated with functional disability and physical pain. Our findings have implications for practitioners on the early assessment of pain and depression after stroke. Future research should explore effective intervention measures for physical-mental stroke complications.

Effects of Different Montages of Transcranial Direct Current Stimulation on Haemodynamic Responses and Motor Performance In Acute Stroke: A Randomized Controlled Trial

Article

Full-text available

Aug 2022

Objective: Transcranial direct current stimulation (tDCS) has shown positive results in neurorehabilitation. However, there is limited evidence on its use in acute stroke, and unclear evidence regarding the best tDCS montage (anodal-, cathodal-, or dualtDCS) for stroke recovery. This study investigated the effects of these montages combined with physical therapy on haemodynamic response and motor performance. Methods: Eighty-two eligible acute stroke participants were allocated randomly into anodal, cathodal, dual, and sham groups. They received 5 consecutive sessions of tDCS combined with physical therapy for 5 days. Cerebral mean blood flow velocity (MFV) and motor outcomes were assessed pre- and post-intervention and at a 1-month follow-up. Results: None of the groups showed significant changes in the MFV in the lesioned or non-lesioned hemispheres immediately post- intervention or at a 1-month follow-up. For motor performance, all outcomes improved over time for all groups; between-group comparisons showed that the dual-tDCS group had significantly greater improvement than the other groups for most of the lower-limb performance measures. All 5-day tDCS montages were safe. Conclusion: MFV was not modulated following active or sham groups. However, dual-tDCS was more efficient in improving motor performance than other groups, especially for lower-limb performance, with after-effects lasting at least 1 month.

The Frequency of Neuropathic Pain In Stroke Patients and Medical Treatment Approaches

Article

Jan 2022

Prevelance of fatigue among chronic stroke subjects

Article

Full-text available

Jun 2022

Objective: Fatigue is still a relatively unexplored, often neglected condition. The fatigue often manifests as physical and mental lack of energy, and many patients mention fatigue as one of the most difficult sequels to which they have to adjust. The objective of study finding the fatigue level of stroke population. Method: A cross sectional study conducted on a chronic stroke subject finding the fatigue levels. The fatigue assessment form was distributed to 120 stroke patients and individual response were collected. Results: The results were calculated using MS Excel and it was found that the mean of Fatigue severity score among participants was 36.71 with standard deviation of 7.25 Conclusion: This study concluded that there increase in fatigue levels in individuals suffering from stroke.

Neuroimaging Parameters Are Not Associated With Chronic Post-stroke Fatigue in Young Stroke Patients

Article

Full-text available

Apr 2022

Introduction Post-stroke fatigue is frequently present in young adults, but its underlying mechanism is still unclear. The aim of the study was to investigate the association between lesion location, network efficiency and chronic post-stroke fatigue based on voxel-based lesion-symptom mapping and structural network connectivity analysis. Patients and Methods One hundred and thirty five young patients, aged 18–50 years, with a first-ever transient ischemic attack or cerebral infarction from the Follow-Up of Transient ischemic attack and stroke patients and Unelucidated Risk factor Evaluation (FUTURE) study, underwent 1.5T MRI and were assessed for fatigue using the self-report Checklist Individual Strength. Stroke lesions were manually segmented, and structural network efficiency was calculated using the diffusion MRI-based brain networks and graph theory for each patient. Univariate and multivariate analyses was performed to study the associations between MRI parameters and chronic post-stroke fatigue. In addition, we used voxel-based lesion-symptom mapping to analyze the relationship between the lesion location and chronic post-stroke fatigue. Results Mean age at index event was 39.0 years (SD ± 8.2), and mean follow-up duration was 11.0 years (SD ± 8.0). 50 patients (37%) had post-stroke fatigue. Voxel-based lesion-symptom mapping showed no significant relation between stroke lesions and the presence of chronic post-stroke fatigue. Furthermore, there were no significant associations between the lesion size or network efficiency, and the presence of chronic post-stroke fatigue. Discussion We did not find any association between stroke characteristics (lesion location and size) and chronic post-stroke fatigue (CIS20-R), nor associations between structural brain network connectivity and post-stroke fatigue on the long term in young stroke patients.

Post Stroke Fatigue Prevalence and its Correlation to the Functional Recovery

Article

Full-text available

Mar 2022

Background: Post Stroke Fatigue (PSF) is an irritating symptom in chronic stroke survivors. They report that the symptoms of the PSF are greater after their stroke's incidence which might affect the rehabilitation process. PSF could limit the active participation of the patient in the environment as well as in different functional tasks of daily living activities.

Comorbidity in Stroke-Survivors: Prevalence and Associations with Functional Outcomes and Health

Article

Oct 2021
J Stroke Cerebrovasc Dis

Objectives The purpose of this study was to evaluate the prevalence and impact of stroke-related comorbidity in a community-based sample of stroke survivors. We sought to find out which types of comorbidity that were most important with respect to the patients’ functional outcomes and general health. Materials and Methods All stroke survivors (n = 330) living in a medium-sized Swedish municipality were included. Patient records were reviewed to determine the presence of comorbidities. A selection of patient reported outcomes were used to assess subjective symptoms, functional outcomes, and general health. Logistic regression models were used to investigate the association between comorbidities, residual symptoms, and subjective symptoms on the one hand, and functional outcomes and general health on the other hand. Results Hypertension (80%) was the most common cardiovascular risk factor. Ischemic heart disease was found in 18% and congestive heart failure in 10%. Of non-cardiovascular disorders, orthopaedic diseases were commonest (30%). Psychiatric disorders and cognitive impairment were present in 11% and 12% respectively. Hemiparesis is associated with both functional outcomes and general health. Additionally, orthopedic disorders, vertigo, cognitive impairment, nicotine use, chronic pulmonary disorders, and age, are associated with different functional outcomes. Psychiatric, orthopedic and neurological disorders are related to general health. The patient-reported outcome measure “feeling of tiredness” is important for many of the outcomes, while “feeling depressed” and “having pain” are associated with general health. Conclusions Many medical conditions, several of which have received little attention so far, are associated with functional outcome and general health in stroke survivors. If the intention is to describe comorbidity relevant to function and general health in stroke patients, disorders that hitherto have received little attention, must be considered.

Effects of Self RehAbilitation Video Exercises (SAVE) on Functional Restorations in Patients with Subacute Stroke

Article

Full-text available

May 2021

Background: Additional exercise therapy has been shown to positively affect acute stroke rehabilitation, which requires an effective method to deliver increased exercise. In this study, we designed a 4-week caregiver-supervised self-exercise program with videos, named “Self rehAbilitation Video Exercises (SAVE)”, to improve the functional outcomes and facilitate early recovery by increasing the continuity of rehabilitation therapy after acute stroke. Methods: This study is a non-randomized trial. Eighty-eight patients were included in an intervention group (SAVE group), who received conventional rehabilitation therapies and an additional self-rehabilitation session by watching bedside exercise videos and continued their own exercises in their rooms for 60 min every day for 4 weeks. Ninety-six patients were included in a control group, who received only conventional rehabilitation therapies. After 4 weeks of hospitalization, both groups assessed several outcome measurements, including the Berg Balance Scale (BBS), Modified Barthel Index (MBI), physical component summary (PCS) and the mental component summary of the Short-Form Survey 36 (SF-36), Mini-Mental State Examination, and Beck Depression Inventory. Results: Differences in BBS, MBI, and PCS components in SF-36 were more statistically significant in the SAVE group than that in the control group (p < 0.05). Patients in the SAVE group showed more significant improvement in BBS, MBI, and PCS components in SF-36 as compared to that in the control group. Conclusions: This evidence-based SAVE intervention can optimize patient recovery after a subacute stroke while keeping the available resources in mind.

Development and Internal Validation of a Nomogram to Predict Post-Stroke Fatigue After Discharge

Article

Full-text available

Dec 2020
J Stroke Cerebrovasc Dis

Objectives We aimed to develop and validate a nomogram for the individualized prediction of the risk of post-stroke fatigue (PSF) after discharge. Materials and methods Fatigue was measured using the Fatigue Assessment Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predictive model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using bootstrapping validation. Finally, a web application was developed to facilitate the use of the nomogram. Results We developed a nomogram based on 95 stroke patients. The predictors included in the nomogram were sex, pre-stroke sarcopenia, acute phase fatigue, dysphagia, and depression. The model displayed good discrimination, with a C-index of 0.801 (95% confidence interval: 0.700–0.902) and good calibration. A high C-index value of 0.762 could still be reached in the interval validation. Decision curve analysis showed that the risk of PSF after discharge was clinically useful when the intervention was decided at the PSF risk possibility threshold of 10% to 90%. Conclusion This nomogram could be conveniently used to provide an individual, visual, and precise prediction of the risk probability of PSF after being discharged home. Thus, as an aid in decision-making, physicians and other healthcare professionals can use this predictive method to provide early intervention or a discharge plan for stroke patients during the hospitalization period.

A Mini-Review: Bridging the gap between Autism Spectrum Disorder and pain comorbidities

Article

Full-text available

May 2020

Background: Pain is a complex neurobiological response with a multitude of causes; however, patients with autism spectrum disorder (ASD) often report chronic pain with no known etiology. Recent research has been aimed toward identifying the causal mechanisms of pain in mouse and human models of ASD. In recent years, efforts have been made to better document and explore secondary phenotypes observed in ASD patients in the clinic. As new sequencing studies have become more powered with larger cohorts within ASD, specific genes and their variants are often left uncharacterized or validated. In this review we highlight ASD risk genes often presented with pain comorbidities. Aims: This mini-review bridges the gap between two fields of literature, neurodevelopmental disorders and pain research. We discuss the importance of the genetic landscape of ASD and its links to pain phenotypes. Results: Among the numerous genes implicated in ASD, few have been implicated with varying severities of pain comorbidity. Mutations in these genes, such as SCN9A, SHANK3, and CNTNAP2, lead to altered neuronal function that produce different responses to pain, shown in both mouse and human models. Conclusion: There is a necessity to use new technologies to advance the current understanding of ASD risk genes and their contributions to pain. Secondly, there is a need to power future ASD risk genes associated with pain with their own cohort, because a better understanding is needed of this subpopulation.

Fatigue post-AVC et corrélation avec les anomalies de perfusion cérébrale objectivées par SPECT/CT

Article

Full-text available

Mar 2020

Introduction La fatigue post-AVC (FP-AVC) est une complication fréquente qui est associée à une moins bonne récupération fonctionnelle des patients à moyen terme et à une augmentation de la mortalité à long terme. Quelques pistes thérapeutiques sont actuellement explorées, mais nous avons encore besoin de mieux comprendre les mécanismes sous-jacents à la FP-AVC pour améliorer ces traitements. Certaines études ont retrouvé un lien entre la localisation de l’AVC, notamment des noyaux gris centraux, et la présence d’une fatigue. L’objectif principal de notre travail était de rechercher une éventuelle corrélation entre l’intensité de la FP-AVC et les anomalies perfusionnelles cérébrales évaluées par tomoscintigraphie couplée à la tomodensitométrie. Méthode Les patients étaient recrutés durant leur hospitalisation initiale en unité neurovasculaire. À 3, 6 et 12 mois (M3, M6 et M12), l’intensité de la FP-AVC était mesurée grâce à la Fatigue Assessment Scale (FAS), un score élevé signifiant un haut niveau de fatigue. De même, chaque patient réalisait une scintigraphie cérébrale à M3, M6 et M12. Les corrélations entre la FAS et l’intensité de fixation du traceur de perfusion observée en scintigraphie ont été calculées en utilisant SPM. Résultats Vingt-huit patients ont été inclus, pour un total de 59 examens (26 à M3, 18 à M6 et 15 à M12). Nous avons retrouvé une corrélation négative entre le score FAS et l’intensité de perfusion des noyaux gris centraux et du pôle temporal ipsilatéraux à l’AVC. Il est intéressant de noter que seulement 5 patients, correspondant à 11 scintigraphies, ont présenté un infarctus des ganglions de la base. Conclusion L’hypoperfusion des noyaux gris centraux et du pôle temporal ipsilatéraux semble impliquée dans le développement de la FP-AVC. De plus, cette hypoperfusion des noyaux gris centraux est due pour certains patients à un infarctus de cette région mais pour d’autre probablement à un diaschisis. L’utilisation de la dopamine dans le traitement de la FP-AVC pourrait donc être une voie à explorer pour améliorer la qualité de vie de ces patients.

Post-stroke shoulder pain subtypes classifying criteria: towards a more specific assessment and improved physical therapeutic care

Article

Full-text available

Mar 2019

Background: Post-stroke Shoulder Pain (PSSP) is a common stroke-related syndrome that prolongs hospitalization and diminishes quality of life. PSSP studies were unsuccessful in clarifying pathophysiological mechanisms. Therefore, cohort's studies with greater variety of the sample and larger follow-up period could provide additional clinical data and may improve medical care. Objective: To classify people with PSSP and identify intergroup clinical differences, providing additional data useful for therapeutic care planning. Methods: One thousand individuals with stroke were selected from all levels of one health Area and followed up during one year. Demographic data, stroke clinical characteristics, stroke-related symptoms and rehabilitation parameters were collected. The shoulder muscle impairment was used to group participants into three clinical profiles: severe muscular impairment, moderate muscular impairment and low muscular impairment groups. Results: A total of 119 individuals were diagnosed with PSSP. The suggested classification criteria showed two groups that differed significantly in relation to the onset and duration of PSSP, presence of sensory and speech impairment, and spasticity. The outcomes did not firmly support the existence of a third suggested PSSP subtype. Conclusions: PSSP may vary in onset, clinical manifestations, severity and syndrome duration. These results highlight the course of different clinical profiles and require multidisciplinary management approaches.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians

Article

Feb 2019
J Stroke Cerebrovasc Dis

Background and Purpose Poststroke fatigue (PSF) is rife among stroke survivors and it exerts a detrimental toll on recovery from functional deficits. The burden of PSF is unknown in sub-Saharan Africa. We have assessed the prevalence, trajectory, and predictors of PSF among 60 recent Ghanaian stroke patients. Methods Study participants in this prospective cohort (recruited between January 2017 and June 2017) were stroke survivors, aged greater than 18 years, with CT scan confirmed stroke of less than 1-month onset. PSF was assessed using the Fatigue Severity Scale (FSS) at enrollment, months 3, 6, and 9. Those with a score of greater than or equal to 4 points on FSS were categorized as “fatigued.” A multivariate logistic regression analysis was performed to identify independent predictors of PSF at enrollment and at month 9. Results Sixty-five percent (65%) of our sample were males with a mean age of 55.1 ± 12.7 years. In addition to all participants having hypertension, 85% had dyslipidemia and 25% had diabetes mellitus. Ischemic strokes comprised 76.6% of the study population. The prevalence of PSF was 58.9% at baseline and declined to 23.6% at month 9, P = .0002. Diabetes mellitus was significantly associated with PSF at baseline with an adjusted odds ratio of 15.12 (95% CI: 1.70-134.30), P = .01. However, at month 9, age greater than or equal to 65 years, adjusted odds ratio (aOR) of 7.02 (95% CI: 1.16-42.52); female sex, aOR of 8.52 (1.23-59.16), and depression, aOR of 8.86 (1.19-65.88) were independently associated with PSF. Conclusions Approximately 6 out of 10 Ghanaian stroke survivors experience PSF within the first month of stroke onset. PSF persists in approximately 1 out of 4 stroke survivors at 10 months after the index stroke. Further studies to elucidate the underlying mechanisms for PSF are required and adequately powered interventional multicenter trials are eagerly awaited to provide solid evidence base for the clinical management of PSF.

Post-stroke fatigue as an indicator of underlying bioenergetics alterations

Article

Full-text available

Apr 2019
J BIOENERG BIOMEMBR

Approximately half of stroke survivors suffer from clinically significant fatigue, contributing to poor quality of life, depression, dependency, and increased mortality. The etiology of post-stroke fatigue is not well understood and treatment is limited. This study tested the hypothesis that systemic aerobic energy metabolism, as reflected by platelet oxygen consumption, is negatively associated with fatigue and systemic inflammation is positively associated with fatigue in chronic ischemic stroke survivors. Data on self-reported level of fatigue, platelet oxygen consumption rates (OCR) and plasma inflammatory markers were analyzed from 20 ischemic stroke survivors. DNA copy number for two mitochondrial genes was measured as a marker of platelet mitochondrial content. Basal and protonophore-stimulated maximal platelet OCR showed a biphasic relationship to fatigue. Platelet OCR was negatively associated with low to moderate fatigue but was positively associated with moderate to high fatigue. DNA copy number was not associated with either fatigue or platelet OCR. Fatigue was negatively associated with C-reactive protein but not with other inflammatory markers. Post-stroke fatigue may be indicative of a systemic cellular energy dysfunction that is reflected in platelet energy metabolism. The biphasic relationship of fatigue to platelet OCR may indicate an ineffective bioenergetic compensatory response that has been observed in other pathological states.

Frequency of post-stroke fatigue and its association with quality of life in Pakistani population: A cross sectional study

Article

Aug 2018

Hina Tariq

Постинсультный болевой синдром

Article

Full-text available

Aug 2014

Tetiana Cherenko

Черенько Т. М. Постинсультный болевой синдром / Т. М. Черенько // Український неврологічний журнал. - 2014. - № 1. - С. 11-18.

Chronic Pain After Stroke: A Hospital-Based Study of It's Profile and Correlation with Health-Related Quality of life

Article

Full-text available

Oct 2018

Chidinma Ezeugwa

New-onset pain in the early phase and three months following stroke – Data from a multicenter study

Article

Full-text available

Sep 2018

Background The reported prevalence of pain after stroke varies considerably, depending on how pain is measured, time after stroke, and characteristics of the selected population. The aims of this study were to investigate the prevalence and distribution of new-onset pain initially and three months after stroke in a general Norwegian cohort, and to examine whether symptoms of anxiety or depression were associated with new-onset pain after stroke. Material and methods Stroke patients were included from eleven different hospitals within 14 days after stroke onset. Pain was assessed at inclusion and three months after stroke, and the distribution of pain was marked on a body map. New-onset pain was defined as pain reported by the patients to have occurred after the stroke. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Results A total of 390 patients were included. Pain data were available in 142 patients at both inclusion and follow-up, while 245 patients had available data for the regression analysis. In patients with follow-up data, new-onset pain occurred in 14 (9.9%) patients at inclusion and in 31 (21.8%) patients three months later, P=0.005. New-onset pain in the affected upper limb and bilaterally in the lower limbs was more common at three months than initially after stroke. Symptoms of anxiety were associated with new-onset pain (OR=1.13, 95% CI 1.01–1.27, P=0.030). Conclusion This study shows that new-onset pain occurs in one out of ten patients initially after stroke and in one out of five patients three months after stroke, and it was associated with symptoms of anxiety. This raises the question of whether easing symptoms of anxiety might help to prevent or treat new pain after stroke.

A Narrative Review of Persistent Post-Stroke Headache - A New Entry in the International Classification of Headache Disorders, 3rd Edition

Article

Full-text available

Aug 2018
HEADACHE

Background: Persistent post-stroke headache is a clinical entity that has recently entered the International Classification of Headache Disorders, 3rd edition. In contrast to acute headache attributed to stroke, the epidemiology, clinical features, potential pathophysiology, and management of persistent post-stroke headache have not been reviewed. Methods: We summarize the literature describing persistent headache attributed to stroke. Results: Persistent headache after ischemic or hemorrhagic stroke affects up to 23% of patients. These persistent headaches tend to have tension-type features and are more frequent and severe than acute stroke-related headaches. Risk factors include younger age, female sex, pre-existing headache disorder, and comorbid post-stroke fatigue or depression. Other factors including obstructive sleep apnea or musculoskeletal imbalances may contribute to headache persistence. Although more evidence is needed, it may be reasonable to treat persistent post-stroke headache according to headache semiology. Conclusion: Recognition of persistent post-stroke headache as a separate clinical entity from acute stroke-attributed headache is the first step toward better defining its natural history and most effective treatment strategies.

Diagnosis and Management of Post-Stroke Fatigue: What Do We Know, What Do We Still Need To Know?

Article

Apr 2018

Benjamin Tseng

Prevalence of chronic pain among individuals with neurological conditions

Article

Mar 2018

Background: The prevalence of pain among people with a variety of individual neurological conditions has been estimated. However, information is limited about chronic pain among people with neurological conditions overall, and about the conditions for which chronic pain is most prevalent. To fill these information gaps, a common method of pain assessment is required. Data and methods: The data are from the Survey on Living with Neurological Conditions in Canada, a cross-sectional national survey. Based on self-reports, chronic pain was assessed for 16 neurological conditions. Multivariable logistic regression was used to produce odds ratios and 95% confidence intervals (CIs). Results: Close to 1.5 million individuals aged 15 or older who lived in private households reported having been diagnosed with a neurological condition. The overall prevalence of chronic pain for the 16 neurological conditions combined was 36% (95% CI: 31% to 42%). The odds of chronic pain were significantly elevated among individuals with spinal cord trauma. Discussion: Chronic pain is highly prevalent among people with neurological conditions, particularly those with spinal cord trauma. These results suggest a need to target health services and direct research to improved pain management, and thereby reduce the burden of neurological disease.

Health Reports Prevalence of chronic pain among individuals with neurological conditions How to obtain more information

Article

Full-text available

Mar 2018

Chronic Pain After Stroke: A Hospital-Based Study of Its Profile and Correlation with Health-Related Quality of Life

Article

Full-text available

Dec 2016

Ajepe Titilope Oluwatobiloba

Background: Chronic pain is one of the most troublesome sequelae of stroke. The correlation between post-stroke pain and patients’ quality of life has not been extensively studied. Objectives: The purpose of this study was to investigate certain profiles of post-stroke chronic pain and evaluate its correlation with health-related quality of life. Methods: The study involved 118 participants with stroke comprising 72 (61.0%) males and 46 (39.0%) females. A convenience sampling technique was used to recruit the subjects for the study. Socio-demographic data of the participants were taken. Data on chronic pain and health-related quality of life (HRQoL) were collected using the brief pain inventory (BPI) and short form health survey (SF-36), respectively. Independent t-test was used to compare HRQoL between participants with and without chronic pain. The correlation of chronic pain with HRQoL was investigated using Spearman’s correlation coefficient. The level of significance was P�0.05. Results: Chronic pain was reported by 88 (72%) out of the 118 participants. Musculoskeletal pain was the most common type of pain. The upper limb was the most reported site of pain (63.6%). Participants with chronic pain had poorer HRQoL than those without chronic pain (P = 0.001). There were significant correlations between chronic pain and all domains of HRQoL (P < 0.05) with r values ranging from 0.181 to 0.309. Conclusions: The study showed that the majority of patients with stroke had chronic pain. The pain had a significant impact on all domains of health-related quality of life among the patients. Keywords: Stroke, Chronic Pain, Health-Related Quality of Life, Correlation

Introduction to Central Pain Syndromes and Painful Peripheral Neuropathy

Chapter

Sep 2022

Neuropathic pain is a complex and challenging secondary pain condition. It is a sequela of central nervous or peripheral nervous system lesions and pathologies. It can be debilitating and affects approximately 7% of the general population. Many factors contribute to the development of this chronic neuropathic pain. It can originate from the central part of the nervous system as a result of brain or spinal cord injury, stroke, or multiple sclerosis. Peripheral neuropathic pain manifests in the peripheral nervous system, and includes large fiber and small fiber polyneuropathy, radiculopathy, and mononeuropathy. Pharmacological options include tricyclic antidepressants (TCA), serotonin and norepinephrine reuptake inhibitors (SNRI), and gabapentinoids. For more severe cases, interventional pain management techniques such as peripheral nerve blocks, spinal cord, or peripheral nerve stimulation may be reasonable options.

Online advice for the symptomatic management of post-stroke fatigue: A scoping review

Article

Sep 2022
J PSYCHOSOM RES

Background Limited medical evidence for managing post-stroke fatigue leads stroke survivors to seek information through other sources. This scoping review aimed to identify and assess the range and quality of web-based recommendations for managing post-stroke fatigue. Methods Publicly accessible websites providing advice for post-stroke fatigue management were considered for review using the Joanna Briggs Institute's methodology. Using the search term “fatigue stroke”, the first two pages of results from each search engine (Google, Yahoo, and Bing) were assessed against predetermined criteria. Findings were reported in accordance with PRISMA-ScR checklist. Quality and readability were also assessed. Results Fifty-seven websites were identified; 16 primary and 11 linked websites met the inclusion criteria and demonstrated moderate to high quality and high readability. Primary websites were curated by non-government organizations (n = 10/16), companies (n = 4/16) or were media and blog websites (n = 2/16). Additional resources were provided on linked websites . All websites provided non-pharmacological advice, with four also describing pharmacological management. Many websites included advice related to physical activity modification (n = 18/27) and energy conservation strategies (e.g. activity prioritization, planning, pacing) (n = 26/27). Direction to seek health professional advice appeared frequently (n = 16/27). Conclusions The quality of publicly available web-based advice for people with post-stroke fatigue was moderate to high in most websites, with high readability. Energy conservation strategies and physical activity modification appear frequently. . The general nature of the advice provided on most websites is supported by direction to healthcare professionals (i.e., clinical referral) who may assist in the practical individualization of strategies for managing post-stroke fatigue.

A blended eHealth intervention for insomnia following acquired brain injury: a randomised controlled trial

Article

May 2022

The high prevalence and severe consequences of poor sleep following acquired brain injury emphasises the need for an effective treatment. However, treatment studies are scarce. The present study evaluates the efficacy of blended online cognitive behavioural therapy for insomnia (eCBT‐I) developed specifically for people with acquired brain injury. In a multicentre prospective, open‐label, blinded end‐point randomised clinical trial, 52 participants with insomnia and a history of a stroke or traumatic brain injury were randomised to 6 weeks of guided eCBT‐I or treatment as usual, with a 6‐week follow‐up. The primary outcome measure was the change in insomnia severity between baseline and after treatment, measured with the Insomnia Severity Index. Results showed that insomnia severity improved significantly more with eCBT‐I than with treatment as usual compared to baseline, both at post‐treatment (mean [SEM] 4.0 [1.3] insomnia severity index points stronger decrease, d = 0.96, p < 0.003) and at follow‐up (mean [SEM] 3.2 [1.5] insomnia severity index points, d = −0.78, p < 0.03). In conclusion, our randomised clinical trial shows that blended CBT is an effective treatment for insomnia, and feasible for people with acquired brain injury, regardless of cognitive and psychiatric complaints. Online treatment has major advantages in terms of availability and cost and may contribute to the successful implementation of insomnia treatment for people with acquired brain injuries.

Intra-rater and inter-rater reliability of pressure pain threshold assessment in stroke patients

Article

Full-text available

Apr 2022
Eur J Phys Rehabil Med

Background: As pain is a common symptom following a stroke, pressure pain threshold (PPT) assessment can be used to evaluate pain status or pain sensitivity of patients. However, the reliability of PPT test in stroke patients is still unknown. Aim: To examine the intra- and inter-rater reliability of PPT measurements in post-stroke survivors and explore their factors. Design: An observational study. Setting: A rehabilitation hospital. Population: A total of 54 patients after stroke. Methods: The study included 16 measured points on the affected and unaffected sides. PPT was assessed by two raters in turn. Intra- and inter-rater reliability was evaluated by intraclass correlation coefficients (ICC). Results: All intra-rater (ICC=0.84-0.97) and inter-rater (ICC=0.83-0.95) reliability for PPT assessment were good or excellent in stroke patients. Of the 16 points, 12 showed higher intra-rater ICC values than inter-rater, whereas no evident difference was observed between the affected and unaffected sides. Furthermore, patients who were male, ischemic, or with higher motor function generally performed higher ICC values than those who were female (24 out of 32 results), hemorrhagic (28 out of 32 results), or mobility dysfunction (26 out of 32 results), respectively. Conclusions: PPT assessment with good or excellent reliability can be used in stroke patients. Neither of the two sides (affected or unaffected) affects PPT reliability, and intra-rater reliability is better than inter-rater reliability. In addition, gender, stroke type, and motor function can affect the reliability of measuring mechanical pain threshold in post-stroke survivors. Clinical rehabilitation impact: The pressure algometer can be used as a reliable and portable tool to assess the mechanical pain tolerance and sensory function in stroke patients in clinics.

Pain in individuals with intellectual disabilities

Chapter

Mar 2022

Expression of pain by individuals with intellectual and related developmental disabilities (e.g. cerebral palsy) and disorders (e.g. autism) is frequently ambiguous and its recognition by caregivers and health care providers can be highly subjective. Until the early 2000s, pain in people with intellectual disability (ID) received little scientific attention and as study participants, individuals with ID have been historically and systematically excluded from pain and related research. This chapter provides an overview of several issues inherent to assessing and managing pain among children and adults with intellectual and developmental disabilities. Acute procedural or postoperative pain management requires the same imaginative approach used in other health care settings. Among individuals where multiple medications are needed to manage a diverse number of conditions it is especially important to be aware of potential drug interactions and the potential for genetic variation in drug response and metabolism.

EXPRESS: Correlation and Difference Between Raman Spectral Characteristic and Feature Evaluation for Leukocytes and Tumor Cells

Article

Sep 2021

Background Fatigue is associated with poor functional outcomes and increased mortality following stroke. Survivors identify fatigue as one of their key unmet needs. Despite the growing body of research into post-stroke fatigue, the specific neural mechanisms remain largely unknown. Aim This observational study aimed to identify resting state brain activity markers of post-stroke fatigue. Method Sixty-three stroke survivors (22 women; age 30–89 years; mean 67.5 ± 13.4 years) from the Cognition And Neocortical Volume After Stroke study, a cohort study examining cognition, mood, and brain volume in stroke survivors following ischemic stroke, underwent brain imaging three months post-stroke, including a 7-minute resting state functional magnetic resonance imaging. We calculated the fractional amplitude of low-frequency fluctuations, which is measured at the whole-brain level and can detect altered spontaneous neural activity of specific regions. Results Forty-five participants reported experiencing post-stroke fatigue as measured by an item on the Patient Health Questionnaire-9. Fatigued compared to non-fatigued participants demonstrated significantly lower resting-state activity in the calcarine cortex ( p < 0.001, cluster-corrected p FDR = 0.009, k = 63) and lingual gyrus ( p < 0.001, cluster-corrected p FDR = 0.025, k = 42) and significantly higher activity in the medial prefrontal cortex ( p < 0.001, cluster-corrected p FDR = 0.03, k = 45). Conclusions Post-stroke fatigue is associated with posterior hypoactivity and prefrontal hyperactivity reflecting dysfunction within large-scale brain systems such as fronto-striatal-thalamic and frontal-occipital networks. These systems in turn might reflect a relationship between post-stroke fatigue and abnormalities in executive and visual functioning. This whole-brain resting-state study provides new targets for further investigation of post-stroke fatigue beyond the lesion approach.

Pervasiveness of Speech-Language Disorders and Fatigue in Stroke: A Systematic Scoping Review

Article

Aug 2021
J COMMUN DISORD

Background — After a stroke, it is highly likely that an individual will experience substantial fatigue that can significantly affect recovery and function; stroke survivors also have more than a 50% chance of having at least one speech-language disorder. Current reviews of post-stroke fatigue have not provided evidence focused on speech-language disorders or the potential influence they may have on post-stroke fatigue and related recovery. Objectives —The aim of this review was to determine how speech-language disorders are represented in post-stroke fatigue research and to catalogue methods used to identify speech-language disorders and measure fatigue. Methods — A systematic scoping review was conducted to identify studies measuring post-stroke fatigue. To identify these studies, a comprehensive literature search was conducted using relevant databases and grey literature sources, followed by several stages of review that adhered to PRISMA guidelines. We evaluated these studies using pre-established eligibility criteria and extracted data regarding the inclusion/exclusion of persons with speech-language disorders and the assessment methods used. Results —The scoping review analysis was conducted on 161 studies. Of these, 41 (26%) excluded all speech-language disorders, 71 (44%) excluded severe speech-language disorders, and 49 (30%) included participants with speech-language disorders. Of the 120 studies that did not explicitly exclude all speech-language disorders, only 34 were confirmed to report data from at least one person with a speech-language disorder. Further, only 5 studies reported data that could be used to determine a relationship between speech-language disorders and fatigue. Conclusions —Persons with speech-language disorders are underrepresented in post-stroke fatigue research and very few studies have examined the relationship between post-stroke fatigue and speech-language disorders, limiting conclusions that can be drawn. This is problematic because medical professionals relying on this evidence to guide clinical practice are likely to be treating individuals with co-occurring fatigue and speech-language disorders and the current research does not provide enough information about the potential impact of fatigue on speech-language disorders or vice versa. To bridge this gap, we suggest methods of assessment that could provide ways to more accurately 1) reflect the real population in post-stroke fatigue studies, and 2) measure and document fatigue in post-stroke speech-language disorder studies. We also propose the Filter-Funnel Model of Post-Stroke Fatigue, which considers the role of speech-language disorders and communicative demands in the context of post-stroke fatigue.

Central Pain Syndromes

Chapter

Jan 2021

Central pain (CP) is a term used to describe pain associated with an insult to the central nervous system (CNS). Clinically, it can be observed as neuropathic pain evolving or persisting in patients with neurologic complications as a result of an injury to the brain or spinal cord. There is a wide spectrum of CP-associated CNS injuries that exist resulting from vascular, infectious, demyelinating, neoplastic, or traumatic etiologies. Most commonly studied conditions associated with CP include spinal cord injury and stroke. The goal of this chapter is to review the pathophysiologic mechanisms, clinical presentation, and current treatment for CP syndromes.

Article

Aug 2020

Background Post-stroke fatigue (PSF) is one of the most common complications of stroke and has a negative impact on quality of life over time. Although several therapeutic approaches have been explored in the last decade, the risk factors responsible for the occurrence of PSF are still largely unknown.Objective The aim of this meta-analysis was to identify the risk factors contributing to PSF, especially clinical and social risk factors, which may help to prevent PSF.MethodsA systematic literature search was performed with PubMed, EMBASE, Cochrane Library, and Web of Science databases from inception until April 2019. Only original studies measuring the association between potential risk factors and PSF were included. All relevant data the included studies were extracted by two independent reviewers using predefined data fields.ResultsFourteen studies (n = 3933) were included in this meta-analysis. Female (OR = 1.39; p < 0.01), thalamus (OR = 1.76; p = 0.02), leucoaraiosis (OR = 1.73; p < 0.01), NIHSS score (OR = 1.16; p < 0.01), modified Rankin Scale (OR = 1.63; p < 0.01), depression (OR = 1.75; p < 0.01), and sleeping disturbances (OR = 2.01; p < 0.01) were all significantly associated with PSF. In the subgroup analysis, depression (OR = 2.75; p < 0.01) tended to be associated with Asian patients with PSF. For patients who had a stroke survive for more than half a year, PSF was more likely to occur in stroke survivors with depression (OR = 1.46; p < 0.01), anxiety (OR = 1.13; p < 0.01), or sleeping disturbances (OR = 1.98; p < 0.01).Conclusion Despite some limitations, this study first identified that female and depression conferred an increased susceptibility to PSF, regardless of whether in European or Asian populations. Risk factors associated with PSF included female, thalamic, leucoaraiosis, depression, sleeping disturbances, diabetes mellitus, and anxiety. This meta-analysis shows that chronic PSF appears to be largely attributable to patients with multiple comorbidities. It is necessary to strengthen the treatment for stroke-related complications and improve stroke patient care, which could help to reduce the incidence of PSF.Trial registrationCRD42019128751

Central Nervous System Pain

Chapter

May 2020

Central nervous system pain is an unpleasant emotional experience due to abnormal processing of information due to a lesion or disease affecting the processing of somatosensory information. Sensation of pain is continuously modulated at the spinal cord level by descending influences and at the brain stem and cortical levels via interconnected pain networks. Neuroplasticity is central to pathological pain, may be initiated by pathology anywhere in the CNS, and occurs at molecular, neuronal, and network levels. Common causes of CPS include central poststroke pain (CPSP), spinal cord injury, and multiple sclerosis. Central pain syndromes are difficult to diagnose as they often coexist with other types of pain and may occur months or years after the initial injury, and there is lack of a clear, widely accepted diagnostic criteria. Diagnosis requires a history consistent with central nervous system pathology and neurologic signs of abnormal pain processing such as allodynia and hyperalgesia. Medications used for treatment of CPS aim to target different pathophysiological mechanisms and include antidepressants, anticonvulsants, cannabinoids, and other drugs. Management of CPS can be challenging as patients often require combinations of medications attained through slow titration and a process of trial and error. Despite this, most patients still experience incomplete pain relief. Neuromodulatory techniques such as transcranial magnetic stimulation, spinal cord stimulation, and deep brain stimulation are promising treatments in select patients. Ultimately, management of CPS requires a multidisciplinary approach with the aggressive treatment of other causes of pain, optimal management of depression and other psychosocial factors, and use of cognitive behavioral therapy, medications, and if needed, neuromodulatory techniques.

Analgesic Use after Aneurysmal Subarachnoid Hemorrhage: A Population-Based Case-Control Study of 1,187 Patients

Article

Mar 2019

Background: The purpose of this population-based case-control study was to evaluate analgesic use after subarachnoid hemorrhage (SAH) caused by rupture of a saccular intracranial aneurysm (sIA). Methods: The study consisted of 1187 patients alive 12 months after an sIA-SAH who were admitted to Kuopio University Hospital (KUH) between 1995 and 2014. Three controls, matched with age, sex, and birthplace, were included for each patient. Data on ruptured sIA cases admitted to KUH from a defined catchment population in Eastern Finland were obtained from the KUH intracranial aneurysm database. Analgesics were classified according to the Anatomical Therapeutic Chemical Classification system. Data on analgesic medication were retrieved from the Finnish national registry of prescribed medicines of the Social Insurance Institution of Finland. Results: Among 1187 patients with sIA-SAH who were alive 12 months after admission, 83 (7.0%) commenced analgesics use within 12 months after the sIA-SAH versus 53 (1.5%) of the 3561 population controls. The results revealed significantly greater initiation rate of analgesic use among patients with sIA-SAH within a year after sIA-SAH as compared with that of matched population controls (odds ratio 5.0; 95% confidence interval 3.5-7.0; P < 0.001). Analgesic use commencement within 12 months of an sIA-SAH was independently associated with the presence of an intracerebral hematoma. Among patients, commencing analgesic use increased 11% when we compared a year before and a year after sIA-SAH. Conclusions: Our results indicate that patients with sIA-SAH had an increased risk for new pain after sIA-SAH as compared with that of matched control population.

Stroke recovery: Does one size fit all?

Article

Oct 2018

Chronic Post-Stroke Fatigue: It May No Longer Be About the Stroke Itself

Article

Sep 2018
CLIN NEUROL NEUROSUR

Objective: Post-stroke fatigue (PSF) is a debilitating complication of stroke recovery. Contributing risk factors, whether they are modifiable, and if they change over time remain understudied. We determine factors associated with PSF and how they evolve from the subacute through chronic phases of recovery. Patients and methods: A consecutive series of patients presenting to our comprehensive stroke center with acute stroke were seen in follow-up within 6 months of infarct and administered the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue scale to evaluate for PSF. It was re-administered >6 months post-infarct. Demographics, stroke characteristics (NIH Stroke Scale [NIHSS], infarct size and location), medical comorbidities, and outcomes (modified Rankin Scale [mRS]) were also recorded. Regression analyses were used to determine factors associated with FACIT scores and PSF at each time point. Results: 203 patients were administered the FACIT a mean 1.6 months post-stroke; 128 underwent re-administration (mean 13.9 months post-event). In adjusted models, stroke severity (follow-up NIHSS [p < 0.001], mRS [p = 0.005]) and posterior circulation localization (p = 0.012) were associated with lower FACIT scores (increased fatigue) in the subacute setting, while medical comorbidities (hypertension [p = 0.024], obstructive sleep apnea [p = 0.020]) and medication use (anticonvulsants [p = 0.021]) were associated with lower scores chronically. Baseline depression (p < 0.001, p = 0.029) was associated with lower scores at both time points. Conclusion: Early PSF appears to be largely attributable to stroke severity, while chronic fatigue occurs in the setting of medical comorbidities and medication use. This has significant clinical implications when considering management strategies at different stages of recovery.

Pituitary dysfunction and association with fatigue in stroke and other acute brain injury

Article

Full-text available

May 2018

Background: Poststroke fatigue (PSF) is a highly prevalent and debilitating condition. However, the etiology remains incompletely understood. Literature suggests the co-prevalence of pituitary dysfunction (PD) with stroke, and the question raises whether this could be a contributing factor to the development of PSF. This study reviews the prevalence of PD after stroke and other acquired brain injuries and its association with fatigue. Summary: We performed a bibliographic literature search of MEDLINE and Embase databases for English language studies on PD in adult patients with stroke, traumatic brain injury (TBI) or aneurysmatic subarachnoid hemorrhage (aSAH). Forty-two articles were selected for review. Up to 82% of patients were found to have any degree of PD after stroke. Growth hormone deficiency was most commonly found. In aSAH and TBI, prevalences up to 49.3% were reported. However, data differed widely between studies, mostly due to methodological differences including the diagnostic methods used to define PD and the focus on the acute or chronic phase. Data on PD and outcome after stroke, aSAH and TBI are conflicting. No studies were found investigating the association between PD and PSF. Data on the association between PD and fatigue after aSAH and TBI were scarce and conflicting and fatigue has rarely been investigated as a primary end point. Key messages: Data according to the prevalence of PD after stroke and other acquired brain injury suggest a high prevalence of PD after these conditions. However, the clinical relevance and especially the association with fatigue needs to be established.

Epidemiology

Chapter

Feb 2018

When one considers neuropathic pain globally, 6.9%–10% of the entire population is affected [1].

Article

Full-text available

Sep 1998

Musculoskeletal disorders of the upper limb and neck are a common cause of morbidity, and in some occupational groups they contribute importantly to loss of time from work.1-5Community-based surveys have indicated point prevalences of 4–20% for pain at specific sites in the neck and upper limb,6-9with lifetime prevalences as high as 60%. Morbidity surveys in primary care have found an annual incidence of first consultation for upper limb disorders of approximately 25 per 1000 person years, with rates increasing from 25 to 45 years of age and then levelling off.10 Upper limb pain may arise from discrete pathological conditions, such as adhesive capsulitis, rotator cuff tendinitis, lateral epicondylitis, and tenosynovitis, or as part of non-specific regional pain syndromes. However, few community surveys have included a clinical examination as an integral component, to enable a distinction to be drawn between these very different categories of disorder. Furthermore, the relative contribution of specific and non-specific rheumatic disorders of upper limb and neck to handicap from occupational and leisure activities is not clear (despite the fact that the risk factors may vary substantially between the two groups). As table 1 illustrates, investigations have differed in their choice of age range, source population, prevalence period, and …

The long-term outcome of arm function after stroke: Results of a follow-up study

Article

Full-text available

Sep 1999

To assess the long-term motor and functional recovery of arm function after stroke. Cohort study. Fifty-four patients with a first stroke, who underwent inpatient rehabilitation, were measured early after stroke, after 16 weeks and after 4 years. Fugl-Meyer Motor Assessment (FM, upper extremity), Action Research Arm Test (ARA), Barthel Index, Arm Function Questionnaire, shoulder pain and range of motion, sensory function, Ashworth Scale and a perceived problem score. Although most of the improvement occurred during the first 16 weeks after stroke, improvement in the FM score continued after 16 weeks in 10 patients. In 13 patients the recovery of arm function only started after 16 weeks. After 4 years a fair to good recovery of arm motor function (FM score > 20) was found in 31 patients. Twenty-seven patients had fair to good functional abilities of the hemiplegic arm (ARA > 25). Submaximal ARA scores for the unaffected arm were found in 11 patients. Barthel scores > 60 were found in 52 patients. Serious shoulder pain persisted in 11 patients. Intact sensory function was found in only 14 patients. It was associated with good motor recovery (FM score > 35 in 11 patients). Loss of arm function was perceived as a major problem by 36 patients. This is the first study to investigate the recovery of arm function after stroke over a period of 4 years. It is encouraging to note that even after 16 weeks improvement still occurred in some patients. However, considerable long-term loss of arm function, associated disability and perceived problems were found. There is an obvious need to develop effective treatment methods for hemiplegic arm function.

Medical management of spasticity in stroke

Article

Full-text available

Apr 2001

Michael P Barnes

Fatigue after Stroke: A Major but Neglected Issue

Article

Full-text available

Sep 2001

Subjective fatigue, defined as a feeling of early exhaustion developing during mental activity, with weariness, lack of energy and aversion to effort, remains virtually unstudied in patients with stroke, bur recent surveys suggest that it is a major, commonly overlooked, stroke sequela. While the few existing series did not show significant correlations between fatigue and stroke severity, lesion location, cognitive and neurological impairment and depression, recent neurobehavioral studies have highlighted an association between fatigue and brainstem and thalamic lesions. This suggests that fatigue may be linked to the interruption of neural networks involved in tonic attention, such as the reticular activating system. In fact, several subtypes of fatigue may develop after stroke, in connection with cognitive sequelae, neurological impairment, psychological factors and sleep disorders. A challenge is to identify and delineate these different subtypes and to distinguish them from mood disorders, which frequently coexist. We emphasize the concept of 'primary' poststroke fatigue, which may develop in the absence of depression or a significant cognitive sequela, and which may be linked to attentional deficits resulting from specific damage to the reticular formation and related structures involved in the subcortical attentional network. In the patients with excellent neurological and neuropsychological recovery, poststroke fatigue may be the only persisting sequela, which may severely limit their return to previous activities. The recognition of poststroke fatigue may be critical during recovery and rehabilitation after stroke.

Snoring, daytime sleepiness and stroke: A case-control study of first-ever stroke

Article

Full-text available

Jan 2004

Previous reports have shown an association between snoring and stroke but it is not clear whether this reflects confounding factors nor whether the association is attributable to obstructive sleep apnoea (OSA). We performed a case-control study of 181 patients admitted to hospital with first-ever stroke and community control subjects matched individually for age, sex and general practitioner. Subjects were interviewed with a structured questionnaire to identify snoring, daytime sleepiness and stroke risk factors. The association between snoring alone and stroke was not statistically significant: odds ratio (95% CI) 1.44 (0.88, 2.41). Daytime sleepiness was, however, significantly associated with stroke: odds ratio 3.07 (1.65, 6.08). Multiple logistic regression showed that hypertension, current smoking, taking alcohol regularly (negatively) and a higher Epworth sleepiness score were independently associated with stroke. The results suggest that the previously reported association between 'simple' snoring and stroke might have been due to poor controlling for confounding variables. Our study suggests an association with greater sleepiness prestroke, the cause of which is unclear, although OSA is a possible candidate.

“Mini-Mental State”. A practical method for grading the cognitive state of patients for the clinician

Book

Dec 1975
J PSYCHIATR RES

The relationship between adult hemiplegic shoulder pain and depression

Article

Jan 1982

This paper addresses the problem of the high incidence of upper extremity pain in the hemiplegic patient. The lack of knowledge regarding the etiology of this condition is discussed and the question raised as to its relationship to the psychological factor of depression. A study was designed to explore the relationship between these factors. Twenty-six patients with hemiplegia were tested for their level of depression, using the Zung Depression Scale. A subjective assessment of mood was made by the treating physiotherapists, who also assessed upper extremity pain. Auxiliary evaluations of spasticity and of the degree of subluxation of the glenohumeral joint were made. The diagnosis of shoulder-hand syndrome, when present, was also recorded. Data were analyzed by computer. Depression, as assessed by the physiotherapists, was found to have a statistically significant relationship with pain. It was concluded that further study using improved methods to assess the major factors of pain and depression is needed. Such methods should be designed specifically for stoke patients.

Le syndrome thalamique

Article

Joseph Jules DEJERINE

Hemiplegic Shoulder Pain

Article

Jan 1987

Judy W Griffin

This article reviews the literature relevant to the possible causes, prevention, and treatment of hemiplegic shoulder pain. Shoulder pain and stiffness impede the rehabilitation of patients with hemiplegia. The cause of this complication is unknown, but it may be related to the severity of neurological deficits, preexisting or posthemiplegic soft tissue injury, subluxation, brachial plexus injury, or shoulder-hand syndrome. Shoulder pain may be preventable if risk factors can be identified and appropriate prophylaxis applied. Resolution of the condition depends on diagnosis and effective treatment at the onset of the symptoms. More clinical research is needed to clarify the cause of hemiplegic shoulder pain and to document the efficacy of prophylactic and treatment methods.

Central post-stroke pain—Neurologic symptoms and pain characteristics

Article

Feb 1989

The intention of the present study was to characterize patients with central post-stroke pain (CPSP) with regard to type and location of the cerebrovascular lesion (CVL), the characteristics of the pain and the neurological symptoms and signs in addition to the pain. Twenty men and 7 women with a mean age of 67 years and a mean pain duration of 44 months were examined 9-188 (mean 53) months after their stroke. The clinical symptoms and signs and the CT scans indicated that the CVL were located in the lower brain-stem in 8 patients, involved the thalamus in 9 patients and were located lateral and superior to the thalamus in 6 patients. In the remaining 4 patients the location of the CVL could not be determined with certainty. The 3 identified hematomata were all located in the thalamus. The onset of the pain was immediate in 4 patients, within the first post-stroke months in 10 patients and delayed by 1-34 months in the rest. The pain was on the left side in 18 patients. Twenty patients had hemipain. Most patients experienced more than one type of pain. The most common qualities were burning, aching, pricking and lacerating, with some differences in the frequencies according to the location of the CVL. Burning pain was most common, except among the patients with thalamic CVL, in whom lacerating pain was more common. Aching and pricking pain were also frequent. All patients considered the pain to be a great burden and most rated the pain intensity as high on a visual analogue scale. The intensity was increased by external stimuli, the most common being joint movements, cold and light touch. Five patients reported aggravation by emotional stimuli. Besides pain, the only neurological symptom common to all patients was decreased temperature sensibility, as shown by quantitative methods. It is possible that pain sensibility was also abnormal in all. Hypersensitivities to cutaneous stimuli, including evoked dysesthesias were found in 88% of the patients, while the detection thresholds for touch and vibration were abnormal in only 52% and 41%, respectively. Similarly, low figures were found for paresis and ataxia, which were present in 48% and 62%, respectively. It is concluded that only a minority of patients with central pain after stroke have thalamic lesions.(ABSTRACT TRUNCATED AT 400 WORDS)

Interobserver Agreement for the Assessment of Handicap in Stroke Patients

Article

Jun 1988

Interobserver agreement for the assessment of handicap in stroke patients was investigated in a group of 10 senior neurologists and 24 residents from two centers. One hundred patients were separately interviewed by two physicians in different combinations. The degree of handicap was recorded by each observer on the modified Rankin scale, which has six grades (0-5). The agreement rates were corrected for chance (kappa statistics). Both physicians agreed on the degree of handicap in 65 patients; they differed by one grade in 32 patients and by two grades in 3 patients. Kappa for all pairwise observations was 0.56; the value for weighted kappa (with quadratic disagreement weights) was 0.91. Our results confirm the value of the modified Rankin scale in the assessment of handicap in stroke patients; nevertheless, further improvements are possible.

Diffuse cerebral symptoms in convalescents from cerebral infarction and myocardial infarction

Article

Jul 1983

Ole Fevejle Leegaard

In order to evaluate occurrence and cause of a number of diffuse cerebral symptoms (DCS), such as impaired memory, inability to concentrate, emotional instability, irritability, etc., 44 survivors of cerebral infarction (CI) and 40 survivors of myocardial infarction (MI) were seen 6-26 months after onset for psychometric testing and an interview about DCS. Although surprisingly common in both groups, DCS were significantly more frequent in CI patients than in MI patients. 1/2 of the former and 1/3 of the latter complained of 5 or more symptoms. In contrast, a significant difference in test performance was demonstrated in only 1 of 4 tests. There was no significant correlation between the number of DCS and test performance. In both groups, DCS occurrence was independent of age, whereas in the MI group, but not in the CI group, test performance was inversely related to age. In the CI group, DCS occurrence was not significantly related to size or site of the infarction. The results indicate that an organic brain damage cannot be the sole cause of DCS, and it is suggested that some of the symptoms are manifestations of a stress response syndrome provoked by insufficient coping with the consequences of the disease.

Adams HP, Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE, TOAST InvestigatorsClassification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke 24:35-41

Article

Feb 1993

The etiology of ischemic stroke affects prognosis, outcome, and management. Trials of therapies for patients with acute stroke should include measurements of responses as influenced by subtype of ischemic stroke. A system for categorization of subtypes of ischemic stroke mainly based on etiology has been developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST). A classification of subtypes was prepared using clinical features and the results of ancillary diagnostic studies. "Possible" and "probable" diagnoses can be made based on the physician's certainty of diagnosis. The usefulness and interrater agreement of the classification were tested by two neurologists who had not participated in the writing of the criteria. The neurologists independently used the TOAST classification system in their bedside evaluation of 20 patients, first based only on clinical features and then after reviewing the results of diagnostic tests. The TOAST classification denotes five subtypes of ischemic stroke: 1) large-artery atherosclerosis, 2) cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. Using this rating system, interphysician agreement was very high. The two physicians disagreed in only one patient. They were both able to reach a specific etiologic diagnosis in 11 patients, whereas the cause of stroke was not determined in nine. The TOAST stroke subtype classification system is easy to use and has good interobserver agreement. This system should allow investigators to report responses to treatment among important subgroups of patients with ischemic stroke. Clinical trials testing treatments for acute ischemic stroke should include similar methods to diagnose subtypes of stroke.

Improved reliability of the NIH stroke scale using video training. NINDS TPA Stroke Study Group

Article

Nov 1994

Despite the frequent use of clinical rating scales in multicenter therapeutic stroke trials, no generally acceptable method exists to train and certify investigators to use the instrument consistently. We desired to train investigators to use the National Institutes of Health Stroke Scale in a study of acute stroke therapy so that all examiners rated patients comparably. We devised a two-camera videotape method that optimizes the visual presentation of examination findings. We then measured the effectiveness of the training by asking each investigator to evaluate a set of 11 patients, also on videotape. We tabulated the evaluations, devised a scoring system, and calculated measures of interobserver agreement among the participants in this study. We trained and certified 162 investigators. We found moderate to excellent agreement on most Stroke Scale items (unweighted kappa > 0.60). Two items, facial paresis and ataxia, exhibited poor agreement (unweighted kappa < 0.40) and should be revised in future editions of the scale. Performance improved with video training compared with previous studies. Inclusion of the motor rating of the unaffected limbs in the total score did not affect reliability. Video training and certification is a practical and effective method to standardize the use of examination scales. Two cameras must be used during the taping of patients to accurately present the clinical findings. This method is easily adapted to any study in which a large number of investigators will be enrolling patients at multiple clinical centers.

Experience with a Swedish version of the Geriatric Depression Scale in Primary Care Centres

Article

Nov 1997

The purpose of this study was to use a Swedish version of the Geriatric Depression Scale (GDS-20) for diagnosis of depression in the elderly in primary care. Elderly consecutive patients visiting two primary care centres (> or = 65 years of age; N = 1189) were rated by educated nurses using the GDS-20. All elderly patients attending two primary care centres in an urban-based community in the south of Sweden. Of the 1189 patients interviewed, 1002 were rated using the GDS-20. The GDS-20, and in 26 patients also the Geriatric Mental State Schedule--Depression Scale (GMSS-DS). Of 1002 rated patients, 93 had scores of 5 or above on the GDS-20. Further analysis showed that 158 (13.3%) suffered from affective disorders. Depression in the elderly is underdiagnosed in primary care centres. A screening instrument such as the GDS-20 is of value in identifying the patients.

Fatigue after stroke

Article

Mar 1999
ARCH PHYS MED REHAB

To determine the frequency and outcome of fatigue, its impact on functioning, and its relationship with depression in patients 3 to 13 months poststroke. Survey. Community. Eighty-eight individuals from a pool of 181 consecutive patients previously admitted to an acute stroke service who were willing and able to complete the self-report questionnaires, and 56 elderly controls living independently in the community. Fatigue Impact Scale (a self-report measure of the presence and severity of fatigue and its impact on cognitive, physical, and psychosocial functions) and the Geriatric Depression Scale. The frequency of self-reported fatigue problems was greater in the stroke group (68%) than in the control group (36%, p < .001) and was not related to time poststroke, stroke severity, or lesion location. Forty percent of the stroke group reported that fatigue was either their worst or one of their worst symptoms. Patients attributed more functional limitations to their fatigue than did control subjects with fatigue. Although the presence of fatigue was independent of depression, the impact of fatigue on functional abilities was strongly influenced by depression. Fatigue can contribute to functional impairment up to 13 months after stroke, and its recognition and treatment are important for maximizing recovery.

Central post-stroke ('thalamic syndrome') and other central pains

Article

Jul 1999

David Bowsher

Experience of Severe Fatigue Long after Stroke and Its Relation to Depressive Symptoms and Disease Characteristics

Article

Feb 2001

Although the experience of abnormal fatigue is recognised as a major disabling symptom in many chronic neurological diseases, little is known about the persistence of severe fatigue after an abrupt neurological incident like a stroke. Therefore, the objectives of this study were to test whether the experience of severe fatigue persists long after a stroke has occurred, and to assess the relation between experienced fatigue and levels of physical impairment and depression. Ninety stroke outpatients and 50 controls returned mailed questionnaires. Compared to age-matched controls, a significantly larger proportion (16 vs. 51%) of the stroke respondents experienced severe fatigue, while 20% of the patients and 16% of the controls had elevated depression symptom scores. The time which had elapsed since the stroke occurred could not explain levels of fatigue. In the control group, the number of depressive symptoms explained most of the variance in levels of fatigue, while impairment of locomotion explained most of the variance in the stroke group.

Treating depression in old age: The reasons to be positive

Article

Feb 2001

David N. Anderson

Depression affects 10-15% of people over 65 living at home in the United Kingdom. It is the commonest and the most reversible mental health problem in old age. Depression is associated with physical illness and disability, life events, social isolation and loneliness. Depression in old age carries an increased risk of suicide and natural mortality. Recognition and simple intervention can reduce morbidity, demand on health and social services and the cost of community care. Despite a favourable response to treatment, depression remains largely undetected and untreated.

Poststroke Fatigue A 2-Year Follow-Up Study of Stroke Patients in Sweden

Article

Jun 2002
STROKE

Fatigue is common among stroke patients. This study determined the prevalence of fatigue among long-term survivors after stroke and what impact fatigue had on various aspects of daily life and on survival. This study was based on Riks-Stroke, a hospital-based national register for quality assessment of acute stroke events in Sweden. During the first 6 months of 1997, 8194 patients were registered in Riks-Stroke, and 5189 were still alive 2 years after the stroke. They were followed up by a mail questionnaire, to which 4023 (79%) responded. Patients who reported that they always felt depressed were excluded. To the question, "Do you feel tired?" 366 (10.0%) of the patients answered that they always felt tired, and an additional 1070 (29.2%) were often tired. Patients who always felt tired were on average older than the rest of the study population (74.5 versus 71.5 years, P<0.001); therefore, all subsequent analyses were age adjusted. Fatigue was an independent predictor for having to move into an institutional setting after stroke. Fatigue was also an independent predictor for being dependent in primary activities of daily living functions. Three years after stroke, patients with fatigue also had a higher case fatality rate. Fatigue is frequent and often severe, even late after stroke. It is associated with profound deterioration of several aspects of everyday life and with higher case fatality, but it usually receives little attention by healthcare professionals. Intervention studies are needed.

Predictors of Severe Stroke Influence of Preexisting Dementia and Cardiac Disorders

Article

Nov 2002
STROKE

There is little research into the impact of prestroke dementia on stroke severity and short-term mortality. We included prestroke dementia, along with other risk factors, to determine independent predictors of stroke severity and early death in a community-based stroke study. All patients (n=377) with a first-ever stroke were evaluated in terms of risk factors. Registration took place over a 12-month period. Stroke severity was evaluated with the National Institutes of Health Stroke Scale. Predictors of severe stroke and early death were analyzed in logistic regression models. The following independent variables were used: age, sex, living alone, arterial hypertension, ischemic heart disease, heart failure, atrial fibrillation, diabetes mellitus, transient ischemic attack, cigarette smoking, peripheral atherosclerosis, and dementia. Risk factors for stroke were found in 82% of the patients. Heart failure, atrial fibrillation, and dementia were associated with more severe strokes. Dementia, atrial fibrillation, heart failure, and living alone were associated with death within 28 days of the event. These results raise the question of whether certain high-risk patients, ie, patients with atrial fibrillation, heart failure, and dementia, can benefit from more aggressive primary and secondary stroke prevention measures.

High Incidence Rates of Stroke in Örebro, Sweden: Further Support for Regional Incidence Differences within Scandinavia

Article

Feb 2002

As a basis for comparison of differences in stroke incidence in Scandinavian countries, a community-based stroke register was established in Orebro in the centre of Sweden. All first-ever cases of stroke were registered during a 12-month period 1999-2000. The study population was 123,503. The WHO definition of stroke was used. Cases were searched inside as well as outside hospital. Multiple overlapping sources and 'hot pursuit' technique were used in the process of case ascertainment. 388 cases of first-ever stroke were found, corresponding to a crude incidence rate of 314 (95% CI, 283-348) per 100,000 per year, 337 (95% CI, 294-386) for females, and 289 (95% CI, 248-336) for males. Adjusted to the European population, the corresponding rates were 254 (95% CI, 227-284) per 100,000 per year, 273 (95% CI, 238-311) for females and 232 (95% CI, 206-261) for males. The overall 28-day case-fatality rate was 19% (95% CI, 15-23). The case-fatality rates for the different subtypes of stroke were as follows: brain infarction, 10%; intracerebral haemorrhage, 20%; subarachnoidal haemorrhage 45%, and undetermined pathological type 56%. The present study as well as other studies in northern and middle Scandinavia show significantly higher incidence rates than studies from other regions. The crude incidence rate, reflecting the age distribution of the population, is even higher, indicating a burden to the community that is rather increasing than decreasing.

Poststroke shoulder pain: A prospective study of the association and risk factors in 152 patients from a consecutive cohort of 205 patients presenting with stroke

Article

Feb 2002

Shoulder pain is known to retard rehabilitation after stroke. Its causes and prognosis are uncertain. This study describes the incidence of poststroke shoulder pain prospectively, in an unselected stroke population in the first 6 months after stroke and identifies risk factors for developing pain. 297 patients with possible stroke were screened and stroke diagnosed in 205 cases. The 152 patients entered the study of which 123 patients were assessed up to 6 months. This cohort, with a mean age of 70.6 years, was examined at 2 weeks, 2, 4, and 6 months. A history of shoulder pain, Barthel score, anxiety and depression score were recorded. Full neurological and rheumatological examination was undertaken, using the contralateral side as a control. Pain outcome and stroke outcome was recorded at subsequent visits. 52 (40%) patients developed shoulder pain on the same side of their stroke. There was a strong association between pain and abnormal shoulder joint examination, ipsilateral sensory abnormalities and arm weakness. Shoulder pain had resolved or improved at 6 months in 41 (80%) of the patients with standard current treatment. Shoulder pain after stroke occurred in 40% of 123 patients surviving, consenting and not too unwell to participate. This included 52 patients of an original cohort of 205 patients presenting with stroke. Eighty percent of patients made a good recovery with standard treatment Patients with sensory and or motor deficits represent at risk sub-groups.

Sleep Apnea and Other Sleep-Wake Disorders in Stroke

Article

Jun 2003

Sleep-disordered breathing (SDB) and sleep-wake disturbances (SWD) are frequent in stroke patients. They deserve attention, because they may significantly influence rehabilitation process and functional outcome. In addition, SDB may increase the risk of stroke recurrence. More than 50% of stroke patients have SDB, mostly obstructive sleep apnea (OSA). In some patients, stroke recovery is accompanied by an improvement of SDB. The treatment of choice for OSA is continuous positive airway pressure. Oxygen, theophylline, and other forms of ventilation may be helpful in patients with other forms of SDB (eg, Cheyne-Stokes breathing). In at least 20% to 40% of stroke patients, SWD are present, mainly in form of increased sleep needs (hypersomnia), excessive daytime sleepiness, or insomnia. Depression, anxiety, SDB, stroke complications (eg, nocturia, dysphagia, and urinary or respiratory infections), and drugs may contribute to SWD and should be addressed first. In patients with SWD of primary neurologic origin, treatment with stimulants or dopaminergic drugs and hypnotics or sedating antidepressants, respectively, can be attempted.

Post-stroke pain case study: Clinical characteristics, therapeutic options and long-term follow-up

Article

May 2004

Per Hansson

Central post-stroke pain (CPSP) is a syndrome characterized by sensory disturbances and neuropathic pain. In 40%-60% of CPSP patients, the onset of central pain following a stroke occurs more than 1 month after the stroke, creating a source of diagnostic uncertainty or significant delay in treatment since healthcare providers familiar with CPSP may no longer be caring for the patient when the symptoms occur. In addition to chronic pain, the presence of somatosensory abnormalities is the most important diagnostic corollary of CPSP. Neuropathic or central pain has been estimated to occur in up to 8% of patients after a stroke, and about 18% of stroke patients with a somatosensory disturbance will develop CPSP. Although largely a matter of conjecture, it is generally agreed that damage to spinothalamic sensory pathways plays a significant role in the pathogenesis of CPSP. A comprehensive examination of the patient for sensory deficits is essential before treatment can be initiated. Functional disturbances such as depression, anxiety and sleep disturbances are significant comorbid conditions associated with CPSP; the physician should incorporate an assessment of these potential comorbidities into the examination. Treatment options for CPSP are limited; at present, amitriptyline is the drug of first choice. Other drugs including antidepressants, anticonvulsants, antiarrhythmics, opioids and N-methyl-d-aspartate antagonists may provide relief for some patients who do not respond to amitriptyline. Included in this review is a case study outlining the challenges of managing the patient with CPSP.

Article

Jun 2004

No study has, to our knowledge, previously been published on health-related quality of life (HRQoL) in a group suffering from long-term pain after a stroke. The aim of the present study was to describe HRQoL in persons with long-term pain after a stroke, and to compare this with different types of pain conditions, age, gender and household status. This study has a design combining qualitative and quantitative methods. Forty three participants suffering from long-term pain after a stroke were included. A qualitative interview was performed and then analysed by means of latent content analysis. In addition, two self-report questionnaires, SF-36 and the Hospital Anxiety and Depression Scale (HAD Scale), were used. The qualitative data revealed that physical and cognitive functioning, economic security and good relationships, support and having the ability to be together with family and friends were important factors with regard to experienced HRQoL. No significant differences were found in SF-36 and the HAD Scale with regard to the different types of pain. The older age group had decreased physical functioning in SF-36. The men had more decreased vitality than the women. The results show, that the participants in this study have a lower HRQoL due to their long-term pain than those in previous studies on stroke survivors. It is evident that further research is needed with longitudinal studies and larger populations to gain more knowledge and thereby provide better supportive care. Awareness and understanding of the patients' perceptions and transitions with regard to their life situation and suffering from long-term pain after a stroke is important in order to support a maintained or increased HRQoL. This is also important after the acute stage and rehabilitation, including quality of life of the relatives, especially to older and dependent persons.

Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment

Jan 1993
35

Adams

Experience with a Swedish version of the Geriatric Depression Scale in primary care centres

Jan 1997
1029

Gottfries

Prevalence and predictors of pain and fatigue after stroke: A population-based study

Abstract

No full-text available

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