Fatigue after stroke.

OBJECTIVES: To examine the phenomenon of fatigue after stroke and to review the knowledge about frequency, consequences, associated factors, physiopathology and treatment. MATERIALS AND METHOD: Medline was systematically searched with the following keywords: stroke, fatigue, sleep disorders, exercise, and rehabilitation. All relevant articles found in the references were screened as well. RESULTS AND DISCUSSION: Fatigue is a common complaint after stroke and occurs in 39-72% of stroke survivors. Some studies show a severe functional impact of this symptom as well as a high mortality rate. Available evidence concerning associated factors is limited, but fatigue is clearly multifactorial. Some studies show that limited exercise capacity, increased gait energy cost, sleep-disordered breathing and sleep disorders can be related to physical fatigue. Other studies show a link between fatigue and depression. The existence of primary fatigue is still controversial. Treatment must follow a diagnostic approach. Treadmill training, among other treatments, improves fitness reserve and lowering of the energy cost of hemiparetic gait, which could be useful in relieving fatigue.     

The therapeutic effect of functional and transcutaneous electric stimulation on improving gait speed in stroke patients: a meta-analysis

OBJECTIVE: To determine the effect of previous treatments of functional electric stimulation (FES) and transcutaneous electric stimulation (TENS) on improving gait speed in subjects poststroke. DATA SOURCES: Relevant articles were obtained through a search of English-language articles cited in Medline, EMBASE, CINHAL, and PubMed databases from January 1966 to May 2005. STUDY SELECTION: Prospective clinical studies were included if electric stimulation was used to treat subjects poststroke and gait speed was used as an outcome measure. Excluded studies examined subjects with a variety of neurologic conditions, used implantable electrodes, or combined electric stimulation with treadmill training. A paired consensus between authors produced 8 articles. DATA EXTRACTION: Two investigators extracted data independently. The methodologic quality of the studies was assessed with the Downs and Black checklist. DATA SYNTHESIS: A fixed-effects model produced a mean difference (.18; 95% confidence interval, .08-.28) that was significant (z=3.65, P<.01), indicating the effectiveness of FES treatment at increasing gait speed in subjects poststroke. The effect sizes of the studies ranged from -.11 to 1.43 for FES and .19 to .42 for TENS. The type of FES and TENS devices, location of electrodes, amount of exposure, and subjects' stages of recovery varied between the studies. CONCLUSIONS: FES is effective at improving gait speed in subjects poststroke. Future research should examine the effectiveness of practical and readily available FES units to improve function in subjects in the subacute stages of recovery from a stroke. These studies should attempt to use a randomized controlled design with blinding and standardized outcome measures.     

Abnormal bone and calcium metabolism in patients after stroke

OBJECTIVE: To review how mineral stores and endocrine factors affect bone mass in poststroke patients immobilized by hemiparesis. DATA SOURCES: Computer databases and published indexes. STUDY SELECTION: Case-control studies of hemiparetic poststroke patients examined regarding bone metabolism. DATA EXTRACTION: References were obtained from MEDLINE; all data concerning the objective were used. DATA SYNTHESIS: Bone loss occurs in affected extremities after stroke. Immobilization from hemiplegia causes hypercalcemia. Insufficiency or deficiency of 25-hydroxyvitamin D (25-OHD) is very common in stroke patients and may be caused by poor dietary intake, decreased sunlight exposure, or both. Compensatory hyperparathyroidism may not occur because hypercalcemia inhibits the parathyroid glands even when 25-OHD is in the insufficient range. However, hyperparathyroidism does occur when 25-OHD is in the deficient range, in which case the parathyroid response to hypovitaminosis D overrides effects of hypercalcemia. Increased bone resorption was observed during the first year after stroke, declining to normal during the second year. During the first year, determinants of bone mineral density (BMD) in hands affected by hemiplegia were age, severity of hemiplegia, duration of paralysis, serum calcium concentration, and 25-OHD concentration. In the second year, BMD determinants on the hemiplegic side were severity of hemiplegia and 25-OHD concentration, whereas 25-OHD concentration was the only BMD determinant on the intact side. Administering 1alpha-hydroxyvitamin D3, vitamin K2, or ipriflavone ameliorated osteopenia on both sides and decreased the frequency of hip fracture on the hemiplegic side. CONCLUSIONS: Bone remodeling and determinants of bone mass for the affected and unaffected sides after stroke differ between the first and subsequent years.     

Central and peripheral contributions to neuromuscular fatigue in people with stroke

Abstract

Objective: To evaluate the evidence for neuromuscular fatigue following stroke and to consider the implications of the findings for clinical practice and future research.

Methods: A search of Ebsco Health and Ovid electronic search engines was undertaken using key search terms. In addition, the reference lists of pertinent articles were screened for other relevant articles.

Results: A total of five relevant research papers were identified for review.

Discussion: There is physiological evidence to suggest that changes in the development of neuromuscular fatigue are likely to occur in both the nervous system (central neuromuscular fatigue) and muscle (peripheral neuromuscular fatigue) following stroke. Based on the experimental research available it may be asserted that people with stroke fatigue differently from control participants, however, the source of these differences remains unclear. There are indications of a relative reduction in the amount of peripheral neuromuscular fatigue, and an increase in the amount of central neuromuscular fatigue, experienced by people following stroke. However, the validity of protocols for measuring fatigue in pathological populations can be questioned. Further elucidation of the presence, extent and cause of neuromuscular fatigue through experimental research, and consideration of neuromuscular fatigue during the rehabilitation process, is warranted.     

Management of diabetes during acute stroke and inpatient stroke rehabilitation

OBJECTIVES: To summarize evidence on the impact of hyperglycemia on stroke outcomes and to present therapy algorithms for inpatient management in diabetic stroke patients. DATA SOURCES: Guidelines for inpatient management of diabetes were reviewed and extracted from a technical review and recommendations from 2 national diabetes and endocrine organizations. MEDLINE database searches were conducted using key words: stroke, diabetes, hyperglycemia, hypoglycemia, inpatient, hospitalized, treatment, outcomes, disability, self-management, and education. STUDY SELECTION: Studies were selected that specifically addressed the impact of the following in stroke patients: hyperglycemia and diabetes on rehabilitation outcomes, management strategies for hyperglycemia and diabetes, and strategies for facilitating diabetes self-management. DATA EXTRACTION: Two authors independently extracted data and management practices from selected articles and published practice guidelines. DATA SYNTHESIS: Diabetes is prevalent in stroke patients and results in poorer inpatient hospital and rehabilitation outcomes. Management of diabetes in stroke patients is further complicated by impairments in mobility and vision, necessitating accommodation strategies and tools for self-management. Optimal management of hyperglycemia using insulin or oral hypoglycemic agents results in reduced morbidity and mortality among diabetic inpatients. CONCLUSIONS: To achieve inpatient glycemic management targets, use of clinical management algorithms, self-management tools, and systems approaches such as diabetes management teams are useful.     

Brief assessment of cognitive impairment in patients with stroke

The Stroke Unit Mental Status Examination (SUMSE) has been developed to provide a reliable poststroke test of cognitive functioning that may be administered at bedside. SUMSE was designed to assess major cognitive disorders caused by stroke (eg, language disorders, visuoperceptual deficits, and memory disorders) while avoiding, as much as possible, reliance on patients' English language skills and motor movements. SUMSE's reliability and validity were evaluated by administering it to patients on a stroke rehabilitation unit in conjunction with already validated tests. The results indicated that SUMSE has the potential to become a useful tool for the bedside assessment of mental impairment in stroke patients.     

脑卒中后抑郁

目的近年来,虽然脑卒中的治疗方法进展很快,但脑卒中后抑郁的发生率高达40%左右.脑卒中后抑郁可影响脑卒中患者神经功能的恢复.因此,认识脑卒中后抑郁有利于脑卒中患者生活质量的提高.资料来源应用网络www.google.com,Medline检索近5年内中国医学核心期刊及国外有关脑卒中后抑郁研究的相关文献,检索词脑卒中,抑郁,发生率,相关因素.资料选择选择有关脑卒中后抑郁的实验研究及临床研究等相关文献42篇,排除非随机研究原著性文献,未排除非盲法研究原著的文献.资料提炼在42篇文献中,内容有不同程度重复的有10篇,给予删除;对32篇文献进行分类整理,其中10篇选用为参考文献.资料综合脑卒中后抑郁的发生率为40%左右,是社会、心理、生物因素共同作用的结果.一般认为,抑郁发生的高危期为脑卒中后一两年,脑卒中后抑郁病程不一.恢复期神经功能缺损程度受脑卒中后抑郁的影响,中重度抑郁可延迟神经功能恢复,脑卒中后抑郁还可导致患者日常生活活动能力恢复差,影响患者的认知功能,增加痴呆的发生率.从临床观察而言,脑卒中后抑郁的治疗已取得明显进展.结论脑卒中后抑郁的发病率较高,其与多种因素有关.脑卒中后抑郁对神经功能、认知功能及日常生活能力等会产生不良影响.积极的干预与治疗,对降低脑卒中后抑郁的发病率有一定作用.     

Fatigue after stroke

OBJECTIVE: To determine the frequency and outcome of fatigue, its impact on functioning, and its relationship with depression in patients 3 to 13 months poststroke. DESIGN: Survey. SETTING: Community. PARTICIPANTS: 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. MAIN OUTCOME MEASURES: 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. RESULTS: 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. CONCLUSION: Fatigue can contribute to functional impairment up to 13 months after stroke, and its recognition and treatment are important for maximizing recovery.     

Diagnosis of stroke in young adults

The cause of stroke in a young adult can usually be ascertained with proper workup. One of the most common causes is atherosclerotic cerebrovascular disease, and cigarette smoking is an important risk factor in young adults. Several types of nonatherosclerotic cerebral vasculopathy can also result in premature cerebral infarction; these include cervicocephalic arterial dissection, nonpenetrating traumatic arterial disease, moyamoya disease, fibromuscular dysplasia, vasculitis, and migraine. Cardiac embolism may play a more important role than was previously thought, and hematologic disorders (eg, sickle cell disease, polycythemia rubra vera, coagulation problems) are known to predispose patients to stroke. A careful history of risk factors and a thorough neurologic and cardiovascular examination followed by adequate testing, including angiography, are essential to diagnosis.     

初发脑梗死后失眠患病率及相关因素分析

目的：探讨初发脑梗死后失眠的发病情况及相关影响因素。方法：纳入脑梗死患者150例,采用匹兹堡睡眠质量指数（PSQI）、改良Barthel指数（MBI）、神经功能缺损程度评分（NDS）、汉密尔顿焦虑量表（HAMA）及汉密尔顿抑郁量表（HAMD）进行测评,并以PSQI量表总分〉7分作为判断失眠的标准。分析卒中患者失眠的类型及特点;分析失眠在不同类型人群中发生率的差异,筛选影响因素;分析失眠患者与非失眠患者各量表评分的差异。结果：150例患者中,73例（48.67%）发生失眠,失眠的形式以入睡困难、早醒、睡眠维持困难为主。失眠的发生率与性别、卒中部位、临床神经功能缺损程度、日常生活能力、精神状态关系密切。失眠患者在神经功能缺损程度、焦虑和抑郁程度方面较非失眠患者严重（P〈0.05）,日常生活能力较低（P〈0.05）。结论：初发缺血性脑卒中患者失眠的发生率较高,影响因素有性别、卒中的部位、生活能力、神经功能缺损程度及精神状态。     

卒中后睡眠障碍

睡眠障碍是卒中患者的常见并发症,包括日间嗜睡、失眠、异态睡眠、发作性睡病、昼夜节律紊乱、睡眠相关运动障碍及睡眠呼吸障碍。卒中后睡眠障碍的发生与多种因素有关,包括神经生物学因素及社会心理学因素。本文就卒中后睡眠结构变化、睡眠障碍的表现形式、流行病学及其病理生理机制做一综述。     

Epidemiologic features,risk factors,and outcome of sepsis in stroke patients treated on a neurologic intensive care unit

Purpose

Because of the immune-suppressive effect of cerebral damage, stroke patients are at high risk for infections. These might result in sepsis, which is the major contributor to intensive care unit (ICU) mortality. Although there are numerous studies on infections in stroke patients, the role of sepsis as a poststroke complication is unknown.

Methods

We retrospectively analyzed incidence of and risk factors for sepsis acquisition as well as outcome parameters of 238 patients with ischemic or hemorrhagic strokes consecutively admitted to the neurologic ICU in a tertiary university hospital between January 1, 2009, and December 31, 2010. Basic demographic and clinical data including microbiological parameters as well as factors describing stroke severity (eg, lesion volume and National Institute of Health stroke scale score) were recorded and included into the analysis. The diagnosis of sepsis was based on the criteria of the German Sepsis Society.

Results

We identified 30 patients (12.6%) with sepsis within the first 7 days from stroke onset. The lungs were the most frequent source of infection (93.3%), and gram-positive organisms were dominating the microbiologic spectrum (52.4%). Comorbidities (chronic obstructive pulmonary disease and immunosuppressive disorders) and Simplified Acute Physiology Score II but none of the factors describing stroke severity were independent predictors of sepsis acquisition. Sepsis was associated with a significantly worse prognosis, leading to a 2-fold increased mortality rate during in-hospital care (36.7% vs 18.8%) and after 3 months (56.5% vs 28.5%), but only in the subgroup of supratentorial hemorrhages, it was an independent predictor of in-hospital and 3-month mortality. Other factors significantly associated with death in a multivariate analysis were chronic obstructive pulmonary disease, malignancies (in-hospital mortality only), and Simplified Acute Physiology Score II (3-month mortality only) for ischemia and heart failure (in-hospital mortality only), National Institute of Health stroke scale score (in-hospital mortality only), and stroke volume for hemorrhages, respectively.

Conclusions

Sepsis seems to be a frequent complication of stroke patients requiring neurologic ICU treatment. Predictors of sepsis acquisition in our study were comorbidities and severity of deterioration of physiological status, but not stroke severity. A better understanding of risk factors is important for prevention and early recognition, whereas knowledge of outcome may help in prognosis prediction. Further studies are needed to clarify the optimal preventive treatment for these patients.     

Heat stroke: a comprehensive review

Heat stroke (HS) is a serious and potentially life-threatening condition defined as a core body temperature >40.6 degrees C. Two forms of HS are recognized, classic heat stroke, usually occurring in very young or elderly persons, and exertional heat stroke, more common in physically active individuals. An elevated body temperature and neurologic dysfunction are necessary but not sufficient to diagnose HS. Associated clinical manifestations such as extreme fatigue; hot dry skin or heavy perspiration; nausea; vomiting; diarrhea; disorientation to person, place, or time; dizziness; uncoordinated movements; and reddened face are frequently observed. Potential complications related to severe HS are acute renal failure, disseminated intravascular coagulation, rhabdomyolysis, acute respiratory distress syndrome, acid-base disorders, and electrolyte disturbances. Long-term neurologic sequelae (varying degrees of irreversible brain injury) occur in approximately 20% of patients. The prognosis is optimal when HS is diagnosed early and management with cooling measures and fluid resuscitation and electrolyte replacement begins promptly. The prognosis is poorest when treatment is delayed >2 hours.     

Poststroke fatigue: course and its relation to personal and stroke-related factors

OBJECTIVES: To describe the course of fatigue during the first year poststroke and to determine the relation between fatigue at 1 year poststroke and personal characteristics, stroke characteristics, and poststroke impairments. DESIGN: Inception cohort. SETTING: Rehabilitation center. PARTICIPANTS: Patients (N=167) with a first-ever supratentorial stroke admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Fatigue Severity Scale measured the presence and impact of fatigue at admittance for inpatient rehabilitation, as well as at 6 months and 1 year poststroke. RESULTS: At admission, 6 months and 1 year poststroke, fatigue was present in 51.5%, 64.1%, and 69.5% of the patients, respectively. Fatigue impact 1 year poststroke was greater among patients with more depressive symptoms, higher age, women, and patients with a locus of control more directed to powerful others. CONCLUSIONS: Because fatigue impact is an increasing problem during the first year poststroke, it deserves more attention in clinical practice and scientific research. Locus of control and depression are related to poststroke fatigue and might be important foci for future interventions.     

缺血性卒中患者认知功能障碍的危险因素分析

目的 探讨急性缺血性卒中患者认知功能障碍的危险因素。方法 纳入50例发生卒中后认知功能障碍（post stroke cognitive impairment, PSCI）的缺血性卒中患者为病例组,以50例未发生PSCI的缺血性卒中患者作为对照组,比较两组患者的临床资料,并分析PSCI的相关因素。结果 与对照组相比,病例组患者年龄更高,合并高血压、糖尿病的比例较高,LDL C、UA、hs CRP水平较高;颞叶梗死、丘脑梗死的比例较高（均P＜0.05）;两组教育程度及卒中次数相比差异有统计学意义（均P＜0.05）。既往卒中2次及以上、糖尿病、LDL C、hs CRP水平升高、颞叶梗死是PSCI的危险因素;初中及以上文化程度是PSCI的保护因素。结论 低文化程度、糖尿病、既往有卒中病史、LDL C及hs CRP水平升高、颞叶梗死的缺血性患者发生PSCI的风险更高。     

Perspective on neuromuscular factors in poststroke fatigue

Purpose: To summarize the potential origins of fatigue poststroke from a neuromuscular perspective, including stroke-induced alterations at the cortical, spinal and muscle levels. Method: Perspective based on narrative literature review. Results: Fatigue is a highly prevalent, but poorly understood symptom poststroke. Neuromuscular fatigue has central and peripheral origins. Individuals with stroke experienced greater central fatigue and less peripheral fatigue during voluntary contractions of the paretic leg in comparison to healthy participants. Neuromuscular adaptations to stroke create an increased susceptibility to central fatigue, which may be a contributing factor to the increased perception of tiredness during performance of activities of daily living. Future studies should investigate whether intervention-induced cortical plasticity, gains in muscle strength and endurance will attenuate self-reported fatigability. Conclusions: Fatigue is a common and debilitating consequence of stroke. Neuromuscular fatigue of central origin may contribute to self-reported fatigue. Continued focused and properly designed research studies should provide substantial insight into the therapeutic interventions that will improve the management of fatigue poststroke.

Implications for Rehabilitation

• Fatigue is a common and debilitating consequence of stroke, which has received little attention in clinical rehabilitation.

• Insufficient understanding of the pathophysiology of poststroke fatigue limits advances in its treatment.

• Neuromuscular fatigue of central origin may contribute to the self-reported fatigue poststroke.

• Although speculative, rehabilitation interventions that foster neuroplasticity, muscle strength and endurance may have a role in the management of fatigue poststroke.

     

Hypersexuality in stroke

Hyposexuality is a common problem in stroke patients. Some stroke patients, however, may present with hypersexuality. We report three stroke patients who demonstrated hypersexuality and deviant sexual behavior after stroke. Abnormal sexual behavior was noted by members of the stroke rehabilitation team while the patients were in hospital. Details of pre- and poststroke sexual activity were obtained from patients and their spouses. All three patients had temporal lobe lesions on computerized tomography, and all had a history of poststroke seizure activity. The 53-year-old man reported poststroke increase in libido and coital frequency with a tendency towards priapism. The two women (47 and 55 years old) exhibited deviant sexual behavior, mood changes, and hyperphagia. The exact cause of these behavior changes is unknown but they may be related to temporal lobe involvement. Hypersexuality has previously been reported in animals and in patients with temporal lobe seizures.     

Shared Mechanisms and Comorbidities in Neurologic and Psychiatric Disorders

Migraine may be comorbid with several other neurologic and psychiatric conditions, including mood disorders (eg, depression, anxiety, panic disorder), epilepsy, stroke, and essential tremor. Comorbidity presents physicians with opportunities and challenges for both diagnosis and treatment. All diseases must be considered, and therapeutic strategies may need to be modified to avoid potential drug interactions. Comorbidities also may provide clues to the pathophysiologies and any shared mechanisms of the two disorders. Longitudinal studies have demonstrated a bidirectional influence between migraine and major depression, but not between migraine and other severe headache. Migraine is strongly and consistently associated with panic disorder. The risk of migraine in epilepsy is increased particularly in individuals with head trauma, partial seizures, and a positive family history of migraine. The influence is bidirectional. There is also growing evidence of an association between migraine and stroke, particularly among women of childbearing age and individuals who experience migraine with aura. Lastly, a bidirectional association between migraine and essential tremor also exists. These findings suggest that migraine, major depression, epilepsy, and essential tremor share one or more common etiologies. Clinicians should be mindful of them as they design treatment strategies, and also should consider the use of a single pharmacologic agent that is effective for all conditions.     

Effect of training programs and exercise in adult stroke patients: literature review.

INTRODUCTION: An increasing number of training programs are proposed for the rehabilitation of patients after stroke, with positive results published but without formal validation, and without recommendations regarding indications for specific techniques and procedures. OBJECTIVE: To review data from the literature about training and exercise programs for stroke patients and to describe the efficacy, limitations, and effect of such programs on organ systems. METHODS: A search of MedLINE and relevant medical journals for articles of clinical trials, meta-analyses, and literature reviews pertaining to physical training and exercise programs after stroke. RESULTS: We found 58 articles reporting on various training and exercise techniques (walking, cardiovascular training, muscle strengthening, and others) and their results (on the cardiovascular, musculoskeletal, and neurologic systems, as well as functional status) in hemiplegic stroke patients. DISCUSSION-CONCLUSION: Training and exercise programs have value in stroke rehabilitation, and published results are, in general, promising. However, differences in the populations tested, methods, and criteria for analysis do not allow for recommending specific procedures.     

Clinical characteristics and mechanisms of stroke after polytrauma

OBJECTIVES: To describe the clinical characteristics of acute stroke attributable to trauma and to analyze the mechanisms and effect of stroke on outcome in patients with polytrauma. PATIENTS AND METHODS: We retrospectively reviewed the medical records of patients with polytrauma complicated by stroke at the Mayo Clinic in Rochester, Minn. The diagnosis of stroke was matched with trauma for the period between January 1, 1985, and December 31, 2001. Polytrauma was defined as at least 2 injuries that involve at least 1 vital organ (eg, lung or liver) and necessitate patient admission to a trauma intensive care unit. RESULTS: We identified 14 patients with polytrauma who had experienced a stroke (13 ischemic and 1 hemorrhagic). Craniocervical artery dissection was the most common mechanism (7 patients), and skull or facial fractures were a possible marker for this (5 of 7 patients). There were frequent delays in identifying stroke, with limb fracture on the side of the paresis (5 of 6 patients) being a possible factor. Four patients died of postischemic brain swelling, and 5 had major neurologic impairment. CONCLUSIONS: Stroke after polytrauma is due to various mechanisms, is frequently difficult to recognize early, and profoundly affects patient outcome.