In our peer support group meetings for stroke survivors that we host at The Valley, this fatigue theme comes up a lot. The activities that are normally part of life now has become more effortful after stroke. Throughout a normal day, such as concentrating, reading, planning the day’s activities, attending to two conversations at once or conversing with background noise. Described as “sensory overload”, individuals with PSF could become even more error prone, distractible, become more uncoordinated without cognitive breaks.
Defining post-stroke fatigue (PSF) is really difficult. Fatigue is a symptom and represents a complex interaction of biological, psychosocial, and behavioral phenomena. It is often accompanied by distress and decreased functional status related to reduced energy.
The frequency of self-reported fatigue is roughly twice as high in patients post stroke as it is in matched controls, and 27% of stroke survivors experience fatigue every day. In regards to the time course of PSF, a recent study of 167 survivors of first-ever stroke, assessed fatigue at admission, 6-months post-stroke, and 1-year post stroke and found it to be present in 51.5%, 64.1%, and 69.5%, respectively.
It has been proposed that the ascending reticular activating system attributed with maintaining tonic attention may become damaged by brainstem and sub-cortical lesions leading to PSF.
Fatigue is also distinctive from sleepiness. Disorders of sleep have been mentioned as part of sickness behavior and are commonly seen after stroke. They have also been linked to PSF which may be improved when sleep issues are corrected.
The exact mechanisms of origin and persistence of PSF are still elusive. Acute stroke causes secretion of cytokines, chemokines, and proteases from activated microglia at the infarct epicenter accompanied by release of cytotoxic-free radicals. The common denominator is activation of an inflammatory response with production of further cytokines. Disordered sympathetic control, therefore, results and may underpin the observations by Harbison and colleagues that systemic hypertension above 145/90mmHg and diastolic dips below 50mmHg on ambulatory blood pressure monitoring in chronic stroke patients is associated with PSF.
The Inflammatory response is thought to induce the so-called “sickness behaviour” of decreased mood, lowered libido, poor appetite, sleep disturbances, psychomotor slowing, and, importantly, fatigue. Treating depressive symptoms may make a valuable difference to the emotional state and motivation of the patient.
There is huge difficulty in quantifying fatigue, the causes of post-stroke fatigue differ from person to person and may include physical causes such as spasticity, paralysis, pain, inactivity, or other health problems. It has been proposed that post-stroke fatigue may result from the combined effects of organic brain lesions and psychosocial stress related to changes in life situation.
Many scales have been developed attempting to measure the nature, severity, and impact of fatigue in a range of clinical populations. Different scales purport to measure different aspects of fatigue and it has been suggested that measures developed to measure fatigue in one clinical condition may not be justified for other clinical conditions. However, it has also been suggested that “since fatigue is an unspecific symptom there should not be need for adopting disease specific fatigue scales for each individual disease.” While there is no consensus on which fatigue scales are most appropriate for use in the assessment of fatigue in stroke survivors, the most commonly used in stroke populations include the Visual Analogue Scale (used in three studies); Fatigue Severity Scale (used in five studies); Furthermore, while there are a number of measures specific to fatigue that can be used, none of these have been validated in stroke populations. FSS is a common scale- designed initially for pts with MS and SLE. The average score for healthy adult is 2.3 and total score of 20.7. Fatigue Impact Scale (FIS)-40-item multidimensional instrument designed to measure how fatigue affects specific aspects of physical, cognitive, and psychosocial functioning
For patients with aphasia or communication impairments following stroke, visuals can be helpful. This pictogram has two questions with five figures representing each response option. The items assess the intensity of fatigue and the impact of fatigue on daily activities. Since it is very short, simple and easy-to-use.
Despite the high prevalence of post-stroke fatigue and its detrimental effects, studies for post-stroke fatigue interventions are scarce. Indeed, a search of the United Kingdom’s National Clinical Guidelines for Stroke (2nd edition)37 and its tables of evidence reveals no evidence on treatments for fatigue, nor is there any mention of fatigue as a condition requiring treatment. Because the causes of fatigue are multidimensional and interrelated, a considerable range of fatigue management options are available, including cause-specific treatments, pharmacological intervention, and non-pharmacological interventions, including educational programs. For example, stroke patients who have been inactive and/or ill for periods of time may have nutritional or metabolic deficits resulting in fatigue.
In a study where all the patients had PSF on two assessment scales, the selective serotonin reuptake inhibitor antidepressant fluoxetine failed to make any change to the fatigue scores after three months’ therapy, yet dutifully improved post stroke depression and emotional disturbance . Percent change in the fatigue scales and the proportion of patients with fatigue did not differ between the treatment groups at either follow-up assessments. However, fluoxetine significantly improved post-stroke emotional incontinence and depression in patients with fatigue. The authors concluded that post-stroke fatigue may be associated with diverse aetiologies (but not closely related to serotonergic dysfunction), and that further studies are required to elucidate the causative factors to find an appropriate treatment for post-stroke fatigue.
We have been focused on research in the role of exercise and nutritional coaching post traumatic brain injury fatigue. Based on data collected in studies of exercise-induced fatigue, it has been proposed that it is the relative predominance of serotonin compared to dopamine which precipitates fatigue and that exercise training increases plasticity of dopaminergic circuitry leading to a more delayed onset over time.
Given these multiple potential causes of post-stroke fatigue, any assessment of fatigue must be multidimensional, and treatment approaches are likely to be differentially beneficial in different etiologically defined subgroups. Evidence from other patient populations with chronic fatigue suggests that tailored cognitive behavioral therapy, exercise therapy, and teaching energy conservation strategies are effective means to alleviate chronic fatigue and related psychological and physical symptoms. Despite there being no literature on its efficacy, patient and family education/counseling has been identified as an important rehabilitation intervention for the management of stroke-related fatigue. Comprehensive-holistic neuropsychological rehabilitation is centered on the goals of fostering patients’ awareness of their functional potential and adapting to the chronic limitations imposed by their injury, in order to alleviate disability in everyday, social functioning. Principles of energy conservation can be very crucial in addressing symptoms of fatigue. This set of principles has been noted to be beneficial in other medical conditions such as post polio syndrome and multiple sclerosis. As part of their rehabilitation, individuals may be taught or re-taught how to prioritize their commitments and are encouraged to recognize their abilities and limitations.
2015: Post Stroke Fatigue - Why Live With It?-Giap
Increase awareness of
manifestations and common
factors in developing of PSF
Review the evidence for
assessment and treatment of
fatigue after stroke
Management –outline practical
non-pharmacological tools for
managing this condition
Off-labeled uses of medications for post stroke fatigue.
Employer Anthem Blue Cross, Commercial Health Plan
Lots of cute baby pictures
In Their own words
“my head is foggy”
“life is too overwhelming!”
hit a “brick wall”
“exhausted” and failing to meet the
Definition of Fatigue
“a subjective experience of extreme and persistent tiredness,
weakness or exhaustion after stroke, which can present
itself mentally, physically or both and is unrelated to
previous exertion levels.
[Lerdal and colleagues]
Scope of the Problem
Prevalence – 38 - 73 %
PSF often does not diminish even years after stroke
can be present within weeks and persist for many months or even years afterwards
identified by 40% as amongst their worst symptoms impacting function, QOL, safety
Fatigue following Stroke: Frequency,
characteristics and associated factors
Not associated with lesion size
Location-fatigue associated lacunar infarcts located within the basal
ganglia, internal capsule, and infra-tentorial areas
greater fatigue was related consistently to a poorer physical function
and symptoms of depression
Pre-morbid level of functioning
Multiple medications effect?
Fatigue is well appreciated in other
traumatic brain injury
pulmonary disease (COPD)
Sleep problems, such as sleep
Lack of physical exercise
Vitamin deficiency/poor nutrition
Infection-acute , chronic
Physical impairments from stroke
Differentiating fatigue from sleepiness
Subjective feeling of
weariness, depleted energy
No real objective measure
Physiological drive to sleep
Measurable signs: Yawning
Can be measured in a sleep
FATIGUE EXCESSIVE DAYTIME