Interventions for post-stroke fatigue: A Cochrane review summary

Study protocol of a double-blind randomized control trial of transcranial direct current stimulation in post-stroke fatigue

Rationale

Post-stroke fatigue (PSF) is a frequent problem in stroke survivors and often hinders their rehabilitation. PSF is difficult to treat, and pharmacological therapy is often ineffective. Transcranial direct current stimulation (tDCS) can modulate motor, sensory, cognitive and behavioral responses, as it alters neuronal activity by delivering a small amount of current via the scalp to the cortex, resulting in prolonged alterations to brain function. tDCS has been studied for the treatment of fatigue associated with other neurological diseases, namely, multiple sclerosis, Parkinson's disease and post-polio syndrome.

Aims

This proposed project will examine the effect of tDCS on PSF.

Sample size estimates

We will recruit 156 participants aged 18 to 80 with chronic stroke and allocate them equally to two groups (i.e., n = 78 per group).

Methods and design

This proposed project will be a double-blind randomized control trial. The participants will be randomly divided into two groups. The control group will receive sham tDCS, and the treatment group will receive active tDCS. The latter treatment will involve application of a constant 2-mA current via one 5 × 5-cm anodal electrode positioned on the scalp over the C3 or C4 positions (motor cortex) of the lesioned hemisphere and one cathodal electrode positioned at the ipsilateral shoulder in two 20-min sessions per day for 5 days. The period of follow-up will be 4 weeks.

Study outcomes

The primary outcome measure will be a change in fatigue severity, as measured using the modified fatigue impact scale (MFIS). The participants' scores on the MFIS (total score and physical, cognitive and psychosocial subscores) will be collected before treatment (T0), after 10 treatment sessions, i.e., 1 day after the fifth treatment day (T1), and 1 week (T2), 2 weeks (T3) and 4 weeks (T4) thereafter. Both per-protocol analysis and intention-to-treat analysis will be performed.

Discussion

This proposed project will provide proof-of-concept, i.e., demonstrate the benefits of tDCS for the treatment of PSF. The beneficiaries are the subjects participated in the study. This will stimulate further research to optimize tDCS parameters for the treatment of PSF.

Clinical trial registration

www.Chictr.org.cn, identifier: ChiCTR2100052515.

Perceptions of Post-Stroke Fatigue among Health Care Practitioners: A Qualitative Interview Study

Background and Objectives: Post-Stroke Fatigue (PSF) is a complex, multidimensional, debilitating condition that affects almost half of all stroke survivors. This study explored the perceptions of physiatrists, physiotherapists, and occupational therapists about PSF and their experiences in managing patients with PSF in Saudi Arabia. Materials and Methods: Qualitative semi-structured interviews were conducted with participants from three different groups: eight physiotherapists (PTs), eight occupational therapists (OTs), and eight physiatrists (DRs). Using purposive sampling, participants with at least one year of experience in the field of PSF management were invited to take part. The data were analysed using inductive thematic analysis. Results: Twenty-four health care participants (eight PTs, eight OTs, eight DRs) were recruited. Five overarching themes encompassing various subthemes and sub-subthemes were generated: 'knowledge about post-stroke fatigue', 'diagnosing post-stroke fatigue', 'treatment approach', 'lack of awareness about post-stroke fatigue', and 'domains to improve'. The data indicated that participants used various strategies to manage PSF, including dietary changes, sleep hygiene, exercise, and energy conservation. Conclusions: Participants acknowledged that they lacked PSF-related management skills, despite possessing adequate knowledge about the management of stroke. Their openness to participating in activities that would improve their ability to diagnose and manage PSF was particularly striking.

Development and evaluation of the Norwegian Fatigue Characteristics and Interference Measure (FCIM) for stroke survivors: cognitive interviews and Rasch analysis

PURPOSE

There is need for a comprehensive measure of post-stroke fatigue with sound measurement properties. This study aimed to develop the Norwegian Fatigue Characteristics and Interference Measure (FCIM) and assess its content validity, structural validity, and internal consistency.

METHOD

This study consisted of three steps: (1) an expert panel developed version 1.0 of the Norwegian FCIM, (2) its content validity was assessed in cognitive interviews with stroke patients (N = 15), (3) a convenience sample of stroke patients (N = 169) completed an online questionnaire with the FCIM, Fatigue Severity Scale, and sociodemographic information; validity and reliability were assessed using Rasch analysis.

RESULTS

FCIM version 1.0 included a 10-item characteristics subscale, a 20-item interference subscale, and two pre-stroke fatigue items. The cognitive interviews revealed content validity issues, resulting in two interference items being removed and five items being flagged but retained for Rasch analysis (version 2.0). Rasch analysis led to removal of four items from the characteristics subscale and six more from the interference subscale. The final six-item characteristics subscale and 12-item interference subscale (version 3.0) both showed adequate fit to the Rasch model with indications of unidimensionality and local independence. The interference subscale had a high person separation index. No significant differential item function (DIF) was found in relation to gender, but one item demonstrated DIF in relation to age.

CONCLUSION

The cognitive interviews and Rasch analysis demonstrated that the Norwegian version of the FCIM has high content validity, structural validity, and internal consistency. Future research should assess its construct validity, reliability, and responsiveness.

Fatigue Experiences in People With Stroke

PURPOSE

Fatigue is a major symptom in patients with stroke. Because fatigue is an overarching multidimensional phenomenon, it is important to understand how the characteristics of fatigue change over time. The purpose of this study was to explore how fatigue characteristics change over time in patients with stroke.

DESIGN

This study used a mixed-method observational design.

METHODS

This study is a secondary analysis of data from a previous study, the results of which indicated fatigue to be a prominent symptom. Participants in that study were patients with stroke who met eligibility criteria and provided informed consent. This secondary analysis used data from numeric rating scale scores for fatigue, Functional Assessment of Chronic Illness Therapy-Fatigue Scale scores, fatigue descriptors, and participant comments about fatigue gleaned from transcribed interviews.

RESULTS

Twenty-two patients participated in the study. Thirteen characteristics of fatigue were evaluated. Seven characteristics showed significant improvement ( p < .05) from admission to 1 month follow-up, and six characteristics did not change significantly.

CONCLUSIONS

Fatigue experiences vary over time and have both physical and mental aspects to them.

CLINICAL RELEVANCE TO REHABILITATION NURSING

Nurses may consider providing a quiet environment for physical rest, which may allow the brain to not be distracted by multiple stimuli.

How do stroke survivors and their caregivers manage post-stroke fatigue? A qualitative study

Objectives

The primary objective was to gain insight into the lived experiences of using day-to-day strategies to manage post-stroke fatigue.

Design

Qualitative, descriptive study.

Setting

Community telephone interviews.

Participants

A purposive sample of 20 stroke survivors with current, or previous, post-stroke fatigue, and 8 caregivers, who provided informal care or support, were recruited.

Main Measures

Semi-structured telephone interviews were undertaken. Data were analysed using a framework approach.

Results

Most participants had found their own ways of coping and their personal strategies included acceptance of having fatigue; ‘pacing’ (spreading activities out and interspersing with rest periods); keeping a diary in order to plan activities and to identify ‘trigger’ activities which induced fatigue; talking to (and educating) others about having fatigue; using relaxation; and accessing professional advice and support. The burden placed on caregivers was considerable and they often had to oversee the post-stroke fatigue management strategies used.

Conclusions

Post-stroke fatigue is managed in different ways and there was not one particular strategy that seemed effective for everyone. Most people in our study had had to devise their own ways of coping practically. Given the scale of this problem, which profoundly impacts the lives of both stroke survivors and caregivers, the management of post-stroke fatigue merits more attention and evaluation. However, this must be directly informed by those with lived experience.

UK clinical approaches to address post-stroke fatigue: findings from The Nottingham Fatigue after Stroke study

Background/Aims

Although post-stroke is common and debilitating, there is little published research on how it is managed by clinicians. The aim of this study was to document UK management of post-stroke fatigue and ascertain whether there are any differences in its management compared to fatigue arising from other conditions.

Methods

A cross-sectional survey was used with allied health professionals, psychologists, doctors and nurses working clinically in hospitals, the community or both, who routinely provided information, management or treatment to patients with fatigue. Questionnaires were designed and underwent pilot testing. Recruitment was conducted using healthcare professional networks, professional and condition special interest groups and social media, snowballing and personal emails targeting key professional experts.

Results

A total of 305 questionnaires were analysed; the majority of responses were from occupational therapists (56%, n=171). Although there were different opinions about whether post-stroke fatigue was the same as fatigue resulting from other conditions, the strategies suggested for both were similar. Post-stroke management included pacing (67%, n=204), which is spreading activities out during the day or week, keeping a fatigue diary (39%, n=119) and education (38%, n=117). There were variations in how support was offered, and marked variations in length of follow up; some services were flexible and could retain patients for up to 18 months, while others offered one session and no follow up.

Conclusions

People with post-stroke fatigue and fatigue arising from other conditions experience different levels of support to manage their fatigue, but the main strategies used in management are similar.

Risk Factors and Imaging Mechanisms of Fatigue After Mild Ischemic Stroke: An Exploratory Study From a Single Chinese Center

Objective: To explore the biochemical risk factors and imaging mechanisms of post fatigue after mild ischemic stroke among a Chinese population. Methods: Forty consecutive patients with mild ischemic stroke within onset of 14 ± 2 days were enrolled between March and June 2018. The clinical information, scale data, biomarkers in peripheral venous blood, and imaging data during hospitalization and follow-up period were collected. Results: Patient age (range 34-78) was positively correlated with the prevalence of fatigue (p = 0.009). Both blood norepinephrine and serotonin levels during hospitalization were negatively correlated to the prevalence of post-stroke fatigue (model 1 p = 0.009 and model 2 P = 0.043, respectively). Infarct of right cerebral hemisphere is positively correlated with the occurrence of fatigue after mild ischemic stroke (p = 0.020). Compared to non-fatigue patients, amplitude of low-frequency fluctuation (ALFF) was lower in several areas of brain in stroke patients with fatigue, including the right orbital inferior frontal, right inner orbital frontal, right frontal, right triangular frontal inferior, right anterior and lateral cingulate, and right medial frontal gyruses. Analysis of the difference in functional connectivity between the fatigue and non-fatigue groups found no cluster. Conclusions: Frontal lobe-related neural pathways may play an essential role in the regulation of fatigue after mild ischemic stroke. Abnormal neural circuits may reduce the levels of neurotransmitters such as serotonin and norepinephrine and lead to post-stroke fatigue.

Exploring the Economic Benefits of Modafinil for Post-Stroke Fatigue in Australia: A Cost-Effectiveness Evaluation

BACKGROUND

In stroke survivors, post-stroke fatigue predicts dependency in daily living and failure to return to work. Modafinil shows promise as a pharmacotherapy to reduce post-stroke fatigue and related sequelae, e.g., poorer functional and clinical outcomes.

AIMS

This study explored the cost-effectiveness of modafinil in treating post-stroke fatigue in the Australian context, by determining its incremental cost-effectiveness ratio (ICER) and by simulating the potential cost-savings on a national scale, through a re-analysis of MIDAS trial data.

METHODS

A post hoc cost-effectiveness analysis was undertaken. Part A: patient-level cost and health effect data (Multidimensional Fatigue Inventory (MFI) scores) were derived from the MIDAS trial and analysis undertaken from a health-system perspective. Part B: a secondary analysis simulated the societal impact of modafinil therapy in terms of national productivity costs.

RESULTS

Part A: Mean cost of modafinil treatment was AUD$3.60/day/patient for a minimally clinically important change (10 points) in total MFI fatigue score, i.e., AUD$0.36/day/unit change in fatigue score per patient. For the base case scenario, the ICER of using modafinil (versus placebo) was AUD$131.73 ($90.17 - 248.15, for minimum and maximum costs, respectively). Part B: The potential productivity cost-savings to society were calculated as nearly AUD$467 million over 1 year, and up to $383,471,991,248 over 10 years, from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors, representing a significant societal benefit.

CONCLUSIONS

Modafinil is a highly cost-effective treatment for post-stroke fatigue, offering significant productivity gains and potential cost-savings to society from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors.

Developing a fatigue programme: Protocol for the Nottingham Fatigue After Stroke (NotFAST2) study

Introduction

Post-stroke fatigue is common and is one of the most distressing symptoms after stroke. It has a negative impact on physical, social and psychological functioning; it is also associated with poor outcomes and increased mortality. The effective management of post-stroke fatigue is therefore regarded as a clinical priority.

Method

This study will use a mixed-methods design with three overlapping phases. Phase 1 will be a survey of existing fatigue management within the United Kingdom. In phase 2, interviews and focus groups will be conducted with stroke survivors with fatigue, carers and clinicians to determine strategies used to manage fatigue successfully. In phase 3, data from phases 1 and 2 will contribute to the co-design of a fatigue management programme with the NotFAST2 study Patient and Public Involvement group. This will be further refined through subsequent focus groups, which will include those with fatigue associated with other health conditions.

Results

Survey data will be analysed using descriptive statistics. Interview and focus group data will be analysed using a framework approach.

Conclusion

Post-stroke fatigue requires a comprehensive management programme necessitating input from key stakeholders. A post-stroke fatigue programme will be developed which will be tested in a future randomised controlled trial.

Post-stroke fatigue: a scoping review

Background: Post-stroke fatigue (PSF) is one of the most common and frustrating outcomes of stroke. It has a high prevalence and it can persist for many years after stroke. PSF itself contributes to a wider range of undesirable outcomes that affect all aspects of daily life. The aim of this review was to identify and summarise the most recent research on PSF, in order to update the evidence base. Methods: We updated an existing review (Hinkle et al. 2017) systematically searching CINAHL, MEDLINE, PsycINFO, and PubMed to cover new research studies between 1 st March 2016 and the search date (19 th January 2020). We included interventional and observational research, and clinical practice guidelines that were not covered in the original review. After duplicate removal in EndNote, two reviewers screened the search results in Rayyan, and data from eligible full texts were extracted onto an Excel spreadsheet. Finally, we used RobotReviewer and a human reviewer to assess the risk of bias of randomised trials for this scoping review. Results: We identified 45 records for 30 studies (14 observational, 10 interventional studies, and 6 guidelines). Apart from one, the interventional studies were single-centred, had high risk of bias and small sample size (median 50). They investigated exercise, pharmacotherapy, psychotherapy, education, and light therapy. Observational studies mainly reported the factors related to PSF including co-morbidities, depression and anxiety, quality of life, activities of daily living, stroke severity, medication use and polypharmacy, polymorphism, pain, apathy, limb heaviness, neuroticism, mobility, and thyroid-stimulating hormone. Guidelines either did not report on PSF or, when reported, their recommendations were supported by little or low level of evidence. Conclusion: Although we identified a number of recent studies which have added to our current knowledge on PSF, none are robust enough to change current clinical practice.

Post-stroke fatigue: a scoping review

Background: Post-stroke fatigue (PSF) is one of the most common and frustrating outcomes of stroke. It has a high prevalence and it can persist for many years after stroke. PSF itself contributes to a wider range of undesirable outcomes that affect all aspects of daily life. The aim of this review was to identify and summarise the most recent research on PSF, in order to update the evidence base. Methods: We updated an existing review (Hinkle et al. 2017) systematically searching CINAHL, MEDLINE, PsycINFO, and PubMed to cover new research studies between 1 st March 2016 and the search date (19 th January 2020). We included interventional and observational research, and clinical practice guidelines that were not covered in the original review. After duplicate removal in EndNote, two reviewers screened the search results in Rayyan, and data from eligible full texts were extracted onto an Excel spreadsheet. Finally, we used RobotReviewer and a human reviewer to assess the risk of bias of randomised trials for this scoping review. Results: We identified 45 records for 30 studies (14 observational, 10 interventional studies, and 6 guidelines). Apart from one, the interventional studies were single-centred, had high risk of bias and small sample size (median 50). They investigated exercise, pharmacotherapy, psychotherapy, education, and light therapy. Observational studies mainly reported the factors related to PSF including co-morbidities, depression and anxiety, quality of life, activities of daily living, stroke severity, medication use and polypharmacy, polymorphism, pain, apathy, limb heaviness, neuroticism, mobility, and thyroid-stimulating hormone. Guidelines either did not report on PSF or, when reported, their recommendations were supported by little or low level of evidence. Conclusion: Although we identified a number of recent studies which have added to our current knowledge on PSF, none are robust enough to change current clinical practice.