Usage of Pain Medications During Stroke Rehabilitation: The Post-Stroke Rehabilitation Outcomes Project (PSROP)

Impact of analgesic regimen on patient outcome following subarachnoid hemorrhage: positive adjuvant effects of metamizole

INTRODUCTION

Various analgesics are used to control intense headaches in patients following subarachnoid hemorrhage. In addition to pain control, it has been shown that some analgesics can affect various pathophysiological cascades. Therefore, we devised a study to assess whether the use of metamizole has a significant impact on the development of ischemic complications, hydrocephalus, and the overall outcome in patients following aneurysmal subarachnoid hemorrhage in the context of the other non-opioids and opioids effects.

METHODS

In our retrospective, single-center cohort study, we enrolled 192 patients diagnosed with subarachnoid hemorrhage. We recorded their initial clinical status, comorbidities, and the daily dosage of analgesics over 14 days of hospitalization after the onset of subarachnoid hemorrhage. Using univariate and subsequent multivariate logistic regression analysis, we assessed the influence of various factors, including analgesics, on the development of delayed cerebral ischemia and hydrocephalus, as well as on 2-week and 6-month outcomes.

RESULTS

Although the administration of non-opioids, in general, had no effect on the development of delayed cerebral ischemia or hydrocephalus, the use of metamizole as the main analgesic was associated with a significantly lower chance of poor outcome at both 2-weeks and 6-months, as well as the development of delayed cerebral ischemia. As opioids were indicated primarily for analgosedation in mechanically ventilated patients with poor clinical status, their usage was associated with a significantly higher chance of poor outcome, delayed cerebral ischemia, and hydrocephalus.

CONCLUSION

Our results suggest that the prescription of metamizole may be associated with better outcomes and a lower chance of delayed cerebral ischemia development in patients after subarachnoid hemorrhage. Considering the retrospective nature of our study and the limited worldwide availability of metamizole due to its prohibition in some countries, our results do not demonstrate a clear benefit but rather justify the need for subsequent prospective studies.

Defining and Managing Pain in Stroke and Traumatic Brain Injury Research

Neurologic conditions such as stroke and traumatic brain injury are challenging conditions to study in humans. Animal models are necessary to uncover disease processes and develop novel therapies. When attempting to model these or other neurologic diseases, the accompanying anesthesia and analgesia create variables that are not part of the onset of the clinical disease in the human population but are critical components of the postinjury care both in humans and animals. To maximize model validity, researchers must consider whether the disease process or a novel therapy is being studied. Damage to the neurons of the brain or the spinal cord is not painful at the neural tissue itself, but alterations to nociceptive signaling along the pain pathway can induce chronic pain. In addition, trauma or surgery leading to the event is associated with damage to peripheral tissue. Inflammation is inextricably associated with tissue injury. Inflammation is known to evoke nociception in the periphery and drive long-term changes to neurons in the CNS. Analgesics and anesthetics alter these responses yet are required as part of humane animal care. Careful planning for effective drug administration consistent with the standard of care for humans and equivalent animal care is required.

Dipyrone comedication in aspirin treated stroke patients impairs outcome

BACKGROUND

>50% of stroke patients rely on analgesic medication to control pain. Aspirin is the mainstay of medical treatment of stroke patients; however analgesic medication with dipyrone impairs aspirin antiplatelet effects ex-vivo. The clinical impact of this impairment is unknown. Therefore, we aimed to determine aspirin antiplatelet effects and neurological outcome in stroke patients with aspirin and dipyrone comedication.

METHODS

We conducted a prospective cohort study in 41 patients with stroke. Primary outcome was pharmacodynamic response to aspirin in dipyrone treated stroke patients. Secondary outcome was neurological recovery after stroke. Pharmacodynamic response to aspirin was measured using arachidonic acid induced aggregation in light-transmission aggregometry. Neurological outcome was determined three months after stroke onset by telephone interview.

RESULTS

Patient's characteristics were similar in the aspirin-alone group and the aspirin+dipyrone group. Impaired pharmacodynamic response to aspirin occurred in 62% (14/21) of patients with aspirin and dipyrone co-medication. Only 10% (2/20) of aspirin treated patients without analgesic comedication displayed residual platelet reactivity (P=0.001; odds ratio [OR], 18 [95% CI, 3.2-100]). Excellent neurological recovery (measured by three months follow-up modified Rankin Scale<2) was observed in 80% (16/20) of patients in the aspirin-alone group and 48% (10/21) of patients in the aspirin+dipyrone group (P=0.037; OR, 4.4 [95% CI, 1.1-17.7]).

CONCLUSIONS

Dipyrone comedication in patients with stroke impairs pharmacodynamic response to aspirin. This is associated with worse clinical outcome. Therefore dipyrone should be used with caution in aspirin treated stroke patients.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/show/NCT02148939; Identifier: NCT02148939.

Suicide in stroke survivors: epidemiology and prevention

Stroke is a dramatic event and is associated with potentially severe consequences, including disability, mortality, and social costs. Stroke may occur at any age; however, most strokes occur in individuals aged 65 years and older. Previous research has found that stroke increases suicide risk, especially among women and younger patients. The aim of the current review is to investigate the relationship between suicide and stroke in order to determine which stroke patients are at elevated risk for suicide. Moreover, we review the literature in order to provide pharmacological treatment strategies for stroke patients at high risk of suicide. We performed a careful search to identify articles and book chapters focused on this issue, selecting only English-language articles published from 1990 to 2014 that addressed the issue of suicide after stroke and its pharmacological management. We found 12 clinical trials that explored the relationship between stroke and suicidal ideation and/or suicidal plans and 11 investigating suicide as the cause of death after stroke. We identified stroke as a significant risk factor for both suicide and suicidal ideation, especially among younger adult depressed patients in all articles, providing further support for the association between post-stroke and suicidality. Suicide risk is particularly high in the first 5 years following stroke. Depression, previous mood disorder, prior history of stroke, and cognitive impairment were found to be the most important risk factors for suicide. Selective serotonin reuptake inhibitors (SSRIs) represent the treatment of choice for stroke survivors with suicide risk, and studies in rats have suggested that carbolithium is a promising treatment in these patients. Early identification and treatment of post-stroke depression may significantly reduce suicide risk in stroke patients.

Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation

[Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management.

Antiplatelet effects of aspirin in chronic kidney disease patients

ESSENTIALS: Chronic kidney disease (CKD) patients have a high risk of cardiovascular events. A pharmacodynamic evaluation of the effects of aspirin in 116 patients was carried out. The antiplatelet effects of aspirin are associated with impaired renal function. The optimal antithrombotic regimen in CKD patients must be investigated on a larger scale.

BACKGROUND

The pharmacodynamic response to aspirin varies significantly between individuals. Insufficient antiplatelet effects of aspirin are associated with increased risk of ischemic events. Chronic kidney disease (CKD) is suggested to affect the pharmacodynamic response to antiplatelet medication. High on-treatment platelet reactivity (HTPR) to clopidogrel has been reported to partially account for the enhanced risk of death and cardiovascular events in CKD patients. Objective To investigate the antiplatelet effects of aspirin in patients with CKD.

METHODS

We conducted a cross-sectional study in 116 patients on permanent aspirin medication. The pharmacodynamic response to aspirin was determined by arachidonic acid-induced thromboxane formation.

RESULTS

HTPR to aspirin was more frequent in patients with impaired renal function (47% vs. 22%; odds ratio, 3.16; 95% confidence interval [CI], 1.34-7.41; P = 0.008). The pharmacodynamic response to aspirin was impaired in patients with moderate/severe CKD (92; interquartile range [IQR], 282 ng mL(-1) ) as compared to patients with normal/mildly reduced renal function (36; IQR, 100 ng mL(-1) ; difference in medians, 57; CI, 5-110 ng mL(-1) ; P = 0.013). Bivariate Pearson analysis showed residual thromboxane formation to be correlated with glomerular filtration rate (R = -0.303; R(2) = 0.092; P = 0.001). Patients with CKD were older and more frequently female. Multivariate linear regression analysis revealed that the correlation was independent of age (R = -0.314; R(2) = 0.082; P = 0.002) and gender (R = -0.305; R(2) = 0.077; P = 0.006).

CONCLUSION

Renal function is correlated with pharmacodynamic response to aspirin. Patients with CKD have an increased risk of impaired antiplatelet effects of aspirin. Larger trials are needed to assess the clinical impact of this finding and investigate the optimal antithrombotic regimen in CKD patients.

The effects of central post-stroke pain on quality of life and depression in patients with stroke

[Purpose] The aim of this study was to assess the effects of central poststroke pain on quality of life, functionality, and depression in stroke. [Subjects and Methods] Twenty-four patients with stroke having central poststroke pain (a mean age of 60.6±8.5 years; 14 males, 10 females; Group I) and 24 similar age-and gender-matched patients with stroke without central poststroke pain (Group II) were enrolled. Characteristics of pain were recorded in patients with stroke having central poststroke pain. The Visual Analogue Scale and Leeds Assessment of Neuropathic Symptoms and Signs pain scale were used to evaluate pain. The Functional Independence Measure was used to assess functionality, the 36-Item Short-Form Health Survey was used to assess quality of life (QoL), and the Beck Depression Inventory was used to assess depression. [Results] There were no significant differences in Functional Independence Measure and Beck Depression Inventory. Some of the 36-Item Short-Form Health Survey domains (physical role limitations, pain, and physical scores) in Group II were significantly higher than those in Group I. Additionally, we found that a unit increase in Leeds Assessment of Neuropathic Symptoms and Signs score led to 0.679 decrease in physical score and 0.387 decrease in mental score. [Conclusion] The physical component of the 36-Item Short-Form Health Survey is negatively affected in patient with central poststroke pain, but the mood and mental components of the scale unaffected.

Improving pain assessment and managment in stroke patients

Stroke patients can experience a variety of pain. Many stroke patients have co-morbidities such as osteoporosis, arthritis or diabetes causing diabetic neuropathy. As well as pain from other long term conditions, stroke patients can experience central post-stroke pain, headaches, and musculoskeletal issues such as hypertonia, contractures, spasticity, and subluxations. These stroke patients can also have communication difficulties in the form of expressive dysphasia and/or global aphasia. Communication difficulties can result in these patients not expressing their pain and therefore not having it assessed, leading to inadequate pain relief that could impact their rehabilitation and recovery. By implementing an observational measurement of pain such as the Abbey pain scale, patients with communication difficulties can have their pain assessed and recorded. Initially 30% of patients on the acute stroke ward did not have their pain assessed and adequately recorded and 15% of patients had inadequate pain relief. The patient was assessed if they were in pain and therefore not receiving adequate pain relief by measuring their pain on the Abbey pain scale. After introducing the Abbey pain scale and creating a nurse advocate, an improvement was shown such that only 5% of patients did not have their pain recorded and all had adequate pain relief.

Association Between Serum 25(OH)D Level and Nonspecific Musculoskeletal Pain in Acute Rehabilitation Unit Patients

OBJECTIVE

Nonspecific musculoskeletal pain can be difficult to manage in acute rehabilitation unit (ARU) patients. We investigated whether vitamin D status is a potential modifiable risk factor for nonspecific musculoskeletal pain in ARU patients.

MATERIALS AND METHODS

This cross-sectional study focused on 414 adults from an inpatient ARU in Mission Viejo, California, between July 2011 and June 2012. On ARU admission, all patients had serum 25-hydroxyvitamin D (25(OH)D) levels measured and were assessed for nonspecific musculoskeletal pain. We performed multivariable logistic regression to test the association of serum 25(OH)D level with nonspecific musculoskeletal pain while adjusting for clinically relevant covariates.

RESULTS

Among these 414 patients, mean (SD) 25(OH)D level was 29 (12) ng/mL, and 30% had nonspecific musculoskeletal pain. After adjustment for age, sex, race, body mass index, Functional Independence Measure score, Deyo-Charlson Comorbidity Index, fractures, steroid use, history of osteoporosis/osteomalacia, and patient type (orthopedic, cardiac, neurological, spinal cord injury, or traumatic brain injury), serum 25(OH)D level was inversely associated with nonspecific musculoskeletal pain (odds ratio [OR] per 10 ng/mL, 0.67; 95% confidence interval [CI], 0.48-0.82). When 25(OH)D level was dichotomized, patients with levels <20 ng/mL had higher odds of nonspecific musculoskeletal pain (OR, 2.33; 95% CI, 1.23-4.17) compared with patients with levels ≥20 ng/mL.

CONCLUSIONS

In adult patients, serum 25(OH)D level on admission to ARU was inversely associated with nonspecific musculoskeletal pain. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to improve nonspecific musculoskeletal pain in ARU patients.

Population-based study of central post-stroke pain in Rimini district, Italy

Central post-stroke pain (CPSP) is still an underestimated complication of stroke, resulting in impaired quality of life and, in addition to the functional and cognitive consequences of stroke, the presence of CPSP may be associated with mood disorders, such as depression, anxiety, and sleep disturbances. This type of pain may also impair activities of daily living and further worsen quality of life, negatively influencing the rehabilitation process. The prevalence of CSPS in the literature is highly variable (1%-12%) according to different studies, and this variability could be influenced by selection criteria and the different ethnic populations being investigated. With this scenario in mind, we performed a population-based study to assess the prevalence of CPSP and its main features in a homogeneous health district (Rimini, Italy), including five hospitals for a total population of 329,970 inhabitants. From 2008 to 2010, we selected 1,494 post-stroke patients and were able to interview 660 patients, 66 (11%) of whom reported pain with related tactile and thermal hyperesthesia, accompanied by needle puncture, tingling, swelling, and pressure sensations. Patients reported motor impairment and disability, which influenced their working ability, rehabilitation, and social life. Despite this severe pain state, there was a high percentage of patients who did not receive adequate treatment for pain.

Chronic Pain Syndromes After Ischemic Stroke

Background and Purpose—

Chronic pain syndromes are reported to be common after stroke, but most previous epidemiological studies have generally included small cohorts of patients with relatively short-term follow-up. In a large cohort with ischemic stroke (Prevention Regimen for Effectively avoiding Second Stroke [PRoFESS] trial), we determined the prevalence, risk factors, and clinical consequence of new poststroke pain syndromes.

Methods—

Within the PRoFESS trial (mean follow-up 2.5 years), a standardized chronic pain questionnaire was administered (at the penultimate follow-up visit) to all participants who reported chronic pain since their stroke and did not have a history of chronic pain before their index stroke. Multivariable logistic regression analyses were used to determine risk factors for poststroke pain (and pain subtypes), and the association between poststroke pain and cognitive (≥3 reduction in Mini-Mental State Examination score) and functional decline (≥1 increase in m-Rankin).

Results—

In total, 15 754 participants were included; of which 1665 participants (10.6%) reported new chronic poststroke pain, and included 431 participants (2.7%) with central poststroke pain, 238 (1.5%) with peripheral neuropathic pain, 208 (1.3%) with pain from spasticity, and 136 participants (0.9%) with pain from shoulder subluxation. More than 1 pain subtype was reported in 86 participants (0.6%). Predictors of poststroke pain included increased stroke severity, female sex, alcohol intake, statin use, depressive symptoms, diabetes mellitus, antithrombotic regimen, and peripheral vascular disease. A new chronic pain syndrome was associated with greater dependence (odds ratio, 2.16; 95% confidence interval, 1.82–2.56). Peripheral neuropathy and pain from spasticity/shoulder subluxation were associated with cognitive decline.

Conclusions—

Chronic pain syndromes are common after ischemic stroke and are associated with increased functional dependence and cognitive decline.

Is pain associated with suicidality in stroke?

OBJECTIVE

To evaluate the relation between poststroke pain and suicidality (SI) in Chinese patients with first or recurrent stroke.

DESIGN

Cross-sectional survey.

SETTING

Acute stroke unit of a university-affiliated general hospital.

PARTICIPANTS

Patients (N=496) with acute ischemic stroke admitted to the Acute Stroke Unit.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients were interviewed 3 months after the index stroke. SI was assessed with the Geriatric Mental State Examination. Pain was evaluated with the Faces Pain Rating Scale-Revised (FPS-R). The association between FPS-R scores and SI was examined and adjusted for potential confounders, including marital status, depression, neurologic deficits assessed by the National Institute of Health Stroke Scale, and functioning measured by the Barthel Index.

RESULTS

Thirty-seven (7.5%) of the patients had SI (the SI group). Compared with the non-SI group, patients in the SI group were more likely to experience pain (59.5% vs 37.7%), had a higher mean FPS-R score (6.0±2.5 vs 4.5±2.3), and had an FPS-R score of >4 (43.2% vs 15.9%). After adjustment for possible confounders, the FPS-R score of >4 (odds ratio=2.9) remained a significant predictor of SI in the subsequent forward logistic regression models.

CONCLUSIONS

These findings should alert clinicians that the early identification and treatment of pain may reduce suicide risk in patients with stroke.

Applying standardized drug terminologies to observational healthcare databases: a case study on opioid exposure

Observational healthcare databases represent a valuable resource for health economics, outcomes research, quality of care, drug safety, epidemiology and comparative effectiveness research. The methods used to identify a population for study in an observational healthcare database with the desired drug exposures of interest are complex and not consistent nor apparent in the published literature. Our research evaluates three drug classification systems and their impact on prevalence in the analysis of observational healthcare databases using opioids as a case in point. The standard terminologies compiled in the Observational Medical Outcomes Partnership’s Common Data Model vocabulary were used to facilitate the identification of populations with opioid exposures. This study analyzed three distinct observational healthcare databases and identified patients with at least one exposure to an opioid as defined by drug codes derived through the application of three classification systems. Opioid code sets were created for each of the three classification systems and the number of identified codes was summarized. We estimated the prevalence of opioid exposure in three observational healthcare databases using the three defined code sets. In addition we compared the number of drug codes and distinct ingredients that were identified using these classification systems. We found substantial variation in the prevalence of opioid exposure identified using an individual classification system versus a composite method using multiple classification systems. To ensure transparent and reproducible research publications should include a description of the process used to develop code sets and the complete code set used in studies.

Cyclobenzaprine: a new look at an old pharmacological agent

Cyclobenzaprine is a tricyclic pharmacologic agent that has enjoyed considerable use since its availability. Most clinical usages have focused on the muscle relaxant properties, the mechanism of action being more recently redefined. Higher orders of the CNS are, nevertheless, affected, and the latter contributes to the spectrum of proclaimed side effects that are otherwise largely anticholinergic in nature. Cyclobenzaprine has a reasonable safety profile and overdoses are not as problematic as those for accepted tricyclic psychotherapeutic agents. Clinical studies have given supportive, albeit not conclusive, evidence for treatment roles in the short-term management of acute neck and back pain, and fibromyalgia. Further and more exacting science is warranted to explore the value of this drug in other neurological and psychiatric contexts.

"Holding me back": living with arthritis while recovering from stroke

OBJECTIVE

To describe the experience of living with arthritis while recovering from stroke.

DESIGN

Qualitative, phenomenological study. During the first three months post-stroke, 14 one-on-one semi-structured interviews were conducted. Analysis was guided by the modified van Kaam method.

SETTING

General community.

PARTICIPANTS

Three men and two women with self-reported pre-existing knee arthritis who were recovering from a first stroke.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

"Holding me back" was central to the experience of living with knee arthritis while recovering from stroke, due to pain, mobility limitations, frustration, and additional coping demands. Experiencing arthritic pain occurred during daily physical activity. As a result, arthritis interfered with participants' ability to fully engage in stroke rehabilitation. The resulting mobility limitations due to arthritis were frustrating experiences that required additional coping strategies by all participants.

CONCLUSIONS

From the perspective of the participants, the slowed recovery from stroke due to arthritis illustrated the need to consider the influence of knee arthritis on stroke recovery during inpatient rehabilitation and after discharge. Stroke rehabilitation interventions that emphasize weight-bearing exercise may not be tolerated by those with arthritis. Alternate pharmacological treatments and physical rehabilitation should be considered for people with pre-existing knee arthritis post-stroke.

Complications during the rehabilitation period in Thai patients with stroke: a multicenter prospective study

OBJECTIVE

To examine the frequency and types of complications in patients with stroke.

DESIGN

A multicenter, prospective cohort study was performed in 327 patients with stroke (134 women, 193 men), who attended inpatient rehabilitation in nine centers. The frequency and severity of consequences and complications related to strokes were monitored weekly. In addition, correlations with stroke-related complications were analyzed.

RESULTS

At least one complication after a stroke was found in 232 (71.0%) patients. The mean age was 62 (+/-12) yrs, and 59% were men. Shoulder subluxation was found in 37.3% with mild to moderate degree. Limb spasticity was presented in 41.6%, and almost all were a severity grade of less than 3 on the Modified Ashworth Scale. The common complications were musculoskeletal pain (32.4%), bowel/bladder dysfunction (31.5%), infection (16.5%), depression (13.8%), and anxiety (5.8%). Symptomatic urinary tract infection was found in 35 (10.7%) patients. Urinary incontinence was the most common among bowel/bladder problems (24.5%). Time since onset of stroke > or = 1 mo (adjusted odds ratio [OR] = 2.12; 95% confidence interval [CI] = 1.07-4.17), length of stay > 21 days (adjusted OR = 2.36; 95% CI = 1.26-4.43), and anxiety score at admission > or = 11 (adjusted OR = 6.87; 95% CI = 2.45-19.29) were statistically associated with stroke-related complications.

CONCLUSIONS

Medical complications were common among patients with stroke who had been hospitalized longer, during inpatient rehabilitation and among those who had high anxiety scores.