Zmęczenie po udarze i jego wymiary w okresie 6 – 12 miesięcy od incydentu niedokrwiennego

Mykhaylo Y. Delva, Iryna I. Delva, Nataliya V. Lytvynenko

Higher State Educational Establishment of Ukraine “Ukrainian Medical Stomatological Academy”, Poltava, Ukraine

ABSTRACT

Introduction: Post-stroke fatigue (PSF) is a common and often debilitating sequel of both ischemic and hemorrhagic strokes.

The aim: Assess the rates and intensities of PSF over the second half year after stroke.

Materials and methods: There were examined 128 patients at 6, 9 and 12 months after ischemic or hemorrhagic stroke onset. PSF was measured by fatigue assessment scale (FAS), multidimensional fatigue inventory-20 (MFI-20) and fatigue severity scale (FSS). Distributions of continuous variables were checked by Shapiro-Wilk test. Parametric variables were represented as mean±standard deviation, non-parametric – as mediana (Me) and interquartile (25%-75%) range (Q1-Q3). Categorical data were represented by number (n) and percentage. The difference between the patients’ proportions with PSF at definite time points after stroke onset was assessed using Cochran’s Q-test. The Friedman F-test for repeated measurements was performed to analyze multiple non-parametric variables. When the Friedman F-test yielded a significant effect (p<0,05), it was followed by Dunnett’s test for determination the differences between initial and subsequent measurements. A p-value <0,05 was considered statistically significant.

Results: According to FAS and MFI-20 “global fatigue” sub-scale, PSF rates over the second half year after stroke were statistically stable and were present, respectively, in 28,1% and 34,0% at 6 months, in 26,2% and 32,4% at 9 months, in and 32,0% and 30,5% cases at 12 months after stroke. Physical, mental, activity-related and motivational PSF domains, due to MFI-20 sub-scales, had roughly similar percentage without any significant dynamics over the studied period. According to FSS value ranks, proportions of patients with different levels of PSF impact on daily life were statistically stable over the studied post-stroke period. However, it has been revealed significant reduction of PSF intensities in physical and activity-related domains whereas severities of mental and motivational PSF aspects have been statistically increased.

Conclusions: Rates of PSF were stable over the second half year after stroke occurrence, however intensities of mental and motivational PSF domains have been statistically increased, whereas severities of physical and activity-related PSF domains have been significantly decreased.

Wiad Lek 2018, 71, 2 cz. II, -317

 

Introduction

Post-stroke fatigue (PSF) is a common and often debilitating sequel of both ischemic and hemorrhagic strokes [1]. PSF adversely affects daily occupational performance and roles, return to work, participation in rehabilitation programs, quality of life, and a higher risk of death [2-4].

As known, PSF is multi-domain entity which consist of different components, such as physical, mental, emotional, so on [5]. Moreover, PSF is a dynamic, evolutionary process that may occur in different post-stroke terms with variable subsequent clinical course [6]. For example, in previous work we revealed that PSF rates and intensities had been significantly increased over the first three post-stroke months [7]. However, up to now almost nothing is known about the time course and severity of global PSF, as well as its certain dimensions over subsequent periods after stroke.

The aim

The objectives of this study were to assess the rates and intensities of PSF over the second half year after stroke.

Materials and methods

Patients were included in the study if they had an acute stroke (ischemic or hemorrhagic), agreed to participate in the study and were able to provide informed consent. Exclusion criteria were major medical illness that could cause secondary fatigue (oncological, hematological diseases, cardiac, liver, kidney and respiratory insufficiency, progressive angina pectoris, acute myocardial infarction), alcohol abuse, consciousness impairments, insufficient cognitive ability (Mini-Mental State Examination scores less than 24) [8], depressive and anxious disorders (Hospital Anxiety and Depression Scale scores more than 10 for both pathologies) [9], impaired speech function to participate (severe dysphasia or dysarthria), impaired language or written ability to complete the study questionnaires, severe functional disabilities (modified Rankin scale scores ≥4).

Patients’ characteristics were evaluated in definite time points: at 6 months (156 patients), at 9 months (139 patients) and at 12 months (128 patients) after stroke.

PSF was measured by three self-report questionnaires: fatigue assessment scale (FAS), multidimensional fatigue inventory-20 (MFI-20) and fatigue severity scale (FSS).

FAS consists of 5 questions about mental components and 5 questions about the physical part of fatigue. The score ≥22 indicates fatigue presence [10].

MFI-20 is a 20-item multidimensional questionnaire which covers global, physical, mental, activity-related and motivational fatigue dimensions. A cut-off of 12 out of 20 for every sub-scale has been suggested for use with people with stroke [11].

The impact of PSF on patients’ functioning and daily life was assessed with FSS. The FSS scores was conditionally categorized into one of the three groups: “no PSF” (FSS <4), “PSF moderate influences on life’s quality” (FSS 4–4,9) and “PSF severe influences on life’s quality” (FSS≥5) [12].

Distributions of continuous variables were checked by Shapiro-Wilk test. Parametric variables were represented as mean±standard deviation, non-parametric – as mediana (Me) and interquartile (25%-75%) range (Q1-Q3). Categorical data were represented by number (n) and percentage. The difference between the patients’ proportions with PSF at definite time points after stroke onset was assessed using Cochran’s Q-test. The Friedman F-test for repeated measurements was performed to analyze multiple non-parametric variables. When the Friedman F-test yielded a significant effect (p<0,05), it was followed by Dunnett’s test for determination the differences between initial and subsequent measurements. A p-value <0,05 was considered statistically significant.

Results

Patients’ age ranged from 43 to 79 years (mean age 63,6±8,3 years). There were 73 (46,8%) males and 83 (53,2%) females. 137 (87,8%) patients suffered of ischemic strokes, 19 (12,2%) had hemorrhagic strokes.

According to FAS score, PSF was present in 47 (30,1%) patients at 6 months, in 46 (33,1%) patients at 9 months and in 41 (32,0%) patients at 12 month after stroke occurence. Cochran’s Q-test of those 128 patients who were observed in all three studied time points did not reveal any significant differences of PSF rates (p=0,62) – 28,1%, 26,6% and 32,0%, respectively.

As seen from Table I, the percentages of each PSF domain were roughly the same in all three studied time points after stroke occurrence. According to Cochran’s Q-test, there were no significant changes in rates of global PSF as well as any PSF domain over the observation period.

Table II shows that severity of global PSF was statistically stable over the second half year after stroke. However, at the same time changes in intensity of certain PSF domains had some statistical regularities – severities of physical and activity-related PSF have been significantly decreased over second half year after stroke, whereas mental and motivational PSF showed significant changes in opposite direction over the same period.

As can be seen from Table III, over the observation period, proportions of patients with different FSS value ranks were roughly the same. Furthermore, according to Friedman F-test there were no significant changes in rates of FSS value ranks (р>0,05).

Discussion

Literature data about PSF prevalence in any post-stroke term as well as in the studied time points are very variable. In particular, according to literature review, at 6 months after stroke, PSF rates range from 23% (measured by FAS) [13] to 64% (by FSS) [14], at 12 months the same range is –21% [13] – 69,5% [14]. Importantly, our results about PSF prevalence were within above mentioned boundaries.

The strength of our study is that, unlike most other works we used longitudinal observation data. So, we found that rates of global PSF as well as rates of each PSF aspect were statistically stable over the second half post-stroke year. Up to now there are only two longitudinal studies about PSF prevalence within the studied period (with roughly similar data). Christensen D. et al. revealed insignificant changes of global PSF rate (measured by MFI-20) between 3 and 12 months after stroke (38% and 44%, respectively) [15]. Schepers V. et al. showed that the percentage of patients reporting PSF (measured by FSS) was slightly increased – from 64,1% at 6 months to 69,5% at 12 months after stroke [14].

The important finding in our study was statistically changes in intensity of certain PSF domains over the second half year after stoke occurrence. Whereas severity of global PSF was stable over the studied period, intensities of mental and motivational PSF aspects have been significantly increased, but severities of physical and activity-related PSF aspects have been statistically changed in opposite way. In literature we found only one work with similar design in which levels of PSF (measured by FSS) between 6 and 12 months after stroke were nearly unchangeable [16].

PSF physical domain, according to MFI-20 sub-scale, can be predominantly described as sensation of inability to do physical tasks. Physical and activity-related aspects of PSF are overlapping each other, so they may have, at least partially, the similar origins and mechanisms of development. As known, most of the functional recovery has taken place within the first months after stroke onset. It is possible that patients during the post-stroke second half year were gradually adapting to the limited functional state and the feeling of physical and, consequently, activity-related PSF was statistically reduced.

The lack of any statistical changes in PSF impact on patients’ daily life (according to FSS value ranks) can be explained, at least partially, in the same way – by the second half of post-stroke year a patient had time to adapt to his (her) new conditions and modified life circumstances.

Mental fatigue, according to corresponding MFI-20 sub-scale, is mainly described as “loss of concentration”, whereas the essence of fatigue motivational component has close overlap with depressive signs. Maybe, intensity increasing of mental and motivational PSF domains is directly or indirectly connected with some qualitative and quantitative peculiarities of patients’ cognitive and emotional areas over studied period. Anyway this question requires further detailed investigations.

Conclusions

1. PSF rates (according to FAS and MFI-20), as well as PSF impacts on patients’ daily life (according to FSS) are stable over the second half year after stroke occurrence.

2. Mental and motivational PSF intensities are statistically increased, whereas intensities of physical and activity-related PSF domains are statistically decreased over the second half year after stroke occurrence.

Future investigations should be directed toward understanding mechanisms, involved in the progression of mental and motivational PSF domains over the second half year after stroke.

REFERENCES

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2. Andersen G, Christensen D, Kirkevold M, Johnsen SP. Post-stroke fatigue and return to work: a 2-year follow-up. Acta Neurol Scand. 2012;125:248-53.

3. Glader E, Stegmayr B, Asplund K. Poststroke fatigue: a 2-year followup study of stroke patients in Sweden. Stroke. 2002;33:1327–33.

4. van de Port I, Kwakkel G, Schepers V, Heinemans C, Lindeman E. Is fatigue an independent factor associated with activities of daily living, instrumental activities of daily living and health-related quality of life in chronic stroke? Cerebrovasc Dis. 2007;23:40–5.

5. Nadarajah M, Goh T. Post-stroke fatigue: a review on prevalence, correlates, measurement, and management. Top Stroke Rehabil. 2015; 22: 208-20.

6. Wu S, Mead G, Macleod M, Chalder T. Model of understanding fatigue after stroke. Stroke. 2015; 46 (3):893–8. doi: 10.1161/STROKEAHA.114.006647.

7. Delva I, Lytvynenko N, Delva M. Post-stroke fatigue and its dimensions within first 3 months after stroke. Wiad Lek. 2017; 70 (1): 43-6.

8. Folstein M, Folstein S, McHugh P. Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-98.

9. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70.

10. Michielsen H, De Vries J, van Heck G. Psychometric qualities of a brief self-rated fatigue measure: The Fatigue Assessment Scale. J Psychosom Res. 2003; 54(4): 345-52.

11. Smets E, Garssen B, Bonke B, Dehaes J. The multidimensional fatigue inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39: 315–25.

12. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989; 46: 1121-3.

13. Duncan F, Greig C, Lewis S, Dennis M, MacLullich A, Sharpe M, et al. Clinically significant fatigue after stroke: a longitudinal cohort study. J Psychosom Res. 2014; 77(5): 368-73.

14. Schepers V, Visser-Meily A, Ketelaar M, Lindeman E. Poststroke fatigue: course and its relation to personal and stroke-related factors. Arch Phys Med Rehab. 2006; 87(2): 184-8.

15. Christensen D, Johnsen S, Watt T, Harder I, Kirkevold M, Andersen G. Dimensions of post-stroke fatigue: a two-year follow-up study. Cerebrovasc Dis. 2008; 26(2): 134-41.

16. Lerdal A, Lee K, Bakken L, Finset A, Kim H. The course of fatigue over the first 18 months after first-ever stroke: a longitudinal study. Stroke Res Treat. 2012; Art. ID 126275. DOI:10.1155/2012/126275.

 

The research described in this paper was performed within the framework of scientific plan of neurological department with neurosurgery and medical genetics at Ukrainian medical stomatological academy “Clinical and pathogenetic optimization of diagnosis, prognosis, treatment and prevention of complicated central nervous system’s disorders and neurological impairments due to therapeutic pathologies” (state registration number 0116U004190).

ADDRESS FOR CORRESPONDENCE

Mykhaylo Delva

Chornovil str., 2b, apt. 229, 36003, Poltava, Ukraine

tel: +380667326385

e-mail: mdelwa@gmail.com

Received: 10.11.2017

Accepted: 26.03.2018

Table I. Frequencies of certain PSF domains over the second half year after stroke

PSF domain

Time point after stroke onset

6 months

9 months

12 months

global

53 (34,0%)

45 (32,4%)

39 (30,5%)

physical

58 (37,2%)

44 (31,7%)

40 (31,3%)

mental

49 (31,4%)

46 (33,1%)

40 (31,3%)

activity-related

41 (26,3%)

35 (25,2%)

29 (22,7%)

motivational

34 (21,8%)

30 (21,6%)

26 (20,3%)

Table II. MFI-20 sub-scales scores over the second half year after stroke (Ме (Q1-Q3))

PSF domain

Time point after stroke onset

6 months

9 months

12 months

global

15 (15-17)

15 (15-17)

15 (14-16)

physical

15 (14-17)

15 (14-16)

14 (13-15)*

mental

14 (13-15)

15 (13-16)

15 (14-17)*

activity-related

15 (13-17)

15 (14-16)

14 (13-15)*

motivational

14 (13-15)

15 (15-16)*

15 (14-16)*

* – significant differences (р<0,05), according to Dunnett’s test, in comparison with 6 months sub-scale score.

Table III. Rates of FSS value ranks over the second half year after stroke

Value ranks

Time point after stroke onset

6 months

9 months

12 months

<4

59 (46,1%)

74 (57,8%)

70 (54,7%)

4,0-4,9

50 (39,1%)

40 (31,3%)

45 (35,2%)

≥5

19 (14,8%)

14 (10,9%)

13 (10,2%)