Medications to Help Stroke Recovery and Sequelae

Post Stroke Resiliency

This presentation will cover medications to help symptoms related to stroke, the research and evidence for medication, and what is recommended by Dr. Sarah Eickmeyer.

We will discuss medications’ ability to help with:

  • Recovery/Depression
  • Fatigue
  • Aphasia
  • Spasticity

And how the medications work.

 

These professionals have published works that have built upon each other and given us our understanding of stroke recovery.

Twitchell created our first understanding of stroke recovery timeline by documenting neurological exams. He noted:

  • Reflexes can become very excitable in chronic stroke
  • Feeling recovery varies by person
  • Spasticity becomes more pronounced with time

These represent synergy:

Flexor Synergy – flexor muscles (our pulling muscles) cause the arm to do these motions when trying to move

Extensor Synergy – pushing muscles cause the arm to extend out; cannot control

Typical Synergy – most commonly seen

*Synergy is not bad, it is a stage of recovery and present differently in people

These are synergy patterns commonly seen in the hips and legs.

Positions marked with “A” are not very typical.

Positions marked “B” and circled are more typical and called “extension synergy.” It is accompanied with stiffness and is hard to bend.

*Patterns are not good or bad, recovery is different for different people.

Brunnstrom turned Twitchell’s work into stages to visualize stroke recovery.

Stages correlate with symptoms along a stroke recovery timeline.

Stages do not necessarily happen in this specific order. Recovery is not linear. For example, someone may remain on a stage for a much longer time, which affects their ability to continue to regain motor control.

 

Fugl-Meyer turned the stages into a point system. There are 66 points for upper extremities and 34 for lower.

Points are given for different movements performed and help to describe the current level of impairment and ability.

The point system describes where a person is in terms of recovery and we still use this point system today.

This graphic describes how each person’s work built upon the previous person’s to get where we are today in terms of our understanding of recovery.

Taub used monkeys as a way of studying constraint therapy. Monkeys were given a stroke and had their unaffected side constrained. When forced to use their affected side, they showed greater signs of recovery.

Lesson: do not ignore your hemiplegic arm, learn how to use it for best recovery results.

Nudo mapped the changes in the brain as a result of the constraint therapy.

The use of the hemiplegic side increases that side’s motor map in the brain. Increased map size increases the ability to use that side. Non-use shrinks that side’s motor map representation.

This is found to be true in humans as well.

 

Neuroplasticity refers to the brain’s ability to change after being damaged from stroke. “Neuro” = brain; “Plastic” = change.

This chart is a theoretical representation of stroke recovery and the brain’s “sensitive period” – the time after a stroke when our brains do a large amount of pathway changing.

The main takeaways from the first section of the presentation include:

Most recovery happens within 3-6 months but can be up to a year for some people.

Larger movements are first to recover, followed by smaller and isolated movements later.

A study from 2011, known as the FLAME trial, looked at the relation between physical therapy and depression medication (SSRI).

It found that physical therapy + SSRI medication improved motor recovery more than PT alone. This is a reason why many people may be prescribed an SSRI following a stroke.

8 years later, the FOCUS Trial found that SSRI did not help with physical therapy, but may have helped depression. It also found a correlation between taking an SSRI and increased risk of fracture.

The AFFINITY trial in 2021 found that SSRI medication did not help with motor recovery and also did not increase risk of fractures, falls, or seizures.

It did find that SSRI may help with depression after stroke

Depression is 3 times more common in people who have had a stroke than in people who have not.

The more severe the stroke and its effect on function, the greater the risk of depression.

Depression after stroke is also correlated with a low amount of social ties and connection.

Depression is associated with an increased risk of dying after stroke. It is also associated with disability. This makes it an important aspect of recovery for treatment.

Medications (SSRI and TCA) are both effective for treating depression. They are correlated with improved mortality and function following a stroke.

Medication addressing depression may help with initial but not long-term recovery.

This study found that speech therapy combined with the use of Donepezil improved aphasia symptoms.

It is accompanied by some side effects that can cause stomach/GI issues, making it best taken at night before bed.

Memantine also showed improvements in aphasia patients after stroke when combined with speech therapy.

This medication is not as well tolerated as the Donepezil, showing more harsh side effects.

Medication might help aphasia recovery after stroke when used in conjunction with speech therapy services. Medication can be taken later on in the recovery process if rehabilitation goals are not as far along as hoped.

Fatigue is common after a stroke. The brain is in recovery and may become overwhelmed during the day.

Talk with a physician if fatigue is a concern. Medication is an option for treatment.

This study found that Ritalin reduced mental fatigue and improved the information processing in people who had a traumatic brain injury. Alertness was improved, but this medication is accompanied by some severe side effects.

Because high blood pressure is a possible side effect, this is not recommended for people with heart issues.

This study found that Modafinil is promising for reducing fatigue in stroke patients. There are little known side effects in people who take this medication, but it is very expensive and can be hard to get.

It is safe to use with heart conditions. There are no studies for this medication and chronic stroke yet.

There are medication options for mental fatigue after a stroke; each has their own risks.

Talk to your physician first to see if there needs to be a lifestyle change (sleep, diet, etc.) for your fatigue before trying medication.

Modafinil is recommended if other sources of fatigue are ruled out.

Spasticity is an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement. These are very excitable reflexes after a stroke, brain injury, or spinal cord injury.

Spasticity is common among stroke survivors.

There are common oral medication options for spasticity.

Botulinum injection goes into the muscle and causes it to relax.

Intravenous or spinal cord drip are also an option for some.

Referrals for these medications are done through your primary care physician. Always discuss your spasticity concerns with your physician to determine the best option for you.

Oral medication is typically tried first to see if it helps reduce spasticity. Additional options are explored if the oral medication does not show improvement.