An increased risk of stroke for patients with psoriasis

A stroke is an event in somebody’s life which truly can alter the life process of an individual and his or her family. Because of a stroke, a person might have problems with mobility, language, logic and emotions. It may also affect the normal body system of a stroke patient. It may weaken the body’s normal response to stressors. That is the usual turn of events after an acute stroke – a stroke is the cause of “something”. However, a new study has made an interesting discovery which counters the series of events after a stroke. This new study had made a link between psoriasis, an autoimmune disorder, which may cause a stroke in the future. Scientists are now looking at psoriasis as another risk factor of having a brain attack.

What is Psoriasis?

Psoriasis is a chronic or lifelong disease which affects the immune system. Its manifestation varies from person to person and response to the known treatment of psoriasis also differs from one person to another. It usually manifests as red lesions and irritations on the skin. It can manifest anywhere in the body. Lesions can form on the eyelids, on the ears, mouth and lips, skin folds, hands and feet and even on the nails.

It occurs when the body’s immune system sends out incorrect signals which speed up the growth cycle of skin cells.  However, it is neither communicable nor contagious. You could not be “infected” by a person with psoriasis and you could not infect other people if you have the disease because it is an autoimmune disorder.  An autoimmune disorder is a condition that occurs when the immune system mistakenly sees the cells of the body as “aliens” and attacks and destroys normal healthy body tissues.

It is considered as the most common autoimmune disease.  There are approximately 7.5 million people affected with psoriasis in the United States alone while all over the globe, about 125 million people are afflicted with this disorder.

A number of people with psoriasis may experience problems with self-confidence because of the lesions on the skin which is the usual symptom of the disorder.

Finding the link between psoriasis and stroke

A new study made by scientists from Denmark had found that patients with psoriasis have an increased risk of experiencing atrial fibrillation (the most common heart problem where both right and left atrium contract very fast and very irregularly) and an ischemic stroke (a stroke caused by a clot in the blood vessels in the brain) in the future. Their study is an addition to the growing body of research which had linked psoriasis with problems with the heart and blood vessels. The results of their study were published online last August in the European Heart Journal.

The link between psoriasis and stroke as well as other cardiovascular diseases can be attributed to two main reasons. First, individuals with the disorder tend to have more cardiovascular risk factors. These include obesity, smoking and having high lipid levels in the blood. Second, people with psoriasis are in a constant state of inflammation. This natural response of the body is believed to be “the link” between the two conditions.

They said that the link between psoriasis and stroke can be attributed to problems with an individual’s lifestyle. The results of the latest study theorized that all persons who have psoriasis are likely candidates for a change of lifestyle which may include smoking cessation having a healthy weight, increasing physical activity, having a healthy diet, and etc.  The latest paper also said that selected patients with psoriasis need to undergo medical treatment such as reducing hypertension, treatment which can lower lipids (fats in the body) and other medical treatments.

The scientists believe that their latest research is a step towards acknowledging the fact that the role of psoriasis as a risk factor for future cardiovascular event which includes a stroke. They also deem that their findings call for an increased awareness of cardiovascular risk factor management in people afflicted with psoriasis. And since a large number of people have the disorder, there is also a bigger problem of how to modify the lifestyles of these patients to lessen their chances of experiencing AF or a stroke in the future.

The numbers game

Using national registries of inpatient hospitalization and dispensing of medications, the researchers tried to determine the risk of having an AF and an ischemic stroke in patients with varying degrees of psoriasis (36,765 patients with mild psoriasis and 2,793 patients with severe psoriasis) and also from a large number of psoriasis-free individuals (4.5 million).

The researchers said that their study showed alarming results. They found out that the risk of having AF was increased by as much as 50% when a patient is below 50 years old and has mild psoriasis. On the other hand, an increase of 16% was observed on patients who have mild psoriasis and were older than 50. People with severe psoriasis were more prone to having AF. The researchers said that the chances of having AF rose by 198% for patients younger than 50 years of age while the chances of older patients was pegged at 29%.

The chances of having an ischemic stroke were no different from the chances of having AF.  They said that the risk of having a future ischemic stroke grew by 97% for patients who have mild psoriasis and were younger than 50 years. They painted a grim picture for people with severe psoriasis. They said that their chances of experiencing an ischemic stroke in the future were increased by as much as 180%.  They also gave a bleak prediction for older patients with mild and severe psoriasis. They said that their chances of having an ischemic stroke grew by 13% and 14% respectively.

What should be done?

The researchers proposed that patients with psoriasis should be closely monitored for any indicators of cardiovascular disease which includes arrhythmias. They also suggested that these individuals should be considered as potential candidates for interventions which can greatly reduce the risk of having cardiovascular disease. These interventions can include lifestyle modifications such as increasing physical activity, smoking cessation and even taking medications.

The researchers did point out that an important goal for future research is to evaluate the impact of changes in primary cardiovascular prophylaxis in patients with psoriasis, such as medical management.   They also revealed that an important thing to consider is whether improving psoriasis treatment such can modify the risk of having cardiovascular events in the future.

Reference:

Medscape.com

Msnbc.msn.com

Nhlbi.nih.gov

Medterms.com

Psoriasis.org

Anti-depressant medication improves motor function in stroke patients

A recent study named “Fluoxetine in Motor Recovery of Patients with Acute Ischemic Stroke (FLAME)” was published online last January. The study reported that stroke subjects who take the antidepressant medication fluoxetine after experiencing an ischemic stroke have a more improved mobility. It also reported that the stroke subjects receiving fluoxetine are more independent with their activities of daily living (ADL) compared with stroke victims who received placebo. Researchers of the clinical study are suggesting that fluoxetine, a selective serotonin reuptake inhibitor (SSRI), could signify a new approach to treating stroke patients.

Fluoxetine (also known by the tradenames Prozac, Sarafem, Fontex, among others) is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class used to treat depression obsessive-compulsive behavior, a number of eating disorders and panic attacks. SSRIs are the most commonly prescribed antidepressant medication. SSRIs are relatively safe and generally cause fewer side effects than any other type of antidepressant. They work by blocking the reabsorption or the reuptake of the neurotransmitter serotonin increasing its levels in the brain. This increase seems to help brain cells send and receive chemical messages which in turn boosts a person’s moods. They are called selective because they only affect serotonin and not the other neurotransmitters in the brain. Side effects of SSRIs may include:

• Nausea
• Dry mouth
• Headache
• Diarrhea
• Nervousness, agitation or restlessness
• Reduced sexual desire or difficulty reaching orgasm
• Inability to maintain an erection (erectile dysfunction)
• Rash
• Increased sweating
• Weight gain
• Drowsiness
• Insomnia

About the study

Dr. François Chollet, MD, the study’s lead author, a professor of neurology at the Toulouse University Hospital in France said that their team thinks that fluoxetine encourages an increase in the brain’s capacity to reorganize – it acts by helping in rewiring the brain. He added that using fluoxetine is like opening another capacity, another target and another pathway for treating patients who had experienced a stroke.

Currently, ischemic stroke patient are being treated with tissue plasminogen activator (tPA), a thrombolytic drug approved by the US Food and Drug Administration. Dr. Chollet’s team hopes that, in the near future, fluoxetine or other SSRIs can also be a treatment option for these stroke patients. However, Dr. Chollet said that before that can take place several questions must be answered first. He said that the researchers need to determine the length of time for optimal treatment; they also need to find out the long-term effects of the treatment on stroke patients; and what are the other possible effects on neuronal activity in general.

The participants of the study

118 subjects 5-10 days after ischemic stroke were randomized from 9 stroke centers in France. These stroke victims were between 18 and 85 years old and either had hemiplegia (paralysis on either the left or right side of the body) or hemiparesis (weakness on either the left or right side of the body) which are the most common deficits caused by a stroke, with a Fugl-Meyer motor scale of 55 or less. Patients with severe post stroke disabilities (NIHSS score > 20), clinically diagnosed with depression (MADRS > 19), pregnant or with other major diseases were excluded from the study.

Results: Fluoxetine vs. placebo

All of the stroke patients were randomly assigned into 2 groups of 59 members. One group was given 20 milligrams of fluoxetine while the other group was only given a placebo. The researchers started to administer fluoxetine or placebo 5-10 days after the onset of the stroke and they continued for a total of 3 months. All of the stroke victims were given standard post-stroke care and they also underwent physical rehab from physical therapists (PT) who were instructed to use conventional therapy according to the protocol of their medical centers. The PTs were also made to assess the motor functions of all the stroke victims starting from day 0 (the baseline), after 30 days and then 90 days after starting the program.

The result of the study shows that the group treated with fluoxetine recorded a 40% improvement on the Fugl-Meyer motor scale as compared to the placebo group (34 points in the fluoxetine group vs. 24.3 in the placebo group).

Fugl-Meyer Motor Assessment (FMA) is a clinical examination performed to assess the upper extremity and lower extremity motor and sensory impairments in post stroke patients. FMA is being increasingly being used for clinical assessment of motor recovery after a stroke. In a recent clinical trial from July 2011, FMA was used to evaluate safety and efficacy on motor recovery of NeuroAiD in 150 Caucasian subjects after stroke. Subjects on NeuroAiD achieved 27% higher recovery on their motor function as compared to the placebo group. Click here to learn more about the Fugl-Meyer Assessment after a stroke.

Limitations of the study

Although the results of this study shows the positive effect of fluoxetine in motor recovery on post ischemic stroke patients, we should not forget that there are some limitations to it. First, the number of patients included was small (118), also they were selected for motor deficit and do not represent the general population of stroke patients. Second, the treatment was performed for 90 days and it is not well known how the motor recovery evolves over time after the treatment has stopped. Third, a potential random error derived from the statistical analysis cannot be ignored, although this probability is remote (the change in FMA score at day 90 had a statistical relevance of p= 0.003, in other words, the odds that it is an error is 3 in 1000).

Benefits and side effects of SSRIs

Fluoxetine is relatively inexpensive and is commonly available. Fluoxetine, is not a new drug so its side effects are well known, generally mild and very infrequent. Other SSRIs aside from fluoxetine may have the same positive effects, as shown by a study published in 2010 which showed patients who are taking escitalopram (another type of SSRI) had a marked improvement in cognition, particularly memory, compared to patients who were given a placebo.

Depression post-stroke

It is not unusual for post-stroke patient to experience depressive symptoms especially if they have disabilities arising from the stroke. Dr. Chollet‘s team noted that the placebo group had a higher number of stroke patients having significant deficits (7%) compared with the fluoxetine group (5%), there were more depressed stroke patients in the placebo. Approximately 30%-50% of post-stroke patients develop some form of depression and fluoxetine could serve as both mood and motor recovery enhancer. This in turn is a welcome combination of benefits to post-stroke patients.

Fluoxetine was given to the stroke patients as soon as possible after their stroke and that there was no “stroke window” during which it must have been delivered. On the contrary, tPAs must be given within 3.5 hours after the onset of the stroke symptoms because of the risk for bleeding. The earlier fluoxetine is administered, the better for the stroke patient. Dr. Chollet added that what healthcare providers know about the natural history of stroke is that patients recover mainly during the first three months. This period is the time where stroke patients experience the biggest improvements. However, it is still not clear what the optimal duration of treatment is. The long-term effects of fluoxetine and possible other benefits on neurologic functions of this new possible treatment for stroke patients needs to be elucidated.

References

Medscape.com

Nlm.nih.gov

Mayoclinic.com

Medicine.mcgill.ca

Fugl-Meyer Assessment after a stroke

There are several words in the English vocabulary that denotes some form of ranking. In terms of number there are the words first, second and third, etc. There are also other words which can denote some form of status between people, objects and things such as good, better, and best, bad, worse and worst, etc.

In the field of stroke recovery, there are also words to denote some form of evaluation which can be used in patients who had just experienced a stroke. Examples of such words are weak or strong, weaker or stronger and others. These words are helpful in giving and determining the current status of a patient. Healthcare providers use them in assessing the difference between the unaffected and affected side of the stroke patient’s body.

However, these words are very subjective and will depend on the judgment of a person. A physician’s assessment of a stroke patient may differ from another member of the stroke rehab team. This may cause a problem since objectivity should always be practiced when assessing a stroke victim.

A complete assessment should be made for the benefit of the stroke survivor which will be used as reference for proper therapeutic management and for the stroke patient’s rehabilitation. Also, the advent of new treatments and rehab options for post-stroke therapy has made measuring recovery after a stroke very important. Aside from establishing the plan of treatment for the stroke patient, such assessments can also prepare the stroke survivor, his or her family and his or her significant other for any anticipated and expected outcomes. A tool currently employed by members of the healthcare team in properly evaluating patients is the Fugl-Meyer Assessment (FMA) for Motor Recovery after a Stroke.

The Fugl-Meyer Assessment (FMA)

The FMA is a stroke-specific and performance-based impairment index. This means that all stroke survivors are considered unique and that a grading system is in place for proper evaluation.  Basically, what it does is it can determine the severity of the stroke, describe motor recovery, plan the post-stroke treatment and evaluate these treatments. It also evaluates the capacity of the stroke survivor to perform activities of daily living (ADL) and pain. Evaluation can be done immediately after a stroke and can be repeated while the stroke patient is already undergoing therapy. It was developed  to be used in both clinical and research setting and is the first quantitative evaluation tool based on the chronological stages of motor and sensory return in hemiplegic (paralysis of either left or right side of the body) stroke patients. It allows the healthcare team to properly measure the motor and sensory recovery of survivors after a stroke (http://physical-therapy.advanceweb.com/Article/The-Fugl-Meyer-Assessment-After-Stroke.aspx).

Aside from motor and sensory functions, it can also assess balance and joint function in post-stroke patients.

A physical therapist, an occupational therapist or any other rehab professional trained on FMA can administer the evaluation on the stroke patient on a one-on-one basis. The person tasked to administer the test shall guide the stroke victim through test through demonstration and by giving out verbal instructions.

It can be applied in any setting – a hospital, a clinic even at the stroke survivor’s home. Most importantly, it does not need any special equipment. Although, it does require a mat or a bed and a number of small objects for assessment of sensation, reflexes and range of motion (ROM).

The test tracks the stroke patient’s progress from the initial day that he or she had the stroke to days, weeks, months or even years post-stroke.

Sections of the evaluation can be administered separately. The FMA is that it usually takes about 30-35 minutes to administer the whole test. A copy of the FMA can be obtained by following the link towards the Institute of Rehabilitation Medicine, University of Gothenburg, in Sweden http://www.neurophys.gu.se/sektioner/klinisk_neurovetenskap_och_rehabilitering/neurovetenskap/rehab_med/fugl-meyer/.

However, certain stroke patients may have difficulty with the assessments and may take longer than usual to finish the test. It had been found that the FMA is quite challenging to administer to aphasic (has problems with speech or language) and severely affected patients post-stroke.  Since it is based on direct observation, stroke victims who need a proxy to complete tasks will not be permitted to undergo the test.

Features and scoring

• Scoring in the FMA is based on direct observation of the stroke survivor’s performance and is based on the ability to complete an item in the test.  Items in the FMA are scored on a 3-point scale.
  • 0 = cannot perform
  • 1 = performs partially
  • 2 performs fully

• The maximum score that a stroke patient can have is 226 points

• There are five domains which is evaluated by the occupational or physical therapist
  • Motor function – this part of the test includes assessing the movement, coordination and reflex action of the shoulder, elbow, forearm, wrist, hand, hip knee and ankle. The score for this test range from 0 (paralysis) to 100 (normal motor function). The total score is divided into:
    • Upper extremity maximum score = 66
    • Lower extremity maximum score = 34
  • Sensory function (evaluates light touch on two surfaces of the arm and leg, and position sense for 8 joints) maximum score = 24
  • Balance (contains 7 tests, 3 seated and 4 standing) maximum score = 14
  • Joint range of motion (8 joints) maximum score = 44
  • Joint pain (maximum score 44)

Depending on the need, each of the five domains of the test can be administered without using the full FMA evaluation. This means that if the therapist wishes only to evaluate upper extremity function, the subsections which specifically deal with assessing upper extremity movement, sensation, joint motion and pain can be performed without having to administer the full test. Also, modified or shortened versions had been developed for these purposes.

References:

Ncbi.nlm.nih.gov

Medicine.mcgill.ca

Rehabmeasures.org

Neurophys.gu.se

Medical-dictionary.thefreedictionary.com

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