Pharmacological risks following stroke.

To the Editor:

The physical therapist's examination of a patient who has had a stroke requires identification of the effects of medications being taken for the symptoms of the stroke and for other conditions. I applaud Joann Gallichio for writing "Pharmacologic Management of Spasticity Following Stroke" in the October 2004 issue, because this article is a valuable resource to the physical therapist examining a patient who has had a stroke.

Physical therapists should recognize the risk for an adverse response with the use of the drugs described in this report. For example, the author reported that diazepam (Valium *) may "reduce motor coordination and impair intellect, attention, and memory" (p 974) and that oral baclofen (Lioresal ([dagger])) may cause "drowsiness, confusion, headache, and lethargy" (p 976). Those responses alone may be sufficient to adversely affect an individual's functional abilities following stroke. However, these medications carry additional risks for our patients.

Using an animal model for stroke, Schallert et al (1) demonstrated that medicating with diazepam (a benzodiazepine) increased the symptoms of hemiplegia. The administration of diazepam during the acute phase (first 22 days) following a unilateral brain injury blocked the recovery of sensory ability in rats, and rats that were allowed to recover that ability developed a transient reinstatement of the deficit when medicated with diazepam) This response appears to have clinical importance, because patients recovering from a stroke who use drugs from the benzodiazepine class have been reported to have a poorer recovery of sensorimotor (2) and upper-extremity (3) function.

Goldstein (4-7) has documented the risks accompanying the use of diazepam and certain other medications by individuals who have had a stroke, and a review of that information is beyond the scope of this letter. However, physical therapists should note that there are medications that risk a detrimental effect on functional outcome following stroke. Goldstein summarized his recommendations about these medications as "the use of a [beta]-adrenergic receptor antagonist is preferable to either an [[alpha].sub.1]- or [[alpha].sub.2]-adrenergic receptor antagonist in the treatment of hypertension following stroke. Thiazide diuretics should be used cautiously. Haloperidol and other dopamine receptor antagonists should not be used unless absolutely necessary.... Benzodiazepines should generally be avoided." (6(q55))

Physical therapists who are managing the care of a patient who has had a stroke must recognize that diazepam (and some other medications) has the potential to adversely affect outcomes such as functional abilities. Therefore, analysis of medication effects should be included in the evaluation of the examination data for a patient who has had a stroke, and collaboration with the prescribing physician may be necessary for risk reduction.

Jim Smith, PT, MA

[e-mail]

* Roche Pharmaceuticals, Roche Products Inc, Manati, Puerto Rico 00674.

([dagger]) Manufactured by Novartis Pharma AG, Basel, Switzerland, for Medtronic Inc, 710 Medtronic Pkwy NE, Minneapolis, MN 55432-5604.

References

(1) Schallert T, Hernandez TD, Barth TM. Recovery of function after brain damage: severe and chronic disruption by diazepam. Brain Res. 1986;379:104-111.

(2) Goldstein LB, Matchar DB, Morgenlander JC, Davis JN. Drugs influence the recovery of function after stroke. Stroke. 1990;21:179.

(3) Goldstein LB. Common drugs may influence motor recovery at]m stroke. Neurology. 1994;44 (suppl 2):A289.

(4) Goldstein LB. Common drugs may influence motor recovery after stroke. Neurology. 1995;45:865-871.

(5) Goldstein LB. Effects of amphetamines and small related molecules on recovery after stroke in animals and man. Neuropharmacology. 2000;39:852-859.

(6) Goldstein LB. Influence of common drugs and related factors on stroke outcome. Curr Opin Neurol. 1997; 10:52-57.

(7) Goldstein LB. Potential effects of common drugs on stroke recovery. Arch Neurol. 1998;55:454-456.