Pharmacotherapy in restorative neurology

Liepert J. Curr Opin Neurol 2008; 21:639-643.

Levodopa, single 100 mg dose. Mixed results when given alone. Floel et al. showed that if given with rTMS, levodopa increased evoked movements into the trained direction. The authors said it could "enhance the ability to encode a motor memory with training." Restermeyer et al in a doubled blinded crossover trial found no differences.

A recent Cochrane review of studies of amphetamines after stroke for motor recovery concluded that it was not possible to determine whether it made a difference.

Walker -Batson et al. studied 21 subacute aphasic patients with 10 mg amphetamines every fourth day with one hour of speech therapy for ten sessions, and assessed subjects with the Porch Index of Communicative ability. Patients receiving amphetamines improved, and even after 6 months had a trend to improvement. Whiting et al. had a study with two patients, one improved, one did not. Mocobemide did not help aphasia after stroke.

Methylphenidate after stroke with Physical therapy improved motor function using Fugl Meyer Scale and reduced depression. (21 patients were studied). In TBI, it improved mental processing speed more than placebo.

Amantadine reduces agitation and aggression and imporves attention and alertness on DRS and FIM in TBI patients. On PET it is associated with increased left prefrontal activity. It helped executive functions in one study.

Reboxetine improves motor skill acquisition. It improves tapping speed and grip strength after a single dose in 10 stroke patients with a session of physiotherapy.

Piracetam 4.8 mg daily in 203 subacute stroke patients decreased aphasia on Aachener Aphasic Test, including written language and "profile level." In 24 patients, speech therapy plus piracetam improved semantic and syntactic structure of speech. PET showed improvement in left appropriate areas including left transverse temporal gyrus, Wernicke's and Broca's area. Cochrane review said piracetam "may be effective."

Donepezil in 26 patietns with poststroke aphasia helped the Aphasia Quotient but not the Communicative Ability Log. In TBI, 18 chronic patients received for 10 weeks and showed improved memory and sustained attention. Rivastigmine did not appear to help TBI patients with memory except a subtype with poor memory.

SSRI fluoxetine helped walking and ADL's in severely disabled stroke patients. In a PET study it caused hyperactivation in ipsilesional motor cortex. Citalopram helped dexterity but not grip strength in affected hand in a group of stroke patients.