Ritalin revisited: does it really help in neurological injury?
Article Type: Product/Service Evaluation
Subject: Brain damage (Drug therapy)
Brain damage (Care and treatment)
Stroke (Disease) (Care and treatment)
Stroke (Disease) (Drug therapy)
Methylphenidate (Usage)
Methylphenidate (Physiological aspects)
Methylphenidate (Evaluation)
Methylphenidate hydrochloride
Brain (Injuries)
Author: Kajs-Wyllie, Marylyn
Pub Date: 12/01/2002
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2002 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Dec, 2002 Source Volume: 34 Source Issue: 6
Product: Name: Ritalin (Medication)
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 95909318
Full Text: Abstract: Methylphenidate (Ritalin) is a commonly used central nervous stimulant. It has been used in various neurological conditions, including attention deficit disorder, depression, and narcolepsy. Methylphenidate has been advocated in patients with traumatic brain injury and stroke for a variety of cognitive, attention, and behavioral problems. It also has been shown to speed recovery from post-stroke depression so that patients can participate more fully in rehabilitation programs. Research suggests that it also may have a role in augmenting activity of injured neuronal tissue in the comatose patient, thus facilitating a return to consciousness. The neuroscience nurse plays an important role in monitoring response to Ritalin, including identifying its side effects. A review of the limited studies on the use of Ritalin, its mechanisms of action, dosing, and weaning provide a current understanding of this adjunctive agent's role in treatment for the neurological population.


Psychostimulants such as amphetamine, dextroamphetamine (DEA), nortriptyline, and methylphenidate have been used to enhance cognition and memory, modulate behavior, and arouse the neurological population for many years. These drugs exercise a positive effect on memory and attention and control behavioral disturbances such as hyperactivity, impulsivity, and emotional lability (Challman & Lipsky, 2000). Animal research has indicated that psychostimulants can influence recovery when given at early or later time points after brain injury (Walker-Batson, Smith, Curtis, Unwin, & Greenlee, 1995). A single dose of DEA was reported to produce an enduring acceleration of motor recovery after experimental lesions in the rat (Feeney, Gonzales, & Law, 1982). Intermittent dosing (every fourth day) also helped recovery in the cat (Hovda & Feeney, 1984). A recent study showed that water maze performance was enhanced after brain-injured rats received methylphenidate (Kline, Yan, Bao, Marion, & Dixon, 2000). Findings suggest that these drugs, which enhance catecholamine neurotransmission, might be a useful adjunct in some neurobehavioral sequelae following head injury in humans (Kline et al.).

Although researchers have suggested the use of various drugs in behavioral recovery for humans, evidence for its clinical application is limited (Walker-Batson et al., 1995). Methylphenidate (Ritalin) is commonly prescribed, specifically for stroke and brain injury patients, in the neuroscience setting. However, its mode of action in humans is not completely understood; it presumably modulates the neurotransmitters dopamine, serotonin, and norepinephrine (Kimko, Cross, & Abernathy, 1999). This article discusses the clinical usefulness of Ritalin in the neurologic patient population and reviews pharmacokinetics and clinical studies from 1984 to 2000.

Pharmacokinetics and Side Effects of Ritalin

Ritalin is a mild central nervous system stimulant whose mode of action is not completely understood (Kimko et al., 1999). It causes a dose-dependent change in behavior very similar to that of amphetamine. Amphetamine is thought to increase extracellular serotonin and dopamine in the caudate putamen and norepinephrine in the hippocampus, which in turn stimulates other circuits in the brainstem and cortex. Ritalin, in comparison, is thought to cause a smaller increase in norepinephrine, has no effect on serotonin, and exerts many of its effects through dopamine uptake blockade instead of a release of dopamine (Kuczenski & Segal, 1997). One recent study suggested that Ritalin enhanced working memory by modulating the frontal and posterior parietal regions in the human brain (Mehta et al., 2000).

Ritalin is a short-acting stimulant with a 1-4 hour duration of action and a half-life of 2-3 hours. However, sustained-release formulations are now available. Because of individual variability in the dose-response relationship, dosage must be divided and titrated up for optimal effect and to avoid toxicity (Stein et al., 1996; Volkow et al., 1998). Ritalin is absorbed well from the gastrointestinal tract and easily passes to the brain. It has mild side effects as compared to amphetamine, with an onset of action of 24-48 hours as compared to 1-2 weeks for antidepressants such as nortriptyline (Kimko et al., 1999).

Adverse effects of Ritalin are related to sympathetic nervous system stimulation, especially with long-term use. These effects include nervousness, insomnia, decreased appetite, nausea and vomiting, dizziness, drowsiness, blurred vision, increased blood pressure and pulse, and rash, pruritis, and fever. Symptoms of overdose include increased agitation, tremors, muscle twitching, confusion, hallucinations, sweating, hypertension, and cardiac arrhythmias (Long, 1999).

Potential adverse effects of Ritalin are of specific concern in patients with neurological injury. An incident of stroke due to cerebral arteritis caused by Ritalin use in an 8-year-old boy (Schteinschnaider et al., 2000) was recently reported. Wang et al. (1994) demonstrated that Ritalin decreased cerebral blood flow 5-10 minutes after its administration, warning that Ritalin should be used with caution when chronically prescribing the drug for patients with cerebrovascular compromise. Clinical evidence has shown that Ritalin may lower the seizure threshold. Hence, clinicians are reluctant to use Ritalin in the brain-injured patient with seizures. However, Wroblewski, Leary, Phelan, Whyte, and Manning (1992) concluded that Ritalin could be used safely in 26 brain-injured patients with active seizure disorders and actually was associated with a trend toward a reduction rather than an increase in seizure frequency. Finally, there is a potential for abuse with any psychostimulant. Deaths have been reported from both parenteral and intranasal abuse of Ritalin (Masello & Carpenter, 1999).

Clinical Uses

Attention-Deficit/Hyperactivity Disorder and Narcolepsy

Methylphenidate is a commonly used medication in the United States. The Food and Drug Administration (FDA) has approved its use for the treatment of attention-deficit/hyperactivity disorder and narcolepsy. It is used with other remedial measures (e.g., psychological, educational, social) for a stabilizing effect in children with distractibility, short attention span, hyperactivity, emotional lability, and impulsivity. In narcolepsy, it improves the signs and symptoms of hypersomnia and hypoarousal (Kimko et al., 1999).


Depression in the hospitalized patient who is elderly has an effect on several outcome measures, including prolonged recovery from medical illness, decreased motivation toward recovery, and noncompliance and decreased participation with medical therapy. Even though Ritalin is not FDA approved for treating depression, two early studies found the drug to be a safe and effective treatment of depression in the medically ill elderly (Koenig, Shelp, Goli, Cohen, & Blazer, 1989; Morris, Robinson, Andrzejewski, Samuels, & Price, 1993). Ritalin has an advantage over antidepressants such as nortriptyline because of its quick observable response and fewer side effects. Based on clinical data, the use of Ritalin in severe depression is cautioned, however, because it may exacerbate behavior disturbance and thought disorder symptoms. Also, the use of Ritalin with tricyclic antidepressants (TCAs) may increase side effects of these drugs (Emptage & Semla, 1996).

Use in the Neurological Patient Population

Ritalin has been used for patients with traumatic brain injury, post-stroke depression and recovery, the neurobehavioral deficits caused by brain tumors, and coma (Challman & Lipsky, 2000). These are all non-FDA-approved uses. There are limited studies involving the use of psychostimulants in the neurological patient. The current literature, which primarily consists of uncontrolled studies, dates back to 1984 and suggests a role for the use of Ritalin (Kraus, 1995).

Brain Injury

The cognitive and behavioral disturbances seen after head injury in both children and adults have been well documented in the clinical literature (Levin, Benton, & Grossman, 1982). Cognitive functions particularly vulnerable to head injury are memory and attentional and intellectual skills. It is common for patients with moderate to severe head injury to display behavioral disturbances, such as impulsivity and hyperactivity, after injury, and then to be treated with psychiatric medications such as antiepileptic drugs, neuroleptics, TCAs, and lithium to control neurobehavioral sequalae. However, these drugs can have an adverse effect on cognition, memory, and attention by blocking re-uptake of norepinephrine and serotonin (Evans et al., 1987).

Thus, attention has turned to psychostimulants for behavior control in the head-injured population, based on the positive effects already seen in animal studies (Boyeson, Krobert, Grade, & Scherer, 1993; Goldstein & Davis, 1990; Hovda & Feeney, 1984; Hurwitz, Dietrich, McCabe, Alonson, & Watson, 1991; Jonason, Lauber, Robbins, Meyer, & Meyer, 1970; Sutton & Feeney, 1992). Psychostimulants in brain-injured rats and cats showed an increase in metabolic activity in regions surrounding the site of injury with the addition of tactile stimulation, an increase in cortical excitability, and, in rats, an increase in synaptogenesis and sprouting.

The rationale for psychostimulant use for individuals with brain injury dates back to Luria, Naydin, and Tesvetkova (1968). Drug treatment was used for the psychopathic symptoms that sometimes follow brain injury such as depression, psychosis, or aggression; drugs were used to correct the cognitive deficits like inattention and memory problems; the dopamine agonists enhanced the course of cortical recovery. Positive effects are apparent within days or within hours after an optimal dose is achieved. Methylphenidate (MPH) and DEA are the stimulants most frequently prescribed (Gualtieri & Evans, 1988).

Another rationale for the use of psychostimulants following brain injury is the effect of the drug on attention deficit hyperactivity disorder. This stimulant improves problems of inattention, distractibility, disorganization, hyperactivity, impulsiveness, and emotional lability in children and adults; similar problems are seen in the brain-injured population. Ritalin probably exercises a therapeutic effect by modulating or enhancing dopaminergic neurotransmission to rostral and axial brain structures, especially in the frontal neocortex and axons. Therefore, Ritalin may be especially beneficial for the patient with injuries to the frontal lobe and brain stem, the most common sites of head injury (Gualtieri & Evans, 1988).

Clinical studies on the use of Ritalin in pediatric traumatic brain injury (TBI) are limited and conflicting (Table 1). A retrospective review of 10 children with mild to severe TBI showed that Ritalin appeared to be an effective treatment for post-TBI cognitive and behavioral sequelae, as well as improved arousal in one minimally responsive brain-injured child (Hornyak, Nelson, & Hurvitz, 1997). However, a controlled study of 10 children who received Ritalin 8 months to 2 years after TBI showed no significant differences between Ritalin and placebo when assessing behavior, attention memory, and processing speed. Ritalin may not be effective so long after injury; the therapeutic window is considered to be 30 days in most of the literature (Williams, Ris, Ayyangar, Schefft, & Berch, 1998).

Clinical studies on the use of Ritalin in the adult brain injury population are more numerous (Table 1). The first reported study (Evans, Gualtieri, & Patterson, 1987) was with a 21-year-old male 2 years after TBI. MPH and DEA were administered in separate low- and high-dose trials of the psychostimulants. This case study showed better cognitive and behavioral responses to the higher dose and positive improvements in verbal memory, learning skills, and ability to maintain attention at school 1 week later. Because DEA has a higher potency than Ritalin, the patient was maintained on DEA for a "sustained" effect (Evans et al.).

In another adult study (N = 15), participants received either a low or high dose of Ritalin or a placebo and were evaluated at baseline, 12 days, monthly, and 1 year after administration (Gualtieri & Evans, 1988). Participants were between 5 months and 12 years after the injury. Fourteen participants reported that the drug was superior to placebo and that they experienced improved mood; increased performance at work, school, or household tasks; greater alertness and organization; and better memory. Over the course of the year, scores improved on the Adult Activity Scale, mood, cooperation, selective reminding, and Digit symbols. It was hypothesized that the drug changed the "responsiveness" of the neurons to enhance the natural recovery process (Gualtieri & Evans). After drug withdrawal, one patient deteriorated 4 weeks later. Because of the limited number of patients who remained on the drug for a year (n = 3), the long-term efficacy of Ritalin is questionable.

Because anger and temper outbursts can be serious problems after brain injury, Mooney and Haas (1993) specifically looked at the effects of Ritalin on brain injury-related anger. This randomized study of 38 males who had suffered serious brain injuries and who were beyond the period of rapid, spontaneous recovery received either 30 mg/day of Ritalin or placebo for 6 weeks. Results suggested that Ritalin helped with anger and memory, but did not have any effect on attention (Mooney & Haas). Another double-blind, placebo-controlled study on 12 individuals 1-8 years after TBI showed that Ritalin did not have any effects on most aspects of sustained attention or measures of motor speed; significant improvement, however, was seen in the speed of mental processing (Whyte et al., 1997).

Kaelin, Cifu, and Matthies (1996) examined the effects of Ritalin in the more acute stage of brain injury (1-11 weeks) and concluded that Ritalin was well tolerated. Participants who received Ritalin demonstrated a significant improvement in attention compared to those in natural recovery in a rehabilitation setting and had a quicker functional recovery as measured by the Disability Rating Scale (Kaelin et al.). These authors advocated the use of Ritalin in the early post-injury phase. This is the time when cerebral edema resolves, neurotransmitter levels stabilize, and new synapses form, allowing the recovering brain to be the most susceptible to therapeutic interventions such as psychostimulants (Kaelin et al.).

One double-blind, placebo-controlled study of 12 patients, 1-8 years after head injury, did not support the use of Ritalin in the treatment of head injury patients (Speech, Rao, Osmon, & Sperry, 1993). No significant differences in attention, learning, and cognitive processing speed were found between Ritalin and placebo. The authors concluded that head injury may produce permanent, disabling changes in cognitive and social behavior; the more chronic the head injury, the less chance of Ritalin being effective (Speech et al.).

In summary, the use of Ritalin for the brain-injured population may be beneficial more so in adults. There are differences in positive effects based on when treatment was begun after injury (i.e., acute versus chronic). Perhaps in the acute stage of recovery. Ritalin as a stimulant acts to "jump start" cortical recovery. Studies have not been able to show Ritalin's long-term efficacy. More well-designed studies are also needed for the pediatric brain injury population.

Post-stroke Depression

Depression is a major problem for stroke survivors. Its prevalence has been found to be 30%-50%, increasing between 6 months and 2 years following stroke to 60% (Beckson & Cummings, 1991; Robinson, Starr, & Price, 1984). Depression is especially problematic because it interferes with the rehabilitation process and can affect the interpersonal relationships already altered by the stroke. Treatment modalities include antidepressants, electroconvulsive therapy (ECT), and the use of psychostimulants such as Ritalin and DEA (Masand, Murray, & Pickett, 1991). Animal studies suggest that stroke-induced lesions produce widespread depletion of biogenic amines, which tricyclic antidepressants and Ritalin can possibly correct (Lipsey, Robinson, Pearigin, Rad, & Price, 1985; Robinson, Shoemaker, Schlumpf, & Coyle, 1975).

The suggestion that Ritalin was an effective treatment for post-stroke depression was first seen in the literature in anecdotal case reports (Table 2). When elderly patients with post-stroke depression were given Ritalin, family members or caregivers reported decreased depression (Kaufman, Cassem, Murray, & Jenike, 1984). Retrospective studies followed. A retrospective chart review on 25 patients who were treated with Ritalin for post-stroke depression within 2 years of their stroke was conducted by Lingam, Lazarus, Groves, and Oh (1988). Thirteen (52%) of the patients responded rapidly (within 48 hours) and completely recovered from their major depression. Another retrospective study of 17 patients who were treated with either Ritalin (n = 6) or DEA (n = 11) during a 5-year period indicated that 82% of the patients showed at least some improvement; 47% were rated as markedly (i.e., complete/near complete remission of all depressive symptoms) or moderately improved (i.e., improvement but without complete remission; Masand et al., 1991). The patients improved quickly, usually within the first 2 days of treatment. The authors found no significant differences in efficacy between the two psychostimulants (Masand et al.).

Johnson, Roberts, Ross, and Witten (1992) reviewed the records of 10 patients treated with Ritalin for post-stroke depression during an inpatient rehabilitation program over a 9-month period. All patients received concomitant supportive psychotherapy. Seven of the 10 patients showed clinical improvement; 4 of the patients were discharged home on Ritalin. Each patient who improved also was described as having an attention-deficit disorder; improvement in mood and attention span were the earliest responses to therapy (Johnson et al.).

A retrospective comparison of Ritalin and nortriptyline on 28 patients with major post-stroke depression revealed that 53% of the Ritalin patients experienced complete remission of depressive symptoms, as compared to 43% of the patients in the nortriptyline group (Lazarus, Moberg, Langsley, & Lingam, 1994). The speed of response was significantly better in the Ritalin group (2.4 days) compared to 27 days for the nortriptyline group. The authors concluded that the rapid effects of Ritalin may be especially useful to speed recovery from depression so that patients can participate more fully in rehabilitation programs (Lazarus et al.).

Another later report of a 76-year-old patient with post-stroke depression confirmed that Ritalin markedly improved the patient's depression (Masand & Chaudhary, 1994). Only one controlled study on the effects of Ritalin on post-stroke depression is documented in the literature. Ten patients who met the DSM-III-R criteria for major depression were given two doses of Ritalin (morning and noon). A total of 80% of the patients showed either a full (50%) or partial (30%) treatment response within 2 weeks of treatment. No adverse effects were reported (Lazarus et al., 1992).

In summary, the use of Ritalin for post-stroke depression appears to either totally or partially relieve depressive symptoms. Its rapid effects and few side effects may be especially useful in speeding recovery from depression so that patients can participate more fully in rehabilitation programs. However, further controlled studies are needed.

Post-stroke Recovery

Stroke recovery encompasses motor as well as cognitive aspects. Both animal and human research studies have indicated potential benefits with the use of psychostimulants to enhance stroke recovery. The first studies looked at recovery from brain lesions in cats and rats with amphetamine. The animals showed an enduring acceleration of motor recovery when amphetamine was administered days to weeks after injury (Feeney et al., 1982).

The first reported human trials, which specifically looked at motor recovery, were done with the psychostimulant amphetamine. Hemiplegic stroke patients who received a single dose of amphetamine 45 minutes before intensive physical therapy scored 40% better on a standardized motor scale than those on placebo. The patients were studied during the acute period (<10 days after stroke onset) but were followed for only 24 hours (Crisostomo, Duncan, Propst, Dawson, & Davis, 1988).

Walker-Baston et al. (1995) conducted a randomized, placebo-controlled study on 10 patients with severe motor deficits in the subacute period (16-30 days). They were given DEA or placebo every fourth day, paired with physical therapy. Recovery rate was accelerated, and their final level of motor recovery was increased as assessed by the Fugl-Meyer Motor Scale. The increase in motor recovery was significant 1 week after the drug session was begun and was maintained at the 12-month follow-up. The authors concluded that the use of psychostimulants might allow the nervous system to adapt unused or alternative pathways.

The use of Ritalin specifically for motor recovery from stroke (Table 2) was first evaluated in 1998 (Grade, Redford, Chrostowski, Toussaint, & Blackwell, 1998). A randomized, double-blind, placebo-controlled study included 21 stroke patients in a rehabilitation setting. Patients received a 3-week treatment of Ritalin or placebo in conjunction with physical therapy; starting at a 5mg dose, gradually increasing to 30 mg, and then tapering off before discharge. Outcome measures assessed weekly included depression, cognitive status, and motor functioning. Patients receiving Ritalin scored lower on the Hamilton Depression Rating Scale (p = .028) and higher on both the Functional Independence Measure (p = .032) and Fugl-Meyer Motor Scale (p = .075) with few side effects. Results of this study indicated that Ritalin was a safe and effective adjunct treatment for the rehabilitation of acute stroke patients (Grade et al.).

A recent study by Unwin and Walker-Batson (2000) also confirmed the safety of amphetamine administration in stroke rehabilitation. Forty-four patients with hemiplegia and/or aphasia 16-42 days after stroke onset were given either 10 mg of amphetamine or placebo every third to fourth day. Thirty minutes after drug/placebo administration, patients were started on physical and/or language therapy, depending on their deficits, for a total of 10 sessions. Blood pressure measurements in the amphetamine-treated patients were compared with those in the placebo-treated patients. Results showed no significant difference from baseline to within 90 minutes of therapy sessions on either systolic or diastolic measurements. Results confirmed limited side effects of amphetamine (Unwin & Walker-Batson).

Only amphetamine has been studied for its effects in promoting recovery of speech and language deficits following stroke. Three studies have been done to explore the long-term effects of amphetamine administration. Between days 16 and 30 after stroke onset, patients received either amphetamine or placebo every fourth day for 10 sessions, paired with speech therapy. Results indicated that amphetamine enhanced recovery from language deficits with no side effects (Walker-Batson, Curtis, Wolf, & Porch, 1996; Walker-Batson, Devous, Curtis, Unwin, & Greenlee, 1990; Walker-Batson et al., 1992).

The effects of Ritalin specifically on other stroke-related cognitive deficits have been studied, although to a limited degree (Table 2). A patient with apathy secondary to multiple subcortical infarcts was treated successfully with Ritalin. Single photon emission computed tomography (SPECT) and reaction time testing during treatment showed improvement of frontal system function (Watanabe et al., 1995).

The usefulness of Ritalin versus placebo in the treatment of organic amnesia for patients with stroke lesions (n = 2) was assessed with a neuropsychological battery of tests. However, no significant benefit of Ritalin was seen in any of the cognitive tests (Tiberti, Sabe, Jason, Leiguarda, & Starkstein, 1998).

In summary, Ritalin appears to be a safe and effective intervention in early post-stroke rehabilitation that may expedite recovery. It offers the advantage of mild side effects and immediate onset of action. However, more controlled studies are needed, because they are limited.

Brain Tumors

Patients with malignant glioma develop progressive neurobehavioral deficits, caused by the disease itself as well as by radiation and chemotherapy. Two studies investigated whether Ritalin treatment could improve the patients' neurobehavioral functioning despite their neurological deterioration (Table 3). In the first study, three patients with a primary brain tumor and with impairments of arousal and psychomotor speed benefited from this stimulant therapy, as evidenced by an increase in wakefulness and participation in activities of daily living (Weitzner, Meyers, & Valentine, 1995).

In the second study of 30 patients with primary brain tumors, significant functional improvements were seen with a 10-mg twice-daily dose (Meyers, Weitzer, Valentine, & Levin, 1998). Improvements included improved gait, increased stamina, and motivation to perform activities and in one patient, increased bladder control. The authors concluded that Ritalin, although not a cure, should be more widely considered as an adjunct to brain tumor therapy to help with the debilitating effects of the disease (Meyers et al.).


The efficacy of the use of Ritalin in the treatment of coma has been reported in the literature in two case studies: the first patient was comatose from a traumatic brain injury and the second patient was in a comatose state secondary to a subdural hematoma that occurred after a fall (Table 3). The first patient was a 19-year-old male who was transferred to a nursing home with a Glasgow Coma Scale (GCS) score of 8, minimally responsive to pain (Worzniak, Fetters, & Comfort, 1997). The patient was started on Ritalin 10 mg twice a day. Within 24 hours there was a dramatic improvement in the patient's level of consciousness; he appeared more alert, his pupils were more active and he exhibited other spontaneous movements (GCS = 10). The dosage was increased to 20 mg twice a day; and he began responding to voice commands (GCS = 14). On day 9 of treatment, the patient began to feed himself and was able to briefly stand on his own and transfer into a chair. After 18 days of treatment, he was verbal, ambulatory; and following commands (GCS = 15). He was transferred to a head injury facility for more intensive speech and physical therapy (Worzniak et al., 1997).

The second case report was a 89-year-old woman who transferred to a long-term-care home, totally unresponsive, requiring total care (GCS = 3). Six days after the initiation of Ritalin 5 mg twice a day; the patient exhibited spontaneous eye movement and spoke a few words (GCS = 10). On day 15 of treatment, the GCS was 14. On day 27 of treatment, dosage was increased to 10 mg twice a day; with the patient becoming more alert (GCS = 15) and in contact with her surroundings. Further improvement occurred after the dosage was increased to three times a day. The feeding tube was removed, she was fed orally, and she could sit in a chair and converse (Worzniak et al., 1997).

Even though these case reports are limited, the authors concluded that treatment with Ritalin might provide neurostimulation by augmenting the activity of injured neuronal tissue within the reticular activating system. Furthermore, it may be a low-cost, potentially effective intervention for reducing coma duration, for preventing life-threatening and costly complications, and for promoting early ambulation and recovery. However, further research on this neurological population using more rigorous research designs is needed (Worzniak et al., 1997).

The Neuroscience Nurse's Role in Treatment

In general, Ritalin appears to be a reasonable treatment choice for certain types of mood, behavior, and cognitive symptoms following neurological injury. However, larger scale, controlled studies are needed to adequately assess the clinical usefulness of this drug. Also, each neurological event is different. The clinical studies reviewed were limited and the sample sizes were small; very few were controlled. Different psychostimulants, as well as various dosages, were used, and the drugs were administered at different times of recovery. Various and different outcome measures also were used. All of this makes the generalizability of the clinical results difficult.

Ritalin continues to be prescribed as adjunct therapy in both the acute and subacute rehabilitation settings. So what can the neuroscience nurse learn from these studies? Ritalin can be administered in the acute or subacute stage, perhaps in the earlier stages of recovery. However, the therapeutic window is considered to be 30 days after injury. If there is no improvement in 1 month, discontinuation of the drug should be considered (Kaelin et al., 1996). Nurses also must be knowledgeable that Ritalin can be used in patients with various neurological injuries and what side effects to watch for.

There are no clear guidelines established for daily dosage of Ritalin. It is not recommended for children younger than 6 years. Long-term efficacy and the side effect profile in the pediatric population have not been established. In the adult, gradual titration of dosage with close monitoring of side effects is essential due to Ritalin's variability in dose response.

Multiple administrations versus single are better. Divided doses, starting at 5 mg twice a day and gradually increasing to 5-10 mg every 2 days, are recommended. The daily average dose is 20-30 mg, but some patients tolerate and require 40-60 mg per day; a daily dosage of >60 mg is not recommended because of the possibility of sympathetic nervous system overstimulation (Stein et al., 1996; Volkow et al., 1998).

With each increase in dose, the neuroscience nurse should monitor the patient's tolerance to the drug. Any side effects such as nausea, vomiting, nervousness, hypotension, or headache must be reported to the physician, so the dose can be reduced or the second dose omitted. Because of Ritalin's stimulating effects, doses should be spaced and should not be administered after 6 pm (Long, 1999). With discontinuation, it is also recommended that the patient be weaned off the drug because severe depression can be unmasked. The time of administration should coincide with periods of greatest activity of the patient (e.g., 30-60 minutes before therapies or academic or behavioral executions). Ritalin is extensively absorbed after oral administration within minutes, peaking at 2 hours (Kimko et al., 1999).

Patients with an element of agitation may react adversely to Ritalin; it is also not recommended for patients with severe, underlying depression (Emptage & Selma, 1996). Ritalin should be used cautiously with pressor agents and MAO inhibitors. Because Ritalin may inhibit anticoagulant, antidepressant, and anticonvulsant metabolism, it is important to monitor therapeutic levels and increase the dosage of these drugs as necessary. Laboratory monitoring such as complete red blood cell (CBC) and platelet count is advised during prolonged therapy (Long, 1999).

New Approaches

A new wakefulness-promoting agent, modafinil (Provigil), has recently been used on the neurological population. It is similar to MPH and amphetamine but has fewer side effects. Even though it has been approved for narcolepsy only, it has been shown to significantly improve fatigue associated with multiple sclerosis and depression (Menza, Kaufman, & Castellanos, 2000; Rammohan, Rosenberg, Pollak, Lynn, Blumenfeld & Nagaraja, 2000; Terzoudi, Gavrielidou, Heilakos, Visviki, & Karageorgiou, 2000).

Modafinil's mechanism of action is unknown; it supposedly works by increasing the neuronal activation in the hypothalamus-cortical pathways. It does not cause the widespread central nervous system stimulation seen in Ritalin and has a low potential for abuse. Dosage is one time, 200 mg, in the morning. Side effects, which are minimal, include headache, nausea, vomiting, and anxiety (Cochran, 2001).

Two recently published studies show some promising benefits of modafinil on other neurological diseases. In a retrospective review of 25 patients with Alzheimer's, stroke, multiple sclerosis, Parkinson's disease, head injury, and brain tumor who received modafinil for the treatment of fatigue, Cochran (2001) showed modafinil was effective in 84% of the patients. It was well tolerated even when used in combination with other medications such as Ritalin. However, the author concluded that the potential for an interaction of modafinil with other drugs used for the treatment of neurological diseases has not been fully determined. The second study looked at the effect of modafinil on the treatment of excessive daytime sleepiness associated with brain injury. Increased wakefulness, attention, and other cognitive benefits were seen in 10 patients within 1-2 hours of taking modafinil (Teitelman, 2001).


Limited controlled studies have shown that Ritalin helps enhance cognition, attention, behavior, and recovery for a variety of neurological conditions. Its immediate action and limited side effects make it the drug of choice over antidepressants and more potent psychostimulants such as amphetamine. Even though there are no standardized treatment protocols or outcome measures established, the literature does show Ritalin's benefits in enhancing recovery for the neurological patient. More controlled studies are needed, however, especially in comparison with the new wakefulness-producing drug modafinil. At this time Ritalin cannot claim to change the result, but perhaps it can help get the patient there faster.


Beckson, M., & Cummings, J.L. (1991). Neuropsychiatric aspects of stroke. International Journal of Psychiatry Medicine, 21, 1-15.

Boyeson, M.G., Krobert, K.A., Grade, C.M., & Scherer, P.J. (1993). Reinstatement of motor deficits in brain injured animals: The role of cerebellar norepinephrine. Restorative Neurology & Neuroscience, 5, 283-290.

Challman, T.D., & Lipsky, J.J. (2000). Methylphenidate: Its pharmacology and uses. Mayo Clininical Procedures, 75, 711-721.

Cochran, J.W. (2001). Effect of modafinil on fatigue associated with neurological illnesses. Journal of Chronic Fatigue Syndrome, 8(2), 65-70.

Crisostomo, E.A., Duncan, P.W., Propst, M., Dawson, D.V., & Davis, J.N. (1988). Evidence that Amphetamine with physical therapy promotes recovery of motor function in stroke patients. Annals of Neurology, 23, 94-97.

Emptage, R.E., & Semla, T.P. (1996). Depression in the medically ill elderly: A focus on methylphenidate. Annals of Pharmacotherapeutics, 30(2), 151-157.

Evans, R.W., Gualtieri, C.T., & Patterson, D. (1987). Treatment of chronic closed head injury with psychostimulant drugs: A controlled case study and an appropriate evaluation procedure. The Journal of Nervous and Mental Disease, 175(2), 106-110.

Feeney, D.M., Gonzales, A., & Law, W. (1982). Amphetamine, haloperidol and experience interact to affect rate of recovery after motor cortex injury. Science, 217, 855-857.

Goldstein, L.B., & Davis, J.N. (1990). Post-lesion practice and amphetamine-facilitated recovery of beam-walking in rats. Restorative Neurology & Neuroscience, 2, 311-314.

Grade, C., Redford, P.T., Chrostowski, J., Toussaint, L., & Blackwell, B. (1998). Methylphenidate in early poststroke recovery: A double-blind, placebo-controlled study. Archives of Physical Medicine and Rehabilitation, 79, 1047-1050.

Gualtieri, C.T., & Evans, R.W. (1988). Stimulant treatment for the neurobehavioral sequelae of traumatic brain injury. Brain Injury, 2, 273-290.

Hornyak, J.E., Nelson, V.S., & Hurvitz, E.A. (1997). The use of methylphenidate in pediatric traumatic brain injury. Pediatric Rehabilitation, 1(1), 15-17.

Hovda, D.A., & Feeney, D.M. (1984). Amphetamine and experience promote recovery and locomotor function after unilateral frontal cortex injury in the cat. Brain Resuscitation, 298, 358-361.

Hurwitz, B.E., Dietrich, W.D., McCabe, P.M., Alonson, O., & Watson, B.D. (1991). Amphetamine promotes recovery from sensory-motor integration deficit after thrombotic infarction of the primary somatosensory rat cortex. Stroke, 22, 648-654.

Johnson, M.L., Roberts, M.D., Ross, A.R., & Witten, C.M. (1992). Methylphenidate in stroke patients with depression. American Journal of Physical Medicine and Rehabilitation, 71, 239-241.

Jonason, K.R., Lauber, S., Robbins,. M.J., Meyer, P.M., & Meyer, D.R. (1970). The effects of d-amphetamine upon discrimination behaviors in rats with cortical lesions. Journal of Complete Physiology & Psychology, 73, 47-55.

Kaelin, D.L., Cifu, D.X., & Matthies, B. (1996). Methylphenidate effect on attention deficit in the acutely brain-injured adult. Archives of Physical Medicine and Rehabilitation, 77, 6-9.

Kaufman, M.W., Cassem, N.H., Murray, G.B., & Jenike, M. (1984). Use of psychostimulants in medically ill patients with neurological disease and major depression. Canadian Journal of Psychiatry, 29, 46-49.

Kimko, H.C., Cross, J.T., & Abernethy, D.R. (1999). Pharmacokinetics and clinical effectiveness of Methylphenidate. Clinical Pharmacokinetics, 37, 457-470.

Kline, A.E., Yah, H.Q., Bao, J., Marion, D.W., & Dixon, C.E. (2000). Chronic methylphenidate treatment enhances water maze performance following traumatic brain injury in rats. Neuroscience Letter, 280, 163-166.

Koenig, H.G., Shelp, F., Goli, V., Cohen, H.J., & Blazer, D.G. (1989). Survival and health care utilization in elderly medical inpatients with major depression. Journal of the American Geriatrics Society, 37, 599-607.

Kraus, M.F. (1995). Neuropsychiatric sequelae of stroke and traumatic brain injury: The role of psychostimulants. International Journal of Psychiatry Medicine, 25(1), 39-51.

Kuczenski; R., & Segal, D.S. (1997). Effects of methylphenidate on extracellular dopamine, serotonin and norepinephrine: Comparison with amphetamine. Journal of Neurochemistry, 68, 2032-2037.

Lazarus, L.W., Moberg, P.J., Langsley, P.R., & Lingam, V.R. (1994). Methylphenidate and nortriptyline in the treatment of poststroke depression: A retrospective comparison. Archives of Physical Medicine and Rehabilitation, 75, 403-406.

Lazarus, L.W., Winemiller, D.R., Lingam, V.R., Neyman, I., Hartman, C., Abassian, M., et al. (1992). Efficacy and side effects of methylphenidate for poststroke depression. Journal of Clinical Psychiatry, 53, 447-449.

Levin, H., Benton, A., & Grossman, R. (1982). Neurobehavioral consequences of closed head injury. New York: Oxford University Press.

Lingam, V.R., Lazarus, L.W., Groves, L., & Oh, S.H. (1988). Methylphenidate in treating poststroke depression. Journal of Clinical Psychiatry, 49(4), 151-153.

Lipsey, J.R., Robinson, R.G., Pearigin, G.D., Rad, K., & Price, T.R. (1985). Nortriptyline treatment of post-stroke depression: A double-blind study. Lancet, 1, 297-300.

Long, P.W. (1995-1999). Methylphenidate [Drug monograph]. Retrieved January 10, 2002, from the Internet Mental Health Web site: http://www.mentalhealth.com

Luria, A., Naydin, V., & Tesvetkova, L. (1968). Restoration of higher cortical function following local brain damage. In R. Vinkin and G.W. Bruyn (Eds.), Handbook of clinical neurology (pp. 368-433). Amsterdam: North Holland.

Masand, P., Murray, G.B., & Pickett, P. (1991). Psychostimulants in post-stroke depression. Journal of Neuropsychiatry & Clinical Neurosciences, 3(1),23-27.

Masand, P., & Chaudhary, P. (1994). Methylphenidate treatment of poststroke depression in a patient with global aphasia. Annals of Clinical Psychiatry, 6, 271-274.

Massello, W., & Carpenter, D.A. (1999). A fatality due to the intranasal abuse of methylphenidate (Ritalin). Journal of Forensic Science, 44, 220-221.

Mehta, M.A., Owen, A.M., Sahakian, B.J., Mavaddat, N., Pickard, J.D., & Robbins, T.W. (2000). Methylphenidate enhances working memory by modulating discrete frontal and parietal lobe regions in the human brain. Journal of Neuroscience, 20(6), 65.

Menza, M.A., Kaufman, K.R., & Castellanos, A. (2000). Modafinil augmentation of antidepressant treatment in depression. Journal of Clinical Psychiatry, 61, 378-381.

Meyers, C.A., Weitzner, M.A., Valentine, A.D., & Levin, V.A. (1998). Methylphenidate therapy improves cognition, mood, and function of brain tumor patients. Journal of Clinical Oncology, 16(7), 2522-2527.

Mooney, G.F., & Haas, L.J. (1993). Effect of methylphenidate on brain injury-related anger. Archives of Physical Medicine and Rehabilitation, 74, 153-160.

Morris, P.L., Robinson, R.G., Andrzejewski, P., Samuels, J., & Price, T.R. (1993). Association of depression with 10-year postroke mortality. American Journal of Psychiatry, 150, 124-129.

Rammohan, K.W., Rosenberg, J.H., Pollak, C.P., Lynn, D.J., Blumenfeld, A., & Nagaraja, H.N. (2000). Efficacy for the treatment of fatigue in patients with multiple sclerosis. Neurology, 54, 24.

Robinson, R.G., Shoemaker, W.J., Schlumpf, M., & Coyle, J.T. (1975). Effect of experimental cerebral infarction in rat brain on catecholamines and behavior. Nature, 255, 332-334.

Robinson, R.G., Start, L.B., & Price, T.R. (1984). A two year longitudinal study of post-stroke mood disorders: prevalence and duration at six months follow-up. British Journal of Psychiatry, 144, 256-262.

Schteinschnaider, A., Plaghos, L.L., Garbugino, S., Riveros, D., Lazarowski, A., Intruvini, S., et al. (2000). Cerebral arteritis following Methylphenidate use. Journal of Child Neurology, 15, 265-267.

Speech, T.J., Rao, S.M., Osmon, D.C., & Sperry, L.T. (1993). A double-blind controlled study of Methylphenidate treatment in closed head injury. Brain Injury, 7, 333-338.

Stein, M.A., Blondis, T.A., Schnitzler, E.R., O'Brien, T., Fishkin, J., Blackwell, B., et al. (1996). Methylphenidate dosing: Twice daily versus three times daily. Pediatrics, 4(1), 748-756.

Sutton, R.I., & Feeney, D.M. (1992). Alpha-adrenergic agonists and atagonists affect recovery and maintenance of beam-walking ability after sensorimotor cortex ablation in the rat. Restorative Neurology & Neuroscience, 4, 1-11.

Teitelman, E. (2001). Modafinil for narcolepsy. American Journal of Psychiatry, 158, 970-971.

Terzoudi, M., Gavrielidou, P., Heilakos, G., Visviki, K., & Karageorgiou, C.E. (2000). Fatigue in multiple sclerosis: Evaluation and a new pharmacological approach. Neurology, 54, 61-62.

Tiberti, C., Sabe, L., Jason, L., Leiguarda, R., & Starkstein, S. (1998). A randomized, double-blind, placebo-controlled study of Methylphenidate in patients with organic amnesia. European Journal of Neurology, 5, 297-299.

Unwin, H., & Walker-Batson, D. (2000). No side effects after low-dose Amphetamine administration in stroke rehabilitation. Stroke, 31, 1788-1789.

Volkow, N.D., Wang, G.J., Fowler, J.S., Hitzemann, R., Gatley, J., Ding, Y.S., et al. (1998). Differences in regional brain metabolic responses between single and repeated doses of methylphenidate. Psychiatry Resource, 83(1), 29-36.

Walker-Batson, D., Curtis, S., Wolf, T., & Porch, B. (1996). Amphetamine treatment accelerates recovery from aphasia. Brain Language, 55, 27-29.

Walker-Batson, D., Devous, M.D., Curtis, S., Unwin, H., & Greenlee, P. (1990). Use of amphetamine to facilitate recovery from aphasia subsequent to stroke. Clinical Aphasiology, 20, 137-144.

Walker-Batson, D., Smith, P., Curtis, S., Unwin, H., & Greenlee, R. (1995). Amphetamine paired with physical therapy accelerates motor recovery after stroke: Further evidence. Stroke, 26, 2254-2259.

Walker-Batson, D., Unwin, H., Curtis, S., Allan, E., Wood, M., Devous, M., et al. (1992). Use of amphetamine in the treatment of aphasia. Restorative Neurology & Neuroscience, 4, 47-50.

Wang, G.J., Volkow, N.D., Fowler, J.S., Ferrieri, R., Schlyer, D.J., Alexoff, D., et al. (1994). Methylphenidate decreases regional cerebral blood flow in normal human subjects. Life Science, 54(9),143-146.

Watanabe, M.D., Martin, E.M., DeLeon., O.A., Gaviria, M., Pavel, D.G., & Trepashko, D.W. (1995). Successful methylphenidate treatment of apathy after subcortical infarcts. Journal of Neuropsychiatry & Clinical Neurosciences, 7, 502-504.

Weitzner, M.A., Meyers, C.A., & Valentine, A.D. (1995). methylphenidate in the treatment of neurobehavioral slowing associated with cancer and cancer treatment. Journal of Neuropsychiatry & Clinical Neurosciences, 7, 347-350.

Whyte, J., Hart, T., Schuster, K., Fleming, M., Polansky, M., & Coslett, H.B. (1997). Effects of methylphenidate on attentional function after traumatic brain injury: A randomized, placebo-controlled trial. American Journal of Physical Medicine and Rehabilitation, 76, 440-450.

Williams, S.E., Ris, M.D., Ayyangar, R., Schefft, B.K., & Berch, D. (1998). Recovery in pediatric brain injury: Is psychostimulant medication beneficial? Journal of Head Trauma Rehabilitation, 13(3), 73-81.

Worzniak, M., Fetters, M.D., & Comfort, M. (1997). Methylphenidate in the treatment of coma. Journal of Family Practice, 44, 495-498.

Wroblewski, B.A., Leary, J.M., Phelan, A.M., Whyte, J., & Manning, K. (1992). Methylphenidate and seizure frequency in brain injured patients with seizure disorders. Journal of Clinical Psychiatry, 53(3), 86-89.

Questions or comments about this article may be directed to: Marylyn Kajs-Wyllie, MSN RN CCRN CNS, via e-mail at marylyn.kajswyllie@stdavids.com or by phone at 512/404-8564. She is a neuroscience clinical nurse specialist at the Neuroscience Center at St. David's Medical Center, Austin, TX.
Table 1. Review of the Literature: Use of Ritalin in Brain Injury
in Pediatric and Adult Populations

    Reference               Sample                    Design

                    Brain Injury: Pediatric

Hornyak, Nelson,    10 children; mild to      Retrospective chart
& Hurvitz, 1997     severe traumatic brain    review; outcome
                    injury (TBI); given       measures: parent/
                    Ritalin                   teacher reports,
                                              evaluation by in- out-
                                              patient rehabilitation

Williams, Ris,      10 children; mild to      Double-blind placebo-
Ayyangar,           severe TBI; 8 months-2    controlled, crossover
Schefft, &          years post-injury;        trial; outcome
Berch, 1998         given Ritalin or          measures: Conner's
                    placebo                   Hyperactivity Index and
                                              Verbal Intelligence

                     Brain Injury: Adult

Evans, Gualtieri,   21-year-old male;         Case report, medication
& Patterson, 1987   moderate head injury;     trial, which was
                    2 years post-injury;      double-blind, placebo-
                    given Ritalin 0.15        controlled, dose-
                    or 0.30 mg/kg or          response; outcome
                    Dexedrine 0.10-0.20       measures: Adult
                    mg/kg or placebo          Activity Scale (AAS),

Gualtieri &         15 mild to moderate       Double-blind,
Evans, 1988         closed head-injured       randomized, placebo-
                    (CHI) patients, 5 to 12   controlled, crossover
                    months post-injury;       study; outcome
                    given Ritalin 0.15        measures: San Diego
                    mg/kg or 0.30 mg/kg       Battery, AAS, self-
                    twice a day or placebo    rating scale (at
                                              baseline, 12 days,
                                              monthly, and 1 year)

Mooney & Haas,      38 males with severe      Randomized, pretest,
1993                CHI; given Ritalin 30     posttest, placebo-
                    mg/day or placebo for     controlled, single-
                    6 weeks                   blind study; outcome
                                              measures: anger
                                              outcome measures

Whyte et al.,       12 individuals, 1-8       Double-blind, placebo-
1997                years after TBI given     controlled, repeated
                    Ritalin 0.3 mg/kg         crossover study; out-
                    twice a day or placebo    come measures: tasks
                                              measuring attentional

Kaelin, Cifu, &     11 individuals, 1-11      Prospective multiple
Matthies, 1996      weeks after TBI; given    baseline study
                    Ritalin 15 mg twice a     (A-A-B-A); outcome
                    day or placebo            measures: 9
                                              subtests, Disability
                                              Rating Scale, pre and

Speech, Rao,        12 chronic CHI            Double-blind,
Osmon, & Sperry,    individuals; given        randomized, placebo-
1993                Ritalin or placebo        controlled, crossover
                                              study; outcome
                                              measures: cognitive
                                              tests of attention,
                                              learning and cognitive
                                              processing speed

    Reference               Results                Implications

                    Brain Injury: Pediatric

Hornyak, Nelson,    Improved cognition,       Effective treatment
& Hurvitz, 1997     behavior; improved        after TBI for cognitive
                    arousal in minimally      and behavioral sequelae
                    responsive child

Williams, Ris,      No significant            Calls into question
Ayyangar,           differences between       effectiveness of
Schefft, &          Ritalin and placebo on    Ritalin in pediatric
Berch, 1998         measures assessing        head injury population
                    behavior, attention,
                    memory, and processing

                     Brain Injury: Adult

Evans, Gualtieri,   Best improvement with     Same positive response
& Patterson, 1987   higher dose of either     to either drug, but
                    drug in verbal memory     patient was maintained
                    and learning skills,      on Dexedrine due to its
                    ability to maintain       "sustained" reaction
                    sustained attention
                    and overall behavior

Gualtieri &         14 of 15 with improved    Stimulants may act to
Evans, 1988         subjective measures       enhance the course of
                    of mood, better           cortical recovery
                    performance at work/      following brain injury;
                    school, more alert,       long-term use is
                    organized, even-          questionable
                    tempered; 10 of 15
                    improved objective
                    measures of behavior,
                    mood, memory, attention

Mooney & Haas,      Ritalin helped with       Ritalin has minimal or
1993                anger and memory; no      absent cognitive
                    effect on attention       toxicity and is well
                                              tolerated by head-
                                              injured individuals

Whyte et al.,       Improvement in the        Ritalin may be useful
1997                speed of mental           for symptoms attributed
                    processing; no effect     to slowed mental
                    on sustained attention    processing
                    and motor speed

Kaelin, Cifu, &     Digit Span, Mental        Ritalin is well
Matthies, 1996      Control and Symbol        tolerated and
                    Search improved;          participants
                    improvement in            demonstrated a
                    Disability Rating         significant improvement
                    Scale scores              in attention

Speech, Rao,        No significant            Does not support the
Osmon, & Sperry,    differences between       clinical use of Ritalin
1993                Ritalin and placebo       in the treatment of
                                              closed head injury

Table 2. Review of Literature: Use of Ritalin in Patients with Stroke

    Reference               Sample                    Design

                      Stroke: Depression

Kauffman, Cassem,   Elderly patients with     Anecdotal case reports;
Murray, &           post-stroke depression;   outcome measures:
Jenike, 1984        received Ritalin          caregiver report

Lingam, Lazarus,    25 patients who met       Retrospective chart
Groves, & Oh,       DSM-III-R criteria for    reviews; placed in
1988                major depression with     groups of responders
                    onset within 2 years of   (complete remission)
                    given Ritalin 20 mg/day   and nonresponders
                    for 5 days                (partial, no, or
                                              worsening of symptoms)

Masand, Murray,     17 patients with          Retropective chart
& Pickett, 1991     depression 2 weeks-10     reviews; categorized as
                    years post-stroke;        markedly improved
                    given Dexedrine or        (complete or nearly
                    Ritalin                   complete remission of
                                              depressive symptoms) or
                                              moderately improved

Johnson, Roberts,   10 patients with post-    Retrospective chart
Ross, & Witten,     stroke depression given   review; outcome
1992                Ritalin 5-15 mg twice     measures:
                    a day for 5 days to 1     subjective measurement
                    month along with          of response by
                    psychotherapy             psychiatrist

Lazarus, Moberg,    Patients who met          Retrospective chart
Langsley, &         DSM-III-R criteria        review; outcome
Lingam, 1994        for major depression,     measures: subjective
                    given Ritalin (N = 28)    measurement of
                    or Pamelor (N = 30)       remission of depressive
                                              symptoms, speed of

Masand &            76-year-old male with     Case report; outcome
Chaudhary, 1994     post-stroke depression    measures: subjective
                    given Ritalin             measurement of

Lazarus et al.,     10 poststroke patients    Controlled study;
1992                who met DSM-III-R         outcome measures:
                    criteria for major        Hamilton Rating Scale
                    depression; given         for Depression (HAM-D),
                    Ritalin 10-40 mg/day      side effects checklist

                    Stroke: Motor Recovery

Grade, Redford,     21 post-stroke            Randomized, double-
Chrostowski,        patients; given Ritalin   blind, placebo-
Toussaint, &        30 mg twice a day or      controlled study;
Blackwell, 1998     placebo for 3 weeks in    outcome measures:
                    conjunction with          Hamilton Depression
                    physical therapy          Rating Scale (HAM-D)
                                              and Zung Self-Rating
                                              Depression Scale (ZDS),
                                              Mini-Mental State Exam
                                              (MMSE), Fugl-Meyer
                                              Scale (FMS), Functional
                                              Independence Measure
                                              (FIM) instrument, side
                                              effects checklist

                      Stroke: Cognition

Watanabe, Martin,   One patient with apathy   Case report; outcome
Deleon, Gaviria,    secondary to multiple     measures: reaction time
Pavel, &            subcortical infarcts,     testing, SPECT scan
Trepashko, 1995     given Ritalin

Tiberti, Sabe,      Four patients with        Randomized, double-
Jason, Leiguarda,   amnesia due to stroke,    blind, placebo-control-
& Starkstein,       given Ritalin (10, 20,    led study; outcome
1998                30 or 40 mg) or placebo   measures: neuropsycho-
                                              logical battery

    Reference               Results                Implications

                      Stroke: Depression

Kauffman, Cassem,   Family/caregiver          Stimulants (Ritalin)
Murray, &           reports of decreased      are effective in elder
Jenike, 1984        depression                patients with
                                              poststroke depression

Lingam, Lazarus,    52% with complete         Ritalin may be a
Groves, & Oh,       recovery within 48        valuable treatment for
1988                hours                     post-stroke depression
                                              because of its rapid
                                              response and lack of
                                              significant side

Masand, Murray,     Overall 82% showed        Psychostimulants appear
& Pickett, 1991     improvement, 47% with     to be a safe and
                    marked or moderate        rapidly effective
                    improvement               alternative to

Johnson, Roberts,   7 of 10 with improved     Ritalin in the
Ross, & Witten,     mood, depression,         treatment of poststroke
1992                attention within 1-4      depression merits
                    days                      further study

Lazarus, Moberg,    Ritalin group: 53% with   The rapid effects of
Langsley, &         remission in 2.4 days;    Ritalin may be useful
Lingam, 1994        Pamelor group: 43% with   to speed recovery from
                    remission in 27 days      depression so that
                                              patients can
                                              participate more fully
                                              in rehabilitation

Masand &            Markedly improved         Psychostimulants are
Chaudhary, 1994     depression depressive     effective in post-stroke
                    symptoms                  patients with depression

Lazarus et al.,     >50% with reduction in    Ritalin is a safe and
1992                HAM-D scores within       effective treatment for
                    1-2 weeks of receiving    post-stroke depression
                    Ritalin; 25% with
                    partial response; no
                    adverse side effects

                    Stroke: Motor Recovery

Grade, Redford,     Patients receiving        Ritalin is a safe and
Chrostowski,        Ritalin scored lower on   effective adjunct
Toussaint, &        the HAM-D and ZDS,        treatment for the
Blackwell, 1998     higher on the FIM and     rehabilitation of acute
                    FMS instruments; no       stroke patients as it
                    difference in the MMSE    showed improvements in
                    between Ritalin and       mood, ability to
                    placebo; no significant   conduct activities of
                    side effects              daily living, and motor

                    Stroke: Cognition

Watanabe, Martin,   Showed selective impro-   Ritalin may improve
Deleon, Gaviria,    vement of frontal         subcortical circuits
Pavel, &            system function with      and behavior in the
Trepashko, 1995     increase in reaction      patient with multi-
                    time testing              infarct apathy

Tiberti, Sabe,      No significant benefit    Not effective for
Jason, Leiguarda,   of Ritalin for any of     organic amnesia
& Starkstein,       the cognitive tests       following stroke;
1998                                          warrants further study

Table 3: Review of Literature: Use of Ritalin in Patients with
Brain Tumors or in Coma

    Reference                Sample                    Design

                                    Brain Tumors

Weitzner, Myers,     3 patients with glio-     Case report; subjective
& Valentine, 1995    blastoma multiform        responses
                     brain tumor related
                     organic brain dysfunc-
                     tion;, given Ritalin

Meyers, Weitzner,    30 patients with prima-   Pre- and post-test
Valentine, &         ry brain tumors,          neuropsychological
Levin, 1998          treated with Ritalin      assessment, ability to
                                               function in activities
                                               of daily living


Worzniak, Fetters,   19-year-old male in       Case reports; outcome
& Comfort, 1997      semi-comatose state       measures: Glasgow Coma
                     after closed head         Scale (GCS), subjective
                     injury, 89-year-old       functional improvements
                     female in comatose
                     state after fall; given
                     Ritalin 20 mg three
                     times a day or 10 mg
                     twice a day

    Reference                Results                Implications

                                    Brain Tumors

Weitzner, Myers,     Improved                  Ritalin can alleviate
& Valentine, 1995                              some of the observed
                                               psychomotor retardation
                                               seen in brain tumor
                                               patients undergoing

Meyers, Weitzner,    Significant improvement   Ritalin should be more
Valentine, &         in cognitive function,    widely considered as
Levin, 1998          improved gait,            adjuvant brain tumor
                     increased stamina and     therapy
                     motivation, and
                     increased bladder con-
                     trol in one patient


Worzniak, Fetters,   Patient 1: GCS 8 [right   Ritalin is a low-cost
& Comfort, 1997      arrow] 15 and Patient     effective intervention
                     2: GCS 3 [right arrow]    for reducing the dura-
                     15                        tion of coma, and for
                                               preventing complications
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