Post-Stroke Pain
Original Editor - Carina Therese Magtibay
Top Contributors - Carina Therese Magtibay and Kim Jackson
Introduction[edit | edit source]
Stroke is one of the primary causes of mortality and adult-onset disability globally.[1][2]Post-stroke pain is a common sequelae of stroke that can significantly reduce quality of life, potentially leading to depression, anxiety, sleep disorders and complicating rehabilitation.[3]Current research shows that post-stroke pain is under-reported and poorly understood.
Common post-stroke pain subtypes:
- central post-stroke pain (CPSP)
- spasticity-related pain
- shoulder pain
- complex regional pain syndrome (CRPS)
- headache
Epidemiology[edit | edit source]
Risk factors for developing post-stroke pain:[3]
- Demographic
- Female sex
- Older age at stroke onset
- Premorbid
- Alcohol use
- Statin use
- Peripheral vascular disease
- Depression
- Clinical features
- Spasticity
- Reduced upper extremity movement
- Sensory deficits
- Stroke-related
- Ischemic stroke
- Thalamic localization
- Brainstem localization
Central Post-Stroke Pain[edit | edit source]
CPSP is defined as the neuropathic pain that arises either acutely or in the chronic phase of a cerebrovascular event and is a result of central lesions of the somatosensory tract.[4] It affects 11% of patients with stroke and it manifests in the first month after stroke in more than 50% of patients.[5]
Clinical Features for identification of CPSP:[3]
- Verbal Descriptors Used: lacerating, aching, burning, freezing, squeezing
- Spontaneous dysesthesia
- Allodynia to touch and mild temperatures
- Variable pain quality
- Abnormal sensitivity to pinprick and high temperatures
- Raised thresholds for perception of touch and two-point discrimination
Pathophysiology:
Management:
At present, both pharmacological and non-pharmacological management studies of CPSP is lacking of large randomized trials. The best current evidence is related to the use of amitriptyline and lamotrigine, but results are from small RCTs and not enough research is available to perform meaningful meta-analysis.[5]
[edit | edit source]
Spasticity is defined as “disordered sensory-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles”[6] It is a prevalent occurrence after stroke, affecting anywhere from 30% to 80% of individuals who had stroke.[7]
Pathophysiology:
The connection between spasticity and pain is not fully understood. There are potential neuropathic and nociceptive mechanisms by which they are related. Abnormal loading on muscles and ligaments caused by spasticity may produce nociceptive pain.[8] Spasticity can cause changes in rheologic muscle properties, leading to fibrosis, and atrophy which can contribute to the experience of pain.[9]
Management:
Generally, the goal of treatment is to reduce reflex activity, thus reducing muscle tone. The use of local neuromuscular blockade or pharmacological treatment must be carefully evaluated against the drawback of potentially losing functional benefits of increased muscle tone.
There is little evidence regarding the treatment of spasticity specifically after stroke [10]
Shoulder Pain Post-Stroke[edit | edit source]
The shoulder is highly mobile and a less stable joint, contributing to its vulnerability to a variety of post-stroke secondary complications such as pain, subluxation and reduced joint range of motion. [11] Usually occurring 2-3 months following a stroke, shoulder pain has a prevalence of up to 12%-49%.[12][13]
Independent risk factors for developing shoulder pain after stroke:[14]
- diabetes
- limited shoulder joint activity
- Brunnstrom grade I-III period
- Ashworth scale 3- 4 grade
- motor arm score of NIHSS 3-4 points
- sensory disturbance.
Pathophysiology:
The causes of shoulder pain after stroke can be broadly classified into 2 categories:[15]
- neurological (paralysis, spasticity, altered sensation and neuropathic pain)
- mechanical factors (glenohumeral subluxation, rotator cuff injury, muscle imbalance and altered scapula position)
Management:
Treatment approaches include physiotherapy, massage therapy, strapping, slings and other supports to minimize glenohumeral subluxation, and local interventions such as nerve blocks and botulinum toxin type A (BTx-A) intra-muscular injections for spasticity.[16] Due to being multifactorial in nature, optimal treatment modalities for hemiplegic shoulder pain remain unclear in current literature.[15]
For more information:
Hemiplegic Shoulder Subluxation
Shoulder Dysfunction Associated with Stroke
Complex Regional Pain Syndrome[edit | edit source]
CRPS after stroke is also known as Shoulder-hand Syndrome. It has been classified as type I due to the lack of obvious peripheral nerve injury.[17]
Main symptoms of post-stroke CRPS:[17]
- pain
- hyperalgesia
- allodynia
- edema
- swelling
- limited range of motion of the shoulder, wrist, and hand joints
- feverish sensation and redness of the wrists and hands.
For more in-depth discussion of CRPS after stroke:
Complex Regional Pain Syndrome (CRPS)
Headache[edit | edit source]
Headache occurred in 6%–44% of the ischemic stroke population. Most headaches had tension-type features, were moderate to severe, and became chronic in nature. [18]
Multi-disciplinary Approach[edit | edit source]
- ↑ Feigin VL, Abajobir AA, Abate KH, Abd-Allah F, Abdulle AM, Abera SF, Abyu GY, Ahmed MB, Aichour AN, Aichour I, Aichour MT. Global, regional, and national burden of neurological disorders during 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet Neurology. 2017 Nov 1;16(11):877-97.
- ↑ Avan A, Digaleh H, Di Napoli M, Stranges S, Behrouz R, Shojaeianbabaei G, Amiri A, Tabrizi R, Mokhber N, Spence JD, Azarpazhooh MR. Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017. BMC medicine. 2019 Dec;17(1):1-30.
- ↑ 3.0 3.1 3.2 Harrison RA, Field TS. Post stroke pain: identification, assessment, and therapy. Cerebrovascular diseases. 2015 Mar 5;39(3-4):190-201.
- ↑ Klit H, Finnerup NB, Jensen TS. Central post-stroke pain: clinical characteristics, pathophysiology, and management. The Lancet Neurology. 2009 Sep 1;8(9):857-68.
- ↑ 5.0 5.1 Liampas A, Velidakis N, Georgiou T, Vadalouca A, Varrassi G, Hadjigeorgiou GM, Tsivgoulis G, Zis P. Prevalence and management challenges in central post-stroke neuropathic pain: a systematic review and meta-analysis. Advances in therapy. 2020 Jul;37:3278-91.
- ↑ Bhimani R, Anderson L. Clinical understanding of spasticity: implications for practice. Rehabilitation research and practice. 2014 Oct;2014.
- ↑ Kuo CL, Hu GC. Post-stroke spasticity: a review of epidemiology, pathophysiology, and treatments. International Journal of Gerontology. 2018 Dec 1;12(4):280-4.
- ↑ Lundström E, Smits A, Terént A, Borg J. Risk factors for stroke‐related pain 1 year after first‐ever stroke. European Journal of Neurology. 2009 Feb;16(2):188-93.
- ↑ Dietz V, Sinkjaer T. Spastic movement disorder: impaired reflex function and altered muscle mechanics. The Lancet Neurology. 2007 Aug 1;6(8):725-33.
- ↑ Demetrios M, Khan F, Turner‐Stokes L, Brand C, McSweeney S. Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post‐stroke spasticity. Cochrane Database of Systematic Reviews. 2013(6).
- ↑ Brandstater EM. Stroke rehabilitation. In: DeLisa JA, Gans BM, editors. Physical medicine and rehabilitation. Principles and practice. 4th ed. Philadelphia: Lippincott Williams and Wilkins;2005. p. 1655–1676
- ↑ Nadler M, Pauls M, Cluckie G, Moynihan B, Pereira AC. Shoulder pain after recent stroke (SPARS): hemiplegic shoulder pain incidence within 72 hours post-stroke and 8–10 week follow-up (NCT 02574000). Physiotherapy. 2020 Jun 1;107:142-9.
- ↑ Anwer S, Alghadir A. Incidence, prevalence, and risk factors of hemiplegic shoulder pain: a systematic review. International journal of environmental research and public health. 2020 Jul;17(14):4962.
- ↑ Hao N, Zhang M, Li Y, Guo Y. Risk factors for shoulder pain after stroke: A clinical study. Pakistan Journal of Medical Sciences. 2022 Jan;38(1):145.
- ↑ 15.0 15.1 Vasudevan JM, Browne BJ. Hemiplegic shoulder pain: an approach to diagnosis and management. Physical Medicine and Rehabilitation Clinics. 2014 May 1;25(2):411-37.
- ↑ Viana R, Pereira S, Mehta S, Miller T, Teasell R. Evidence for therapeutic interventions for hemiplegic shoulder pain during the chronic stage of stroke: a review. Topics in Stroke Rehabilitation. 2012 Nov 1;19(6):514-22.
- ↑ 17.0 17.1 Chae J. Poststroke complex regional pain syndrome. Topics in stroke rehabilitation. 2010 May 1;17(3):151-62.
- ↑ Harriott AM, Karakaya F, Ayata C. Headache after ischemic stroke: a systematic review and meta-analysis. Neurology. 2020 Jan 7;94(1):e75-86.
