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Post Stroke Pain syndromes: In development


Learning objectives

  • Understand Post stroke pain

Introduction

  • Chronic post-stroke pain can be seen in 30-40% of patients at 6 months
  • It can be divided into two basic forms
  • Can have a huge effect on quality of life and mood
  • Depression, anxiety, excessive worry, withdrawal, apathy, and sleep disorder

Central Post-stroke Pain

  • Synonyms: Dejerine-Roussy Syndrome, Post Stroke Pain, Thalamic Pain Syndrome
  • Described 1906 by Dejerine and Roussy as a “severe persistent, paroxysmal, often intolerant pain on the hemiplegic side, not yielding to analgesic treatment"
  • Has previously been referred to as thalamic pain but may be seen in any strokes affecting the spino-thalamo-cortical pathway.
  • Thalamic pain patients were noted to have lesions mainly in lateral and posterior thalamic nuclei on MRI
  • Pain tends to come on weeks or months after the initial event
  • There is intense spontaneous or evoked pain in the affected extremities and can affect the entire side of the body with an aching and burning quality.
  • Sensory disturbance is a major component of CPSP, including abnormal temperature sensation, dysesthesia and hypersensitivity to cutaneous stimuli.
  • In contrast, there is often a normal response to light touch and vibration.
  • Pain appears to be alleviated with relaxation and worsened with emotional and physical stress.
  • Treatment includes antidepressants and anticonvulsants, while opioids, NSAIDs and paracetamol are not felt to be effective.
  • Tricyclic antidepressant amitriptyline given at 75mg/day was found to be useful and is usually started at 10 or 25mg/day and titrated up to 75mg/day. Best given at night as it can cause sedation. It has some anti-cholinergic side effects and needs care especially for elderly patients.
  • Gabapentin has also been used and is an analogue of GABA. It is relatively safe but may cause dizziness and sedation. It is started at 300mg BD and titrating up to 300mg TDS. Higher doses have not been evaluated but may be tried.
  • Lamotrigine is a non-NMDA anti-glutamatergic activity and is relatively well-tolerated. There are risks of Stevens-Johnson syndrome and toxic epidermal necrolysis. May be used at maximum doses of 200mg/day.
  • Others: TENS - Transcutaneous Electrical Nerve Stimulation. Surgery including Deep Brain Stimulation or Motor Cortex Stimulation
  • Mexiletine, an antiarrhythmic agent, may be used as an adjunct to TCAs in refractory cases
  • Intravenous (IV) lignocaine may provide pain relief in some patients with CPSP as a temporary ‘rescue’ agent in severe cases refractory to oral medications.
  • Referral to a multidisciplinary pain centre should be considered if a patient remains refractory to pharmacological treatment
  • Early cognitive behavioural therapy (CBT) and other psychological treatment approaches may be beneficial in many types of chronic pain, including CPSP

Complex Regional Pain Syndrome

  • Complex regional pain syndrome (CRPS) type 1 is a sympathetically mediated pain disorder presenting with the qualities of neuropathic pain.
  • Mechanisms are unclear and may include Spasticity and limited range of motion of the shoulder, especially external rotation.
  • The most common presentation of post-stroke CRPS is severe shoulder and hand pain with sparing of the elbow together with swelling, especially in the hand.
  • There may be other forms of neuropathic pain with vasomotor, sudomotor, and trophic changes.
  • Management: Amitriptyline as described above. High dose Oral corticosteroids (Prednisolone 100 mg/day for 2 weeks)have been used.
  • Gabapentin at 600mg/day and titrated upwards to 1800mg/day maximum. Consider Pregabalin.
  • Referral to a multidisciplinary pain centre should be considered if a patient remains refractory to pharmacological treatment
Complex regional Pain syndrome clinical findings (STAMP)
  • Sensory: allodynia, hypo/hyperalgesia, hypo/hyperesthesia
  • Trophic: Skin changes, hair loss, nail changes
  • Autonomic: swelling, oedema, sweating
  • Motor: weakness, contractures, atrophy
  • Pain

Musculoskeletal Pain Hemiplegic Shoulder Pain

  • Stroke can cause biomechanical changes at the shoulder after stroke. Often multifactorial and complex.
  • Weakness +/- Spasticity of the rotator cuff can retract the scapula and depress, adduct and internally rotate the shoulder.
  • Pain with external rotation. Some develop Adhesive capsulitis, glenohumeral subluxation and rotator cuff injury.
  • Adhesive capsulitis: slow insidious global loss of shoulder movement in multiple planes of movement, but especially external rotation and abduction. Loss of shoulder complex motion eventually leads to decreased soft tissue elasticity and then to joint contracture.
  • Gleno-humeral subluxation after a stroke most commonly occurs in the anterior and inferior directions. Supraspinatus is ineffective in supporting the humerus. The soft tissues supporting gleno-humeral joint become over-stretched. There can be a painful tendon, soft tissue. Brachial plexus injuries through poor handling may be seen. Prevention is by proper positioning of the affected upper extremity and arm support which must be understood by patient, carers and staff. Steroid injections may help in a case by case basis.
  • Intra-muscular botulinum toxin A (BTA) injections may provide targeted muscle relaxation and inhibit sensory neuron neurotransmitter release

References


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