https://health.usnews.com/health-care/patient-advice/articles/2018-06-19/combating-post-stroke-pain-to-improve-recovery
In the throes of a heart attack, most people experience pain or discomfort. Chest pain is a common, classic symptom, of course – but the pain may be felt in other areas from the arms to the stomach, according to the American Heart Association, and women are more likely to experience symptoms such as back or jaw pain. By comparison, when someone is having a stroke, they’re not likely to be in pain.
“You may get numbness, but you almost never get pain that comes on with the stroke,” says Dr. Joseph Broderick, a spokesperson for the American Stroke Association, which is part of AHA, and director of the University of Cincinnati Gardner Neuroscience Institute. Yet, experts say many survivors suffer from pain that takes hold after a stroke. Estimates vary greatly, but anywhere between 10 percent to half of stroke survivors report the new onset of pain following a stroke, depending on factors such as the severity of the stroke and the part of the brain affected. While some experience post-stroke pain immediately, the discomfort often doesn’t start until weeks or even months following. That can make it an afterthought in treatment. “Pain following stroke is commonly reported but often incompletely managed, which prevents optimal recovery,” notes Dr. Andrew Treister of the University of California, San Diego and co-author of a paper on post-stroke pain published last year in PM&R, the scientific journal of the American Academy of Physical Medicine and Rehabilitation.
A host of different factors can contribute to post-stroke pain. “It’s not just one thing usually,” says Dr. Aaron Bunnell, an assistant professor of rehabilitation medicine at the University of Washington School of Medicine, who treats patients at UW Medicine’s Comprehensive Stroke Center at Harborview Medical Center. The multifaceted nature of post-stroke pain can make diagnosing and treating it more difficult, particularly when it’s not managed by a health team or at a medical center specializing in stroke rehab.
There are several types of PSP. That includes central post-stroke pain, or central pain syndrome, caused by damage to certain parts of the brain, like the thalamus, that affects sensory processing. This can cause and increase the pain a person feels. In addition, complex regional pain syndrome – a type of chronic pain – can affect an arm or leg following an injury or heart attack or stroke and occasionally gets worse and spreads to other areas of the body, like an opposite limb. Some stroke survivors experience pain related to spasticity, in which muscles – for example of the arm – involuntarily contract or spasm in a way that’s painful. And some have post-stroke joint pain – particularly in the shoulder – like when weakness in the arm leaves the joint vulnerable to partial dislocation, or subluxation. Even PSP that may seem straightforward like shoulder pain can have various causes – not only mechanical, but neurological. For example, the involuntary contraction that characterizes spasticity, caused by damage to the brain sustained during a stroke, can contribute. “So the muscles, instead of being flaccid, are now tight, and will begin to put the shoulder out of joint itself,” Bunnell points out. That can cause significant discomfort in addition to the pain for the spasticity itself.
Treatment of PSP depends on the type of pain and the underlying cause. For example, with spasticity, it may be treated with medication, such as baclofen, which helps relax muscles. In some cases Botox is injected into the affected muscles, Broderick says, so they’re not so contracted and painful, and to help with function. And electrical stimulation may be used to get the muscle to contract and build some strength and tone, Bunnell adds.
With muscle or joint weakness, it’s important to provide support as necessary – such as through bracing – and to practice caution, like ensuring caregivers don’t take a patient by a weak arm. But experts don’t recommend simply keeping it stationary. Rather it’s key to work on getting function back to the extent possible. “We use physical therapy to work on strengthening of the shoulder, range of motion without causing pain, and helping them to get a maximal recovery of that strength to improve their pain,” Bunnell says.
The complexity of PSP and, specifically, questions still surrounding the physiological underpinnings with central post-stroke pain and complex regional pain syndromes can complicate treatment. Both pain syndromes are commonly treated with medication, like gabapentin – an anticonvulsant drug that’s used to treat seizure disorders and nerve damage – along with other medications such as antidepressants. But, particularly for central post-stroke pain, there’s no drug that reliably makes it go away. “None of them work great – and often you’re stuck with trying to keep the patient as active as possible, and trying to live with pain, to treat any mood disorder associated with it, which sometimes can make the pain worse,” Treister says. “But it’s a hard pain to treat.”
Part of taking a big picture approach to treating PSP in general includes treating depression – where present. “Depression is very common after stroke, and depression and pain can definitely be linked – and often depression worsens pain,” Bunnell says. “So making sure that you’re managing any depression or anxiety that are a result of the stroke, or pre-existing – that often is very helpful for managing pain as well.”
For some with central pain syndrome, treatment involves undergoing deep brain stimulation, or having electrodes implanted to deliver electrical impulses to the brain. The review of PSP-related research that was published in PM&R last year noted that a meta-analysis of a small group of patients who’d had electrodes permanently implanted through deep brain stimulation found more than half were able to achieve long-term pain relief. But Broderick says overall results from the stimulation procedure have been inconsistent.
Despite the challenges of treating PSP – particularly central pain syndrome – experts urge stroke survivors to work with specialists in stroke rehab to properly diagnose their pain and determine the best approaches to manage it.
Beyond the obvious discomfort, PSP can have an impact on a person’s ability to engage in rehab and to recover after a stroke. “It affects your happiness and just well-being,” Bunnell says. “It affects your functional outcomes – so your ability to participate in therapies, ability to do your own self-care; and it affects other things like sleep and mood.” That’s all the more reason to make sure the pain is addressed.
Michael O. Schroeder, Staff Writer
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