7 Practical Strategies for Managing Central Post-Stroke Pain for Yourself or a Loved One by Flint Rehab

 'Management' IS NOT WHAT IS NEEDED! Prevent it from occurring!

7 Practical Strategies for Managing Central Post-Stroke Pain for Yourself or a Loved One

Repetitive transcranial magnetic stimulation in central post-stroke pain: a meta-analysis and systematic review of randomized controlled trials

 Right now what is your doctor EXACTLY doing to cure your central post-stroke pain? ANYTHING AT ALL? The keyword there is cure!

Repetitive transcranial magnetic stimulation in central post-stroke pain: a meta-analysis and systematic review of randomized controlled trials

Ying Liu^1†Runqing Miao^2†Hui Zou¹Qian Hu³Shao Yin⁴Fengya Zhu^5*

• ¹Department of Acupuncture and Rehabilitation, Traditional Chinese Medicine Hospital of Renshou County, Meishan, China
• ²Department of Preventive Treatment, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
• ³Department of Hematology, Meishan City People's Hospital, Meishan, China
• ⁴School of Clinical Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
• ⁵Traditional Chinese Medicine Department, Zigong First People's Hospital, Zigong, China

Background: The rehabilitation of central post-stroke pain (CPSP) is a complex clinical challenge, and repetitive transcranial magnetic stimulation (rTMS) has been widely applied in the research of neurofunctional recovery following stroke. However, there is currently no reliable evidence-based medicine supporting the efficacy of rTMS in central post-stroke pain. This review aims to evaluate the effects of rTMS on central post-stroke pain.

Methods: Following the PRISMA guidelines, we conducted searches on PubMed, Cochrane Library, Embase, Web of Science, CNKI, and Wan Fang Data Knowledge Service Platform. We searched for randomized controlled trials (RCTs) investigating the use of rTMS in treating central post-stroke pain, and conducted screening based on inclusion and exclusion criteria. Characteristics of the included RCTs were extracted. The heterogeneity of the trials was assessed using the I2 statistic. Meta-analysis was performed using Stata 17 software. Bias risk and methodological quality were evaluated using the Cochrane RoB 2 tool and the Pedro scale.

Results: A total of six randomized controlled trials involving 288 patients met our inclusion criteria. In our analysis, rTMS was more effective in treating patients with CPSP compared to the placebo group (SMD=-1.15, 95% CI: −1.69, −0.61, P < 0.001). Furthermore, results from subgroup analysis indicated no statistically significant difference in the improvement of pain for durations exceeding 6 months when comparing rTMS to conventional treatment (SMD=-0.80, 95% CI: −1.63, 0.03, P = 0.059).

Conclusion: TMS can alleviate pain in CPSP patients and improve their motor function, but its effects on depression, anxiety, and MEP-latency are not significant.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, CRD42024497530.

1 Introduction

Stroke is one of the diseases with high global incidence, disability rates, and mortality rates (Zhang et al., 2020). Despite comprehensive rehabilitation treatments, most stroke patients experience varying degrees of recovery in motor and sensory functions. However, some patients still suffer from persistent pain on the affected side of the body after a stroke. This pain, occurring after a stroke and associated with the damaged area while excluding other causes, is referred to as CPSP (Radiansyah and Hadi, 2023). Although the onset time of CPSP may be related to the severity and progression of the condition, more than half of the cases manifest within the initial months following a stroke (Klit et al., 2009; Osama et al., 2018; Vukojevic et al., 2018). The incidence rate ranges from 1% to 35% (Dub and Mercier, 2011; Hansen et al., 2012). Many patients may experience various forms of pain concurrently with sensory abnormalities, such as searing, pressing, pulsating, or freezing sensations, numbness, and decreased sensation (Kumar, 2009; Klit et al., 2011). CPSP significantly impacts the sleep, emotions, and overall quality of life for stroke patients, hindering the implementation of effective rehabilitation treatments. The pathogenesis of CPSP is not fully understood, and its treatment remains challenging. Currently, the primary approach involves medications for neuropathic pain. Existing evidence suggests that even with the use of high-dose medications, pain relief is often difficult to achieve for the majority of CPSP patients (Scuteri et al., 2020; Singh et al., 2020; Choi et al., 2021; Mohanan et al., 2023). Additionally, these medications are associated with various side effects (Banerjee et al., 2013; Kim, 2014) and may lead to drug dependence (Kumar and Soni, 2009).

rTMS provides a non-invasive, painless method for studying and treating neuropathic pain states (Lefaucheur, 2016). By applying a magnetic field to the cerebral cortex, it induces electric currents, influencing neural electrical activity. This, in turn, regulates cerebral blood flow and neurotransmitter expression to alleviate pain. Currently, it is recommended by relevant treatment guidelines for various pain conditions (Winstein et al., 2016; Lefaucheur et al., 2020). In addition to its impact on the target area, the synaptic effects produced by rTMS contribute to its distal therapeutic effects (Hallett et al., 2017), but there is no uniform standard for therapeutic parameters in the treatment of CPSP using rTMS. Diverse treatment parameters, including stimulation frequency, target site, and duration of therapy, yield varying analgesic effects. Traditionally, low-frequency (LF) rTMS, defined as stimulation below 1 Hz, has been shown to reduce cortical excitability, whereas high-frequency (HF) rTMS, with frequencies above 1 Hz, exerts the opposite effect (Cruccu et al., 2007; Bai et al., 2022). Previous studies investigating the analgesic effects of rTMS on PSP have discovered that HF-rTMS (5–20 Hz) can effectively alleviate PSP-related pain (Pazzaglia et al., 2018). Compared to single and short-term interventions, multiple sessions and longer durations of intervention have been found to produce superior analgesic outcomes (Hosomi et al., 2013; Ramger et al., 2019).

The meta-analytic review conducted by McDonnell and Stinear (2017) indicated that, in stroke patients, the M1 of the non-affected hemisphere did not exhibit heightened activation during both active muscle contraction and rest, as evidenced by the absence of significant disparities in the parameters of aMT (active motor threshold), rMT (resting motor threshold), and MEPs (motor evoked potentials) when compared to those of healthy controls. This finding suggests that directly enhancing the excitability of the affected M1 may confer greater therapeutic benefits than indirectly suppressing the excitability of the unaffected M1 in facilitating motor recovery following stroke. Numerous previous studies have also discovered that LF-rTMS and continuous theta-burst stimulation (cTBS) not only suppress the amplitude of MEPs in the stimulated M1, but also enhance the MEP amplitude in the non-stimulated M1 (Di Lazzaro et al., 2011; Boddington and Reynolds, 2017). The increased cortical excitability within the unstimulated M1 may be associated with an elevated intrinsic excitability of excitatory interneurons responsible for glutamatergic non-NMDA receptor activity (Heide et al., 2006).

In studies utilizing a rat model of thalamic pain, it has been observed that neuronal structural damage occurs in the lesion area following cerebral hemorrhage or infarction, leading to increased neural excitability. Such alterations may precipitate a range of clinical manifestations, including limb pain and motor functional impairments (An et al., 2019). Other animal experiments have also demonstrated that CPSP reduces the functional connectivity between the VPL and S1/S2 (primary and secondary somatosensory cortices), responsible for perceiving pain location, intensity, and duration, while enhancing connectivity between the thalamus (involved in attention, cognitive abilities) and amygdala (associated with emotional aspects of pain assessment) (Sweet et al., 1971), rTMS can alleviate this abnormal connectivity (Gruart and Delgado-García, 1994).

In recent years, some reviews have summarized the impact of rTMS on pain (Pan et al., 2022; Cheng et al., 2023; Mohanan et al., 2023; Radiansyah and Hadi, 2023), suggesting that rTMS may have a beneficial effect in alleviating pain. However, some reviews primarily focus on exploring the mechanisms and concentrate on conditions such as fibromyalgia, postherpetic neuralgia, malignant neuropathic pain. There is limited analysis in these reviews regarding the clinical evidence of rTMS in treating CPSP. The effectiveness of rTMS for CPSP has not yet received sufficient support from evidence-based medicine. Therefore, to establish the relationship between rTMS and the relief of CPSP, we conducted a systematic review and meta-analysis of published randomized controlled trials. This meta-analysis aims to provide the latest evidence for the use of transcranial magnetic stimulation in the treatment of CPSP.

More at link.

Thermal Grill Illusion in Post-Stroke Patients: Analysis of Clinical Features and Lesion Areas

Seems similar to Margaret Yekutiel wrote a whole book about this in 2001, 'Sensory Re-Education of the Hand After Stroke'.

Of course, your competent? doctor put together somatosensory protocols from this earlier research a long time ago, right? Oh no, you DON'T have a functioning stroke doctor, do you? Too bad, it's your problem to solve since your stroke hospital board of directors is fucking incompetent in running their hospital! 24 years of incompetence! WOW, that's got to be a record for staying incompetent!

Thermal Grill Illusion in Post-Stroke Patients: Analysis of Clinical Features and Lesion Areas

Authors Matsuda S , Igawa Y, Uchisawa H, Iki S, Osumi M

Received 3 August 2023

Accepted for publication 8 November 2023

Published 14 November 2023 Volume 2023:16 Pages 3895—3904

DOI https://doi.org/10.2147/JPR.S433309

Checked for plagiarism Yes

Review by Single anonymous peer review

Soichiro Matsuda,¹ Yuki Igawa,^1,2 Hidekazu Uchisawa,^1,2 Shinya Iki,³ Michihiro Osumi<sup>1,4

1</sup>Graduate School of Health Sciences, Kio University, Nara, Japan; ²Department of Rehabilitation, Nishiyamato Rehabilitation Hospital, Nara, Japan; ³Department of Rehabilitation, Kawaguchi Neurosurgery Rehabilitation Clinic, Osaka, Japan; ⁴Neurorehabilitation Research Center, Kio University, Nara, Japan

Correspondence: Soichiro Matsuda, Graduate School of Health Sciences, Kio University, 4-2-2 Umaminaka, Kitakatsuragigun, Nara, 635-0832, Japan, Tel +745-54-1601, Fax +745-54-1600, Email f1996957@kio.ac.jp

Purpose: In the thermal grill illusion, participants experience a feeling similar to burning pain. The illusion is induced by simultaneously touching warm and cool stimuli in alternating positions. In post-stroke pain, central sensitization is caused by a variety of factors, including damage to the spinothalamic tract and shoulder pain. Because the thermal grill illusion depends on central mechanisms, it has recently been suggested that it may be a useful indicator of central sensitization. Therefore, we hypothesized that post-stroke patients who are more likely to experience central sensitization may also be more likely to experience a thermal grill sensation of pain and discomfort than the likelihood among those who are less likely to experience central sensitization. However, the effects of the thermal grill illusion in post-stroke patients have not yet been reported. In this pilot study, we conducted the thermal grill illusion procedure in post-stroke patients and analyzed the relationship between clinical somatosensory functions and thermal grill sensations. We also conducted brain imaging analysis to identify brain lesion areas that were associated with thermal grill sensations.
Patients and Methods: Twenty patients (65.7 ± 11.9 years old) with post-stroke patients participated in this study. The thermal grill illusion procedure was performed as follows: patients simultaneously touched eight water-filled copper bars, with the water temperature adjusted to provide alternate warm (40°C) and cold (20°C) stimuli.
Results: Thermal grill sensation of pain and discomfort tended to be associated with the wind-up phenomenon in bedside quantitative sensory testing and thermal grill sensation of discomfort was also related to damage to the thalamic lateral nucleus.
Conclusion: These findings suggest that the thermal grill illusion might measure central sensitization, and that secondary brain hyperactivity might lead to increased thermal grill sensations.

Randomized clinical trial of deep brain stimulation for post-stroke pain

Hopefully your doctor becomes aware of this solution.
https://www.mdlinx.com/internal-medicine/medical-news-article/2017/04/06/post-stroke-pain-deep-brain-stimulation/7124427/?

Annals of Neurology

Lempka SF, et al.

sponsor

The researchers aimed to test the hypothesis that targeting limbic neural pathways would modulate the affective sphere of pain and alleviate suffering. In chronic pain management, ventral striatum/anterior limb of the internal capsule (VS/ALIC) deep brain stimulation (DBS) to modulate the affective sphere of pain represents a paradigm shift. VS/ALIC DBS revealed an acceptable safety profile and statistically–significant improvements in multiple outcome measures related to the affective sphere of pain while this exploratory study was negative for its initial endpoint. They, therefore, believe these outcomes justify further work in neuromodulation therapies targeting the affective sphere of pain.

Methods

• A prospective, double-blinded, randomized, placebo-controlled, crossover study of DBS targeting the ventral striatum/anterior limb of the internal capsule (VS/ALIC) in 10 patients with post-stroke pain syndrome was conducted.
• 1 month after bilateral DBS, they randomized patients to active DBS or sham for 3 months, followed by cross-over for another 3-month period.
• The initial endpoint was a ≥ 50% improvement in the Pain Disability Index in 50% of patients with active DBS compared to sham.
• This 6-month blinded phase was followed by an 18-month open-stimulation phase.

Results

• In this study, 9 participants completed randomization.
• The researchers did observe significant differences in multiple outcome measures related to the affective sphere of pain (e.g. Montgomery-Asberg Depression Rating Scale, Beck Depression Inventory, Affective Pain Rating Index of the Short-form McGill Pain Questionnaire) although this trial was negative for its primary and secondary endpoints.
• They recorded and resolved 14 serious adverse events.

Weekly sessions of non-invasive brain stimulation improve outcomes in patients with post-stroke pain

So write up and publish a stroke protocol on this.
http://www.news-medical.net/news/20150610/Weekly-sessions-of-non-invasive-brain-stimulation-improve-outcomes-in-patients-with-post-stroke-pain.aspx

Weekly sessions of non-invasive repetitive transcranial magnetic stimulation provided sufficient long-term pain relief in 61 percent of patients with central post-stroke pain, and delivered long-term relief for patients who continued for one year, according to a study presented at the International Neuromodulation Society 12th World Congress by Masahito Kobayashi, MD, PhD, of the Department of Neurosurgery, Saitama Medical University - Department of Neurology, Institute of Brain and Blood Vessels, Mihara Memorial Hospital in Saitama, Japan.
Of 18 patients in the open-label series, 11 patients achieved satisfactory-to-excellent pain relief. Pain relief was sustained in six patients who continued treatment for one year. All patients received repetitive transcranial magnetic stimulation (rTMS) to their primary motor cortex once a week for at least 12 weeks.
Satisfactory relief was considered a 40 - 69 percent reduction in pain scores (6 patients) and excellent relief, pain reduction of 70 percent or more (5 patients). Overall, 8 patients who had severe stroke-caused dysesthesias, such as uncomfortable numbness or prickling, experienced less relief than patients without severe dysesthesias, suggesting possible neural circuit damage was inhibiting response to treatment.
The study participants had all been treated medically after a blood clot or bleed in one side of the brain (unilateral ischemic or hemorrhagic stroke). Several weeks into their recovery, they had begun to experience severe hand or leg pain as a consequence of brain damage from the stroke. Such central post-stroke pain can be extremely disabling and difficult to treat, impacting general functioning, mood, and overall quality of life.
Since the 1990s, Japan has been an active center of research into the study of electrical motor cortex stimulation (EMCS) to treat post-stroke pain using surgically implanted devices. The study reported at the INS 12th World Congress builds on observations that electrical motor cortex stimulation's effectiveness in relieving central post-stroke pain can be predicted by rTMS, suggesting the techniques share similar pain-relief mechanisms.
However, Kobayashi and colleagues point out in their peer-reviewed online publication of this study, "Repetitive Transcranial Magnetic Stimulation Once a Week Induces Sustainable Long-Term Relief of Central Poststroke Pain" (Neuromodulation: Technology at the Neural Interface: April 23, 2015) that there has still been controversy about the efficacy of rTMS in post-stroke pain. Kobayashi said in comparison to EMCS, his impression is rTMS efficacy seemed almost the same, without requiring surgery.

In 2014, a review suggested that there is probable efficacy (a level A recommendation) for short-term rTMS treatment of neuropathic pain, including central post-stroke pain, but did not speak to long-term efficacy.
Since pain relief from rTMS increases a few days after treatment, weekly treatment sessions were selected to try to sustain pain relief at treatment intervals that could be maintained on an outpatient basis.
Kobayashi believes neurologists would especially have an interest in this method, which is also attractive due to its low side-effect profile. None of the 18 patients reported any serious side effects from weekly sessions of 10 trains of 10-second 5Hz rTMS, at 90 percent of the active motor threshold. Two patients reported transient, slight scalp discomfort after rTMS.
In addition to the potential of rTMS in pain relief, there has been growing research into noninvasive stimulation to augment progress in physical rehabilitation soon after stroke. It is believed that the stimulation aids in plasticity, the ability of the brain to gradually form new neural connections to take on functions previously performed by damaged areas.
A first phase of the study assessed whether rTMS had a treatment effect on pain. In it, the research team randomly assigned six patients to receive either sham or active rTMS one week and the other treatment the next, measuring pain scores before and after each session.
Once that phase had shown that rTMS did reduce the patients' pain, an open-label treatment phase began. In this second phase, the 18 patients underwent 12 weekly rTMS sessions. The patients' pain scores were measured just before each weekly session.
Data were collected for eight years, ending in 2014. Kobayashi said that some patients really hoped to continue rTMS after the study because their pain worsened after rTMS treatment sessions were over, and almost all the patients said that after the study ended, their pain increased to the level before rTMS.
He added that the remaining question to answer is whether the level of the patients' severe uncontrollable pain would continue to decrease if rTMS continued for several years.

Source:

The International Neuromodulation Society (INS)

Estimates of the Prevalence of Acute Stroke Impairments and Disability in a Multiethnic Population

Look at all the impairments post-stroke that I bet your doctors have no stroke protocols for. Ask them before your next stroke if they have anything at all to help you recover. And writing 3 prescriptions of E.T.( Evaluate and Treat to your physical therapist, occupational therapist and speech therapist are not really helping at all.  You really are completely on your own. And they are missing fatigue, spasticity, and central post stroke pain. 

Estimates of the Prevalence of Acute Stroke Impairments and Disability in a Multiethnic Population

Table 3.

Age-Adjusted Prevalence Rates of Impairment and Disability by Pathological and Bamford Subtype of Stroke

Impairment	TACI n=189	PACI n=250	POCI n=142	LACI n=283	PICH n=170	SAH n=77
Gaze paresis	42 (35–50)	7 (4–11)	25 (17–32)	4 (1–7)	29 (21–37)	46 (37–65)
Visual field defect	94 (90–98)	21 (16–26)	32 (24–39)	…	35 (26–44)	25 (0–54)
Visual neglect	67 (59–74)	25 (19–31)	17 (11–24)	…	31 (22–39)	48 (40–56)
Sensory inattention1	91 (86–97)	35 (29–42)	18 (11–25)	…	33 (23–42)	38 (38–38)
Upper limb motor deficit	100	78 (73–83)	54 (46–62)	88 (85–92)	79 (73–86)	66 (53–79)
Lower limb motor deficit	99 (98–100)	63 (57–69)	50 (42–58)	84 (80–89)	76 (69–82)	66 (53–79)
Upper limb sensory deficit	72 (65–79)	38 (31–44)	22 (15–29)	33 (28–38)	39 (31–48)	32 (9–55)
Lower limb sensory deficit	68 (60–75)	34 (28–41)	21 (14–28)	27 (21–32)	36 (28–44)	32 (9–55)
Dysphagia	81 (75–86)	33 (28–39)	34 (26–41)	26 (20–31)	62 (54–70)	68 (56–81)
Dysarthria1	85 (78–91)	49 (42–55)	44 (35–53)	54 (48–60)	54 (45–64)	5 (0–12)
Dysphasia	51 (43–58)	45 (38–51)	10 (5–15)	…	29 (21–37)	25 (0–53)
Urinary incontinence	87 (82–92)	37 (31–43)	38 (30–45)	25 (20–30)	70 (63–78)	71 (57–85)
Urinary catheterisation1	66 (60–73)	22 (16–27)	25 (18–33)	12 (8–15)	52 (44–60)	61 (46–77)
MMSE <241	89 (84–95)	64 (58–71)	51 (41–60)	50 (44–56)	78 (70–86)	85 (72–99)
GCS <15	69 (63–75)	37 (31–43)	35 (27–42)	15 (11–19)	63 (55–70)	82 (70–93)
GCS <9	23 (17–28)	3 (1–5)	12 (7–18)	3 (1–6)	36 (29–43)	67 (55–80)
7-d BI <202	100	80 (74–85)	77 (70–84)	73 (68–78)	96 (93–99)	94 (92–97)
7-d BI <152	95 (93–98)	59 (53–66)	54 (46–62)	50 (44–56)	87 (81–92)	90 (83–97)
7-d BI <102	90 (85–94)	35 (29–41)	36 (27–44)	32 (27–38)	70 (62–78)	76 (59–95)

• Values are % (95% CI).
• 1 For gaze paresis, sensory inattention, dysarthria, urinary catheterisation and MMSE were not assessed for 70 patients.
• 2 For BI, 208 died by day 7.

Stroke as written up in PubMedHealth

It is pretty f*cking appalling. Absolutely nothing in there on treatments that your doctor does for you in the first week. Namely stopping the neuronal cascade of death.  Nothing useful on a post-stroke diet. Nothing on how to treat fatigue, spasticity, central post stroke pain or any other complications from a stroke.  You are completely on your own. Deal with it, because no one is going to help you. And yet you are paying your neurologist.
This is the extent of the treatment plan;
Once you receive initial treatment, your doctor will try to treat your stroke risk factors and prevent complications. 

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0063013/