Post Stroke Pain

1. Post Stroke Pain By: Maura Green (Stroke Liaison Nurse, Havering ONEL) Maria Fong (Stroke Coordinator, Barking &Dagenham CHS)

2. Definition of pain The International Association for the study of Pain defines pain as an unpleasant sensory and emotional experience with actual or potential tissue damage or one that is described in such terms. (Inbody 1998)

3. Types of Pain including post stroke • Acute: Usually time limited and resolve completely. • Chronic: Continuous or intermittent for more than 6 weeks. Usually associated with a chronic pathological process. Recurs at intervals of months or years.

4. Specific Post Stroke Pain • Sites – usually one sided (Shoulder, including arm, Lower limbs, Anterior & posterior chest, headaches) • Types of pain – paraesthesia, spasm, tightness/increased tone

5. Pain after stroke? • 40% ipsilateral pain in the 6month after stroke (6% Central Post Stroke Pain) - Gamble et al 2002: • 22% reported moderate to severe shoulder pain in the year following stroke - Lindgren et al 2007:

6. Causes of limb pain after stroke Regional Pain Central post stroke pain Complex regional pain syndrome Chronic widespread pain

7. Regional shoulder pain • 152 patients followed from 2 weeks to 6 months • 34% developed regional shoulder pain • 28% of these within 2 weeks • Associated with motor and sensory loss and low mood Gamble et al 2002

8. Regional shoulder pain • Adhesive capsulitis • Glenohumeral subluxation • Rotator cuff lesions • Frozen shoulder • Shoulder x-ray of little value

9. Predictors of regional shoulder pain • Motor loss • Sensory loss • Low mood • Pre-stroke history of shoulder pain

10. MANAGEMENT OF ACUTE PAIN - Treatment aims is to eradicate the underlying cause and control the pain MANAGEMENT OF CHRONICPAIN - Emphasis is on developing effective coping strategies.- To eradicate the underlying cause and control the pain and alleviate anxiety

11. Positioning – avoid further damage Mobilisation Pain Ladder

12. How they work • Steroids - suppress inflammation, allergic reactions and immune system activity • Opioids - depress activity in the CNS • Anticonvulsants and antidepressants can relieve neuropathic pain they inhibit brain cells and damp down electrical activity in the neurones and also affect neurotransmitter levels and neuronal activity.

13. Treatment outcome • 41% resolved completely • 37% improved • 18% no change • 4% worse Gamble et al 2002

14. Complex Regional Pain Syndrome • Shoulder pain with swollen hand and wrist • MCPJ, PIPJ stiff • MCPJ tender to palpation • Less common but it does happen

15. Central Post Stroke Pain or Thalamic Pain Neuropathic pain: caused by damage to the thalamus. Resulting in hypersensitivity affecting all ADL • Inbody 1998: Caused by vascular injury to parts of the thalamus, which is an important part of sensory processing. • Greiff 1883: “tearing pains” after thalamic stroke • Dejerine and Roussy 1906: hemiplegia, hemi-anaesthesia, paroxysmal, intolerable pain associated with lateral thalamic lesion

16. Thalamic pain or CPSP • Neuropathic pain arises from damage to the neuron themselves. The myelin damage causes abnormal conduction and consequently abnormal or exaggerated sensation, they are irritable, unstable, and can initiate signals without involving specific pain receptors in the tissue. • Painless experience such as being touched can be experienced as painful. This is called alloydynia

17. Lancinating Lacerating Burning Icy Shooting Stabbing Clawing Loss of sensation to light touch, pinch and hot/cold in painful area Allodynia (60%) to hot/cold, light brush Sleep disturbance Signs & Symptoms of CPSP

18. Mechanisms of post stroke pain • Most patients have a thermosensory deficit in the painful area • Lesions coincide with ascending pathways for discriminative pain sensation • Only 60% involve thalamus • Loss of opiate receptor bearing neurones in CPSP

19. Pain management (acute & chronic) Non pharmacological treatments • Mobilisation • Positioning • Splinting or manipulation • Relaxation and breathing exercises - reduces anxiety levels lowers muscle tone. • Psychotherapy • Use of hot or cold compresses. (Hot compresses increase blood flow relaxes muscle tone (use cautiously for patients with sensory problems) • Cold compresses causes vasoconstriction and decreased nerve conduction and bleeding. (Use with caution in pts with circulatory problems and reduced sensation). • Electrical nerve stimulation (TENs) • Self hypnosis and visualisation • Complimentary therapies (massage, reflexology, aromatherapy) • Support groups including distraction

20. Pain management(acute & chronic) Pharmacological Treatment • Analgesia • Steroids • Anti-inflammatory • Antidepressants • Anticonvulsants

21. Management of CPSP Paracetamol 1g qds Paracetamol 1g qds Amitryptiline/nortryptiline starting dose 10mg Gabapentin/Pregabalin opiates If inadequate response consider alternatives or combination therapy

22. Principles of post stroke pain management • Early recognition, intervention and management – better outcomes • MDT approach – positioning, therapy, medications, alternative/complementary • Sensory examination e.g. temperature, feeling • Mood screening and treat as necessary • May need SSRI in addition to low dose TCA • Early specialist intervention • Post stroke pain clinic (stroke nurse/rheumatology) • Risk factors awareness • Accurate history • Holistic approach • Patient and carer education • Consider alternative treatments eg motor imagery programme (cortical reorganisation) (Moseley 2004, 2005)

23. Pain assessment • There are a variety of validated pain assessment tools that use different strategies to assess pain. • Act promptly on the results shown from the assessment. • Choose a tool that is simple and quick to use • Ensure that who ever uses the tool understands how to use them • Observe for non verbal cues/signs/body language/behaviour • Observe physiological and manifestations of the effects of pain • Listen to family or who ever reports the pain. • Monitor the effects of intervention used. • Evaluate effects of treatment • Record keeping