Recognize Post-Stroke Pain, a Complication that is Often Ignored

    Stroke is one of the most common neurological emergency conditions. Stroke occurs due to disruption of the blood supply to the brain, which causes the death of brain tissue (due to disruption of oxygen and nutrients supply). Various complications can arise from a stroke, such as persistent body weakness, impaired cognitive function, speech disorders, seizures, pain, and other complications that involve specific areas of the brain.

    One of the common but often ignored complications is post-stroke pain. Some epidemiological data show that the incidence of pain reaches 10-45.8% of the total post-stroke cases. In general, these complaints are often ignored because patients are unable to express them (due to disturbances of cognitive function and speech). Some doctors and health practitioners also often ignored these condition because they too focus on obvious complications such as physical disabilities. Patients only express the pain if the pain already very severe and bothersome or if doctors asks the patient about pain complication. The delay in detecting post-stroke pain makes pain management harder later.

Common types of post-stroke pain:

Shoulder Pain

    Shoulder pain is the most common pain complication that occurs after a stroke. It generally occurs in patients with spasticity and severe upper extremity motor weakness, where the incidence rate is approximately 75% of stroke events. Pain generally appears 2-3 weeks after a stroke. After intensive management and medical rehabilitation, shoulder pain will heal within 6 months, but 20% of cases tend to develop into persistent shoulder pain. This pain causes the patient's quality of life decrease and causes impaired functional recovery.

Spasticity-Related Pain

    Spasticity or stiffness of the body and extremities due to a stroke is a very common complication of stroke. Spasticity incidence for about 65% of the total stroke cases. The incidence of spasticity has a large impact to daily functional because it impedes patients mobilization and often accompanied with pain. Spasticity-related pain can occur since one week after developing spasticity. A prospective observational study showed a strong association between the development of spasticity and pain, that 72% of patients with spasticity developing pain and only 1,5% of non spastic patients experienced pain syndrome.

Research by Wissel et al in 2010 showed a strong relationship between post-stroke spasticity and the incidence of pain. It was found that 72% of patients with spasticity experienced pain, and only 1.5% of non-spastic patients experienced pain.

Post Stroke Headache

    Headache often occurs at acute stroke, where the incidence ranges from 30-50%. About 10% of cases have persistent headaches for months or years after the stroke. The severity of persistent post-stroke headache has been reported to be moderate to severe, and may be worse than headaches in acute phase of a stroke. The type of post-stroke persistent headache that most often complained of was tension-like (50%), followed by throbbing (31%).

Central Post-Stroke Pain (CPSP)

    Central Post Stroke Pain (CPSP) is also a common post-stroke pain syndrome, estimated to occur in one-third of post-stroke pain cases. Generally it develops within 3-6 months of stroke, but some cases can appear within 1 month after the stroke.

Symptom onset often appears gradually, occurs on affected side that initially lost the feeling of touch, but when the feeling begins to improve, patients feel painful sensation with characteristics of sharp, dull, throbbing, stabbing, or burning pain. CPSP usually appears on the peripheral of the body, such as the feet and hands. Several risk factors for development of CPSP are young age, a history of depression, smoking, and the severity of stroke.

Complex Regional Pain Syndrome (CRPS)

    Complex Regional Pain Syndrome (CRPS) involves the sensation of pain, swelling, vasomotor changes such as changes in skin colour and temperature, and impaired movement function. This syndrome is a condition of severe chronic pain that generally affects the extremities. The incidence of CRPS varies, ranging from 2-49% of the incidence of post-stroke pain. The cause is not clearly understood, but some theories believe it is due to damage to the peripheral nervous system and the central nervous system.

    CRPS is classified into two types, CRPS Type I (if there is no evidence of nerve damage in the affected limb), and CRPS Type II (if there is a lesion in the nerves). Generally CRPS after stroke is categorized as Type I CRPS.

    Handling post-stroke pain is not easy, where generally the goals of treatment focus on reducing pain intensity, maintaining joint movement, and optimizing the patient's functionality. Post-stroke pain management varies, depending on the type of pain that occurs. Generally, administration of symptomatic drugs is the initial and primary choice in pain management. Other treatment options include botulinum toxin injections in cases of spasticity, nerve blocks in CRPS cases, medical rehabilitation in cases of shoulder pain, and neurostimulation such as repetitive transcranial magnetic stimulation (rTMS), high-frequency transcutaneous electrical nerve stimulation (TENS), motor cortex stimulation (MCS), and other neurostimulation in patients with CPSP and post-stroke headaches. Early recognition of post-stroke pain is very important, because the outcome will be better if pain can be treated early and aggressively.

References:

1. Harrison, R.A., Field, T.S. Post Stroke Pain: Identification, Assesment, and Therapy. Cerebrovasc Dis 2015; 39: 190-201. DOI: 10.1159/000375397
2. Plecash, A.R., Chebini, A., Ip, A. et al. Updates in the Treatment of Post-Stroke Pain. Curr Neurol Neurosci Rep 19, 86 (2019). https://doi.org/10.1007/s11910-019-1003-2
3. Ri, S. The Management of Poststroke Thalamic Pain: Update in Clinical Practice. Diagnostics 2022; 12, 1439 : 1-13. https://doi.org/10.3390/ diagnostics12061439
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