Central Poststroke Pain

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Condition: Central poststroke pain (CPSP) is a chronic, painful condition that may develop following a stroke, generally in the same part of the body affected by the stroke.

Background: About 8% of stroke patients develop CPSP in the weeks to months after incurring a stroke. CPSP usually emerges gradually, starting within the first month of a stroke, but occasionally occurring immediately post-stroke. Onset more than 6 months after a stroke is rare.

Risk Factors: The exact mechanism of CPSP continues to be an ongoing discussion. However, a known risk factor for the process is a lesion at the level of the sensory pathways of the brain, such as a stroke in the region called the thalamus.

History and symptoms: CPSP is typically described as a burning sensation, or sometimes as aching or shooting pains. Patients may have either increased or decreased sensitivity to light touch, painful stimulation, vibration, and temperature (especially to cold temperature stimulation).

Physical Exam: Since many other painful conditions may co-exist in a patient, the first step in diagnosing CPSP is to rule out all other possible causes of pain. There are no clear-cut physical signs that characterize CPSP. Supportive signs, however, include impairments in sensory examination (to light touch, 2-point discrimination, proprioception, vibratory sense, pain sensation), including the face.

Diagnostic Process: No laboratory tests are available to accurately diagnose CPSP. Imaging studies with MRI or CT may be helpful in pinpointing the damaged areas of the brain that are the source of the pain. Certain areas of the brain, such as involvement of the thalamus, can are more consistent with the development of CPSP.

Rehab Management: Treatment usually involves a combination of pharmacologic therapy and non-pharmacologic interventions aimed at reducing but not eliminating symptoms, preserving function, and preventing further complications. Selecting the optimal combination of drugs and other therapies for each patient is determined through trial and error. Drugs may include antidepressants, anticonvulsants, anesthetics, and, if needed, opioid analgesia. Additional treatments may include desensitization techniques, relaxation, biofeedback, or one of a number of procedures that stimulate areas of the brain where the pain signals are originating. The presentation of a patients CPSP may start in the inpatient setting and continue upon discharge. Therefore, treatment plans may need to be periodically re-evaluated and adjusted. The physical medicine and rehabilitation (PM&R) physician is optimally equipped with the knowledge to manage this condition both in the inpatient and outpatient setting. PM&R physicians can continue to manage this pain syndrome outside of the hospital given their training in proper medicines, physical modalities and their expert ability to design comprehensive, patient-centered treatment plans. Frequent reassessment with adjustment of both medical and physical interventions provides the PM&R physician the best opportunity to reduce symptoms and improve function in patients presenting with CPSP. This allows the patient to have an improved quality of life and minimize interference with participation with rehabilitation and potential complications including spasticity, contractures and functional decline.

Other Resources for Patients and Families: Family education and involvement in the rehabilitation program is an important step in the treatment plan given the potential for CPSP to be a long-term complication. Patients and families should be clearly educated on the disease process including the goals the treatment. These goals include reducing (not eliminating) symptoms, preventing further functional decline and improving quality of life. Family training and participation in treatment strategies such as psychological and desensitization interventions can be beneficial for the long-term management of the patient.


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