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Pain is a common complication after stroke and is associated with the presence of depression, cognitive dysfunction, and impaired quality of life. It remains underdiagnosed and undertreated, despite evidence that effective treatment of pain may improve function and quality of life.
We provide an overview of the means for clinical assessment and ris...
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Context 1
... development of shoulder pain is likely multifacto- rial and can involve glenohumeral subluxation, impinge- ment, rotator cuff tears, bicipital tendinitis, and CRPS. The shoulder joint is unique compared to most joints in the body, as it is loosely constrained by a thin articular capsule, relying on muscles and ligaments for stability ( fig. 2 ). Weakness can thus lead to instability and immo- bility of the glenohumeral joint. Glenohumeral sublux- ation, can result from the weakness of these surrounding muscles. Subluxation can occur immediately after stroke, when the upper extremity has flaccid tone and is most vulnerable to instability [76] . However, pain most often becomes apparent when spasticity develops [69] . The evolution of subluxation is associated with the develop- ment of shoulder pain, and reduced functional outcomes of the affected upper extremity [77] . Potential complica- tions of subluxation also include CRPS [18] and second- ary brachial plexus injury [78] ...
Citations
... The evaluation of additional BPs deficits (anosognosia for hemiasomatognosia, over-care for the UL, etc.) were initially included in the questionnaire, but removed in order to keep the time of administration of the questionnaire compatible with clinical practice. Since some studies suggest that pain could alter body perception [29], and that it is a common symptom after stroke [30,31], the ALPQ also assesses pain as control item. ...
Background
Following a stroke, patients may suffer from alterations in the perception of their own body due to an acquired deficit in body representations. While such changes may impact their quality of life as well as recovery, they are not systematically assessed in clinical practice. This study aims at providing a better understanding of the rate, evolution, and impact on recovery of upper limb (UL) body perceptions (BPs) alterations following stroke. In addition, we will investigate associations among BPs alterations items, their associations with the sensorimotor functions, UL activity, damages in brain structure and connectivity.
Methods
We developed a new tool named ALPQ (for Affected Limb Perception Questionnaire) to address the present study objectives. It assesses subjective alterations in the perception of the affected UL following stroke, by measuring several dimensions, namely: anosognosia for hemiplegia, anosodiaphoria for hemiplegia, hemiasomatognosia, somatoparaphrenia, personification of the affected limb, illusion of modification of physical characteristics (temperature, weight, length), illusory movements, super- or undernumerary limb, UL disconnection, misoplegia, and involuntary movement. This study combines a cross-sectional and longitudinal design. The completed data sample will include a minimum of 60 acute and 100 sub-acute stroke patients. When possible, patients are followed up to the chronic stage. Complementary evaluations are administered to assess patients’ sensorimotor and cognitive functions as well as UL activity, and brain lesions will be analysed.
Discussion
This study will provide a better understanding of BPs alterations following stroke: their rate and evolution, as well as their associations with sensorimotor deficit, cognitive profile and UL activity, brain lesions and recovery. Ultimately, the results could support the personalization of rehabilitation strategy according to patients’ UL perception to maximize their recovery.
Study registration
The protocol for this study has been pre-registered on the Open Science Framework on July the 7th, 2021: https://osf.io/p6v7f.
... Right hemisphere strokes are more frequently linked to CPSP because the right hemisphere is crucial at processing pain and keeping track of the somatic state [31,32]. CPSP is also common in small vessel infarcts, which are closely associated with pontine or thalamic injuries [33]. The deafferentation and subsequent neuronal hyperexcitability may manifest with the presence of sensory loss and hypersensitive symptoms in the painful loci [34]. ...
Brain-derived neurotrophic factor (BDNF) is vital for synaptic plasticity, cell persistence, and neuronal development in peripheral and central nervous systems (CNS). Numerous intracellular signalling pathways involving BDNF are well recognized to affect neurogenesis, synaptic function, cell viability, and cognitive function, which in turn affects pathological and physiological aspects of neurons. Stroke has a significant psycho-socioeconomic impact globally. Central post-stroke pain (CPSP), also known as a type of chronic neuropathic pain, is caused by injury to the CNS following a stroke, specifically damage to the somatosensory system. BDNF regulates a broad range of functions directly or via its biologically active isoforms, regulating multiple signalling pathways through interactions with different types of receptors. BDNF has been shown to play a major role in facilitating neuroplasticity during post-stroke recovery and a pro-nociceptive role in pain development in the nervous system. BDNF-tyrosine kinase receptors B (TrkB) pathway promotes neurite outgrowth, neurogenesis, and the prevention of apoptosis, which helps in stroke recovery. Meanwhile, BDNF overexpression plays a role in CPSP via the activation of purinergic receptors P2X4R and P2X7R. The neuronal hyperexcitability that causes CPSP is linked with BDNF-TrkB interactions, changes in ion channels and inflammatory reactions. This review provides an overview of BDNF synthesis, interactions with certain receptors, and potential functions in regulating signalling pathways associated with stroke and CPSP. The pathophysiological mechanisms underlying CPSP, the role of BDNF in CPSP, and the challenges and current treatment strategies targeting BDNF are also discussed.
... PSP is a multidimensional experience encompassing various types of pain that pose unique challenges for stroke survivors. Complex regional pain syndrome and central PSP are characterized by having neuropathic characteristics, indicating disruptions in the somatosensory nervous system [2,23]. The nociceptive aspect may manifest in conditions such as poststroke shoulder pain, implicating musculoskeletal issues, and spasticity-related pain, linked to muscle overactivity. ...
Pain and somatosensory impairments are commonly reported following stroke. This study investigated the relationship between somatosensory impairments (touch detection, touch discrimination and proprioceptive discrimination) and the reported presence and perception of any bodily pain in stroke survivors. Stroke survivors with somatosensory impairment ( N = 45) completed the Weinstein Enhanced Sensory Test (WEST), Tactile Discrimination Test, and Wrist Position Sense Test for quantification of somatosensation in both hands and the McGill Pain Questionnaire, visual analog scale and the Neuropathic Pain Symptom Inventory (NPSI) for reporting presence and perception of pain. No relationship was observed between somatosensory impairment (affected contralesional hand) of touch detection, discriminative touch or proprioceptive discrimination with the presence or perception of pain. However, a weak to moderate negative relationship between touch detection in the affected hand (WEST) and perception of pain intensity (NPSI) was found, suggesting that stroke survivors with milder somatosensory impairment of touch detection, rather than severe loss, are likely to experience higher pain intensity [rho = −0.35; 95% confidence interval (CI), −0.60 to −0.03; P = 0.03]. Further, a moderate, negative relationship was found specifically with evoked pain (NPSI) and touch detection in the affected hand (rho = −0.43; 95% CI, −0.72 to −0.02; P = 0.03). In summary, our findings indicate a weak to moderate, albeit still uncertain, association, which prevents making a definitive conclusion. Nevertheless, our findings contribute to our understanding of the complexities surrounding the experience of pain in survivors of stroke and provide direction for future studies.
... This relationship has been reported in adult brain injury [35], but to the best of our knowledge, this is the first time it has been reported in pediatric stroke. In addition, this study is the first to report chronic pain as a barrier to recovery in pediatric stroke, despite chronic pain being well known because of adult stroke [36]. ...
Background
The incidence of stroke in children is low, and pediatric stroke rehabilitation services are less developed than adult ones. Survivors of pediatric stroke have a long poststroke life expectancy and therefore have the potential to experience impairments from their stroke for many years. However, there are relatively few studies characterizing these impairments and what factors facilitate or counteract recovery.
Objective
This study aims to characterize the main barriers to and facilitators of recovery from pediatric stroke. A secondary aim was to explore whether these factors last into adulthood, whether they change, or if new factors impacting recovery emerge in adulthood.
Methods
We performed a qualitative thematic analysis based on posts from a population of participants from a UK-based online stroke community, active between 2004 and 2011. The analysis focused on users who talked about their experiences with pediatric stroke, as identified by a previous study. The posts were read by 3 authors, and factors influencing recovery from pediatric stroke were mapped into 4 areas: medical, physical, emotional, and social. Factors influencing recovery were divided into short-term and long-term factors.
Results
There were 425 posts relating to 52 survivors of pediatric stroke. Some survivors of stroke posted for themselves, while others were talked about by a third party (mostly parents; 31/35, 89% mothers). In total, 79% (41/52) of survivors of stroke were aged ≤18 years and 21% (11/52) were aged >18 years at the time of posting. Medical factors included comorbidities as a barrier to recovery. Medical interventions, such as speech and language therapy and physiotherapy, were also deemed useful. Exercise, particularly swimming, was deemed a facilitator. Among physical factors, fatigue and chronic pain could persist decades after a stroke, with both reported as a barrier to feeling fully recovered. Tiredness could worsen existing stroke-related impairments. Other long-standing impairments were memory loss, confusion, and dizziness. Among emotional factors, fear and uncertainty were short-term barriers, while positivity was a major facilitator in both short- and long-term recovery. Anxiety, grief, and behavioral problems hindered recovery. The social barriers were loneliness, exclusion, and hidden disabilities not being acknowledged by third parties. A good support network and third-party support facilitated recovery. Educational services were important in reintegrating survivors into society. Participants reported that worrying about losing financial support, such as disability allowances, and difficulties in obtaining travel insurance and driving licenses impacted recovery.
Conclusions
The lived experience of survivors of pediatric stroke includes long-term hidden disabilities and barriers to rehabilitation. These are present in different settings, such as health care, schools, workplaces, and driving centers. Greater awareness of these issues by relevant professional groups may help ameliorate them.
... In general, CPSP occurs three to six months following cerebrovascular attack [6] , still, latent cases may present with pain symptoms even several years after initial stroke with a minor fraction [7,8] . Clinical manifestation of CPSP includes intractable pain in the affected limb and/or trunk [9] , which is characterized by burning, pinpricking, tearing, cutting, and occasionally squeezing or feeling cold [5,10] . As a result, ongoing requirement of pain intervention is essentially needed, and it significantly reduces the quality of life [11] . ...
Introduction
Post-stroke central pain is disabling yet ineffectively treated with routine medical intervention. In this study we presented an alternative neuromodulation therapy and, conducted a brief narrative literature review to examine current evidence of spinal cord stimulation treatment for central post-stroke pain
Case presentation
Here we reported a case of severe post-stroke syndrome, who achieved satisfactory improvement of pain symptom, as well as muscle rigidity with a novel neuromodulation therapy of short-term implantation of cervical spinal cord stimulation.
Clinical discussion
It remains a great challenge in management of post-stroke pain, which in turn significantly reduces the quality of life and worsens the burden of public health system. Spinal cord stimulation therapy is an emerging neuromodulation approach to restore pathological pain status and functional impairment, to provide a prospective insight of neuromodulation and rehabilitation option in management of post-stroke syndrome.
Conclusion
A potential role of spinal cord stimulation in treatment of post-stroke pain is proposed in combined with traditional medication or other neuromodulation strategy, to achieve better control of pain in the future.
... The prevalence of PSP is 11-66% [4]. PSP has different forms such as headaches, pain in shoulders, pain because of muscle stiffness, spasms, complex regional pain syndrome and CPSP [5]. ...
... Risk factors of PSP include sex (females are more affected), old age, consumption of alcoholic drinks, and depression. On the other hand, ischaemic stroke, spasticity, decreased upper limb movement as well as sensory dysfunction are among the stroke-related risk factors of PSP [4]. ...
Background. Central post-stroke pain (CPSP) occurs following cerebrovascular accidents and is a neuropathic pain syndrome that is characterized by stimulation-independent pain; shooting, burning, or electric shock-like sensation and paresthesia. Multiple pathogenetic theories have been proposed for the CPSP including disinhibition, central sensitization, thalamic changes, and altered function of spinothalamic tract (STT). Investigations such as MRI DTI can help to understand the pathogenesis of CPSP. Objective. To determine the radiological and clinical biomarkers in cases with CPSP. Methods. This case-control study was retrospectively conducted upon 60 persons divided into 20 CPSP cases (group 1), 20 cases with no CPSP (group 2) and 20 healthy controls (group 3). All subjects had Routine MRI and complete neurological examination including “Sensory testing but stroke patients were evaluated by quantitative assessment of neuropathic pain, the National Institutes of Health Stroke Scale (NIHSS), Ashworth scale, Modified Rankin Scale (MRS) and Hamilton depression rating scale (HAM-D scale). Results. Significant differences existed among studied groups as regard motor examination, sensory examination, NIHSS score and Hamilton depression score. A non-significant difference was detected among the groups regarding MRS findings. A significant difference existed between groups 1 and 2, between groups 1 and 3 while no significant difference was detected between groups 2 and 3 for all FA readings and all ADC readings in ipsilateral affected side assessed at internal capsule, midbrain, and pons. No significant difference existed between groups 1 and 2, between groups 1 and 3 and between groups 2 and 3 as regard FA readings and ADC readings in contralateral side assessed at internal capsule, midbrain, and pons. Conclusion. Our study highlighted the significance of white matter tracts (WMT) other than the conventional pain pathways in CPSP and can thus serve as a predictive marker for CPSP onset or a prognostic marker after any drug therapy or neuromodulatory treatment.
... PSP includes several phenotypes. Common PSP subtypes are central, spasticity-related pain, complex regional pain syndrome, and post-stroke headache [3]. The pathophysiology of these post-stroke pain subtypes varies, and several theories have been postulated for various post-stroke pain subtypes. ...
Background: Post-stroke pain is common after a stroke and might be underreported. We describe Persistent Facial Pain (PFP) developed in post-stroke patients. Method: ology: This was a prospective hospital-based cohort study of stroke patients, and patients were followed up. Out of 415 stroke patients, 26 developed PFP. Result: Out of all PFP patients, six patients had an ischemic stroke, and 20 had a hemorrhagic stroke. 57.7% of patients had hypertension, while 34.6 patients had diabetes. The stroke location was left-sided in 12 patients and right-sided in 14 patients. 46.15% of patients responded to venlafaxine, 30.77% responded to amitriptyline, and 23.08% responded to pregabalin. Conclusion: Persistent facial pain is a pain syndrome that might be missed in patients post-stroke. It might be more common in hemorrhagic stroke patients than in ischemic stroke patients. It responds adequately to antidepressants. A high index of suspicion is required to diagnose and appropriately manage these patients.
... In general, we expect that people with neurological diseases such as stroke and spinal cord injury will tolerate the evoked sensations because they often have sensory deficits in addition to motor deficits, and furthermore, intrafascicular stimuli of similar intensity did not provoke discomfort even when they were specifically used to activate sensory fibers in amputees [27]. However, some of these patients might suffer from hyperalgesia or allodynia [42], [43]. Moreover, it should be verified that the sensations perceived, even if tolerable, are not distracting or obstructive to the control. ...
Objective: Brain-body interfaces (BBIs) have emerged as a very promising solution for restoring voluntary hand control in people with upper-limb paralysis. The BBI module decoding motor commands from brain signals should provide the user with intuitive, accurate, and stable control. Here, we present a preliminary investigation in a monkey of a brain decoding strategy based on the direct coupling between the activity of intrinsic neural ensembles and output variables, aiming at achieving ease of learning and long-term robustness. Results: We identified an intrinsic low-dimensional space (called manifold) capturing the co-variation patterns of the monkey's neural activity associated to reach-to-grasp movements. We then tested the animal's ability to directly control a computer cursor using cortical activation along the manifold axes. By daily recalibrating only scaling factors, we achieved rapid learning and stable high performance in simple, incremental 2D tasks over more than 12 weeks of experiments. Finally, we showed that this brain decoding strategy can be effectively coupled to peripheral nerve stimulation to trigger voluntary hand movements. Conclusions: These results represent a proof of concept of manifold-based direct control for BBI applications.
... secondly, overlapping central neuronal networks mediating both pain and spasticity have been described. 6,7 treatment of sMo and its consequences (including post-stroke pain) is a challenge in clinical practice. current therapies often have side effects or are insufficiently effective. ...
Introduction:
Spasticity is a common problem in stroke patients. Treatments of spasticity often have side effects or are insufficiently effective. Dry needling (DN) has been proposed as a potential additional option to consider in the multimodal treatment of post-stroke spasticity, although questions about its safety remain. The goal of this study is to assess the safety of DN in stroke patients.
Evidence acquisition:
A systematic search in Medline, Embase, The Cochrane Library, Web of Science, CIHNAL and PEDro was conducted in June 2023. Two reviewers independently screened abstracts according to the eligibility criteria.
Evidence synthesis:
Twenty-five articles were included in this review. Only six studies reported adverse events, all of which were considered minor. None of the included studies reported any serious adverse events. In four of the included studies anticoagulants were regarded as contra-indicative for DN. Anticoagulants were not mentioned in the other included studies.
Conclusions:
There is a paucity of literature concerning the safety of DN in stroke patients. This review is the first to investigate the safety of DN in stroke patients and based on the results there is insufficient evidence regarding the safety of DN in stroke patients.
Clinical rehabilitation impact:
Although DN could be a promising treatment in post-stroke spasticity, further research is indicated to investigate its mechanism of action and its effect on outcome. However, before conducting large clinical trials to assess outcome parameters, the safety of DN in stroke patients must be further investigated.
... Most studies focused on patients with mild to moderate aphasia (Mandysova et al., 2022). Also, despite varied self-report pain scales, stroke patients are less likely than age-matched controls to be able to complete these pain scales (Harrison & Field, 2015;Price et al., 1999). Evidently, an appropriate alternative method of assessment of the presence of pain in persons with aphasia who are unable to self-report is needed. ...
Background
The use of self-report pain scales in persons with aphasia can be challenging due to communication and cognitive problems. An observational scale may be used as an alternative. The aim of this study is to examine the validity and reliability of the observational Pain Assessment in Impaired Cognition (PAIC15) scale that was developed for people with dementia, in persons with aphasia.
Methods
In 14 Dutch nursing homes, persons with aphasia were observed during rest and transfer by two observers using the PAIC15. The PAIC15 comprises 15 items covering the three domains of facial expressions, body movements, and vocalizations. When able, the person completed four self-report pain scales after each observation. The observations were repeated within one week. For criterion validity, correlations between the PAIC15 and self-report pain scales were calculated and for construct validity, three hypotheses were tested. Reliability was determined by assessing internal consistency, and intra- and interobserver agreement.
Results
PAIC15 observations were obtained for 71 persons (mean age 75.5 years) with aphasia. Fair positive correlations (rest: 0.35–0.50; transfer: 0.38–0.43) were reported between PAIC15 and almost all self-report pain scales and, one of the three construct validity hypotheses was confirmed. Results showed acceptable internal consistency. Intraobserver agreement was high during transfer but not during rest, interobserver agreement was high on the three PAIC15 domains during transfer but not during rest.
Conclusions
Recognition of pain in persons aphasia using the PAIC15 observational scale showed mixed yet promising results in this clinical study.
