What is Central Post-Stroke Pain Syndrome (Stroke Pain)?

Central poststroke pain syndrome, often shortened to CPSPS, is a type of nerve pain that can occur after a stroke. It can show up as constant or sudden bursts of pain or unusual sensations. This syndrome is quite similar to another condition known as thalamic pain syndrome. However, CPSPS is characterized by a more general impact on the nervous system, commonly affecting nerve pathways involved in the transmission of pain and sensation. Symptoms including tingling sensations, increased sensitivity to pain, and extreme reactions to touch usually appear 3 to 6 months after a stroke, though they can also occur earlier or later.

Diagnosing CPSPS can be quite complicated as it involves ruling out other conditions that can occur after a stroke, such as muscle stiffness, headaches, and musculoskeletal issues. Unfortunately, only 30% of patients receive treatment in the early stages after a stroke. This lack of treatment can lead to severe issues like sleep disturbances, depression, and in some cases, even suicide. But, recent research efforts are gathering information about common symptoms and treatment options to improve patient outcomes.

When we take a closer look, we understand that CPSPS occurs as a result of damage to various parts of the central nervous system after a stroke. While affected areas can vary, some parts of the nervous system are often involved. The thalamus, which serves as a relay center for sensory information, is one key area. Damage to the pathways that relay pain and temperature sensations to the thalamus frequently contributes to this syndrome.

If the stroke affects the areas controlling the trigeminal nerve, known for facial sensation, patients may experience facial pain or a condition called trigeminal neuralgia. Damage to the section of the brain responsible for processing touch can also lead to unusual pain perception. Moreover, interference with the brain’s normal pain regulating systems can play a part in the development of CPSPS.

What Causes Central Post-Stroke Pain Syndrome (Stroke Pain)?

Pain after a stroke can result from damage to certain parts of the nervous system, such as the spinothalamic tract, trigeminothalamic tract, and thalamus, after a cerebrovascular accident (CVA), known as a stroke. However, not every injury to these parts leads to this type of pain, known as CPSPS. The type of stroke also matters, with pain being more likely to occur following strokes caused by blocked blood vessels (ischemic strokes) than strokes caused by bleeding in the brain (hemorrhagic strokes).

Even though it would seem logical that the location of the stroke could predict the likelihood of CPSPS, this is not always the case. Some studies suggest that damage near the thalamus and brainstem is more likely to lead to this condition than damage to the lower spinal cord. Other studies point to greater risk with damage to the spinothalamic tract than damage to the thalamus. However, the specific reasons explaining this increased risk are not fully understood.

Identifying which patients are likely to develop CPSPS after a stroke remains challenging because our understanding of what triggers this condition is still limited.

Risk Factors and Frequency for Central Post-Stroke Pain Syndrome (Stroke Pain)

Central Post-Stroke Pain Syndrome (CPSPS) occurs in roughly 1% to 12% of people after a stroke (CVA), according to some studies. Some research suggests this figure may be as high as 25% or more. However, figuring out how widespread this condition really is can be tough because pain symptoms might not immediately appear after a stroke, and individuals’ pain experiences can be subjective.

Researchers have identified several factors that might increase a person’s chance of developing CPSPS. These include:

  • Being older,
  • Being female,
  • Having depression,
  • Using alcohol,
  • Having peripheral vascular disease (a condition that blocks blood flow to your limbs), and
  • Using statins (medicines that lower cholesterol in the blood).

On top of these, they noted other risk factors that come from the complications of a stroke. These include muscle tightness (spasticity), limited movement in the upper body, and sensory issues, especially following a type of stroke known as an ischemic stroke.

Central Poststroke Pain Syndrome, Potential Sites of Involvement. Lesions at
various levels of the spinothalamic tract, including the thalamus, can
contribute to central poststroke pain syndrome. Thalamic lesions were initially
thought to be solely responsible, but later research identified the involvement
of the lateral medulla, pons, lenticulocapsular area, and cortex. The condition
may result from the loss of somatosensory integration and changes in cortical
plasticity.
Central Poststroke Pain Syndrome, Potential Sites of Involvement. Lesions at
various levels of the spinothalamic tract, including the thalamus, can
contribute to central poststroke pain syndrome. Thalamic lesions were initially
thought to be solely responsible, but later research identified the involvement
of the lateral medulla, pons, lenticulocapsular area, and cortex. The condition
may result from the loss of somatosensory integration and changes in cortical
plasticity.

Signs and Symptoms of Central Post-Stroke Pain Syndrome (Stroke Pain)

Central post-stroke pain syndrome (CPSPS) is a condition that can cause a variety of symptoms such as throbbing, stabbing, shooting, and burning pain which may or may not be triggered by something. Symptoms typically begin 1 to 6 months after a stroke, but sometimes they can start even after a year. This makes it challenging to spot the condition in a timely manner. The symptoms can be grouped into six categories:

  • Heat allodynia (pain from stimuli that don’t normally cause pain)
  • Cold allodynia
  • Spontaneous dysaesthesia (unusual sensations)
  • Evoked dysaesthesia
  • Hyperalgesia (increased sensitivity to pain)
  • Paresthesias (tingling or prickling sensations)

Diagnosing CPSPS requires a detailed medical history and a physical examination because it needs to be differentiated from other conditions that can occur after a stroke. These include muscle stiffness (spasticity), headaches, shoulder pain, and musculoskeletal issues. For instance, up to 40% of stroke survivors experience shoulder pain, and practitioners need to ensure this isn’t mistaken for CPSPS. Understanding the timing of pain helps. While musculoskeletal and shoulder pains usually appear within 2 weeks to 3 months after a cerebrovascular accident (CVA) or stroke, pain from spasticity can appear within 2 to 12 months. This requires a thorough exam of musculoskeletal and nerve function to make an accurate diagnosis.

Looking into a patient’s history, particularly the types of sensations experienced, can help differentiate between CPSPS and pain from motor or range-of-motion issues. The Ashworth Scale is a tool that can help gauge the severity of spasticity. A physical exam, especially targeting cranial nerves and sensory function, can help pinpoint the location of brain lesions, helping to differentiate CPSPS from other stroke-related conditions. Various techniques, such as pinprick tests, applications of hot or cold stimuli, and blunt objects for touch assessment are used to evaluate the spinothalamic tract (involved in transmitting pain and temperature sensations). These methods help locate brain lesions and identify responses to pain, increased sensitivity to pain, decreased sensitivity to pain, and unusual sensations when evoked. In cases involving the thalamus or the pathways transmitting pain and facial sensations, patients typically experience pain and tingling on the opposite side to where the stroke occurred.

Testing for Central Post-Stroke Pain Syndrome (Stroke Pain)

It’s important to combine several types of information for accurate diagnosis. Currently, there are no laboratory markers that can conclusively diagnose chronic post-surgical pain. Imaging techniques, such as magnetic resonance imaging (MRI), functional MRI (fMRI), and computed tomography scan, can play a critical role in identifying the issue and pinpointing where it started. By using these imaging tools along with a detailed personal history and physical examination, doctors can identify the exact location of the problem faster and make an accurate diagnosis.

Treatment Options for Central Post-Stroke Pain Syndrome (Stroke Pain)

The management of Central Post-Stroke Pain Syndrome (CPSPS) is a debatable topic that has led to the exploration of different treatment methods. These methods can be grouped into two categories: non-pharmacologic interventions, like physical therapy, stretching, acupuncture, and certain types of brain stimulation, and pharmacologic treatments, like different types of medications.

Prescribing medication for CPSPS can be contentious, with various treatment models suggested by different studies. A common first-line medicine is amitriptyline, which is a type of antidepressant that works by preventing serotonin and norepinephrine from being reabsorbed by cells. Other first-line options include medications like gabapentin, lamotrigine, and pregabalin. These drugs work by reducing the release of neurotransmitters, which are chemicals that transmit signals in the brain, or by blocking channels that allow ions to pass through cell walls. Some studies suggest that combining amitriptyline with gabapentin or pregabalin can improve pain control when one drug alone doesn’t provide enough relief.

If first-line medications don’t work, common alternatives include other types of antidepressants and anticonvulsants, as well as opioids like tramadol. However, opioids are typically avoided due to their potential for addiction. Less common options include drugs like phenytoin, pamidronate, steroids, lidocaine, and ketamine. Some of these drugs have shown success, but research on their effectiveness is limited or unclear.

Non-drug interventions for CPSPS can also be helpful. For example, a technique called repetitive transcranial magnetic stimulation (rTMS) involves placing magnets on the scalp to generate pulses that can either enhance or suppress nerve signals. High-frequency rTMS appears more effective than low-frequency stimulation. The technique works by altering signals in the brain involved in pain. However, how effective rTMS is for pain control in the long-term (beyond 3 months) remains unclear.

Deep brain stimulation is another promising technique that stimulates certain areas of the brain and has been found to considerably reduce pain in various trials, especially in cases that do not respond to regular treatment. However, it is invasive and is usually the last resort.

Acupuncture can potentially help to reduce post-stroke pain as well, although there is limited research to support this claim. Similarly, physical therapy – including stretching and exercise – might be beneficial, but more research is needed in this area as well. However, the therapy has been shown to improve overall function and quality of life by managing pain linked to stroke progression and spasticity.

What else can Central Post-Stroke Pain Syndrome (Stroke Pain) be?

Neuropathic pain, which affects between 3% to 17% of people, can be confused with several other health conditions. This type of pain needs to be accurately diagnosed. To achieve this, different health professionals like neurologists, pain specialists, and general practitioners need to work together.

There are several conditions that can cause neuropathic pain similar to stroke. These include multiple sclerosis, injuries to the spinal cord, Parkinson’s disease, and disorders of the mind that result in physical pain, such as conversion or somatic symptom disorder. To correctly identify the cause of the pain, doctors will assess the patient’s medical history, perform a neurological examination, and use diagnostic imaging tools.

Sometimes, the pain associated with CPSPS, a specific type of stroke-related neuropathic pain, may not start until several months after the stroke event. It’s crucial to rule out other conditions before diagnosing a patient with CPSPS. These could include other sources of neuropathic pain, headaches, and musculoskeletal disorders, which involve the muscles and skeleton.

What to expect with Central Post-Stroke Pain Syndrome (Stroke Pain)

Information on how long chronic pain after a stroke (CPSP) lasts is not widely available. Some people might see their pain lessen or even go away because of changes in their nervous system or successful treatment. However, others continue to struggle with pain depending on how severe or where their stroke occurred. As more doctors become aware of CPSP and can diagnose it more accurately, we should gain a better understanding of how long it lasts and how recovery might look.

Possible Complications When Diagnosed with Central Post-Stroke Pain Syndrome (Stroke Pain)

People living with PSPS, a condition causing chronic pain, significantly struggle both psychologically and physically. This chronic discomfort often leads to an increase in anxiety and depression. The persistent pain can limit a person’s movements, hamper routine activities, and result in deteriorating physical health. In extreme cases, the continuous procedure of managing PSPS and its outcomes may even lead to behavioural problems, severe depression, and thoughts of self-harm.

What adds to the challenge in managing PSPS is that patients may find it hard to stick to their treatment plan. This could lead to less than ideal pain relief and a potentially worse medical outlook. Early recognition of these psychological and behavioural effects by healthcare professionals can greatly improve treatment adherence, therapeutic results, and the overall wellbeing of the patient.

Preventing Central Post-Stroke Pain Syndrome (Stroke Pain)

CPSPS, or chronic central pain syndrome, is a condition where pain can continue for months or even years after a stroke. Patients often have heightened sensitivity, meaning normal touches or changes in temperature could feel painful. This ongoing pain can have significant impacts on daily activities, affect sleep, and decrease the patient’s quality of life.

Treating this condition requires a team approach involving medications, physical therapy, and emotional support strategies. These treatment plans often need multiple adjustments to get the right combination that really works for the patient. Apart from medication, rehabilitation programs featuring physical and occupational therapies can also help. These therapies can improve patients’ ability to function normally, increase mobility, and reduce the severity of pain. It’s important to remember that each individual’s experience of CPSPS can be different, so treatments should be personalized to each patient’s specific symptoms and needs.

Frequently asked questions

Central Post-Stroke Pain Syndrome (Stroke Pain) is a type of nerve pain that can occur after a stroke. It is characterized by constant or sudden bursts of pain or unusual sensations. CPSPS affects nerve pathways involved in the transmission of pain and sensation, and symptoms usually appear 3 to 6 months after a stroke.

Central Post-Stroke Pain Syndrome (CPSPS) occurs in roughly 1% to 12% of people after a stroke, according to some studies.

The signs and symptoms of Central Post-Stroke Pain Syndrome (CPSPS), also known as Stroke Pain, can include: - Throbbing, stabbing, shooting, and burning pain - Pain that may or may not be triggered by something - Symptoms typically beginning 1 to 6 months after a stroke, but sometimes starting even after a year - Heat allodynia (pain from stimuli that don't normally cause pain) - Cold allodynia - Spontaneous dysaesthesia (unusual sensations) - Evoked dysaesthesia - Hyperalgesia (increased sensitivity to pain) - Paresthesias (tingling or prickling sensations) It is important to note that diagnosing CPSPS requires a detailed medical history and a physical examination to differentiate it from other conditions that can occur after a stroke, such as muscle stiffness (spasticity), headaches, shoulder pain, and musculoskeletal issues. Understanding the timing of pain can also help in making an accurate diagnosis, as musculoskeletal and shoulder pains usually appear within 2 weeks to 3 months after a stroke, while pain from spasticity can appear within 2 to 12 months.

Central Post-Stroke Pain Syndrome (Stroke Pain) can result from damage to certain parts of the nervous system, such as the spinothalamic tract, trigeminothalamic tract, and thalamus, after a stroke.

The doctor needs to rule out the following conditions when diagnosing Central Post-Stroke Pain Syndrome (Stroke Pain): - Muscle stiffness - Headaches - Musculoskeletal issues - Multiple sclerosis - Injuries to the spinal cord - Parkinson's disease - Disorders of the mind that result in physical pain, such as conversion or somatic symptom disorder

The text does not mention any specific tests that are needed for Central Post-Stroke Pain Syndrome (CPSPS). However, it does mention that imaging techniques such as magnetic resonance imaging (MRI), functional MRI (fMRI), and computed tomography scan can play a critical role in identifying the issue and pinpointing where it started. These imaging tools, along with a detailed personal history and physical examination, can help doctors identify the exact location of the problem and make an accurate diagnosis.

Central Post-Stroke Pain Syndrome (CPSPS), also known as Stroke Pain, can be treated through a combination of non-pharmacologic interventions and pharmacologic treatments. Non-pharmacologic interventions include physical therapy, stretching, acupuncture, and certain types of brain stimulation such as repetitive transcranial magnetic stimulation (rTMS) and deep brain stimulation. Pharmacologic treatments involve prescribing medications such as amitriptyline, gabapentin, lamotrigine, pregabalin, and other types of antidepressants and anticonvulsants. If first-line medications do not work, alternatives like opioids may be considered, although they are typically avoided due to their potential for addiction. Less common options include drugs like phenytoin, pamidronate, steroids, lidocaine, and ketamine, although research on their effectiveness is limited or unclear.

The prognosis for Central Post-Stroke Pain Syndrome (CPSPS) can vary depending on the individual and the severity of their condition. Some people may see their pain lessen or even go away due to changes in their nervous system or successful treatment. However, others may continue to struggle with pain depending on the severity and location of their stroke. As more doctors become aware of CPSPS and can diagnose it more accurately, a better understanding of prognosis and recovery can be gained.

Neurologist, pain specialist, and general practitioner.

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