American Stroke Foundation

Dr. Sarah Eickmeyer, MD introduces the talk “My Stroke is a Pain.”

Dr. Sarah Eickmeyer, MD introduces the talk “My Stroke is a Pain.”

Objectives of the talk include reviewing the common causes of pain after stroke, understanding why there is pain exists, and knowing what can alleviate that pain.

Shoulder pain is a common topic in Dr. Eickmeyer’s clinical practice.

This study of patients who have had a stroke showed where the patients had pain and what it was causing it. Joint pain, in the orange circle, represents 40% of the pain. 20% was mostly in the shoulder. In the green circle, 10% reported headaches. Central post stroke pain (nerve pain or neuropathic pain), in dark blue, was reported at 8%. Spasticity or muscle spasms were reported by 7% as shown in light blue. Very rarely was complex regional pain syndrome reported.

These kinds of pain often overlapped. Finding the cause and treating some of these
together can be helpful.

Bones and muscles make up the shoulder joint, as shown here. This joint has a lot of mobility but isn’t very stable. The rotator cuff muscles help to hold it in place. After a stroke, the muscles of one side may be weakened (hemiplegia), including the muscles of the rotator cuff.

Lifting the shoulder and moving it is a complex motion. Normally the shoulder blade (scapula) rotates to allow normal arm motion to raise arms over head. This normal movement helps us to avoid rotator cuff injury or impingement.

Shoulder impingement occurs when the shoulder blade and rotator cuff don’t rotate normally. The bursa at the joint, a fluid-filled sac, becomes impinged and causes pain when lifting the arm.

If you have hemiplegia (weakness), the arm hangs down from shoulder joint (subluxation) and the shoulder blade (scapula) doesn’t rotate. This leads to early rotator cuff impingement and pain.

Poor posture can make shoulder pain worse. If you are hunched over in a wheelchair, that won’t feel good on your shoulder. This posture could have to do with the fit, non-supportive back, lack of arm support. Simple adjustments can improve the posture.

The ideal seating position is 90 degrees at the hips, knees, and ankles, with good support of the back. An arm trough or lap tray can be ordered with a therapist or physician.

Subluxation, or the arm hanging down from the joint, puts stress on the shoulder muscles and tendons. Rotator cuff impingement can lead to shoulder bursitis, tendonitis, or tears when the arm is raised. This can lead to other problems down the line, such as guarding from pain (protecting and not moving due to pain) and early frozen shoulder (tightening due to lack of movement).

In a shoulder subluxation, the arm hangs down from the shoulder joint. This often occurs early after stroke, when there is little movement. Shoulder subluxation often resolves after spasticity develops in the rotator cuff muscles which pull the shoulder back together. However, if not managed early, this can cause pain and rotator cuff injury.

If you have persistent subluxation, the first and most important thing to consider is proper positioning in the bed and chair. Using pillows, an arm trough, foam wedge, etc. for support.

If your arm hangs down and is painful during transfers, a sling for ambulation and transfers may help (ex. GivMohr or cuff style slings). Slings can be ordered by a physician and check what words with a therapist. Regular shoulder stretching is important and may usually requires assistance from family/friend and/or Physical or Occupational Therapy. A physician can prescribe medications for pain. The next slides discuss Kinesiotaping and Electrical stimulation.

Kinesiotaping is different kinds of taping techniques, usually done by a Physical or Occupational therapist. The research trials has mixed results, but anecdotes are often positive, and Olympic athletes can be seen using it. It is used for a lot of different things, and some people find it feels good.

Electrical Stimulation is a battery pack with pads placed over different muscles. It may reduce pain over time and reduce subluxation. Usually done by a Physical or Occupational therapist, but it can be taken home. These machines can be used on many areas after stroke such as the hand or shoulder.

What happens if pain continues and rotator cuff injury occurs?

Bursitis and tendonitis just mean inflammation of the rotator cuff tendons and bursa.
If unresolved, it may lead to rotator cuff tears over time. Some found up to 40% incidence in stroke survivors, and others found no relation between stroke and rotator cuff tear.

If you do have a rotator cuff injury or suspect you do, ice and heat can help. Regular shoulder stretching is important. If there is pain during particular activities, you may need to modify activities or ask for help. PT or OT may be appropriate. Consult your physician for medications or steroid injections. Surgery may be an option, but only if it is a severe tear or other things don’t help.

Shoulder pain leads to guarding which leads to decreased range of motion. This causes a thickening of the joint capsule. One study found that 77% of painful, stiff shoulders after stroke had frozen shoulder.

Use your weak arm! Don’t avoid it. Use it or use it. Movement is medicine. Regular shoulder stretching will help.

Physical Therapy is an option.

Steroid injections may help.

Surgical manipulation may be needed, but only if severe or other things don’t work. We try other things first.

We looked at shoulder pain, now we will look at other causes of pain after stroke.

Spasticity is a common cause of pain after stroke. Spasticity is an increase in reflexes and muscle tightness after a stroke affecting 23% of stroke survivors. It becomes problematic in about 30% of survivors through pain, sleep disruption, and decreased function.

Regular stretching – you will notice this is a common theme. Stretching is always a good idea.

Braces can stretch out the spastic muscles. Therapy can help for a short time and help teach stretches. Medical options include medications, botulinum toxin injections and baclofen pumps. Surgery is necessary only if severe or other things don’t work.

CRPS involves nerve pain after illness, injury or nerve damage.

By definition, it only affects one limb.

In stroke called “Shoulder hand syndrome” because it causes severe shoulder pain, avoids the elbow, and affects the hand, causing swelling and intense pain. This only affects 1% of stroke survivors, especially in severe stroke or stroke with loss of sensation.

There are many signs and symptoms of CRPS. Some are general differences between the limbs in appearance and sensation.

Stroke specific indicators include shoulder pain, hand pain, tenderness of hand joins, and pain with range of motion. If squeezing the join causes pain, that is a sign. This is associated with severe weakness, sensory loss, or subluxation right after the stroke.

The biggest advice is to use the painful arm. The more you use it, it will start to feel better. Desensitization includes tapping, rubbing, or massaging the painful arm, for example with a cotton ball. Again, regular stretching is great. A compression glove helps with associated swelling in the hand. PT and OT can help. If this goes on long enough, it can cause people to feel down or depressed, so psychology can help. Medication and injections are also available.

•Contrast baths – alternating between warm water and very cold water.

•Desensitization – tapping, rubbing, friction massage.

•Gentle stretching and strengthening exercises to use the hand.

•Edema control with glove or wrapping techniques.

•Stress loading (scrubbing) where you intentionally put weight through the painful arm.

•Ergonomics like posture is important.

•Movement therapy and normalization of use of the affected limb and functional
restoration.

•Mirror therapy uses mirrors to look at the limb and movement to reduce pain.

In mirror therapy, a mirror hides the affected hand and makes it appear that the reflection in the mirror is the affected hand. Then actions are performed.

In this study, at the end of 4 weeks of mirror therapy, those who did mirror therapy had less pain that those without.

Generalized nerve pain after stroke occurring after stroke located in areas of the body that have sensory loss. In some people, half the body is numb after stroke, but then they feel severe pain. The brain just feels numbness so it substitutes with pain. It can affect half of the body (face, arm, trunk and leg).

Generalized nerve pain after stroke occurring after stroke located in areas of the body that have sensory loss. In some people, half the body is numb after stroke, but then they feel severe pain. The brain just feels numbness so it substitutes with pain. It can affect half of the body (face, arm, trunk and leg).

There is a lot you can do to manage the pain, almost identical to complex regional pain syndrome treatments. Generally, use the painful side, do regular stretching. Seek PT or OT and psychology as necessary. Consider medication or injections if necessary.

There is a lot you can do to manage the pain, almost identical to complex regional pain syndrome treatments. Generally, use the painful side, do regular stretching. Seek PT or OT and psychology as necessary. Consider medication or injections if necessary.

Pain is very common after stroke. Don’t ignore it, tell someone about it.

Things to try on your own:

Use the weak side, don’t avoid it! Your function and pain will improve.

Use good positioning and posture when sitting and laying down.

Practice regular stretching and use ice and heat.

Finally, talk to your doctor about other options.

Physiatry (PM&R doctors) can do a number of things:

• Diagnose and treat pain after stroke
• Prescribe Physical or Occupational Therapy
• Recommend different medications
• Order braces and positioning devices
• Perform injections (steroid, botox)
• Refer to surgeons only if needed, though we try to use all the tools at our disposal.