Diagnosis, Prevalence, Characteristics, and Treatment Of

® VOLVO XXIIIL XXI • NNOO 13 •• J APRILUNE 2013 2015 Diagnosis, Prevalence, Characteristics, Vol.ÊXXI,ÊIssueÊ1Ê JuneÊ2013 andEditorial Treatment Board of Central Poststroke Pain Editor-in-Chief PsychosocialÊAspectsÊofÊChronicÊPelvicÊPain ain is a common complaint mortality.49,62,63 Since the incidence severe pain attributed to a vascular JaneÊC.ÊBallantyne,ÊMD,ÊFRCA Anesthesiology,ÊPainÊMedicinefollowing stroke, reported of stroke increases with age and life lesion in the thalamus. This pain syn- USA in 11–55% of stroke sur- expectancy is rising, the prevalence drome became known as the “Dejerine- Pain is unwanted, is unfortunately common, and remains essential for survival (i.e., 5,24,31,47 PAdvisoryÊBoardvivors. Poststroke of poststrokeevading dang pain,er) a includingnd facilitati centralng med ical dRoussyiagnos esyndrome”s. This com orple “thalamicx amalgamati painon of painMichaelÊJ.ÊCousins,ÊMD,ÊDSC can arise from muscles, joints, poststrokesensation, pain em o(CPSP),tions, a isnd also though likelyts ma nifesyndrome.”sts itself as pExpertsain beh alatervior .demonstrated Pain is a moti - PainÊMedicine,ÊPalliativeÊMedicine 1 - or viscera,Australia or from the peripheral to increasevating fact inor the for future. physicia Itn isconsu imporltati- ons that and extrathalamicfor emergency vasculardepartme lesionsnt visit scan and is or central nervous system.39,63 The tant to assess the presence most common types of poststroke of pain in stroke survivors pain include hemiplegic shoulder because of its negative pain, pain due to painful spasms or impact on quality of life and spasticity, poststroke headache, and rehabilitation. central poststroke pain. Patients may have several types of poststroke pain Central Poststroke Pain concomitantly.24,39,63 CPSP is a central neuropathic Risk factors for poststroke pain pain condition in which pain include young age, female sex, stroke arises as a direct result of severity, spasticity, diabetes, sensory a cerebrovascular lesion in disturbance, depression, and pain the central somatosensory before stroke onset. Up to 40% of nervous system. Other com- stroke patients who develop post- also cause pain, and so the term “cen- mon causes of central neuropathic pain stroke pain have other pre-existing tral poststroke pain” is preferable.27,28,54 include multiple sclerosis, spinal cord pain conditions.31 Poststroke pain In this issue of Pain: Clinical Updates we injury, syringomyelia and syringobul- can reduce quality of life, increase will review the diagnosis, prevalence, bia, tumors and abscesses in the central fatigue, complicate rehabilitation, clinical characteristics, and evidence- nervous system (CNS), and other disturb sleep, affect mood and social based treatment of CPSP. inflammatory CNS diseases (e.g., my- functioning, and increase long-term elitis). Like poststroke pain in general, Diagnosing CPSP Henriette M. Klit, MD CPSP has a negative effect on quality of Henriette M. Klit, MD life in stroke survivors.12 It is important to distinguish between Danish Pain Research Center Aarhus, Denmark Central poststroke pain was first nociceptive and neuropathic pain in Email: henriette.klit@clin.au.dk described by the French neurolo- stroke patients, as the choice of treat- Nanna Brix Finnerup, MD gist Déjerine and the Swiss-French ment often differs in these conditions. Danish Pain Research Center neuropathologist Roussy in 1906 in However, there are no particular Aarhus, Denmark Email: finnerup@clin.au.dk their famous paper “Le syndrome features in the history or the clinical Troels Staehelin Jensen, MD, DMSc thalamique.”13 The authors reported a findings that can separate neuropathic Danish Pain Research Center small series of patients with a constel- and musculoskeletal pain with cer- Aarhus, Denmark Email: tsjensen@clin.au.dk lation of neurological symptoms and tainty, and making such a distinction PAIN: CLINICAL UPDATES • APRIL 2015 1 can sometimes be difficult.53 A further complication is the fact that stroke pa- Poststroke pain can reduce quality of life, increase fatigue, tients often have other pain conditions. complicate rehabilitation, disturb sleep, affect mood and Also, some poststroke pain conditions social functioning, and increase long-term mortality. may be mixed pain types, as in the case of shoulder pain. In 2008, a new grading burning, painful cold, electric shocks, quantitative sensory testing (QST),23 system emerged for neuropathic pain aching, pressing, stinging, and pins additional imaging, or neurophysio- with different inclusion criteria for and needles; and allodynia or dyses- logical examinations, to rule out other neuropathic pain, but these criteria thesia to touch. In the same paper, we causes of pain. did not include the exclusion of other published a grading system, based on causes of pain. Therefore, in 2009 we the diagnostic criteria, enabling re- Prevalence published a proposal for diagnostic searchers to classify CPSP as “possible,” The reported prevalence of central criteria for CPSP based on the grad- “probable,” or “definite” (Table 1). poststroke pain varies between 1% and ing system,37 including mandatory and As implied by the proposed 12%.2,9,25,31,36,39,42,47,52,61,64 In a population- supportive criteria. The mandatory cri- diagnostic criteria, the diagnosis of based study from Denmark, based on teria for the diagnosis of CPSP include CPSP is based on the stroke and pain a questionnaire of 608 stroke patients the following: pain within an area of history and the clinical examination and a clinical examination of 51 pa- the body corresponding to the CNS with a focus on the sensory find- tients with possible CPSP, the minimum lesion, a history suggestive of a stroke ings. If possible, the vascular lesion prevalence of definite or probable CPSP and onset of pain at or after stroke should be visualized by imaging, was 7.3% (N = 35) and 8.6% (N = 41) if onset, confirmation of a CNS lesion by either computed tomography (CT) or CPSP-like dysesthesia was included.36 imaging and/or negative or positive magnetic resonance imaging (MRI). The median time of follow-up was 4.4 sensory signs confined to the area of Other useful tools include pain draw- years. the body corresponding to the CNS ings and standardized pain question- In a Finnish study of CPSP in lesion, and, if possible, exclusion of naires, including neuropathic pain young patients with ischemic stroke other causes of pain such as nocicep- scales such as the DN4 (Douleur with a median follow-up time of 8.5 tive or peripheral neuropathic pain. Neuropathique en 4 Questions) and years, a total of 49 out of 824 patients The supportive criteria include: no the Leeds Assessment of Neuropathic had CPSP, corresponding to a preva- primary association with movement, Symptoms and Signs (LANSS) scale.23 lence of 5.9%. Out of the remaining inflammation, or other local tissue Sometimes it is necessary to perform 775 patients, 246 had sensory abnor- damage; certain descriptors such as supplementary investigations, such as malities and 529 had neither sensory Table 1 Grading system for central poststroke pain (CPSP)* Criteria to Be Evaluated for Each Patient Comments 1. Exclusion of other likely causes of pain No other obvious cause of pain No primary relation to movement, inflammation, or other local tissue damage Descriptors such as burning, painful cold, electric shocks 2. Pain with a distinct neuroanatomically plausible Pain localized unilaterally or crossed face/body in a body area corresponding to distribution a cerebrovascular lesion 3. A history suggestive of a stroke Sudden onset of neurological symptoms with pain starting at or after stroke onset 4. Demonstration of the distinct neuroanatomically Findings of positive and/or negative sensory signs in an anatomically plausible plausible distribution by a clinical neurological distribution and pain localized within a territory of sensory abnormality examination 5. Demonstration of the relevant vascular lesion Visualization of a lesion that can explain the distribution of sensory findings, by imaging either CT or MRI * Possible CPSP: Criteria 1 + 2 + 3 fulfilled. Probable CPSP: Criteria 1 + 2 + 3 fulfilled plus either 4 or 5. Definite CPSP: Criteria 1–5 fulfilled. 2 PAIN: CLINICAL UPDATES • APRIL 2015 abnormalities nor CPSP. The investiga- majority of patients report moderate tors found that patients with CPSP had pain.2,44,52,64 In a population-based study, Sensory descriptors used a lower quality of life compared with the reported median pain intensity in patients with CPSP patients without CPSP, both with and was 5 on a numeric rating scale (range include burning, aching, without sensory abnormalities. Forty 0–10).36 The pain can be spontaneous, (82%) of the CPSP patients had other evoked, or both. Pain-evoking factors pricking, lacerating, shooting, concomitant pain complaints.25 In this can be internal stimuli, such as stress squeezing, throbbing, sharp, study, as in other studies on CPSP, and emotions, or external stimuli, stabbing, painful pins and 9,44 the presence of CPSP was associated such as touch and cold. Pain usually needles, dull, and cramping. with stroke severity, but not with age seems to be chronic, often life-long and at stroke onset, sex, or stroke subtype constant, but in a few patients, the pain patients with CPSP. For a definition of based on stroke etiology. reduces over time.38 these terms, see the pain taxonomy In a population–based study from Sensory descriptors used in published by IASP.1 In one study,36 Rimini, Italy, published in 2013, CPSP patients with CPSP include burning, pinprick hyperalgesia was present in was diagnosed in 66 out of 601 pa- aching, pricking, lacerating, shooting, 57%, cold allodynia in 40%, and brush- tients, corresponding to an incidence squeezing, throbbing, sharp, stabbing, evoked dysesthesia in 51% of patients of 11%.52 CPSP was equally prevalent in painful pins and needles, dull, and with CPSP. males and females. In the majority of cramping.2,7,22,44,55,64 Abnormal pain and tempera- patients, pain developed immediately ture sensation is found in almost (58%) or within the first month after a Clinical Findings all patients with CPSP.

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