Challenges in Managing A Patient With Central Post-Stroke Pain

Abstract

Objective: This is a case illustration of the challenges in managing a patient with central post stroke pain secondary to right thalamic bleed. We describe in detail the events of this case management and the challenges that we had encountered. Method: We report a case of a 68-year-old lady who had right thalamic bleed secondary to hypertensive crisis in 2015 and was further complicated with central post stroke pain over the hemiparetic side. In our report, we describe in detail the challenges in managing the patient to improve her function to achieve a better quality of life. Conclusion: This article illustrates the importance of a multidisciplinary approach and knowledge of various methods in managing a patient with central post stroke pain.

Full text

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BangladeshJournalofMedicalScienceVol.18No.02April’19
Case report:
Challenges in Managing A Patient With Central Post-Stroke Pain
Mazatulfazura SF Salim1, Muhammad Haz Hana2, Tan Yew Chin3, Nur Karyatee Kassim4, Mazlina
Mazlan5
Abstract :
Objective:Thisisacaseillustrationofthechallengesinmanagingapatientwithcentralpost
strokepain secondary toright thalamic bleed.Wedescribeindetail the eventsof this case
managementandthechallengesthatwehadencountered. Method:Wereportacaseofa68-year-
oldladywhohadrightthalamicbleedsecondarytohypertensivecrisisin2015andwasfurther
complicatedwithcentralpoststrokepainoverthehemipareticside.Inourreport,wedescribein
detailthechallengesinmanagingthepatienttoimproveherfunctiontoachieveabetterquality
of life. Conclusion:Thisarticleillustratestheimportanceofamultidisciplinaryapproachand
knowledgeofvariousmethodsinmanagingapatientwithcentralpoststrokepain.
Correspondence to: Dr Muhammad Haz Hana, Senior Lecturer / Rehabilitation Medicine Specialist,
Rehabilitation Medicine Unit, School of Medical Sciences, UniversitiSainsMalaysia16150KubangKerian,
Kelantan, Malaysia. Email:drmdhaz@usm.my
Bangladesh Journal of Medical Science Vol. 18 No. 02 April’19. Page : 416-418
DOI: https://doi.org/10.3329/bjms.v18i2.40717
Case presentation:
A68-years-oldladywithuncontrolled hypertension
sustained a right thalamic bleed in 2015. She was
premorbidly well prior to the cerebrovascular
accident.Shedevelopedanacuteonsetofleftsided
hemiparesis,hemisensorylosswithneuropathicpain
overherleftupperlimb.Thepoweroftheaected
limbs were 4/5 according to Medical Research
Councilgradingscalewithevidenceofmildspasticity
overtheleftbicep,andgastrocnemius/soleusmuscle
complex with Modied Ashworth Scale of 1. She
was still able to ambulate indoor independently
usingquadripodandperformsomesimpledomestic
activities of daily living. The major problem that
aectedherdailylifewastheneuropathicpainover
theleftupperlimb.
She described the pain as burning and pricking
in nature, which was severe enough to disturb her
activitiesofdailylivingwithNumericalRatingScale
(NRS)of 7 to8over 10. The painwas continuous
throughout the day and frequently at night, which
causedserioussleepdisturbance.Thepainwasfelt
overthe entire aspect of thewhole leftupper limb
andoccasionallyspreadtoherleftfaceandneck.She
deniedanyhyperalgesiaorallodynia.
She was started on Amitryptiline 25mg daily two
weeksafter thepain onset. However,there was no
improvementintheNRSpainscoreafterstartingthe
medicationforalmostamonth.Increasingthedoseup
till50mgdailydidnotbringforthanyimprovement
1. Dr Mazatulfazura SF Salim, MBBCh BAO, MMed (Rehab Med) Lecturer / Rehabilitation Medicine
Specialist,DepartmentofMedicine,FacultyofMedicineandHealthSciences,UniversitiPutraMalaysia,
43400Serdang,Selangor,Malaysia.fazurasf@upm.edu.my
2. DrMuhammadHazHana,MBBS,MMed(Rehab Med.)SeniorLecturer/RehabilitationMedicine
Specialist,RehabilitationMedicineunit,SchoolofMedicalSciences,UniversitiSainsMalaysia,16150
KubangKerian,Kelantan,Malaysia.drmdhaz@usm.my
3. Dr Tan Yew Chin, MD, MMed (Neurosurgery) Senior Lecturer / Neurosurgeon & Pain Specialist,
DepartmentofNeurosciences,SchoolofMedical Sciences Universiti Sains Malaysia,16150Kubang
Kerian, Kelantan, Malaysia. drtanyc@usm.my
4. Dr Nur Karyatee Kassim MBBS, MPath (Chemical Pathology) Senior Lecturer/ Chemical Pathologist
Basic Sciences Unit, School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan,Malaysia.karyatee@usm.my
5. Associate Professor Dr Mazlina Mazlan, MD, MMed (Rehab Med.) Associate Professor / Rehabilitation
MedicineSpecialist.DepartmentofRehabilitationMedicine,FacultyofMedicine,UniversityofMalaya,
59100KualaLumpur,Malaysia.mazlinamazlan@ummc.edu.my

412
CentralPost-strokePain
too.Wewereabitcautiousnottoincreasethedosage
furtherasthispatienthaspre-existingcardiovascular
disease. We then stopped the Amytripiline
and changed the medication to Gabapentin, an
anticonvulsant.  She only showed signicant pain
reliefwithGabapentin600mgtds,wherebyherNRS
scoreimproved to4 over 10. However, the patient
experiencedintolerablesideeectsatthisdose,where
shefelt lightheadedness andsleepyduring daytime
and was unable to perform her normal activities
of daily living. She became frustrated and started
to display depressive symptoms such as persistent
low mood and lost of interest in daily activities.
Nonethelesswedidnotstartheronanymedications,
as her PHQ-9 score was only 5, which indicated
mild depression.  We then reduced the Gabapentin
dosage to 300mg tds and incorporated counseling
andpsychologicalmanagementto address thepain.
Theseinvolvedcognitivebehavioralapproachsuch
as breathing and relaxation therapy and distraction
techniques.However,these techniques require high
commitmentfromthepatienttopracticethemdaily.
WehadeducatedMadamHonthesignicantroleof
psychologicalapproachbesidesthepharmacological
managementintreatingthepainandemphasizedon
the importance of applying the technique correctly
and regularly. The managing team had failed to
convinceher topractice those techniquesregularly
eventhoughmultipletherapysessionswerearranged.
Besides, she also underwent acupuncture as an
alternativetreatmenttomanageherpain.Shestopped
afterseveralsessionsandclaimedthatitdidnothelp
torelieveherpain.HerNRSscorewasmaintained
at 6 over 10, which, according to the patient, was
notthedesirablescore.SinceGabapentinseemedto
work,wecontinuedthemedicationwithalowerdose
of300mgtds and encouragedhertocomplyonthe
breathing,relaxationanddistractiontechniques.
After 6 months of initiating treatment for the
neuropathicpain,theNRSpainscorewasstill6to
7 over 10. The patient felt dissatised and started
todeterioratein her dailyfunction.She wished for
theneuropathic pain to be completelytreated. Due
to the therapy resistance, we oered her electrical
neurostimulation therapy for further reduction of
painbutshe refused.Shehaddecidedto continue
withtheGabapentin300mgtdsonlyeventhoughit
controlsthepainsuboptimally.
Ethical Clearance:
Thiscasereportwassubmittedforpublicationafter
gettingEthicalapprovalfromtheEthicsCommittee
of the School of Medical Sciences, Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan,
Malaysia.
Discussion:
Centralpoststrokepainbelongstoagroupofchronic
paindisordersthataretermedcentralneuropathicpain
becausethepainisduetoalesionordysfunctionof
the central nervous syste1.Neuropathicorcentralpain
hasbeen estimatedtooccurinupto8%ofpatients
aftera strokeduring 1 year follow up.About18%
of stroke patients with somatosensory disturbances
developed central post stroke pain2. In clinical
practice,the treatment ofpatientswith central post
strokepainisoftenbasedontrialanderroruntilpain
reliefisfound.Ourcasepresentedhereshowedsome
challengesinoptimizingthepain.Thereisageneral
consensusthatamitriptylineisthedrugofrstchoice,
butnotallpatientsreportaresponse3.Thetricyclic
antidepressantamitriptylinegivenat75mgdailywas
found to be eective in improving the pain scores
in10outof15patientswithcentralpoststrokepain
versus1of15inaplacebogroupofadouble-blinded
placebo-controlled study at 2 weeks and 4 weeks
from the start of treatment4.Amitriptylineisusually
startedat10 or 25mg/dayand titrated up to75mg/
day.OurpatientdidnotrespondtoAmitryptilineat
50mgdailyhoweverwedidnotincreasethedosage
furtherasourpatienthadapreexistingcardiovascular
disease.Thus,wehadtotryonanothertypeofdrug,
which is Gabapentin, the anticonvulsant group.
Although the ecacy of Gabapentin on peripheral
and central neuropathic pain is well documented.
It is associated with side-eects such as dizziness,
decreasedintellectualperformance,somnolence,and
nausea5.Thesesideeectshavecausedourpatientto
beunabletoperformherdailyactivitiesandthedose
hadtobereducedtoasub-optimaldose.
Besides medical therapy, the psychological
approachesalsoplaysimportantrole.Dierentcoping
strategies have been recommended and used for
post-strokepainsuppression.Cognitivebehavioural
therapy including breathing, relaxation and
distractiontechniquesmayhelptomodifynegative
thoughts related to pain. This can help patients to
increasetheir activitylevel andfunctioning, which
inturncanhelpimprovemood,sleepandqualityof
life.Inthecasewepresentedabove,thepatientfailed
to apply the techniques taught to her in her daily
activitiesdespitereassuranceontheeectivenessof
thepsychologicalapproach.
Acupuncture is a complementary and alternative
medical modality.The World Health Organization
(WHO) in 2002 released a report entitled

413
MazatulfazuraSFSalim,MuhammadHazHana,TanYewChin,NurKaryateeKassim,MazlinaMazlan
“Acupuncture:Review andAnalysisof Reportson
Controlled Clinical Trials”. This report states that
acupuncturecanberegardedasthemethodofchoice
fortreatingmanychronicallypainfulconditions.For
poststrokecomplications,therewereonlyevidences
on eectiveness of acupuncture for shoulder pain
after stroke6. For central post stoke pain, there are
stilllowevidencesthatacupunctureshowssignicant
eect7.In the casepresented here, acupuncturedid
nothelpinalleviatingthepain.
Other non-pharmacological treatment, including
repetitive transcranial magnetic stimulation
(rTMS), deep brain stimulation (DBS) and motor
cortex stimulation (MCS) has been reported in
case series and brief reports, but there are no
controlled trials in this eld. Due to low-quality
evidence, recommendations for MCS and DBS are
“inconclusive”inthetreatmentofcentralpoststroke
pain. Therefore, it is recommended that electrical
neurostimulation should be considered in drug-
resistantcentralpoststroke pain patients only8. We
suggested a trial of electrical neurostimulation to
our patient since she did not respond optimally to
pharmacological treatment, psychological therapy
and alternative treatment.
Inconclusion,managingcentralpoststrokepainwas
indeed very challenging and there is a great need to
identifybettertreatmentregimes. However,holistic
approach, including medical and psychological
togetherwithpatient’sparticipationandcommitment
towardstreatment oeredare theonly current best
practiceinmanagingcentralpoststrokepain.
Conict of interest: None declared
Authors’ Contributions:
Datagatheringandideaownerofthisstudy:Salim
MSF,HanaMH
Studydesign:SalimMSF,HanaMH,TanYC
Data gathering: Salim M SF, Mazlan M
Writingandsubmittingmanuscript:SalimMSF,
HanaMH
Editingandapprovalofnaldraft:SalimMSF,
HanaMH,TanYC
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