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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.
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
Abstract :
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-
of life. Conclusion:Thisarticleillustratestheimportanceofamultidisciplinaryapproachand
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
Bangladesh Journal of Medical Science Vol. 18 No. 02 April’19. Page : 416-418
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
limbs were 4/5 according to Medical Research
complex with Modied Ashworth Scale of 1. She
was still able to ambulate indoor independently
activities of daily living. The major problem that
She described the pain as burning and pricking
in nature, which was severe enough to disturb her
(NRS)of 7 to8over 10. The painwas continuous
throughout the day and frequently at night, which
overthe entire aspect of thewhole leftupper limb
She was started on Amitryptiline 25mg daily two
weeksafter thepain onset. However,there was no
1. Dr Mazatulfazura SF Salim, MBBCh BAO, MMed (Rehab Med) Lecturer / Rehabilitation Medicine
2. DrMuhammadHazHana,MBBS,MMed(Rehab Med.)SeniorLecturer/RehabilitationMedicine
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.
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,
5. Associate Professor Dr Mazlina Mazlan, MD, MMed (Rehab Med.) Associate Professor / Rehabilitation
disease. We then stopped the Amytripiline
and changed the medication to Gabapentin, an
anticonvulsant.  She only showed signicant pain
scoreimproved to4 over 10. However, the patient
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.
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.
as breathing and relaxation therapy and distraction
techniques.However,these techniques require high
the importance of applying the technique correctly
and regularly. The managing team had failed to
convinceher topractice those techniquesregularly
Besides, she also underwent acupuncture as an
at 6 over 10, which, according to the patient, was
of300mgtds and encouragedhertocomplyonthe
After 6 months of initiating treatment for the
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
Ethical Clearance:
of the School of Medical Sciences, Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan,
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
found to be eective in improving the pain scores
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/
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,
Besides medical therapy, the psychological
strategies have been recommended and used for
therapy including breathing, relaxation and
thoughts related to pain. This can help patients to
increasetheir activitylevel andfunctioning, which
to apply the techniques taught to her in her daily
Acupuncture is a complementary and alternative
medical modality.The World Health Organization
(WHO) in 2002 released a report entitled
“Acupuncture:Review andAnalysisof Reportson
Controlled Clinical Trials”. This report states that
on eectiveness of acupuncture for shoulder pain
after stroke6. For central post stoke pain, there are
eect7.In the casepresented here, acupuncturedid
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
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.
indeed very challenging and there is a great need to
identifybettertreatmentregimes. However,holistic
approach, including medical and psychological
towardstreatment oeredare theonly current best
Conict of interest: None declared
Authors’ Contributions:
Data gathering: Salim M SF, Mazlan M
1. Treede,R.D.,etal.,A classication of chronic pain for
2. Andersen, G., et al., Incidence of central post-stroke
pain. Pain, 1995. 61(2):p.187-93.
3. Dworkin, R.H., et al., Pharmacologic management of
neuropathic pain: evidence-based recommendations.
4. Leijon, G. and J. Boivie, Central post-stroke pain--a
controlled trial of amitriptyline and carbamazepine.
Pain, 1989. 36(1):p.27-36.
5. Finnerup, N.B., et al., Algorithm for neuropathic pain
treatment: an evidence based proposal. Pain, 2005.
6. Lee, J.A., et al., Acupuncture for shoulder pain after
stroke: a systematic review.JAlternComplementMed,
7. Mulla, S.M., et al., Management of Central Poststroke
Pain: Systematic Review of Randomized Controlled
8. Kumar, B., et al., Central poststroke pain: a review of
pathophysiology and treatment. Anesth Analg, 2009.
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In the elderly, physical activity is essential in maintaining good health. In a resource constrained environment, where supervised exercise classes are conducted once a week, a suitable home exercise programme can provide the recommended weekly level of physical activity needed. The Otago Exercise Programme(OEP) is effective in the prevention of falls and increasing strength in the older adult. The efficacy of the OEP as a supplementary intervention to exercise classes; on falls, balance and health enhancing physical activity in the older adult with chronic lower back pain (CLBP) has not been reported. Mr X regularly attends the weekly land-based and aquatic exercise programme at a tertiary hospital in the public sector in Kwa Zulu-Natal. He demonstrated willingness to follow the OEP as prescribed by the Otago exercise manual as a home exercise programme and continued with other leisure, walking and activities of daily living. Post the exercise programme Mr X showed remarkable improvement in the chair to stand test, four-test balance scale and health enhanced physical activity. The OEP is effective and can be used as a supplemental programme to regular supervised exercise classes. The OEP can be beneficial for elderly patients with weakness and chronic lower back pain. Bangladesh Journal of Medical Science Vol.19(2) 2020 p.339-342
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The upcoming 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) of the World Health Organization (WHO) offers a unique opportunity to improve the representation of painful disorders. For this purpose, the International Association for the Study of Pain (IASP) has convened an interdisciplinary task force of pain specialists. Here, we present the case for a reclassification of nervous system lesions or diseases associated with persistent or recurrent pain for ≥3 months. The new classification lists the most common conditions of peripheral neuropathic pain: trigeminal neuralgia, peripheral nerve injury, painful polyneuropathy, postherpetic neuralgia, and painful radiculopathy. Conditions of central neuropathic pain include pain caused by spinal cord or brain injury, poststroke pain, and pain associated with multiple sclerosis. Diseases not explicitly mentioned in the classification are captured in residual categories of ICD-11. Conditions of chronic neuropathic pain are either insufficiently defined or missing in the current version of the ICD, despite their prevalence and clinical importance. We provide the short definitions of diagnostic entities for which we submitted more detailed content models to the WHO. Definitions and content models were established in collaboration with the Classification Committee of the IASP's Neuropathic Pain Special Interest Group (NeuPSIG). Up to 10% of the general population experience neuropathic pain. The majority of these patients do not receive satisfactory relief with existing treatments. A precise classification of chronic neuropathic pain in ICD-11 is necessary to document this public health need and the therapeutic challenges related to chronic neuropathic pain.
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Shoulder pain, for which acupuncture has been used, is a common complication after a stroke that interferes with the function of the upper extremities. The aim of this systematic review is to summarize and evaluate the effects of acupuncture for shoulder pain after stroke. Randomized controlled trials (RCTs) involving the effects of acupuncture for shoulder pain, published between January 1990 and August 2009, were obtained from the National Libraries of Medicine, MEDLINE(®), CINAHL, AMED, Embase, Cochrane Controlled Trials Register 2009, Korean Medical Database (Korea Institute of Science Technology Information, DBPIA, KoreaMed, and Research Information Service System), and the Chinese Database (China Academic Journal). Among the 453 studies that were obtained (300 written in English, 137 in Chinese, and 16 in Korean), 7 studies met the inclusion criteria for this review. All of them were RCTs published in China and reported positive effects of the treatment. The quality of the studies was assessed by the Modified Jadad Scores (MJS) and the Cochrane Back Review Group Criteria List for Methodologic Quality Assessment of RCTs (CBRG); the studies scored between 2 and 3 points on MJS, and between 4 and 7 points on CBRG. It is concluded from this systematic review that acupuncture combined with exercise is effective for shoulder pain after stroke. It is recommended that future trials be carefully conducted on this topic.
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Central poststroke pain (CPSP) is a disabling morbidity occurring in 8%-14% of patients with stroke. It is infrequently recognized and difficult to manage. We systematically reviewed the pathophysiology and treatment of CPSP. We conducted a Medline search using the key words "central post-stroke pain," "post-stroke pain," "CPSP and basic studies," "CPSP and clinical features," "CPSP and pharmacological treatment," "CPSP and nonpharmacological treatment" and "CPSP and treatment guideline." The articles related to CPSP were categorized into clinical features, pathophysiology and treatment, and then systematically reviewed. Stroke along the spinothalamocortical pathway may result in CPSP after a variable period, usually after 1-2 mo. CPSP may be spontaneous or evoked, variable in intensity and quality. It tends to improve with time. CPSP is associated with mild motor symptoms with relative sparing of joint position and vibration sensations. The pathophysiology of CPSP is not well understood, but central disinhibition, imbalance of stimuli and central sensitization have been suggested. There are few class I and class II studies regarding its management. Amitriptyline and lamotrigine (class IIB) are recommended as first-line and mexiletine, fluvoxamine and gabapentin as second-line drugs. In pharmacoresistant patients, repetitive transcranial magnetic stimulation and deep brain stimulation have been beneficial. CPSP patients present with diverse sensory symptoms and its pathophysiology is still poorly understood. Amitriptyline and lamotrigine are effective treatments. Further studies are needed to understand the pathophysiology and investigate newer therapeutic modalities.
Background and Purpose—Central poststroke pain is a chronic neuropathic disorder that follows a stroke. Current research on its management is limited, and no review has evaluated all therapies for central poststroke pain. Methods—We conducted a systematic review of randomized controlled trials to evaluate therapies for central poststroke pain. We identified eligible trials, in any language, by systematic searches of AMED, CENTRAL, CINAHL, DARE, EMBASE, HealthSTAR, MEDLINE, and PsychINFO. Eligible trials (1) enrolled ≥10 patients with central poststroke pain; (2) randomly assigned them to an active therapy or a control arm; and (3) collected outcome data ≥14 days after treatment. Pairs of reviewers, independently and in duplicate, screened titles and abstracts of identified citations, reviewed full texts of potentially eligible trials, and extracted information from eligible studies. We used a modified Cochrane tool to evaluate risk of bias of eligible studies, and collected patient-important outcomes according to recommendations by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. We conducted, when possible, random effects meta-analyses, and evaluated our certainty in treatment effects using the Grading of Recommendations Assessment, Development, and Evaluation System. Results—Eight eligible English language randomized controlled trials (459 patients) tested anticonvulsants, an antidepressant, an opioid antagonist, repetitive transcranial magnetic stimulation, and acupuncture. Results suggested that all therapies had little to no effect on pain and other patient-important outcomes. Our certainty in the treatment estimates ranged from very low to low. Conclusions—Our findings are inconsistent with major clinical practice guidelines; the available evidence suggests no beneficial effects of any therapies that researchers have evaluated in randomized controlled trials.
Central post-stroke pain (CPSP) is a neuropathic pain syndrome characterized by constant or intermittent pain in a body part occurring after stroke and associated with sensory abnormalities in the painful body part. This study describes CPSP prospectively during the first year after stroke and characterizes the cerebrovascular lesions and neurological signs associated with the CPSP syndrome. Two hundred and sixty-seven consecutively admitted patients younger than 81 years were examined in the first week, at 1, 6 and 12 months after stroke. Sensibility to touch (cotton wool), temperature (20°C and 40°C), and pinprick was studied using the contralateral face and extremity as control. A CT scan was done 8 (median) days (range: 1–34 days) after stroke. Two hundred and seven (78%) patients surviving at least 6 months who were able to communicate reliably formed the basis of the study. Abnormal sensory signs were found at least once in 87 (42%) patients. CPSP was found in 16 (8%) patients of whom all but 1 patient also had evoked dysesthesia or allodynia. Further 1 patient had persistent evoked dysesthesia but denied pain. CPSP was not related to sex or age. In patients with single acute cerebral lesions there were no relation between size or location of the lesions and the presence of CPSP. The pain was light in 6 (3%) patients and moderate to severe in 10 (5%) patients. The pain quality was usually lacerating or aching. Fifteen (94%) patients had decreased temperature, touch and pain sensibility and 9 (56%) reported allodynia to cold stimulation and another 9 (56%) patients reported this to touch. Pain onset was within 1 month after stroke in 10 (63%) patients, between 1 and 6 months in 3 (19%) patients and more than 6 months after stroke in 3 (19%) patients.
A double-blind, 3-phase, cross-over, placebo-controlled trial of the pain-relieving effect of amitriptyline and carbamazepine was carried out in 15 patients with central post-stroke pain (CPSP) but without signs of depression. Treatment was given, in randomized order, for periods of 4 weeks, separated by 1 week wash-out. The final doses were 75 and 800 mg/day, respectively, for amitriptyline and carbamazepine. The treatment effects were assessed by daily ratings of pain intensity on a 10-step verbal scale and at the end of each treatment period by a global rating of the analgesic effect on a 5-step verbal scale. For the assessment of depression the Comprehensive Psychopathological Rating Scale (CPRS) was used. Amitriptyline produced a statistically significant reduction of pain when compared to placebo. According to the global rating, 10 of the 15 patients were responders to this drug. The effect could already be noticed during the second treatment week and it appeared to be correlated to the plasma concentration, since the median total ami- and nortriptyline concentrations were 497 and 247 nmol/l, respectively, for responders and non-responders. The early onset, together with the fact that the patients were not depressed, nor did they obtain reduced scores on ratings of depressive symptoms and signs, provides strong support for the conclusion that the pain relief was not caused by an antidepressive effect. Five of the 14 patients treated with carbamazepine reported some pain relief, but the effect did not reach statistical significance when compared to placebo. No correlation was found between effect and plasma concentration. In general, the patients tolerated the planned final dose of amitriptyline well. No final dose reduction was necessary. Carbamazepine caused more side effects and the final dose had to be reduced in 4 patients. However, only 1 patient had to be taken off medication, on day 25, due to drug interaction.
New studies of the treatment of neuropathic pain have increased the need for an updated review of randomized, double-blind, placebo-controlled trials to support an evidence based algorithm to treat neuropathic pain conditions. Available studies were identified using a MEDLINE and EMBASE search. One hundred and five studies were included. Numbers needed to treat (NNT) and numbers needed to harm (NNH) were used to compare efficacy and safety of the treatments in different neuropathic pain syndromes. The quality of each trial was assessed. Tricyclic antidepressants and the anticonvulsants gabapentin and pregabalin were the most frequently studied drug classes. In peripheral neuropathic pain, the lowest NNT was for tricyclic antidepressants, followed by opioids and the anticonvulsants gabapentin and pregabalin. For central neuropathic pain there is limited data. NNT and NNH are currently the best way to assess relative efficacy and safety, but the need for dichotomous data, which may have to be estimated retrospectively for old trials, and the methodological complexity of pooling data from small cross-over and large parallel group trials, remain as limitations.
MMed (Rehab Med) Lecturer / Rehabilitation Medicine Specialist, Department of Medicine, Faculty of Medicine and Health Sciences
  • Dr Mazatulfazura
  • S F Salim
  • Bao Mbbch
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.