Pain Syndromes after stroke

Transcription

1 Diagnosis and Management of Complex Regional Pain Syndrome (CRPS) after Stroke Leonard S.W. Li Honorary Clinical Professor, Department of Medicine, The University of Hong Kong Director, Neurological Rehabilitation Centre Virtus Medical Group, Hong Kong Pain Syndromes after stroke Central Pain (CPSP) 2 8% Nociceptive (Hemiplegic shoulder) Pain 38%-84%. Complex Regional Pain Syndrome CRPS 20-70% 1

2 Complex Regional Pain Syndrome (CRPS) The physiopathology of the disease is still not known. Hypothesis: a localized neurogenic inflammation is at the basis of oedema, vasodilation and hyperhidrosis that are present in the initial phases of CRPS. The repeated discharge of the C fibres causes an increased medullary excitability (central sensitization). Another important factor is the reorganisation of the central nervous system, and in particular this appears to affect the primary somatosensory cortex. CRPS Diagnosis (Clinical) Color, edema Temperature 2

3 CRPS Proposed Diagnostic Criteria (symptoms) 1. Continuing pain, which is disproportionate to any inciting events. 2. Report of at least one symptom in three of the four following categories: Sensory: reports of hyperesthesia Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin colour asymmetry Sudomotor/edema: reports of edema (with or without joint stiffness) and/or sweating changes and/or sweating asymmetry; or Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (nails, hair, skin). Budapest IASP consensus group CRPS: Proposed Diagnostic Criteria (Signs) 3. At least one sign in two or more of the following categories: Sensory: evidence of hyperalgesia (to pinprick) or allodynia (to light touch Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or asymmetry Sudomotor/edema: objective evidence of edema (with or without joint stiffness) and/or sweating changes and/or sweating asymmetry; or Motor/trophic: evidence of decreased range of motion (including joint stiffness) and/or motor dysfunction and/or trophic changes 4. No other potential cause of pain is identified Budapest IASP consensus group 3

4 Post Stroke Central Pain Differential Diagnosis Investigation Plain X-ray or MRI: patchy osteoporosis Three phases of bone scan 4

5 SSR (Sympathetic Skin Response) and Post Stroke CRPS Sympathetic Skin Response study: Increase in amplitude in Post Stroke CRPS Clinchot DM,et al. Am J Phys Med Rehabil Jul-Aug;75(4):252-6 Selçuk et al.: Neurology India September 2006 Vol 54 Issue 3 SSSR (Sympathetic Skin Response) and Post Stroke CRPS Obstacles in application of clinical use: May be absence in age >70 Criteria of abnormality varied Variable increase in amplitude observed in CRPS 5

6 Application of SSR in the diagnosis of Post Stroke CPRS Amplitude: Ratio between paretic and normal hands, Data not published yet Treatment Objectives Conservative care: The goal of the treatment is physical restoration and pain control; Early, aggressive care is encouraged; Emphasis should be on improved functioning of the symptomatic limb. Physical/occupational therapy should be focused on increasing functional level; Other medications: as long as it promotes improved function. 6

7 Quality of Evidence High Moderate intravenous regional blockade with guanethidine is not effective Quality of Evidence Low Gabapentine, ketamine, bisphosphonates and calcitonin may effectively reduce pain when compared with placebo at least in the short term local anaesthetic sympathetic blockade is not effective passive attention vs. control are associated with small positive effects at one year follow up that are unlikely to be clinically important 7

8 Quality of Evidence Very Low compared with placebo, oral corticosteroids reduce pain compared with placebo, epidural clonidine reduced pain intravenous regional block (IVRB) ketanserin and IVRB bretylium may be effective; sympathetic blockade with botulinum toxin A(BTX) may deliver a longer duration of pain relief than local anaesthetic sympathetic blockade Very Low Quality of Evidence physiotherapy and occupational therapy improve pain more than a passive attention social work control for up to six months and that physiotherapy but not occupation therapy improves impairment for up to four months compared to the same control be effective versus sham Qigong therapy acupuncture may offer short-term improvement in pain when added to rehabilitation compared with rehabilitation alone in post-stroke CRPS and that electro-acupuncture plus rehabilitation therapies (details not specified) might be more effective than lidocaine, triamcinolone acetonide and vitamin B12 acupuncture is not superior to sham No Evidence efficacy of surgical sympathectomy 8

9 Mirror therapy and CRPS I De Blass et al. NEJM 361;6,Aug 6, 2009 Graded Motor Imagery VAS Functional Scale 9

10 Mechanism?? Damaged hemisphere Damaged hemisphere Motor Cortex Somatosensory Cortex Occipital Cortex Mirror Therapy and Interhemispheric Interaction H.E. Rossiter, M. R. Borrelli, R. J. Borchert1 D.Bradbury, N. S. Ward, Neurorehab and Neural Repair 2015, Vol. 29(5)

11 Intervention Strategies Evaluation TARGET: Functional Restoration Pharmacological intervention 11

12 Functional Restoration : A Gradual Approach 1. Mirror therapy, Reactivation, Contrast Baths, Desensitization, Exposure Therapy 2. Edema Control, Flexibility (active), Isometric Strengthening, Treatment of 2nd Myofascial Pain 3. Stress Loading, Isotonic Strengthening ROM (gentle, passive) 4. Ergonomics, Movement Therapies, Normalization of Use, Functional Rehabilitation fmri and imagined allodynia Heidrun H. Krämer, The Journal of Pain, Vol 9, No 6 (June), 2008: pp

13 Psychological Intervention Coping skills for Chronic Pain disturbed sleep, fatigue, diminished capacity, mood changes, and stress in relationships. Different coping strategies making the pain comprehensible, planning of activities, taking medications, Communicating, and Distractions. 13

14 Interventional Treatment negative recommendation Sympathetic blocks, stellate ganglion blocks, Spinal cord stimulation (SCS) may be considered if do not respond to pharmacological treatments or rehabilitation therapies. a positive effect on both the somatosensory system and the vasomotor disturbances Kemler MA et al. N Engl J Med 2000; 343: Key word to prevent and manage Poststroke Pain Appropriate and Proper mobilization of paretic limbs early 14

15 Thank You End of Presentation 15