Stroke, complex regional pain syndrome and phantom limb pain: Can commonalities direct future management?

Abstract

Despite being different conditions, complex regional pain syndrome type 1, phantom limb pain and stroke share some potentially important similarities. This report examines experimental and clinical findings from each patient population. It identifies common aspects of symptomatic presentation, sensory phenomena and patterns of cortical reorganization. Based on these common findings, we argue that established principles of stroke rehabilitation are also applicable to rehabilitation of complex regional pain syndrome type 1 and phantom limb pain. In addition, we contend that promising treatment approaches for complex regional pain syndrome type 1 and phantom limb pain may be helpful in stroke rehabilitation. Examples of emerging supportive evidence for these hypotheses are provided and discussed.

Persistent shoulder pain after stroke

“…Both the frequency 1,16,30 and severity 7 of somatosensory loss show considerable overlap with our findings in patients with chronic PSSP. Interestingly, an abnormal response (including both decreased and increased sensation) to thermal testing, a diagnostic criterion for central post-stroke pain 61 , was observed in 79 % of PSSP patients.…”

“…A higher frequency of somatosensory loss as compared to controls has also been reported for CPSP 1,30,55 and for post-stroke complex regional pain syndrome 11,36 . Both the frequency 1,16,30 and severity 7 of somatosensory loss show considerable overlap with our findings in patients with chronic PSSP.…”

“…1,32,44,54,74 The cell bodies in the lateral part of the thalamus are highly somatotopically organized, project to the primary (S1) and secondary (S2) somatosensory cortices and are involved in the discriminative aspects of somatosensation. Cell bodies located in the medial part of the thalamus project to parts of the limbic system, such as the insula and ACC that are involved in the sensory quality, homeostatic functions and the motivational and emotional aspects of pain respectively 83 .…”

“…In addition, pain is common after stroke. 1,18 Poststroke pain can be a great burden for the patient, increases hospital stay, reduces quality of life and interferes with functional recovery after stroke. 3,21 The most commonly reported type of pain after stroke is post-stroke shoulder pain (PSSP), also named hemiplegic shoulder pain.…”

“…7,10 Traditionally, post-stroke shoulder pain (PSSP) is considered as a nociceptive pain. 1,18 In addition, PSSP has been related to central post-stroke pain, complex regional pain syndrome type 1, depression and sensory abnormalities and may be caused and maintained by various pain mechanisms. 8,10,11,14 Although the prognosis and treatment of PSSP is largely dependent on suspected involvement of nociceptive and/or neuropathic pain mechanisms, there is no gold standard or consensus regarding the diagnostic tools to differentiate PSSP of predominantly neuropathic from that of predominantly nociceptive origin.…”