[ARTICLE] Mirror therapy for an adult with central post-stroke pain: a case report – Full Text

Abstract

Background
Treatment of central post-stroke pain (CPSP) after a thalamic-capsular stroke is generally based on pharmacological approach as it is low responsive to physiotherapy. In this case report, the use of mirror therapy (MT) for the reduction of CPSP in a subject after a stroke involving thalamus is presented.

Case presentation
Five years after a right lenticular-capsular thalamic stroke, despite a good recovery of voluntary movement that guaranteed independence in daily life activities, a 50-year-old woman presented with mild weakness and spasticity, an important sensory loss and a burning pain in the left upper limb. MT for reducing arm pain was administered in 45-min sessions, five days a week, for two consecutive weeks. MT consisted in performing symmetrical movements of both forearms and hands while watching the image of the sound limb reflected by a parasagittal mirror superimposed to the affected limb. Pain severity was assessed using visual analogue scale (VAS) before and after the intervention and at one-year follow-up. After the two weeks of MT, the patient demonstrated 4.5 points reduction in VAS pain score of the hand at rest and 3.9 points during a maximal squeeze left hand contraction. At one-year follow-up, pain reduction was maintained and also extended to the shoulder.

Conclusion
This case report shows the successful application of a motor training with a sensory confounding condition (MT) in reducing CPSP in a patient with a chronic thalamic stroke.

Background

Stroke often causes impairment in movement control but can also affect perception [1, 2]. Alterations of stimulus integration are common after a stroke, with variable reported prevalence ranging from 11 to 85% [3], and sometimes these alterations of perception result in pain. Pain relates with the site of lesion and it is completely distinct from other painful conditions such as shoulder pain or spasticity [4]. It typically emerges from hemispheric lesions that involve the spinothalamic and thalamocortical pathways, leading patients to complain of sharping, stabbing, or burning through an experience of hyperpathia and allodynia [5, 6]. This association between sensory abnormalities and constant or intermittent central neuropathic pain, arising from damage of the sensory tracts, is known as the central post-stroke pain (CPSP) syndrome [7, 8]. The estimated incidence of CPSP comes up to 1 every 6 patients presenting a vascular lesion in the thalamus [8, 9], but its prevalence is difficult to estimate because of the co-occurrence of other painful conditions, such as spasticity or shoulder pain [4]. The pathophysiological mechanisms underlying the development of CPSP are thought to be related to the hyperexcitability or to the spontaneous discharge of damaged neurons located in the thalamus or in the cortex [10]. The CPSP syndrome is one of the less responsive conditions to physiotherapy treatment and it usually requires a pharmacological approach through the use of Amitriptyline, Gabapentin and Pregabalin [2].

Mirror therapy (MT), defined as the use of a mirror reflection of unaffected limb movements superimposed on the affected extremity, is often used to treat motor and perception problems [11, 12]. This technique was described for the first time in 1995 in studies reporting the reduction of phantom limb pain in arm amputees [13]; more recently, its use was described also for recovery of motor function after stroke [14, 15], for the treatment of complex regional pain syndrome type I [12] and other painful conditions (e.g., brachial plexus avulsion and after surgery) [16, 17].

This case report describes the beneficial effect of MT for the reduction of pain of the upper limb in a subject presenting CPSP in the left body side combined to sensory loss and mild movement disorders after a right haemorrhagic lenticular-capsular, thalamic stroke occurred five years before. To the best of our knowledge, the effect of MT for the treatment of CPSP has never been observed despite it has been defined deserving to be explored [11].

Case presentation

Case description

The patient was a 50-year old, right-handed woman who experienced a haemorrhagic stroke in 2010. The computed tomography scan performed immediately after the acute event revealed a right lenticular-capsular, lateral thalamic and intraparenchymal hematoma, with a midline shift toward the left side. Two days after the acute event a magnetic resonance imaging scan of the brain confirmed the presence of this lesion (Fig. 1). After six weeks as inpatient for a rehabilitation program in our Institute, the patient entered a daily physiotherapy program for two months as outpatient, which led to a good recovery in motor control and strength.

Fig. 1Magnetic resonance images showing the acute right lenticular-capsular-thalamic stroke lesion assessed with T1-weighted, Fluid-attenuated inversion recovery (FLAIR), and T2-weighted sequences (a); one-year follow-up MRI showing the lesion evolution assessed with FLAIR sequence. The red arrows show the posterior thalamic involvement (b)

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