- •Pain is a subjective experience that results from the complex modulation of nociception conveyed to the brain via the nervous system.
- •Psychological factors such as cognitions (eg, pain catastrophizing), emotions (eg, depression), and pain-related behaviors (eg, avoidance) can influence perceived pain intensity, physical function, and treatment outcomes.
- •Several evidence-based interventions to address pain-related psychological risk factors are available and can be integrated into hand therapy.
Posts Tagged pain
Pain is a subjective experience that results from the modulation of nociception conveyed to the brain via the nervous system. Perception of pain takes place when potential or actual noxious stimuli are appraised as threats of injury. This appraisal is influenced by one’s cognitions and emotions based on her/his pain-related experiences, which are processed in the forebrain and limbic areas of the brain. Unarguably, patients’ psychological factors such as cognitions (eg, pain catastrophizing), emotions (eg, depression), and pain-related behaviors (eg, avoidance) can influence perceived pain intensity, disability, and treatment outcomes. Therefore, hand therapists should address the patient pain experience using a biopsychosocial approach. However, in hand therapy, a biomedical perspective predominates in pain management by focusing solely on tissue healing.
Purpose of the Study
This review aims to raise awareness among hand therapists of the impact of pain-related psychological factors.
Methods and Results
This literature review allowed to describe (1) how the neurophysiological mechanisms of pain can be influenced by various psychological factors, (2) several evidence-based interventions that can be integrated into hand therapy to address these psychological issues, and (3) some approaches of psychotherapy for patients with maladaptive pain experiences.
Discussion and Conclusion
Restoration of sensory and motor functions as well as alleviating pain is at the core of hand therapy. Numerous psychological factors including patients’ beliefs, cognitions, and emotions alter their pain experience and may impact on their outcomes. Decoding the biopsychosocial components of the patients’ pain is thus essential for hand therapists.
An advisory panel from the United States Food and Drug Administration (FDA) has recommended the approval of a novel epilepsy drug that is made up of ingredients from marijuana. The agency normally follows the recommendations of the advisory panels regarding approvals and rejections of applications of new drugs. The recommendation statement came yesterday (19th April 2018).
If this drug gets a green light, it is expected to become the first cannabis-derived prescription medicine to be available in the US. The drug is named Epidiolex and is made by GW Pharmaceuticals from Britain. It contains cannabidiol or CBD that is derived from cannabis. However the drug is not seen to cause any intoxication among the users.
The use of only one of the components of cannabis also makes it different from medical marijuana that is approved for pain management and other conditions around the world and in the United States. Synthetic forms of chemicals in the cannabis plant are also used to treat nausea among cancer patients and in AIDS patients to prevent weight loss.
Dr. Igor Grant, director of the Center for Medicinal Cannabis Research at the University of California San Diego welcomed this new recommendation from the panel saying, “This is a very good development, and it basically underscores that there are medicinal properties to some of the cannabinoids… I think there could well be other cannabinoids that are of therapeutic use, but there is just not enough research on them to say.”
As of now the panel has recommended the use of this new drug for two types of epilepsy only – Lennox-Gastaut syndrome and Dravet syndrome. These are notoriously difficult to treat and most people continue to have seizures despite treatment. Multiple seizures may occur in a day and this makes the children with these conditions vulnerable for developmental and intellectual disabilities. Lennox-Gastaut syndrome can appear in toddlers at around ages 3 to 5 and Dravet syndrome is usually diagnosed earlier. Nearly 30,000 children and adults suffer from Lennox-Gastaut syndrome and similar numbers of people are diagnosed with Dravet syndrome. Due to the small population of diagnosed patients Epidiolex was filed and classified under orphan drug status.
An orphan drug is one that is developed for a relatively rare disease condition. The FDA provides special subsidies and support for development of orphan drugs and often speed tracks their approval process.
The recommendation from the advisory panel is based on the results of three randomized, double-blind, placebo-controlled trials that included patients of both these disease conditions. The agency statement says, “The statistically significant and clinically meaningful results from these three studies provide substantial evidence of the effectiveness of CBD for the treatment of seizures associated with LGS and DS.” They drug causes liver damage but the report says that this could be managed effectively.
The FDA will conduct a final vote for approval of this drug in June. Oral solution of the drug for a small group of patients with these conditions would be allowed.
The use of antiepileptic drugs is associated with an increased risk of Alzheimer’s disease and dementia, according to a new study from the University of Eastern Finland and the German Center for Neurodegenerative Diseases, DZNE. Continuous use of antiepileptic drugs for a period exceeding one year was associated with a 15 percent increased risk of Alzheimer’s disease in the Finnish dataset, and with a 30 percent increased risk of dementia in the German dataset.
Some antiepileptic drugs are known to impair cognitive function, which refers to all different aspects of information processing. When the researchers compared different antiepileptic drugs, they found that the risk of Alzheimer’s disease and dementia was specifically associated with drugs that impair cognitive function. These drugs were associated with a 20 percent increased risk of Alzheimer’s disease and with a 60 percent increased risk of dementia.
The researchers also found that the higher the dose of a drug that impairs cognitive function, the higher the risk of dementia. However, other antiepileptic drugs, i.e. those which do not impair cognitive processing, were not associated with the risk.
“More research should be conducted into the long-term cognitive effects of these drugs, especially among older people,” Senior Researcher Heidi Taipale from the University of Eastern Finland says.
Besides for epilepsy, antiepileptic drugs are used in the treatment of neuropathic pain, bipolar disorder and generalized anxiety disorder. This new study is the largest research on the topic so far, and the first to investigate the association in terms of regularity of use, dose and comparing the risk between antiepileptic drugs with and without cognitive-impairing effects. The results were published in the Journal of the American Geriatrics Society.
The association of antiepileptic drug use with Alzheimer’s disease was assessed in Finnish persons diagnosed with Alzheimer’s disease and their controls without the disease. This study is part of the nationwide register-based MEDALZ study, which includes all 70,718 persons diagnosed with Alzheimer’s disease in Finland during 2005-2011 and their 282,862 controls. The association of antiepileptic drug use with dementia was investigated in a sample from a large German statutory health insurance provider, Allgemeine Ortskrankenkasse (AOK). The dataset includes 20,325 persons diagnosed with dementia in 2004-2011, and their 81,300 controls.
[WEB SITE] Lost & Found: Caps, Sunglasses, and Earplugs – Strategies for Coping with Sensory Hypersensitivity – brainline.org
If it seems like your sense of touch, taste, smell, hearing, or vision is extra sensitive or heightened after your brain injury, it’s not your imagination. Sensory hypersensitivities are another major, yet not as obvious, contributor to fatigue and overload after brain injury. What we experience with our senses is essentially more information for our injured brains to try to process and organize. You can have difficulties processing sensory information just like any other information in your brain. Some examples of sensory hypersensitivities are:
- Sounds that you barely noticed before are alarming and startle you.
- It feels like you have megaphones in your ears.
- Background sounds and stimulating environments become overwhelming.
- Fluorescent and bright lights give you headaches.
- Clothing that was comfortable before feels irritating now.
- Large gatherings of people feel overwhelming.
Pain and fatigue can intensify sensory hypersensitivities, putting you in a hyper-sensitive or hyper-vigilant state. When you are in a hyper-sensitive or hyper-vigilant state, even subtle stimulants feel overwhelming. Especially sights and sounds that didn’t bother you before, may now trigger anxiety and the fight-or-flight response where your whole being feels threatened and out of control. You may shut down and not be able to do any more or you may feel compelled to escape from the situation. It can be very taxing, physically and mentally.
Stress management, movement and using all of your senses can help your brain organize and integrate the senses. This is similar to what children do. Consider how physically active children are as they grow and develop!
See Brain Recharging Breaks at the end of this chapter for some basic meditation techniques. Meanwhile, following are suggestions for coping with sensory hypersensitivities.
General Coping Suggestions
Limit exposure to avoid sensory overload.
- Avoid crowds and chaotic places where there are a lot of stimuli, like shopping malls.
- Do shopping and errands early in the week and early in the day, when stores are less crowded and quieter.
- Shop in smaller, quieter stores when possible.
- Eat out in restaurants when they are quieter, in between regular meal times.
- Hold conversations in a quiet place.
- Ask people to please speak one at a time. Explain that you’d really like to hear what everyone has to say but you can only hear one person at a time.
- Sleep during car trips.
- If you want to attend a function that you expect will be taxing, plan to stay only a short while. Take your cap, sunglasses and earplugs. Sit towards the back to minimize the sound and where you can easily exit to a quieter place or the car.
Monitor your pain, stress and fatigue levels.
Lights and sounds will bother you the most when you are stressed or fatigued. If you are feeling especially sensitive, use it as a cue that you need to take a break and use some relaxation techniques.
Try avoiding nicotine, caffeine and alcohol.
They may make the symptoms worse. If you have vertigo, try limiting your salt intake, which can cause fluid retention. Consider strengthening exercises for your neck with the guidance of a physical therapist.
When you are starting to feel stressed or anxious, try incorporating another sense.
- Put something in your mouth to chew or suck on. Strong flavors like peppermint or cinnamon are especially effective.
- Put on some soothing music.
- Apply some deep pressure. Give yourself a hug or press your palms firmly together or on the table. Squeeze the steering wheel if you are driving the car.
Experiment with activities and alternative therapies that involve your senses.
Listen to music, experiment with movement, dance, yoga, water, art, aromatherapy, etc.
Challenge your sensitivities.
Gradually increase your exposure and tolerance when using earplugs, sunglasses, etc.
Don’t eliminate the senses completely or you set yourself up for super-sensitivity.
Specific Coping Strategies
Sensitivities to sound
- Limit your exposure to noisy stores and loud situations like sporting events, the movie theatre and children’s school activities. Don’t participate or plan to stay for a limited amount of time. Sit on the outskirts so you can gracefully escape to a quieter place if needed.
- Use earplugs, try different kinds, and carry them with you.
- Use headphones for TV and music:
- For others, when you don’t want to hear it.
- For yourself, when you want to hear it better.
- Minimize distractions from snacking while doing things like working in groups or playing games. Use bowls for food instead of eating directly from noisy bags.
- Add some background sound – a fan, white noise machine, soothing music.
- Remove yourself from the situation and go to a quieter place as soon as possible, even the bathroom, when you feel overwhelmed or anxious. Then try:
- Closing your eyes
- Taking slow deep stomach breaths
- Putting an ice pack on your forehead and eyes
- Gradually expose yourself to different sounds and louder sounds to increase your tolerances.
Sensitivities to light
- Avoid bright light and fluorescent lights.
- Use sunglasses or a cap with a brim, even indoors.
- Try yellow tinted glasses if florescent lights are a problem.
- Try polarized sunglasses if driving glare is a problem.
- Try yellow tinted glasses if night driving is a problem.
- Make sure you are getting plenty of vitamin A (but not too much!).
- Eat orange colored fruits and vegetables like carrots, sweet potatoes, squash, and cantaloupe.
- Take a moment to just close your eyes for a few minutes when you are starting to feel stressed or anxious. This blocks out the visual stimuli.
Sensitivities to touch, taste, and smell
- Experiment! Cultivate an awareness of how things feel, taste and smell.
- Rub different textures on your arms, increasing the intensity to gradually decrease sensitivities.
- Add texture, contrasting temperatures and flavors to your food, like ice cream with crunchy nuts or chips with spicy taco sauce.
- Notice the textures.
- Pay attention to smells.
- How do different aromas make you feel?
If your sense of smell is altered, make sure to have functioning smoke and gas detectors in your home.
Doing cognitive work
- Plan to do cognitive work when your environment is quiet. Eliminate as many distractions and interruptions as possible.
- Screen out distractions by using earplugs or headphones, playing soothing music, or using a fan or white noise machine if you have sensitivities to sound.
- Turn down the volume on the phone and let the machine get it.
- Work in an uncluttered space or use a three sided table screen, to help screen out visual distractions.
- Give children headphones for the TV if you are having trouble screening it out.
- Do your “thinking” work while children are in school or asleep.
- Still having trouble concentrating? Try bringing in another sense.
- Put on some soothing nature or instrumental music, something without words at a low volume.
- Try chewing or sucking on something while you are working. Coffee stirrers can substitute for fingernails. Strong flavored or fizzy candies and gum can aid alertness.
- Try using some deep pressure by giving yourself a hug, pressing your palms strongly against each other or on the table.
- Try sitting on a large therapy ball while you work. A great strategy if you have trouble sitting still!
- Take a physical break, every 15 min. at first. Resist the urge to push through. I know it feels counter-intuitive but taking breaks will actually help you work longer! Gradually you will find you can increase the time between breaks.
- Use a timer – without a ticking sound!
- Pause and stretch, drink some water or make a cup of tea, walk around the house or the yard, rock in a chair, walk the dog, pat the cat.
Visual Processing Problems
Vision is an extremely important and complex source of sensory information. What you see with your eyes travels through your brain to the back area of your brain, where it is processed in the occipital lobe. There is a lot of territory between the eyes and the back of the brain where an injury can occur. The occipital lobe may be damaged directly from impact to the back of the head or it may be damaged indirectly from the ricochet of the brain inside the skull when the front of the brain is impacted. Damage to the occipital lobe frequently occurs in car accidents, falls and sports injuries. Even subtle visual problems following a brain injury can have a significant impact on cognition and functioning.
I wish I had known about visual problems and visual therapy when I had my car accident. I thought I was really going crazy! Fortunately for me, my issues improved with time but not without mishaps, like falling off a curb!
Some common problems after a brain injury related to vision include:
- Double vision
- Trouble tracking words on a page
- Impaired depth perception
- Hypersensitivities to light
- Difficulties remembering and recalling information that is seen
- Difficulties “filling in the gaps” or completing a picture based on seeing only some of the parts
- Trouble seeing objects to the side
- Low tolerances to changing light or clutter
- Impaired balance, bumping into objects
- Feeling overwhelmed when there is a lot of visual stimuli
If you notice problems in areas related to visual processing, please consult a visual therapist or a neuroopthalmologist, they can help!
- Don’t eliminate any sense completely or you set yourself up for a super-sensitivity.
- Gradually expose yourself to more light, sound, touch, smell, and taste.
- Be patient, in many cases your sensory hypersensitivities will decrease in time!
- Ask for physical therapy or occupational therapy with a therapist with a background in sensory integration for help with sensory sensitivities.
Some good news about sensory hypersensitivity is that it is also associated with a heightened sense of awareness and intuition. You may find that you feel more aware of your intuition and more creative since your brain injury. This is not uncommon. Enjoy!
Brain Recharging Breaks
If I had to choose one strategy that helped me the most after my brain injury, it would be learning to meditate. Meditation is especially helpful when you are experiencing sensory overload. It can help you calm yourself down from that hyper-sensitive state. It was also the only way I have found to give my brain a rest, to put it temporarily in a “cast”, like you would a broken limb. Often, after meditating for 15-20 minutes, the “logjam” in my brain clears up and I am somehow able to think again!
I recommend using some stress management or meditation techniques at least once a day. Plan it, schedule it in your planner, make it part of your daily routine. Meditation is not as mysterious as you might think. Try these basic steps:
- Get in a comfortable position on the bed, in a recliner or even in the car; uncross your arms and legs. Cover yourself with a blanket if you are cool.
- Close your eyes and do some slow deep breathing.
- Slowly inhale, expanding your stomach and counting to 7.
- Exhale gradually, contracting your stomach towards your spine, counting to 7.
Repeat. Repeat. Repeat.
When you are feeling more relaxed, as you continue your slow deep breathing, experiment with the following suggestions to increase the effectiveness of the experience.
Do a body scan checking for areas of pain or stress.
- Eyes closed, inhale deeply, picture your forehead and notice any stress or pain.
- Exhale and imagine the pain floating away with your exhale.
- Inhale, picture your eyebrows and notice any stress or pain. Exhale and release it, imagining the stress floating away.
- Repeat for your eyes, ears, jaw, throat, back of neck, shoulders … down to your toes. Breathe in relaxation, breathe out stress and pain.
Notice how you feel after you get to your toes!
- Visualize or imagine yourself in a warm, secure, relaxing, happy, peaceful place; floating on a cloud, floating in the water, or recalling a happy memory.
- Continue slow deep breathing.
- Focus on a picture or artwork that you like, noticing each detail.
- Continue slow deep breathing.
- Listen to music, any music that is soothing to you. Nature sounds or instrumental music is a good place to start experimenting.
- Continue slow deep breathing.
- Use aromatherapy – any scent that smells good to you. Favorite scents are often from childhood memories!
- Continue slow deep breathing.
Strive to let go of that never-ending tape of worries and “shoulds” that plays in your head. Focus on your senses – your breath, the music, a relaxing place, a comforting aroma. If thoughts drift in, gently push them away. It gets easier with practice, you’ll find what works best for you and you’ll be amazed at how much it helps you!
If you find these suggestions helpful and you want to learn more, check out classes in meditation, yoga, Tai Chi, and Qui Gong. Local medical facilities and high schools often offer classes at reasonable rates.
There are television programs that demonstrate different practices as well as a variety of DVDs you can rent from your local library to get an idea of which discipline suits you best.
Excerpted from Lost & Found: A Survivor’s Guide for Reconstructing Life After a Brain Injury by Barbara J. Webster. © 20ll by Lash & Associates Publishing/Training Inc. Used with permission. Click here for more information about the book.
- Vision Issues After Brain Injury: BrainLine Talks with Dr. Gregory Goodrich
- Vision Is Our Dominant Sense
- Vision and Rehabilitation After Brain Trauma (Part 1)
- Diagnosing Vision Problems After a Brain Injury
- Eating Issues After TBI
- Anosmia or Loss of Smell from Brain Injury
- The Tale of Two Smell Tests Post-Brain Injury
- Tinnitus and Brain Injury
- Hearing Loss After TBI
Introduction and Purpose of the Study
After traumatic hand injury, extensive physical and psychological adaptation is required following surgical reconstruction. Recovery from injury can understandably be emotionally challenging, which may result in impaired quality of life and delayed physical recovery. However, the evidence base for identifying high-risk patients is limited.
A PROSPERO-registered literature search of MEDLINE (1946-present), EMBASE (1980-present), PsychInfo, and CINAHL electronic databases identified 5156 results for studies reporting psychological outcomes after acute hand trauma. Subsequent review and selection by 2 independent reviewers identified 19 studies for inclusion. These were poor quality level 2 prognostic studies, cross sectional or cohort in design, and varied widely in methodology, sample sizes, diagnostic methods, and cutoff values used to identify psychological symptoms. Data regarding symptoms, predisposing factors, and questionnaires used to identify them were extracted and analyzed.
Patients with amputations or a tendency to catastrophize suffered highest pain ratings. Persisting symptom presence at 3 months was the best predictor of chronicity. Many different questionnaires were used for symptom detection, but none had been specifically validated in a hand trauma population of patients. Few studies assessed the ability of selection tools to predict patients at high risk of developing adverse psychological outcomes.
Discussion and Conclusion
Despite a limited evidence base, screening at 3 months may detect post-traumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes.
Stroke patients are starting a trial of a new electronic device to recover movement and control of their hand.
Neuroscientists at Newcastle University have developed the device, the size of a mobile phone, which delivers a series of small electrical shocks followed by an audible click to strengthen brain and spinal connections.
The experts believe this could revolutionise treatment for patients, providing a wearable solution to the effects of stroke.
Following successful work in primates and healthy human subjects, the Newcastle University team are now working with colleagues at the prestigious Institute of Neurosciences, Kolkata, India, to start the clinical trial. Involving 150 stroke patients, the aim of the study is to see whether it leads to improved hand and arm control.
Stuart Baker, Professor of Movement Neuroscience at Newcastle University who has led the work said: “We were astonished to find that a small electric shock and the sound of a click had the potential to change the brain’s connections. However, our previous research in primates changed our thinking about how we could activate these pathways, leading to our study in humans.”
Recovering hand control
Publishing today in the Journal of Neuroscience, the team report on the development of the miniaturised device and its success in healthy patients at strengthening connections in the reticulospinal tract, one of the signal pathways between the brain and spinal cord.
This is important for patients as when people have a stroke they often lose the major pathway found in all mammals connecting the brain to spinal cord. The team’s previous work in primates showed that after a stroke they can adapt and use a different, more primitive pathway, the reticulospinal tract, to recover.
However, their recovery tends to be imbalanced with more connections made to flexors, the muscles that close the hand, than extensors, those that open the hand. This imbalance is also seen in stroke patients as typically, even after a period of recuperation, they find that they still have weakness of the extensor muscles preventing them opening their fist which leads to the distinctive curled hand.
Partial paralysis of the arms, typically on just one side, is common after stroke, and can affect someone’s ability to wash, dress or feed themselves. Only about 15% of stroke patients spontaneously recover the use of their hand and arm, with many people left facing the rest of their lives with a severe level of disability.
Senior author of the paper, Professor Baker added: “We have developed a miniaturised device which delivers an audible click followed by a weak electric shock to the arm muscle to strengthen the brain’s connections. This means the stroke patients in the trial are wearing an earpiece and a pad on the arm, each linked by wires to the device so that the click and shock can be continually delivered to them.
“We think that if they wear this for 4 hours a day we will be able to see a permanent improvement in their extensor muscle connections which will help them gain control on their hand.”
The techniques to strengthen brain connections using paired stimuli are well documented, but until now this has needed bulky equipment, with a mains electric supply.
The research published today is a proof of concept in human subjects and comes directly out of the team’s work on primates. In the paper they report how they pair a click in a headphone with an electric shock to a muscle to induce the changes in connections either strengthening or weakening reflexes depending on the sequence selected. They demonstrated that wearing the portable electronic device for seven hours strengthened the signal pathway in more than half of the subjects (15 out of 25).
Professor Stuart Baker added: “We would never have thought of using audible clicks unless we had the recordings from primates to show us that this might work. Furthermore, it is our earlier work in primates which shows that the connections we are changing are definitely involved in stroke recovery.”
The work has been funded through a Milstein Award from the Medical Research Council and the Wellcome Trust.
The clinical trial is just starting at the Institute of Neurosciences, Kolkata, India. The country has a higher rate of stroke than Western countries which can affect people at a younger age meaning there is a large number of patients. The Institute has strong collaborative links with Newcastle University enabling a carefully controlled clinical trial with results expected at the end of this year.
A patient’s perspective
Chris Blower, 30, is a third year Biomedical Sciences student at Newcastle University and he had a stroke when he was a child after open heart surgery. He describes his thoughts on the research:
I had a stroke at the age of seven. The immediate effect was paralysis of the right-hand side of my body, which caused slurred speech, loss of bowel control and an inability to move unaided. Though I have recovered from these immediate effects, I am now feeling the longer term effects of stroke; slow, limited and difficult movement of my right arm and leg.
My situation is not unique and many stroke survivors have similar long-term effects to mine. Professor Baker’s work may be able to help people in my position regain some, if not all, motor control of their arm and hand. His research shows that, in stroke, the brains motor pathway to the spinal cord is damaged and that an evolutionarily older signal pathway could be ‘piggybacked’ and used instead. With electrical stimulation, exercise and an audible cue the brain can be taught to use this older pathway instead.
This gives me a lot of hope for stroke survivors. My wrist and fingers pull in, closing my hand into a fist, but with the device Professor Baker is proposing my brain could be re-taught to use my muscles and pull back, opening my hand out. The options presented to me so far, by doctors, have been Botox injections and surgery; Botox in my arm would weaken the muscles closing my hand and allow my fingers to spread, surgery would do the same thing by moving the tendons in my arm. Professor Baker’s electrical stimulations is certainly a more appealing option, to me, as it seems to be a permanent solution that would not require an operation on my arm.
I was invited to look around the animal house and observe a macaque monkey undergoing a test and this has made me think about my own stroke and the effect it has had on my life.
I have never seen anything like this before and I didn’t know what to expect. The macaque monkey that I observed was calmly carrying out finger manipulation tests while electrodes monitored the cells of her spinal cord.
Although this procedure requires electrodes to be placed into the brain and spine of the animal, Professor Baker explained how the monkey had been practicing and learning this test for two years before the monitoring equipment was attached. In this way the testing has become routine before it had even started and the animal was in no pain or distress, even at the sight of a stranger (me).
The animals’ calm, placid temperaments carry over to their living spaces; with lots of windows, natural light and high up spaces the macaques are able to see all around them and along the corridors. This means that they aren’t feeling threatened when people approach and are comfortable enough that even a stranger (me, again) can approach and say ‘hello’.
From my tour of the animal house at the Institute of Neuroscience I saw animals in calm, healthy conditions, to which the tests were just a part of their daily routine. Animal testing is controversial but I think that the work of Professor Baker and his team is important in helping people who have suffered stroke and other life-changing trauma to regain their independence and, often, their lives.
After stroke, loss of mobility isn’t the only long-term problem that prevents survivors from resuming normal activities. Post-stroke pain affects more than half of all stroke survivors. In some cases, this pain is chronic, leaving survivors with constant discomfort and hypersensitivity. Let’s walk through the common types of pain that stroke survivors experience, and introduce the tools and therapeutic techniques that were designed to reduce it and restore mobility.
Understanding the Effects of Stroke
Researchers and health care providers are tapping into new technology and learning more about the connections between brain damage and pain. Today, we know which types of brain damage and muscle loss cause certain types of post-stroke pain, making it easier to address the problem at its root. But after stroke, it’s important for patients and their caregivers to understand the distinctions between their symptoms too.
More than one-third of all stroke survivors experience stiff or tight muscles after stroke. This is actually caused by increased muscle tone, also known as spasticity, that develops due to brain or spinal cord damage. While bodybuilders and other athletes strive for increased muscle tone, stroke survivors experience a heightened amount of muscle tension, which can damage tissues and cause painful cramps. If the muscles contract too much, patients may not be able to move their affected joints and muscles at all.
Spasticity also causes localized pain in certain parts of the body. If you suffer from chronic or recurring joint pain after stroke, this is most likely an example of local pain. Local post-stroke pain may affect both sides of the body, because it’s caused by awkward muscle movements and abnormal positions after stroke. While it’s a secondary side effect of the brain damage that happens during stroke, it affects everyday tasks and makes it more difficult for patients to reprogram healthy brain cells.
One of the most debilitating side effects of stroke is central pain. This is caused by brain damage that disrupts the brain’s ability to interpret sensory responses. After stroke, a patient with central pain will experience some of these symptoms:
- Interpreting light, normal touches as uncomfortable or painful
- Numbness to heat or cold
- Heightened sensitivity to heat or cold
- “Pins and needles” sensation without identifiable triggers
- Constant aching on the side of the body affected by stroke
Even when central pain is moderate (rather than severe), its constant presence can have serious psychological consequences that impede both their motivation and their ability to recover. Chronic central pain can lead to drug misuse, depression, and refusal to continue physical therapy programs. That’s why it’s so important to minimize this pain as the patient begins their journey to recovery.
Reducing Discomfort with Dynamic Splints
When stroke survivors have weakened or paralyzed limbs, their discomfort is often exaggerated by muscle stiffness and gravitational forces. Splints provide extra support for the affected arm or leg, reducing the burden on the patient’s muscles. Traditional splints are static in nature causing increased pressure on the finger joints. This can lead to increased pain and joint damage. Dynamic splints are adjustable and bendable which helps reduce pain.
The SaeboStretch is a dynamic splint that offers an adaptable alternative for stroke survivors. Because it reduces or eliminates some of the triggers of pain – such as pressure on the joints or stiffness of the limbs – it can actually improve patient morale and increase home program compliance.
Restoring Range of Motion with Devices
Of course, splints can only do so much to assist stroke survivors and reduce the effects of gravity and muscle stiffness. If you don’t move your muscles regularly, fluid buildup can cause additional swelling and discomfort, especially if your weakened muscles are trying to support their own weight. Swollen hands are a common side effect of this buildup.
Mechanical devices like the SaeboGlove actually incorporate extra features that support specific joints and muscles, decreasing the impact of gravity and making it easier to move stiff or sore joints. Spasticity is less likely when patients rely on these artificial tension systems, which can be adjusted as they regain more strength and mobility. Tension systems within the SaeboGlove actually step in to extend and release crucial joints in the fingers, thumb, and wrist.
Restoring Circulation with Tight-Fitting Gloves
Do you or your patient suffer from swollen hands? This is a common side effect of stroke, because muscles need to move constantly in order to keep the blood flowing through them. If a stroke survivor cannot move their hand or forearm, fluids may build up in the tissue, requiring external stimulation to recirculate it.
Tight-fitting gloves, or edema gloves, are one effective way to recirculate these fluids and prevent painful and uncomfortable swelling. After health care providers rule out blood clots and cardiac problems, they may recommend a tight-fitting glove to push fluids back out of the arm and hand. It’s very important to recirculate this fluid until the arms can be used appropriately again.
Stretching the Muscles to Reduce Contractures
Muscle contracture is the complete loss of voluntary movement due to stiff joints and muscles. This painful and debilitating symptom usually affects muscles that haven’t been moved properly after stroke. If you already suffer from spasticity after stroke, physiotherapy is a great way to maintain healthy movements until you can regain more muscle control.
Physiotherapists help stroke survivors prevent contractures by gently manipulating their affected limbs into a variety of different positions. Although voluntary movement may still be impossible, these stretching exercises prevent the muscles from atrophying completely or becoming too tight or stiff to move.
Reduce Spasticity with Botox
Botox isn’t just a cosmetic way to reverse the effects of aging. This injectable prescription substance actually originated as a way to relax the muscles and reduce pain associated with muscle tension and contracture. Because more than one-third of all stroke survivors experience spasticity, some turn to Botox treatments to reduce their muscle tone and make it possible to straighten their limbs again.
Botox works by preventing the transmission of signals between the body and brain. Specifically, it blocks the chemical that tells your muscles to start contracting. Doctors now inject very tiny portions of Botox directly into stroke survivor’s arms and legs, effectively reducing their risk of spasms or spasticity. By preventing stiffness and complete paralysis of the limbs, Botox may help thousands of stroke survivors regain function.
(Photo Source: New York Times)
Combat Pain And Recover Faster
Because pain makes it more difficult for patients to retrain their brains and bodies, it’s very important to minimize post-stroke pain as much as possible and allow patients to focus on their rehabilitation. We hope that these tools and techniques were helpful to you as you learn how to combat the most common side effects of stroke and help reprogram the neural connections that make everyday tasks possible.
[Abstract] Effects of low-level laser therapy (LLLT 808 nm) on lower limb spastic muscle activity in chronic stroke patients.
A cerebrovascular accident (CVA) may affect basic motor functions, including spasticity that may be present in the upper extremity and/or the lower extremity, post-stroke.
Spasticity causes pain, muscle force reduction, and decreases the time to onset of muscle fatigue. Several therapeutic resources have been employed to treat CVA to promote functional recovery. The clinical use of low-level laser therapy (LLLT) for rehabilitation of muscular disorders has provided better muscle responses.
Thus, the aim of this study was to evaluate the effect of the application of LLLT in spastic muscles in patients with spasticity post-CVA. A double-blind clinical trial was conducted with 15 volunteer stroke patients who presented with post-stroke spasticity. Both males and females were treated; the average age was 51.5 ± 11.8 years old; the participants entered the study ranging from 11 to 48 months post-stroke onset. The patients participated in three consecutive phases (control, placebo, and real LLLT), in which all tests of isometric endurance of their hemiparetic lower limb were performed. LLLT (diode laser, 100 mW 808 nm, beam spot area 0.0314 cm2, 127.39 J/cm2/point, 40 s) was applied before isometric endurance. After the real LLLT intervention, we observed significant reduction in the visual analogue scale for pain intensity (p = 0.0038), increased time to onset of muscle fatigue (p = 0.0063), and increased torque peak (p = 0.0076), but no significant change in the root mean square (RMS) value (electric signal in the motor unit during contraction, as obtained with surface electromyography).
Our results suggest that the application of LLLT may contribute to increased recruitment of muscle fibers and, hence, to increase the onset time of the spastic muscle fatigue, reducing pain intensity in stroke patients with spasticity, as has been observed in healthy subjects and athletes.
[ARTICLE] OnabotulinumtoxinA Improves Pain in Patients with Post-Stroke Spasticity: Findings from a Randomized, Double-Blind, Placebo-Controlled Trial – Full Text HTML/PDF
Patients with post-stroke spasticity (PSS) commonly experience pain in affected limbs, which may impact quality of life.
To assess onabotulinumtoxinA for pain in patients with PSS from the BOTOX® Economic Spasticity Trial, a multicenter, randomized, double-blind, placebo-controlled trial.
Patients with PSS (N=273) were randomized to 22- to 34-weeks double-blind treatment with onabotulinumtoxinA + standard care (SC) or placebo injection + SC and were eligible to receive open-label onabotulinumtoxinA up to 52 weeks. Assessments included change from baseline on the 11-point pain numeric rating scale, proportion of patients with baseline pain ≥4 achieving ≥30% and ≥50% improvement in pain, and pain interference with work at week 12, end of double-blind treatment, and week 52.
At baseline, most patients (74.3%) experienced pain and 47.4% had pain ≥4 (pain subgroup). Mean pain reduction from baseline at week 12 was significantly greater with onabotulinumtoxinA + SC (–0.77, 95% CI –1.14 to –0.40) than placebo + SC (–0.13, 95% CI –0.51 to 0.24; P < 0.05). Higher proportions of patients in the pain subgroup achieved ≥30% and ≥50% reductions in pain at week 12 with onabotulinumtoxinA + SC (53.7% and 37.0%, respectively) compared with placebo (28.8% and 18.6%, respectively;P<0.05). Reductions in pain were sustained through week 52. Compared with placebo + SC, onabotulinumtoxinA consistently reduced pain interference with work.
This is the first randomized, placebo-controlled trial demonstrating statistically significant and clinically meaningful reductions in pain and pain interference with work with onabotulinumtoxinA in patients with PSS.
Pain prevalence varies widely (10–70%) among post-stroke patients 1, 2, 3 and 4. Several mechanisms may contribute to this range (e.g., peripheral nerve damage, soft tissue trauma, central post-stroke pain, complex regional pain syndrome 5, 6, 7 and 8). Spasticity and pain are factors contributing to “learned non-use” of the affected limb and are often disabling, interfering with daily activities, sleep, walking, physiotherapy, leisure activities, and ultimately affecting patients’ quality of life 9, 10 and 11.
In randomized, double-blind, placebo-controlled trials, onabotulinumtoxinA has been shown to significantly reduce excess muscle tone and decrease disability among patients with upper-limb spasticity 12 and 13, and to further reduce spasms and improve gait in patients with lower-limb spasticity 14 and 15. OnabotulinumtoxinA is effective at reducing pain in patients with cervical dystonia and chronic migraine 16. Prospective open-label studies have shown that onabotulinumtoxinA can reduce pain in patients with post-stroke spasticity (PSS) 8, 17 and 18. However, the efficacy of onabotulinumtoxinA in reducing pain in patients with PSS has not been demonstrated in a large, randomized, placebo-controlled study.
The BOTOX® Economic Spasticity Trial (BEST) was a prospective clinical trial designed to compare the efficacy of onabotulinumtoxinA or placebo (in addition to standard care [SC]) in helping patients with PSS achieve their personal functional goals 19. Here we present results from BEST comparing the effectiveness of onabotulinumtoxinA + SC versus placebo + SC on pain.
In the United States more than 700,000 people suffer a stroke each year and approximately two-thirds of these individuals survive and require rehabilitation. The goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life. Even though rehabilitation does not “cure” the effects of stroke in that it does not reverse brain damage, rehabilitation can substantially help people achieve the best possible long-term outcome.
What is post-stroke rehabilitation?
Rehabilitation helps stroke survivors relearn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity. Rehabilitation also teaches survivors new ways of performing tasks to circumvent or compen sate for any residual disabilities. Individuals may need to learn how to bathe and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed, well-focused, repetitive practice—the same kind of practice used by all people when they learn a new skill, such as playing the piano or pitching a baseball.