Chapter 46 Pain following spinal cord injury. Incidence of central post-stroke pain Central poststroke pain in young ischemic stroke survivors in the Helsinki Young Stroke Registry Somatosensory symptoms and signs and conditioned pain modulation in chronic post-stroke shoulder pain. Poststroke shoulder pain: a prospective study of the association and risk factors in 152 patients from a consecutive cohort of 205 patients presenting with stroke. Analgesic effect of transcranial direct current stimulation on central post-stroke pain. A sham-controlled, phase II trial of transcranial direct current stimulation for the treatment of central pain in traumatic spinal cord injury A randomized controlled pilot study of a cognitive-behavioral therapy approach for painful diabetic peripheral neuropathy. Influence of heterotopic noxious conditioning stimulation on spontaneous pain and dynamic mechanical allodynia in central post-stroke pain patients Central pain modulation after subthalamic nucleus stimulation Repetitive transcranial magnetic stimulation of the left premotor/dorsolateral prefrontal cortex does not have analgesic effect on central poststroke pain. Preoperative back pain is associated with diverse manifestations of central neuroplasticity Repetitive transcranial magnetic stimulation of the motor cortex attenuates pain perception in complex regional pain syndrome type I Longstanding neuropathic pain after spinal cord injury is refractory to transcranial direct current stimulation: A randomized controlled trial A comprehensive pain management programme comprising educational, cognitive and behavioural interventions for neuropathic pain following spinal cord injury. Intramuscular neuromuscular electric stimulation for poststroke shoulder pain: a multicenter randomized clinical trial. Neuropathic pain post spinal cord injury part 1: systematic review of physical and behavioral treatment.
Publisher Summary This chapter explores that spinal cord injury ( SCI ) has a number of severe and disabling consequences . Although loss of function is often considered the primary issue , pain is also a major problem . In central pain conditions , small r and omized trials have shown the effectiveness of amitriptyline and lamotrigine in central post-stroke pain and of dronabinol , a cannabinoid , in pain in multiple sclerosis . It is not known whether the efficacy of drugs in other central or peripheral neuropathic pain conditions can be anticipated to have similar effects in SCI neuropathic pain . Central neuropathic pain is often considered more refractory than peripheral neuropathic pain . It has been suggested that central post-stroke pain responds better to antidepressants than SCI pain . The chapter also review s that because of the lack of sufficient data in neuropathic SCI pain , efficacy in other neuropathic pain conditions has to be considered in choosing treatment & NA ; 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 prospect ively 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 Objective : We describe the frequency , duration , clinical characteristics , and radiologic correlates of central poststroke pain  ( CPSP ) in young ischemic stroke survivors in a prospect i ve study setting . Methods : A question naire of pain and sensory abnormalities and EQ-5D quality -of-life question naire were sent to all 824 surviving and eligible patients of the Helsinki Young Stroke Registry . Patients ( n = 58 ) with suspected CPSP were invited to a clinical visit and filled in the PainDETECT , Brief Pain Inventory , and Beck Depression Inventory question naires . Results : Of the included 824 patients , 49 had CPSP ( 5.9 % ) , 246 patients ( 29.9 % ) had sensory abnormality without CPSP , and 529 patients ( 64.2 % ) had neither sensory abnormality nor CPSP . The median follow-up time from stroke was 8.5 years ( interquartile range 5.0–12.1 ) . Patients with CPSP had low quality of life compared to those with sensory abnormality without CPSP ( p = 0.007 ) as well as to those with no sensory abnormality and no CPSP ( p < 0.001 ) . Forty ( 82 % ) of the patients with CPSP had concomitant other pain . CPSP was associated with moderate ( p < 0.001 ) and severe ( p < 0.001 ) stroke symptoms , but there was no difference in age at stroke onset or subtype of stroke according to the TOAST classification between the groups . Stroke localization was not correlated with CPSP . Conclusions : Late persistent CPSP was found in 5.9 % of young stroke survivors and was associated with concomitant other pain , impaired quality of life , and moderate or severe stroke symptoms UNLABELLED Persistent shoulder pain is a common complication after stroke . Its etiology and underlying mechanisms are not well understood and treatment is generally unsatisfactory . The objective of this study was to assess the role of central sensitization and disinhibition in chronic stroke patients with chronic PSSP ( n = 19 ) , pain-free stroke patients ( n = 29 ) , and healthy controls ( n = 23 ) .  Positive and negative somatosensory symptoms and signs were assessed using clinical examination and electrical and mechanical quantitative sensory testing ( QST ) . Conditioned pain modulation ( CPM )  was assessed by comparing QST thresholds before and after applying a cold pressor test .  Sensory abnormalities were more frequently observed and more severe in patients with PSSP , including positive signs such as allodynia at the affected side and generalized hyperalgesia at the unaffected side . CPM was similar in stroke patients and healthy controls . This study showed that chronic PSSP was associated with several positive and negative somatosensory signs , implicating a role for central sensitization and possibly for disinhibition . Since the causal relationship remains unclear , and may be related to either neuroplasticity induced by ongoing nociception as well as to the neuropathic brain lesion , prospect i ve studies are warranted . PERSPECTIVE The assessment of somatosensory symptoms and signs and endogenous pain modulation demonstrated a role for central sensitization and possibly for disinhibition in chronic PSSP . Prevention and treatment of PSSP could benefit from a more detailed analysis of both peripheral and central pain mechanisms BACKGROUND AND PURPOSE Shoulder pain is known to retard rehabilitation after stroke . Its causes and prognosis are uncertain . This study describes the incidence of poststroke shoulder pain prospect ively , in an unselected stroke population in the first 6 months after stroke and identifies risk factors for developing pain . METHODS 297 patients with possible stroke were screened and stroke diagnosed in 205 cases . The 152 patients entered the study of which 123 patients were assessed up to 6 months . This cohort , with a mean age of 70.6 years , was examined at 2 weeks , 2 , 4 , and 6 months . A history of shoulder pain , Barthel score , anxiety and depression score were recorded . Full neurological and rheumatological examination was undertaken , using the contralateral side as a control . Pain outcome and stroke outcome was recorded at subsequent visits . RESULTS 52 ( 40 % ) patients developed shoulder pain on the same side of their stroke . There was a strong association between pain and abnormal shoulder joint examination , ipsilateral sensory abnormalities and arm weakness . Shoulder pain had resolved or improved at 6 months in 41 ( 80 % ) of the patients with st and ard current treatment . CONCLUSIONS Shoulder pain after stroke occurred in 40 % of 123 patients surviving , consenting and not too unwell to participate . This included 52 patients of an original cohort of 205 patients presenting with stroke . Eighty percent of patients made a good recovery with st and ard treatment Patients with sensory and or motor deficits represent at risk sub-groups Pain that occurs after a stroke lowers the quality of life . Such post-stroke pain is caused in part by the brain lesion itself , called central post-stroke pain . We investigated the analgesic effects of transcranial direct current stimulation ( tDCS ) in stroke patients through quantitative sensory testing . Fourteen participants with central post-stroke pain ( 7 female and 7 male subjects ) were recruited and were allocated to either tDCS ( n = 7 ) or sham-tDCS ( n = 7 ) group . Their ages ranged from 45 to 55 years .  tDCS was administered for 20 min at a 2-mA current intensity , with anodal stimulations were performed at primary motor cortex . The sham-tDCS group was stimulated 30-second current carrying time . Both group interventions were given for 3 days per week , for a period of 3 weeks . Subjective pain was measured using the visual analogue scale ( VAS ) of 0 to 10 . Sensations of cold and warmth , and pain from cold and heat were quantified to examine analgesic effects . The sham-tDCS group showed no statistically significant differences in time . In contrast , tDCS group showed decreased VAS scores and skin temperature ( p < 0.05 ) . The threshold temperatures for the sense of cold and pain from cold increased ( p < 0.05 ) , and those for the sense of warmth and pain from heat decreased ( p < 0.05 ) . Our findings indicate that tDCS improved sensory identification and exerted analgesic effects in the stroke patients with central post-stroke pain Abstract Past evidence has shown that motor cortical stimulation with invasive and non‐invasive brain stimulation is effective to relieve central pain . Here we aim ed to study the effects of another , very safe technique of non‐invasive brain stimulation – transcranial direct current stimulation ( tDCS ) – on pain control in patients with central pain due to traumatic spinal cord injury . Patients were r and omized to receive sham or active motor tDCS ( 2 mA , 20 min for 5 consecutive days ) . A blinded evaluator rated the pain using the visual analogue scale for pain , Clinician Global Impression and Patient Global Assessment . Safety was assessed with a neuropsychological battery and confounders with the evaluation of depression and anxiety changes . There was a significant pain improvement after active anodal stimulation of the motor cortex , but not after sham stimulation . These results were not confounded by depression or anxiety changes . Furthermore , cognitive performance was not significantly changed throughout the trial in both treatment groups . The results of our study suggest that this new approach of cortical stimulation can be effective to control pain in patients with spinal cord lesion . We discuss potential mechanisms for pain amelioration after tDCS , such as a secondary modulation of thalamic nuclei activity UNLABELLED The purpose of the present pilot study was to assess the efficacy of cognitive-behavioral therapy ( CBT ) for painful diabetic peripheral neuropathy . This was a r and omized , treatment as usual ( TAU ) , controlled , nonblinded intervention pilot study with a 4-month follow-up conducted in a VA medical center . It was hypothesized that participants who received CBT , as compared to those who received TAU , would report significant decreases on self-report measures of pain severity , interference , and depressive symptoms from pretreatment to 4-month follow-up . Participants meeting inclusion criteria were r and omly assigned to 1 of the study conditions . Of the 20 eligible participants , 12 were r and omized to CBT and 8 were r and omized to TAU .  Participants r and omized to CBT showed significant decreases on measures of pain severity ( B = -.54 ) and pain interference ( B = -.77 ) from pretreatment to 4-month follow-up . There were no significant changes in the TAU participants ' scores on measures of pain severity ( B = .00 ) or pain interference ( B = -.09 ) . Neither CBT nor TAU participants showed significant changes in their levels of depressive symptoms from pretreatment to 4-month follow-up . CBT may be an effective treatment approach for reducing pain severity and interference associated with painful diabetic peripheral neuropathy . PERSPECTIVE The results of this study suggest that engaging patients in CBT for painful diabetic peripheral neuropathy may provide them the skills to become more active and experience less pain ABSTRACT In 10 patients with central post‐stroke pain ( CPSP ) , the influence of ischemia‐induced heterotopic noxious conditioning stimulation ( HNCS ) on the intensity of spontaneous ongoing‐ and brush‐evoked pain was examined . In addition , the modulating effect of ongoing pain and HNCS on pain sensitivity in a remote pain‐free area was explored . A semi‐quantitative brushing technique was employed in combination with a computerized  visual analogue scale ( VAS ) to monitor the allodynic percept over time , by calculating the area under the VAS curve as the total brush‐evoked pain intensity . Heat‐ and pressure pain thresholds and sensitivity to suprathreshold heat‐ and pressure pain in the pain‐free area were assessed before and during HNCS . No significant alterations of ongoing‐ or brush‐evoked pain were found during HNCS , although 6 of 10 patients rated a reduction of about 50 % of the brush‐evoked pain . At baseline significantly increased pressure pain sensitivity ( threshold P < 0.05 ; suprathreshold P = 0.05 ) were demonstrated in patients compared to controls . During HNCS , higher pressure pain thresholds were demonstrated in patients and controls alike ( P < 0.001 ) , whereas in controls only decreased sensitivity to suprathreshold pressure pain was found ( P < 0.05 ) . Lack of influence from HNCS on ongoing‐ and brush‐evoked pain on a group level , indicates inability of modulation from endogenous pain controlling systems on nociceptive activity generated in the brain . Increased pressure pain sensitivity at baseline suggests alteration in corticofugal control of nociceptive sensitivity due to the brain lesion , whereas patients during HNCS seemed to activate modulatory systems interacting with nociceptive input from the spinal level equal to controls Objective : To investigate the acute effect of subthalamic nuclei deep brain stimulation ( STN-DBS ) and levodopa on pain and tolerance thresholds in patients with Parkinson disease . We hypothesized that a modification of pain threshold after STN-DBS would suggest a central modification of pain perception , whereas the absence of pain threshold change after STN-DBS would correspond to a peripheral mechanism via a decrease of painful stimuli . Methods : Nineteen patients with Parkinson disease were included in this double-blind , r and omized , crossover study . Postoperatively , we evaluated pain thresholds ( thermal and mechanical ) and motor symptoms under 3 acute conditions : stimulation on/medication off ; stimulation off/medication on ; and stimulation off/medication off . We also conducted a retrospective analysis of the data prospect ively recorded during the follow-up of the cohort pre- and postoperatively ( Unified Parkinson ’s Disease Rating Scale [ UPDRS ] score , Hoehn and Yahr stage , equivalent levodopa daily dose , and tapping test score ) . Results : We found a significant increase of pain and tolerance mechanical thresholds not only after acute STN-DBS but also after acute levodopa administration . We did not find any significant correlation between postoperative clinical pain improvement and UPDRS-III improvement after acute levodopa or STN-DBS , nor with motor complications improvement assessed with UPDRS-IV after chronic STN-DBS . No correlation was found between postoperative clinical pain improvement and mechanical pain threshold modification . Conclusion : Clinical pain alleviation after STN-DBS can not be considered merely as a consequence of motor complications improvement and could be attributable to a direct central modulation of pain perception , via increased mechanical pain and tolerance thresholds UNLABELLED Central poststroke pain ( CPSP ) is caused by an encephalic vascular lesion of the somatosensory pathways and is commonly refractory to current pharmacologic treatments . Repetitive transcranial magnetic stimulation ( rTMS ) of the premotor cortex/dorsolateral prefrontal cortex ( PMC/DLPFC ) can change thermal pain threshold toward analgesia in healthy subjects and has analgesic effects in acute postoperative pain as well as in fibromyalgia patients . However , its effect on neuropathic pain and in CPSP , in particular , has not been assessed . The aim of this prospect i ve , double-blind , placebo-controlled study was to evaluate the analgesic effect of PMC/DLPFC rTMS in CPSP patients . Patients were r and omized into 2 groups , active ( a- ) rTMS and sham ( s- ) rTMS , and were treated with 10 daily sessions of rTMS over the left PMC/DLPFC ( 10 Hz , 1,250 pulses/d ) . Outcomes were assessed at baseline , during the stimulation phase , and at 1 , 2 , and 4 weeks after the last stimulation . The main outcome was pain intensity changes measured by the visual analog scale on the last stimulation day compared to baseline . Interim analysis was scheduled when the first half of the patients completed the study . The study was terminated because of a significant lack of efficacy of the active arm after 21 patients completed the whole treatment and follow-up phases . rTMS of the left PMC/DLPFC did not improve pain in CPSP . PERSPECTIVE The aim of this double-blind , placebo-controlled study was to evaluate the analgesic effects of rTMS to the PMC/DLPFC in CPSP patients . An interim analysis showed a consistent lack of analgesic effect , and the study was terminated . rTMS of the PMC/DLPFC is not effective in relieving CPSP & NA ; Increased or decreased gain in central nervous system processing after surgery , i.e. neuroplasticity , may play an important role in postoperative pain . Identification of patient subgroups particularly vulnerable to either type of post‐surgical neuroplasticity is thus of interest . Preoperative pain has also been suggested to increase vulnerability to post‐surgical chronic pain complications due to central facilitation . To study if back pain preoperatively is associated with differences in central sensory processing , we measured  transcutaneous electric sensation , pain detection and pain tolerance thresholds  at the upper arm , lower back and lower leg in 52 consecutive patients scheduled for back surgery in a blinded , prospect i ve fashion . Patients with no pain had significantly lower pain thresholds than patients with pain in the leg , and significantly higher pain thresholds than those with pain in the back . These results suggest that preoperative pain can induce diverse central neuroplastic changes , i.e. inhibition and facilitation , and that the nature of this neuroplasticity depends on the nature of the pain involved . The presence of facilitation may be the basis of the increased vulnerability described in some studies of patients with significant preoperative pain , whereas the implication s of reduced pain sensitivity are less clear . The demonstration of neuroplasticity and its diversity are , however , likely to be of significant clinical relevance In complex regional pain syndrome ( CRPS ) many clinical symptoms suggest involvement of the central nervous system . Neuropathic pain as the leading symptom is often resistant to therapy . In the present study we investigated the analgesic efficiency of repetitive transcranial magnetic simulation ( rTMS ) applied to the motor cortex contralateral to the CRPS-affected side . Seven out of ten patients reported decreased pain intensities . Pain relief occurred 30 s after stimulation , whereas the maximum effect was found 15 min later . Pain re-intensified increasingly 45 min after rTMS . In contrast , sham rTMS did not alter pain perception . These findings provide evidence that in CRPS I pain perception can be modulated by repetitive motor cortex stimulation Summary In a r and omized sham‐controlled crossover study , transcranial direct current stimulation over the primary motor cortex did not provide relief for long‐st and ing neuropathic spinal cord injury pain . Abstract Neuropathic pain remains one of the most difficult consequences of spinal cord injury ( SCI ) to manage . It is a major cause of suffering and adds to the physical , emotional , and societal impact of the injury . Despite the use of the best available treatments , two thirds of people experiencing neuropathic pain after SCI do not achieve satisfactory pain relief . This study was undertaken in response to a recent clinical trial reporting short‐term , clinical ly significant reductions in neuropathic SCI pain with primary motor cortex transcranial direct current stimulation ( tDCS ) . In this investigation , we aim ed to build on this previous clinical trial by extending the assessment period to determine the short‐ , medium‐ , and long‐term efficacy of tDCS for the treatment of neuropathic pain after SCI . We found that , contrary to previous reports , after 5 tDCS treatment periods , mean pain intensity and unpleasantness rating were not significantly different from initial assessment . That is , in this trial tDCS did not provide any pain relief in subjects with neuropathic SCI pain ( n = 10 ) . A similar lack of effect was also seen after sham treatment . Because the injury duration in this study was significantly greater than that of previous investigations , it is possible that tDCS is an effective analgesic only in individuals with relatively recent injuries and pain . Future investigations comparing a range of injury duration s are required if we are to determine whether this is indeed the case OBJECTIVE To assess whether a comprehensive multidisciplinary pain management programme could contribute to improvement regarding sleep quality , mood , life satisfaction , health-related quality of life , sense of coherence and pain for patients with a spinal cord injury and neuropathic pain . DESIGN A prospect i ve intervention study . PATIENTS Twenty-seven patients with spinal cord injury and neuropathic pain participated in a pain management programme  in parallel with 11 patients in a control group . METHODS A comprehensive pain management programme comprising educational , cognitive , and behavioural interventions was created for patients with spinal cord injury and neuropathic pain . The pain management programme consisted of 20 sessions over a 10-week period and included educational sessions , behavioural therapy , relaxation , stretching , light exercise and body awareness training . All patients were followed-up 3 , 6 and 12 months after completion of the programme . RESULTS At the 12-month follow-up , levels of anxiety and depression in the treatment group decreased compared with baseline values , and a tendency towards better quality of sleep was seen . In comparison with the control group , patients in the treatment group improved regarding sense of coherence and depression . CONCLUSION This study implies that a multidimensional pain management programme can be a valuable complement in the treatment of spinal cord injured patients with neuropathic pain OBJECTIVE To assess the effectiveness of intramuscular neuromuscular electric stimulation ( NMES ) in reducing poststroke shoulder pain .  DESIGN Multicenter , single-blinded , r and omized clinical trial . SETTING Ambulatory centers of 7 academic rehabilitation centers in the United States . PARTICIPANTS Volunteer sample of 61 chronic stroke survivors with shoulder pain and subluxation . INTERVENTION Treatment subjects received intramuscular NMES to the supraspinatus , posterior deltoid , middle deltoid , and trapezius for 6 hours a day for 6 weeks . Control subjects were treated with a cuff-type sling for 6 weeks . Main outcome measure Brief Pain Inventory question 12 ( BPI 12 ) , an 11-point numeric rating scale administered in a blinded manner at the end of treatment , and at 3 and 6 months posttreatment . RESULTS The NMES group exhibited significantly higher proportions of success based on the 3-point or more reduction in BPI 12 success criterion at the end of treatment ( 65.6 % vs 24.1 % , P<.01 ) , at 3 months ( 59.4 % vs 20.7 % , P<.01 ) , and at 6 months ( 59.4 % vs 27.6 % , P<.05 ) . By using the most stringent " no pain " criterion , the NMES group also exhibited significantly higher proportions of success at the end of treatment ( 34.4 % vs 3.4 % , P<.01 ) , at 3 months ( 34.4 % vs 0.0 % , P<.001 ) , and at 6 months ( 34.4 % vs 10.3 % , P<.05 ) . CONCLUSIONS Intramuscular NMES reduces poststroke  shoulder pain  among those with shoulder subluxation and the effect is maintained for at least 6 months posttreatment BACKGROUND Neuropathic pain has various physiologic and psychosocial aspects . Hence , there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury ( SCI ) . OBJECTIVE The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI . METHODS MEDLINE , CINAHL , EMBASE , and PsycINFO data bases were search ed for articles addressing nonpharmacological treatment of pain post SCI . Articles were restricted to the English language . Article selection was conducted by 2 independent review ers with the following inclusion criteria : the subjects participated in a treatment or intervention for neuropathic pain ; at least 50 % of the subjects had an SCI ; at least 3 subjects had an SCI ; and a definable intervention was being studied . Data extracted included study design , study type , subject demographics , inclusion and exclusion criteria , sample size , outcome measures , and study results . R and omized controlled trials ( RCTs ) were assessed for quality using the Physiotherapy Evidence Data base ( PEDro ) assessment scale . Levels of evidence were assigned to each intervention using a modified Sackett scale . RESULTS The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI : physical and behavioral treatments . The pooled sample size of all studies included 433 participants . Of the 16 studies included , 7 were level 1 , 3 were level 2 , and 6 were level 4 studies . CONCLUSIONS Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain . Of these interventions , transcranial electrical stimulation had the strongest evidence of reducing pain . Despite a growing body of literature , there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain
Results suggested that all therapies had little to no effect on pain and other patient-important outcomes .
Our findings are inconsistent with major clinical practice guidelines ; the available evidence suggests no beneficial effects of any therapies that research ers have evaluated in r and omized controlled trials
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 .