F30 Pain after stroke – referenced version
A stroke can leave someone with various physical effects, such as weakness,
paralysis or changes in sensation. Unfortunately some people also experience
pain. This factsheet outlines some of the causes of pain after stroke, the
treatments that are available. It also gives details of useful organisations that
can provide further information and support.
Stroke causes interruption and
damage to the normal functioning of
the brain, often resulting in weakness
“hemiparesis” or paralysis “hemiplegia”
on one side of the body (see our
factsheet F26 Hemiplegia and stroke for
further information). This can
unfortunately lead to spasticity and
other painful conditions. As with many
aspects of stroke, pain may persist for
some time, but physiotherapy and other
treatments are successful in many
instances and there are coping
techniques that can be learned to help
you manage with long-term pain.
Spasticity and contractures
after stroke
Spasticity is a form of muscle
tightness that can arise after stroke1.
It involves increased muscle tone,
tendon jerks and can interfere with
normal movements2,3. It can also lead
to tissue and joint damage. It happens
when there is damage to the area of the
brain that controls the muscles in the
body. Spasticity is common,
particularly in the affected arm4.
Some degree of spasticity is found in
almost every patient with hemiplegia
and usually begins within the first
© The Stroke Association September 2009
week5. Some people who have had a
stroke find they develop contractures
in their affected limbs (where the
muscles tighten up and can’t be
straightened out) 6. This can make
normal mobility impossible and
cause painful muscular spasms7.
Early physiotherapy aims to prevent or
reduce contractures and should begin
as soon as possible. An assessment
should be carried out after 24 hours by
a team of specialists who will decide
upon the best treatment methods on an
individual basis8.
Physiotherapy
Anyone with spasticity should have
physiotherapy every day to move the
affected joints. The affected areas
should be moved into all positions
possible. The physiotherapist will assist
and gently place the body part into
different positions. This is called
passive stretching and should be
taught to the family and carers9.
Splinting/Casting
If stretching alone does not control
contractures, splinting or casting may
be used10. This involves using an aid
(usually a splint or a cast) that molds to
or lies along the affected limb and
1
holds it in place. The purpose of using
splints is to prevent abnormal
positioning of the body11,12.
Medication
Once the muscles start tightening, it is
difficult to get them to relax again and
the doctors may want to consider using
drugs or botox13,14 to help reduce the
pain and disability that can follow from
what is termed high, or excessive,
muscle tone.
Some oral medicines that may be
prescribed for generalized spasticity
include15, 16 .
 Baclofen (a muscle relaxant)
works on the central-nervous
system17
 Tizanidine ( a muscle relaxant)
works on the nerves18
 Gabapentin ( an anticonvulsant) acts on the brain
cells and dampens down
electrical activity19
 Dantrolene (a muscle relaxant)
works directly on the muscle20
 Diazepam (an anti-anxiety)
works on a chemical released by
the brain called
norapinephrine21.
If spasticity affects only one or two
specific parts of the body, injections
of Botulinum Toxin (Botox) may be
given directly into the muscle. The
muscle relaxing effects usually last for
about three months and do not interfere
with nerve sensation22.
© The Stroke Association September 2009
In severe cases of contractures,
surgery to release tendons may be
carried out23. Advances in drug
treatment have reduced the need for
surgical treatment (our factsheet F33
Physical Effects of Stroke provides
more detail about spasticity and
treatment options).
Shoulder Problems
These are quite common after a
stroke24 and always occur on the
affected side, resulting in prolonged
stiffness, loss of movement and often
severe pain. It is thought that several
problems combine to cause the pain
and that before treatment, an
assessment should be carried out by
specialists to determine where the
problem lies.
Often, a painful shoulder after stroke
may be referred to as ‘frozen
shoulder’, ‘capsulitis’, or ‘adhesive
capsulitis’. This means that there is
thickening and inflammation in the
shoulder joint25. A complication of
shoulder problems is ‘shoulder
subluxation’. This is a partial or
incomplete dislocation26 and is a
warning sign that the shoulder is not
supported properly by the muscles.
Pain, inflammation and restricted
movement can be reduced by:
• Correct positioning and handling:
After the stroke, good movement and
positioning, including shoulder care, are
2
vital. Foam arm supports may be used
if necessary but overhead arm slings
should be avoided27. The affected arm
initially could be placed on a pillow to
provide support, as gravity alone can
may damage the joint.
• Mobilising the shoulder:
In the first stage of treatment, passive
movement can be applied by the
physiotherapist to counteract the
paralysis and loss of coordination
arising from the stroke and keep the
shoulder joint mobile28. The
physiotherapist can also provide
advice about how to protect the
shoulder during everyday movements
such as combing your hair.
If the shoulder causes pain, mild
painkillers such as paracetamol and/or
anti-inflammatory drugs, should help to
control it. Often, doctors can prescribe
something stronger if necessary29.
Transcutaneous electrical
nerve stimulation (TeNS)
This alternative to drugs for pain
management is widely used by
hospitals and pain clinics throughout
the UK. It is best for treating localised
pain including arthritis, sciatica and
lumbago, but may sometimes be used
for frozen shoulder. There are no side
effects and it can be used alongside
any other medication without fear of
interference. (People fitted with a
cardiac pacemaker are advised not to
use TeNS unless under medical
direction.)
© The Stroke Association September 2009
The standard treatment time is around
40 minutes and this can provide
several hours of significant or total
relief from even chronic pain. Self
adhesive pads (electrodes) are placed
directly onto the skin around or adjacent
to the area of pain. At the higher
frequencies, it instigates ‘gateway
control’, which prevents the pain
signals from moving along the nerve
pathways. The lower frequencies help
the body to release natural painkillers
called endorphines30.
Central post-stroke pain (CPSP)
Approximately 5 per cent of people
who have a stroke will develop pain
called central post-stroke pain
(CPSP)31. This is also known as
thalamic pain syndrome32, Dejerine
Roussy, or central pain syndrome33.
The onset of pain may occur at the time
of the stroke but more often it begins
several months later34.
The pain is often described as an icy
burning sensation, throbbing, or
shooting pain in the part of the body
affected by the stroke. It is a form of
neuropathic pain which means that it
does not have to occur as a response
to the environment or damage to
tissue.
The precise cause of the pain is
unknown. In some cases it is due to
damage to the thalamus; the brain’s
‘pain centre’. Because the brain is
damaged it can sometimes feel pain
3
when it should be feeling a sensation
that is not painful. This is known as
hypersensitivity or allodynia. In 20
per cent of people the pain gets better
over a period of years35.
Usual painkillers have little effect on
this pain. Some medications originally
developed for epilepsy and depression
can have a positive effect. The most
effective medicines are thought to be
the tricyclic antidepressants such as
amitriptyline36. Referral onto a pain
management programme37,
relaxation, visualisation techniques,
meditation, aromatherapy, counselling
and hypnotherapy may also be
beneficial38.
Pain Clinics and Pain
Management Programmes
If you develop pain after a stroke your
GP may refer you to a pain clinic for a
diagnosis. An assessment should be
carried out to determine the cause of
the pain.
If you are diagnosed with CPSP you
may be offered some of the treatments
mentioned in this factsheet. You may
also be referred to a pain management
programme39.
There is no cure for CPSP, but, pain
management aims to help people cope
better with their pain in the long term.
The programmes are run by a
combination of healthcare
professionals, such as
physiotherapists, clinical
© The Stroke Association September 2009
psychologists and doctors who can
help with poor posture, frustration,
depression and other obstacles. People
learn about pacing their actions,
breathing and relaxation, positive
thinking and exercise patterns. Pain
management programmes strive to
improve quality of life40.
Swollen, painful hand
Sometimes after a stroke the hand can
swell up and become painful. This
usually happens when the hand isn’t
being moved very much (for example;
if it is paralysed). The fluid normally
present in the hand tissue stops
circulating and collects, causing the
swelling and discomfort. Gravity can
also add to the problem if the hand is
often hanging downwards41. To
overcome this it is best to raise your
hand and place it on a pillow. Using a
machine to apply pressure at intervals,
(once thought to be helpful), is no
longer used to encourage circulation42,
although a tight fitting glove (called an
oedema glove) may sometimes be
worn to push the fluid out of the hand.
This needs to be fitted correctly to
avoid causing too much pressure 43.
Paracetamol can sometimes help to
relieve this pain44.
Headache
It is quite common for people to
experience headaches after a stroke
caused by a bleed (haemorrhagic
stroke). Less commonly, pain will be
experienced a few days after a stroke
caused by a blockage if there is
4
swelling of the brain45. The pain tends
to lessen over time and can usually be
controlled by painkillers such as
paracetamol (aspirin should usually be
avoided after a bleed). Drinking plenty
of water (2-3 litres per day) and
avoiding caffeine and alcohol can
help to reduce these headaches46.
If a technique called Lumbar Puncture
has been performed, a headache can
occur because the levels of
cerebrospinal fluid (CSF) the fluid that
fills the space between the brain and
the skull) are lower than normal47.
This should only last for a few days.
Too much CSF can also cause
headaches48. This is known as
hydrocephalus and affects about 10
per cent of people who experience
haemorrhagic stroke. This can usually
be treated by placing a tube into the
brain that allows the excess fluid to be
drained away49.
Medicines can also cause side effects
that include headaches. Common
examples include Nifedipine (Adalat)
50, which is given for high blood
pressure, Glyceryl trinitrate51, which is
given for angina and dipyridamole
(Persantin) 52; an antiplatelet (blood
thinner).
Anyone experiencing a sudden, severe
headache or a persistent headache
should seek medical attention
urgently to find out what is causing it.
© The Stroke Association September 2009
Useful resources
Pain relief audio tapes/CD’s
A series of simple and effective audio
cassettes for home use, describing
techniques used on the Pain
Management Programme at the Walton
Centre for Neurology and Neurosurgery
are available from the Pain Relief
Foundation (see Useful organisations).
Titles: Coping with Pain, Coping with
Back Pain, Coping with Headache and
Migraine, Anxiety (all priced at £8.50
inc. P&P), The Relaxation Kit, and,
Feeling Good (£13.99 inc P&P).
Books
“The Pain Relief Handbook: Self-help
methods for managing pain”
By Dr Chris Wells & Graham Nown
Vermilion, London 1996. Available from
the Pain Relief Foundation, price
£10.99 + £1.00 P&P or from book
shops.
“Taking Control of your Pain”
By Toni Battison price £6.99 plus £1.95
P&P. Available from Age Concern
Books, Units 5 and 6, Industrial Estate,
Brecon, Powys, LD3 8LA, Tel: 0870
442 2120.
“Pain Relief without Drugs”
By Jan Sadler. Available from The Pain
Relief Foundation price £12.99 (inc
P&P).
Useful organisations
All organisations are UK wide unless
otherwise stated
5
Action on pain
PO Box 134 Shipdham Norfolk IP25
7XA Tel: 0845 6031593
Website: www.action-on-pain.co.uk
Supports and campaigns for people
living with pain.
The British Pain Society
3rd Floor Churchill House 35 Red Lion
Square London WC1R 4SG
Tel: 020 7269 7840
Website: www.britishpainsociety.org
Has a number of publications for
patients.
Central Pain Syndrome Alliance
International internet resource:
www.centralpain.org
Chronic Pain Policy Coalition
c/o Policy Connect CAN Mezzanine
32-36 Loman Street London SE1 0EH
Tel: 020 7202 8580
Website: www.paincoalition.org.uk
A forum uniting professionals,
parliamentarians and patients to
develop an improved strategy for issues
surrounding chronic pain.
Pain Association Scotland
Cramond House Cramond Glebe Road
Edinburgh EH4 6NS
Tel: 0800 783 6059
Website: www.chronicpaininfo.org
Support for people with chronic pain.
Pain Concern
PO Box 12356 Haddington
East Lothian EH41 4YD
Listening-ear helpline: 0844 499 4676
© The Stroke Association September 2009
Website: www.painconcern.org.uk
Offers a range of publications,
information and support about living
with chronic pain
The Pain Relief Foundation
c/o Pain Research Institute
Clinical Sciences Centre
University Hospital Aintree
Lower Lane Liverpool L9 7AL
Tel: 0151 529 5820
Website:
www.painrelieffoundation.org.uk
PainSupport
www.painsupport.co.uk
A dedicated UK website offering
support to people with chronic pain
through a series of self-help pages, an
online discussion/contacts group and
newsletter. Recommends compiling a
Tool Kit notebook of favourite self-help
pain relief methods, which is useful
when pain flares up.
SCOPE
6 Market Road London N7 9PW
Cerebral Palsy Helpline: 0808 800 3333
Website: www.scope.org.uk
Information sheets about spasticity,
splinting and botox treatment.
Second Skin
United Kingdom Office
60b Hermiston Village
Currie Edinburgh EH14 4AQ
Tel: 0131 449 9479
Email: Edinburgh@secondskin.com.au
Website: www.secondskin.com.au
6
The only organisation selling Lycra
Dynamic Splints – a treatment for
spasticity that originated in Australia.
SCOPE has promoted its acceptance
by the NHS; it is currently an expensive
option.
Talking Life
36 Birkenhead Road Hoylake
Wirral CH47 3BW
Tel: 0151 632 0662
Email: wendy@talklife.u-net.com
Website: www.talkinglife.co.uk
Produces training courses and
materials for the NHS and Public
Sector.
TeNS Medical Services Ltd
Central House 37 Gate Lane
Boldmere, Sutton Coldfield B73 5TS
Tel: 0845 0900 800
Website: www.tens.co.uk
Produce and sell TeNS machines.Pain
forum for professionals, patients and
members of the parliament.
© The Stroke Association September 2009
Disclaimer: The Stroke Association
provides the details of other
organisations for information only.
Inclusion in this factsheet does not
constitute a recommendation or
endorsement.
Glossary of Terms
Adhesive Capsulitis = limitation of
movement of the shouldher joint, often
causing pain
Allodynia = hypersensitivity (perceived
pain to a stimulus that is not painful)
Contracture = abnormal shortening of
a muscle that results in deformity
CPSP = central post-stroke pain
CSF = cerebrospinal fluid (fluid that
bathes the brian and spine)
Hemiparesis = weakness of one part of
the body
Hemiplegia = paralysis of one part of
the body
Hydrocephalus = build up of CFS in or
around the brain
Oedema = abnormal accumulation of
fluid in the tissues causing swelling
Spasticity = a form of muscle
tightening
7
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8
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9
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Additional Reading
Pain Support. The Pain Gate http://www.painsupport.co.uk/relief/01paingate.html
Pain Concern. A Guide to Managing Pain, Physio Footnotes 1-5. http://www.painconcern.org.uk/pages/page9.php
Pain Relief Foundation. “Over-The-Counter” Medicines For Pain Relief.
http://www.painrelieffoundation.org.uk/paininfo/druginfo_overthecountermedicines.html
© The Stroke Association September 2009
10