Slide 1
Pain and Stroke
Central South Regional Stroke
Program
September 2007
Funded by the Ministry of Health and
Long-Term Care
Slide 2
Session Overview
The types of stroke.
The common changes that result from
stroke.
 The connection between stroke and pain.
 Review how residents may expresses their
pain (verbal and non-verbal).
 Identify strategies to assist in minimizing pain
from occurring.
 Identify what needs to happen when a
resident is identified as being in pain.

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Slide 3
What is a Stroke

An interruption of the supply of blood and
oxygen to an area of the brain.
 This causes the brain cells in an area to die,
and reduces the brain function in that area.
 The area of the body controlled by the
damaged area in unable to function properly.
 There are two types of stroke.
http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef
Slide 4
What is a Stroke?
A stroke can
happen when a
blood clot blocks
a blood vessel in
the brain.
80% of strokes are
this type.
A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada,
Slide 5
What is a Stroke?
A stroke can also
happen when a
blood vessel
breaks and results
in bleeding in the
brain.
20% of strokes are
this type.
A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada,
Slide 6
Risk factors you can do
something about…
High blood pressure
 High blood
cholesterol
 Heart disease
 Diabetes

Being overweight
 Excessive alcohol
use
 Physical inactivity
 Smoking
 Stress

Pearson et.al., (2002) AHA Guidelines for Primary Prevention of Cardiovascular Disease and
Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients
Without Coronary or Other Atherosclerotic Vascular Diseases Circulation, 106, 388-391.
Slide 7
Stroke Statistics
There are between 40,000 and 50,000
strokes survivors in Canada each year.
 10% (4-5,000) of strokes survivors each year
require long-term care.
 40% (16-20,000) of strokes survivors each
year are left with a moderate to severe
impairment.

http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=n
ews&From=SubCategory
Slide 8
What does a resident
who has had a stroke
look like in LTC?
Slide 9
What are some of the losses
due to stroke?
 paralysis
or weakness on one side of
the body;
 vision problems;
 trouble speaking or understanding
language;
http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef
Slide 10
What are some of the losses
due to stroke?
 inability
to recognize or use familiar
objects
 tiredness;
 depression;
http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef
Slide 11
What are some of the losses
due to stroke?
 exaggerated
or inappropriate emotional
responses;
 difficulty learning and remembering new
information; and
 changes in personality.
http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef
Slide 12
Slide 13
Up to 70% of seniors
in long-term care have
untreated pain.
Won et.al., (2004) Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing Home Residents
Journal of the American Geriatric Society 52(6), 867-874.
Ferrell, B.A., Ferrell, B.R., Rivera, L. (1995) Pain in cognitively impaired nursing home patients. Journal of Pain and
Symptom Management 10 (8), 591–598.
Slide 14
Pain is such an
uncomfortable feeling
that even a tiny amount
of it is enough to ruin
every enjoyment
Will Rogers
Slide 15
Pain after stroke is a
symptom often forgotten,
unnoticed although it is
reported to be a great
problem in care.
Widar M, Alström G. Disability after stroke and the influence of long-term pain on
everyday life. Scand J Caring Sci 2002;16:302-310.
Slide 16
Types of Stroke
Pain
Shoulder Pain
2. Stiffness and Tightness of Muscles
3. Nerve Pain
1.
Adapted from: http://www.ebrsr.com/modules/appendix5.pdf
Slide 17
Shoulder Pain
•Up to 72% of stroke survivors
have shoulder pain
•This occurs due to little or no
voluntary movement of the upper
limb
•Carefully position and handle the
limb to prevent pain
•Risk of dislocating (subluxed)
shoulder
ThePostgraduate Medical Journal (2001); 77:645-
Slide 18
Stiffness and Tightness of
Muscles
•Support affected arm at all times
•Don’t do passive range of motion
exercises on the limb unless
you’re trained
•Never pull on a limb during a
transfer, positioning or walking
•Pay attention to supported
positioning and good alignment
BE CAREFUL!
Harvey, R.L. (1998) Tailoring therapy to a stroke patient’s potential
Postgraduate Medicine Online. Vol 104 (2)
Slide 19
Nerve Pain
Descriptors:
• Burning
• aching
• pricking
• cutting, piercing, or
stabbing
• numbness
• cold ↑ pain
Leijon et. al., (1989) Hansen, 2004, Morley-Forster, 2006
Slide 20
How would the pain
show?
Slide 21
Pain Behaviours
Pain words
 rubbing
 pain noises
 bracing
 pain faces
 restlessness
 changes from typical behaviour
 resistance to care

Jones et.al., (2005) Measuring Pain Intensity in Nursing Home Residents.
Journal of Pain and Symptom Management, Volume 30, Issue 6, Pages 519-527
Slide 22
Do These…
If a resident’s usual behavior changes,
consider pain as a possible cause (poor
appetite, depressive symptoms, sleep
problems, changes in function, agitated
behavior, refusal of care, restlessness)
 follow up on the resident’s report of pain –
ask more about it

TELL SOMEONE!
Adapted from: K.S. (2000). Improving assessment and treatment of pain in cognitively impaired
nursing home residents. Annals of Long-Term Care, 8, 36-42.
Slide 23
And These…
Ask yes/no questions
 use the word “pain,” and also try other simple
words (aching, sore, hurts)
 point areas thought to be painful while asking
questions
 ask about pain during or following movement

Adapted from: K.S. (2000). Improving assessment and treatment of pain in cognitively impaired
nursing home residents. Annals of Long-Term Care, 8, 36-42.
Slide 24
And These…
Assume people with dementia experience
pain
 be patient with residents and allow them to
explain their pain
 be aware that just because a pain medication
is prescribed, the pain is not necessarily
relieved

Adapted from: K.S. (2000). Improving assessment and treatment of pain in cognitively impaired
nursing home residents. Annals of Long-Term Care, 8, 36-42.
Slide 25
Challenges with Pain
Residents don’t report pain because they
don’t want to be a burden (Loeb, 1999)
 Residents may have sensory or cognitive
impairments (Martin et. al., 2005 Can J Nurs Res, 37:142-164)
 Residents are not asked to see if they are
experiencing pain.
 Cognitive impairment in residents (Loeb, 1999)

D.T. Cowan et al. (2003) International Journal of Nursing Studies 40:291–298
Slide 26
Residents in Pain

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 or no enjoyment of
recreational activities
decreased mobility
decreased socialization
anxiety
sleep disturbances
impaired posture
D.T. Cowan et al. / International Journal of Nursing Studies 40 (2003) 291–29
Slide 27
Residents in Pain
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 appetite
 memory
depression
changes in bowel and
bladder function
 participation in
dressing and grooming
 irritability
resistance to care
D.T. Cowan et al. / International Journal of Nursing Studies 40 (2003) 291–29
Slide 28
Nurses in all practice settings
should assess clients for pain
using a validated tool (such as
the Numeric Rating Scale, the
Verbal Analogue Scale).
Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario (2005).
Stroke Assessment Across the Continuum of Care. Toronto: Heart and Stroke Foundation of
Ontario and Registered Nurses’ Association of Ontario, 39.
Slide 29
Numeric Pain Rating Scale
From McCaffery, M. Pasero C; Pain: Clinical manual, p. 63., 1999. Copyrighted by Mosby, Inc.
Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario (2005). St
Assessment Across the Continuum of Care. Toronto: Heart and Stroke Foundation of Ontario and
Nurses’ Association of Ontario, 100.
Slide 30
You can use a rating scale to
describe:
How the pain feels at its worst
 how the pain feels most of the time
 how the pain feels at its least
 how the pain changes with treatment

Slide 31
Please, be aware that
persistent pain makes it
difficult for residents to
participate in their own care.
Check to see if the resident
has had their pain
medication before you begin
their care.
Slide 32
General Pain Strategies
Don’t pull on the arm
 Don’t let it dangle
 Don’t raise the arm above the shoulder
 Always be gentle

Harvey, R.L. (1998) Tailoring therapy to a stroke patient’s potential
Postgraduate Medicine Online. Vol 104 (2)
Slide 33
Bathing
• Always keep affected
•
•
arm supported while
washing
do not let the affected
arm dangle at side of
body
always support the
person’s whole arm at
the wrist and elbow
while moving during
any activity
Adapted from Harvey, R.L. (1998) Tailoring therapy to a stroke patient’s potential
Postgraduate Medicine Online. Vol 104 (2)
Slide 34
Dressing

•
Dress weaker arm
first
choose easy to fit
clothing
Slide 35
Toileting

Use recommended
toileting equipment for
the resident (I.e.
commode, urinal)
 remind the resident to
use the recommended
equipment (I.e. grab
bars)
Slide 36
Eating

Ensure person is
positioned best for
safety and comfort
when eating
 remember to use the
adaptive equipment for
the resident (lipped
plate, built-up grips,
adjustments to table
height)
Slide 37
Walking/Transfers

Assist resident to wear
proper footwear
 ensure that they are
positioned to transfer
safely
Ask registered staff to
request an OT/PT
assessment for transfer
and walking strategies
Slide 38
Clara
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Clara is a resident at Cozy Acres Nursing Home
and has recently arrived there from hospital after
having a stroke. Clara is right-handed.
Clara is unable to speak and her responses, even
Y/N are unreliable.
Clara has severe weakness in her right arm.
She needs help dressing her weak arm and with
buttons, and with grooming, and removing her
pants for her toileting.
Clara requires assistance with walking (walker) and
transfers with supervision from bed to
chair/commode.
Slide 39
Clara
What are some of the strategies that
you would use to assist Clara to
decrease her chance of experiencing
pain during her morning care?
Slide 40
Clara
When you go into Clara’s room to begin her
morning care Clara pushes you away, is
unwilling to allow you to care for her. Clara
withdraws when you touch her on the right
side and is tense.
What do you think is going on? Could Clara be
in pain? Could something else be going on
with Clara?
Slide 41
Pain is inevitable.
Suffering is optional.
M. Kathleen Casey
Slide 42
Next Steps…
You are the eyes and ears of your facility
 Be aware of the diagnosis of your residents
 Take this information and use it with the
residents that you work with.
 Share this information with other staff.

Slide 43
More Information
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Acute Changes and Stroke
Continence and Stroke
Dementia and Stroke
Falls and Stroke
Pain and Stroke
Please contact:
Rebecca Fleck or Kim Young
Community and Long Term Care Specialist
Central South Regional Stroke Program
905-521-2100 x 44127
Slide 44
Acknowledgements
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Best Practices long term care advisory group
Best Practices long term care evaluation group
Best Practice Pain Working Group, Brant
Darrell Yip and Erica Moyer, Physiotherapists, Integrated Stroke Unit,
Hamilton General Hospital.
Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term
Care Central South Region
Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care
Central West.
Rhonda Whiteman, Hamilton Health Sciences, Best Practice Coordinator
Tammy Tebbutt, District Stroke Coordinator, Waterloo/Wellington Region
Central South Regional Stroke Program
Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuroambulatory Centre
Melanie Fall Stratton, Regional Stroke Program, Program Manager,
Kim Young, Regional Stroke Program, Community and Long-term Care
Specialist
Lisa Colizza, Regional Stroke Program, Regional Stroke Development
Specialist
Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation
Coordinator
Carol Pereira, Regional Stroke Program, LTC Project Coordinator
Slide 45