Ask Doctor K: Many options exist to treat pain following a stroke

DEAR DOCTOR K: I’ve been in pain ever since I had a stroke about six months ago. What will relieve it?

DEAR READER: Pain is a frequent complication of stroke. It generally falls into one of two types, local or central.

Local pain results from joint and muscle problems. Strokes can make some muscles weak and stiff. That, in turn, can make the muscles hurt when they move (or are moved). It also can cause the bones in a joint moved by those muscles to shift out of their proper place, producing pain in the joint. Treatment is fairly straightforward and may involve a variety of options:

• range-of-motion and stretching exercises;
• over-the-counter or prescription pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs);
• use of a sling or armrest to support a weak shoulder;
• strategic positioning of a weak leg while in a wheelchair or in bed;
• cortisone injections to reduce inflammation.

Electrical stimulation of the involved muscles, botulinum toxin injections to relax tight and stiff muscles, or acupuncture may also help.

Less common, but more difficult to manage, is a neurological condition called central pain syndrome (CPS). CPS results from damage to sensory pathways.

What are sensory pathways? Sensations (like pain, heat, touch, vibration) from all over the body travel up nerves to the spinal cord. From there they travel up the spinal cord to different centers in the brain. Strokes can affect those centers. As a result, the brain misinterprets normal sensory input as painful sensations.

Central pain is typically constant and moderate to severe in intensity. The pain may be felt over a large part of the body or in specific areas. It is always on the side of the body affected by the stroke. It may be felt as a burning pain, pins and needles, or a pressing, sharp or aching pain.

Pain medications may not be effective. However, anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) may help. Stress tends to increase the intensity of all symptoms. Therefore, managing stress may also help reduce pain.

Another stroke complication that causes pain is spasticity, an involuntary contraction of your muscles. This leads to stiff, tight muscles and tendons that make stretching difficult. Without treatment, the affected muscles may remain in abnormal and often painful positions. Treatments include:

• physical therapy that involves stretching the affected muscles and using braces that hold the muscles in a normal position;
• medications, including muscle relaxants and anti-anxiety drugs known as benzodiazepines.
• Botulinum toxin (Botox) injections, which can ease spasticity by blocking the signals sent from nerves to muscles. Injections of a different toxin, called phenol, reduce nerve impulses to the spastic muscle. A third possibility is an implanted pump that delivers a muscle relaxant to the spinal cord.

Finally, a doctor can surgically correct a tendon that has become contracted and permanently shortened due to spasticity. So you have many options to treat the pain you’re suffering following your stroke.

Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.