After a stroke, around 30% of survivors experience pain. This is most likely to happen soon after a stroke, but can also develop sometime later. Types of post-stroke pain include muscle and joint pain such as spasticity and shoulder pain. Headaches are more common soon after a stroke but should reduce over time. Some people get painful sensations like tingling, known as central post-stroke pain.
If you are in pain after a stroke, try speaking to your GP or stroke nurse. The pain could be related to the stroke, or it could have another cause. You need help to find out why it is happening, and get the best treatment to reduce your pain.
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Pain in your joints and soft tissues (spasticity and contractures)
Spasticity and contractures
A stroke can damage the way the nerves control your muscles. This can lead to muscles contracting for long periods or going into spasm, which can be painful. This muscle tightness is known as spasticity or hypertonia.
A stroke can cause muscle weakness down one side, also known as hemiparesis. Spasticity affects the weakened muscles, often in the arms and hands, but also in the legs. Up to a third of stroke survivors experience spasticity. If it’s not treated, spasticity can lead to the muscles being permanently shortened. The joints and muscles can become so stiff that it is impossible to move them, causing a contracture.
How is spasticity treated?
If you have muscle weakness after your stroke you should be assessed for spasticity, and receive therapy to reduce the risk of contractures. Treatments may include a combination of physiotherapy, injections of botulinum toxin type A, and other medications.
If you have spasticity you should have physiotherapy every day to move your joints. This will help to stretch your muscles, keeping them flexible and reducing the possibility of contractures. Your physiotherapist will gently place your affected limb into as many different positions as possible using techniques called positioning, passive movement and active movement.
Botulinum toxin type A
You may be given botulinum toxin type A as an injection directly into your muscle. The main brand names used for this treatment are Botox, Dysport and Xeomin. Botulinum toxin type A works by blocking the action of the nerves on the muscle, reducing your muscle’s ability to contract. This reduces muscle tone (makes the muscle less tight), which can help you to straighten out your limbs.
This treatment is mainly used for post-stroke spasticity in the hands, wrists and ankles. The muscle-relaxing effects of botulinum toxin type A usually last for about three months, and you shouldn't notice any changes in sensation in your muscles.
The treatment should be given with further rehabilitation such as physiotherapy, or other treatments like splinting or casting to ensure that any range gained in the muscle is maintained. You should also have an assessment three to four months after the treatment, and be offered further injections if they are considered helpful.
If you have generalised spasticity, or if botulinum toxin A treatment doesn’t reduce spasticity in the injected muscle, other types of medication can help reduce the stiffness and pain that often comes with spasticity.
There are different types of drugs that you could be given. They all work in slightly different ways, but they all help to relax your muscles. When your muscles are relaxed they can move more easily and you can stretch them further. You may also find that it becomes easier to straighten or bend your affected limbs, and you may notice fewer muscle spasms.
You will usually be prescribed baclofen or tizanidine first. If these drugs don’t work, there are other drugs that may help, but they should only be prescribed by someone who specialises in managing spasticity.
How are contractures treated?
If you develop contractures, your physiotherapist may use a splint or a cast that moulds to or lies along your affected limb and holds it in place. This treatment helps to stretch out the muscles in your tight limbs and is usually combined with physiotherapy.
Sometimes this treatment is used to try to prevent contractures from forming by making sure that your body is not in an abnormal position. Unfortunately, sometimes splints and casts can be uncomfortable. Talk to your physiotherapist about what would be best for you.
Shoulder pain after stroke
Shoulder pain affects up to a quarter of stroke survivors and usually happens on the side of your body that is affected by the stroke. There are many different conditions that cause shoulder pain and while some improve with targeted treatment, it sometimes becomes a long-term condition.
After a stroke, you may find that your shoulder is very stiff and that it hurts when you move it. This is called frozen shoulder, or capsulitis. The shoulder is a ‘ball and socket’ joint, with a rounded shape at the end of the upper arm fitting into a hollow space in the shoulder blade. Muscles and ligaments hold the arm bone in place. There is a layer of tissue that surrounds this joint which is called a capsule.
If your arm muscles are very weak, stiff or paralysed, the effect of gravity puts a strain on your ligaments and your capsule. This can cause these parts of your shoulder joint to become inflamed, stretched and damaged. Having weakness in your arm muscles may contribute to this pain in your shoulder.
Another cause of shoulder pain is shoulder subluxation. This means partial dislocation, when the rounded end of the upper arm bone moves slightly out of its socket. This might be because the muscles that normally hold this joint in place are too weak to do this properly.
How is shoulder pain treated?
If you have weakness in your arm following your stroke, your medical team will try to prevent shoulder pain developing. They will make sure that anyone who handles your arm knows how to do so with care and without causing strain on your shoulder joint.
They should also ensure that your arm and shoulder are positioned correctly. Correct positioning is vital because it can help to reduce the strain on your ligaments and capsule, helping to prevent frozen shoulder from developing. It may also help to prevent your shoulder blade and upper arm bone from moving apart (subluxation). Your medical team may use foam supports to make sure that your shoulder is supported in the correct position. Your arm can also be supported using a pillow.
Shoulder taping or orthotic supports may be useful. However, they should be prescribed by your therapist, with clear guidance on usage. Supports should be regularly monitored and should not stop you moving your arm.
Your physiotherapist may also use electrical stimulation on the muscles around your shoulder to help prevent or reduce subluxation. If this is prescribed, the device often needs to be used throughout the day, following the advice of your therapist.
You may be given painkillers such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen.
If you also have inflammatory arthritis, a steroid may be injected into your joint to help reduce the pain.
Moving your shoulder
It is important to keep the muscles in your shoulder and arm active so that any stiffness does not get worse. Your physiotherapist may use stretching exercises to move your shoulder joint in all directions. They can also provide you with advice about how to protect your shoulder during everyday movements such as reaching for something or getting dressed.
Central post-stroke pain (CPSP)
Up to 20% of people who have a stroke may develop central post-stroke pain (CPSP). This problem may occur if structures in the brain that interpret pain are affected by the stroke. It’s often diagnosed by excluding other more common causes first. This is also known as neuropathic pain, or central pain syndrome.
There are different types of pain you might experience if you have CPSP. Many people describe it as a burning or burning cold sensation or a throbbing or shooting pain. Some people also experience pins and needles or numbness in the areas affected by the pain. For most stroke survivors with CPSP, the pain occurs in the side of their body that has been affected by the stroke. The pain may begin immediately after your stroke but more often it begins several months later. Some people find this pain becomes worse because of other factors such as movement or a change in temperature.
How is CPSP treated?
Ordinary painkillers such as paracetamol or ibuprofen are not helpful in relieving CPSP. Some other types of drug can be helpful, including antidepressants and anti-epilepsy drugs. If the first medication you try does not work, you should be offered another drug to try with, or instead of, the first one.
Other approaches to reducing pain include pain clinics and TENS (transcutanious electrical nerve stimulation.
In rare cases, if your pain is severe and other treatments have been unsuccessful, you may be offered deep brain stimulation (DBS). This is a procedure where small electrical leads are placed deep within your brain and are connected to a battery-powered machine, which sits under your skin. This procedure can only be carried out in specialist centres and is not routinely available on the NHS. It is not suitable for everyone, and success rates after one year of treating pain with DBS are still very variable.
Other painful conditions
Developing a swollen hand can happen if you are not moving your hand very much, or are unable to move it. Older patients and those who have experienced more severe strokes are most likely to experience this condition. The swelling may happen because fluid builds up in the tissue if the muscles are not moving around. It’s more likely to happen if the hand is hanging downwards. The painful swelling can make it more difficult to move your hand and arm, which can make spasticity worse.
Supporting your hand in a raised position on a pillow or a cushion can help, along with advice from a physiotherapist.
There are many reasons why you might experience headaches following your stroke. Find out more information about headaches after stroke here.
Alternative methods of treating pain
If you find that medication and or physiotherapy has not helped to relieve your pain, you may wish to try some alternative techniques. You may gain temporary relief from TENS, massage or acupuncture. Learning a relaxation technique, such as meditation or yoga, having psychological therapy such as counselling, or attending a pain clinic may be helpful.
Transcutaneous electrical nerve stimulation (TENS)
TENS treatment uses electrical impulses to reduce pain. Sticky pads are attached to your skin and linked to electrodes, which are attached to a battery-operated machine. Electrical impulses are then sent through the electrodes onto your skin. These impulses can help to block the pain signals from travelling along the nerve pathways to your brain. At a low frequency, TENS can help your body to release natural painkillers called endorphins.
There is not enough evidence to say definitively whether TENS is an effective and reliable way of reducing pain. It provides temporary pain relief with no side effects, other than possible skin redness. You should ask your doctor before using it if you have a heart pacemaker or other type of electrical or metal implant in your body. It may not be suitable early in pregnancy, or for people with epilepsy or heart problems.
Pain clinics and pain management programmes
Pain clinics and pain management programmes can help you find ways to manage your pain in the longer-term to improve your quality of life. If you are in pain despite the initial treatment, and it's causing you distress or significantly limiting what you're able to do, ask your GP to refer you to a pain clinic.
Pain clinics provide different treatments and advice to help you manage your pain. The kinds of treatment that are available from pain clinics vary across the UK.
Some pain clinics run pain management programmes. They use psychological and practical methods to deal with managing your pain, and the effect that it has on your life. Carried out in groups, the programmes usually run for a set amount of time over a number of weeks. Doctors, nurses, psychologists, physiotherapists and occupational therapists may be involved with the programme. For example, a physiotherapist might help you to work on the physical difficulties that the pain causes by strengthening your muscles, and a psychologist might help you to manage the emotional effects that pain can have, such as depression and frustration.