SECTION 4 Post-stroke pain

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Post-stroke pain Defining pain Facts about post-stroke pain Types of pain in stroke survivors Identifying pain in stroke survivors Pain assessment and pain scales

Defining pain Duration Acute pain - usually short lived. It comes from an event, such as surgery or trauma. If it is not treated properly, it may lead to chronic pain. 4

Defining pain Duration (cont’d) Chronic pain - usually lasts more than 3 to 6 months. It lasts longer than the time it takes a wound to heal. It may cause anxiety, fear, depression and sleeplessness. People with chronic pain may become cut off from others. 5

Defining pain Tissue damage leads to a pain that can be sharp, dull, or aching. Nerve damage can be in either the: Central nervous system (the brain and spinal cord) Peripheral nervous system (the nerves outside the central 6

Key point Pain is very common in stroke survivors. 7

Facts about post-stroke pain Pain can be present in: parts of the body with impaired mobility people with dementia or cognitive impairment people who are not conscious. 1 in 2 survivors have pain. 7 in 10 have untreated pain. 8

Facts about post-stroke pain If not treated properly, pain: Causes anxiety, sleep disturbances, memory problems, depression, impaired posture and reduced appetite Interferes with daily activities like going to the bathroom, dressing, and grooming Reduces the ability to move around, talk to other people and participate in recreational activities Increases irritability and causes people to refuse care 9

Types of pain in stroke survivors Central post-stroke pain - caused by damage to the brain or spinal cord from a stroke. The survivor may be in constant pain or might find that their pain comes and goes. It feels like burning, tingling, stabbing, or like acid under the skin. Physical activity, a light touch, stress, cold temperature, or a change in the weather can worsen the pain. 10

Types of pain in stroke survivors Central post-stroke pain (cont’d) The survivor may complain of pain: Where there is no visible tissue damage From a light touch, such as bedding touching the legs When pain is unusually severe – for example, when a person feels extreme pain after bumping their elbow 11

Types of pain in stroke survivors How you can help: Watch for symptoms that may indicate the stroke survivor is in pain. Acknowledge the survivor’s pain. Report the pain to the appropriate person, so that a specialized consultation can take place. 12

Types of pain in stroke survivors Hemiplegic shoulder pain - shoulder pain on the side affected by stroke caused by: Partial dislocation or shoulder subluxation Muscles that are contracted (spasticity) or limp (flaccidity) Shoulder or hand syndrome 13

Key point Identifying and treating shoulder pain early is important. Treatment is difficult and may be even more difficult after the pain is established. 14

Types of pain in stroke survivors Shoulder subluxation - Low-tone muscles around the shoulder allow the joint capsule to stretch and the shoulder joint to separate. 15

Types of pain in stroke survivors Shoulder subluxation How you can help: Always handle the shoulder carefully. This can help prevent painful stretching of shoulder muscles and ligaments. Support the shoulder joint appropriately when the survivor is walking, standing or sitting. If you are not sure about the care strategies, talk to members of the health care team. 16

Types of pain in stroke survivors Spasticity (high tone) - abnormally high muscle tone. It shortens the muscles and reduces the shoulder joint space How you can help:Treat the high-tone arm gently. This means: Not forcing the arm to move Applying prescribed splints properly for the correct length of time Using proper positioning If you are not sure about the care strategies, talk to members of the health care team. 17

Types of pain in stroke survivors Shoulder or hand syndrome - may begin with shoulder pain. The person can develop a stiff, swollen, and painful hand and wrist. How you can help Use recommended positioning to protect the affected arm and hand Use the prescribed exercises If you are not sure about the care strategies, talk to members of the team 18

Key point Failing to support the shoulder joint or pulling on the affected arm during transfers can cause the shoulder to partially dislocate. 19

Other shoulder and arm conditions Rotator cuff tear Tendonitis Shoulder bursitis Upper arm fracture 20

Identifying pain Stroke survivors may not say they are in pain – but they may express pain: Verbally Using pain words: burning, itching, throbbing Making sounds: moans, groans, grunts, cries, Exclamations and cursing: That hurts! Ouch! Stop that! 21

Identifying pain Physically Rubbing or massaging the painful area Bracing, holding, or guarding an area, especially when they move Frequent shifting, restlessness, rocking Impairment of bowel and bladder function 22

Identifying pain Through facial expressions Through behaviour changes Frowning Grimacing Wincing Through behaviour changes A usually restless survivor is quiet A usually quiet survivor is restless Change in appetite 23

Key point Pain assessment is completely subjective. There is only one person who knows how severe the pain is -- the person feeling it. 24

Pain assessment scale 25

Key point Be observant and recognize pain in the stroke survivors you care for. Up to 70% (7 out of 10) residents in long-term care homes have untreated pain. Pain is inevitable — suffering is optional. 26

How you can help Your knowledge of the individual survivor is an important tool in identifying pain. Ask survivors who report pain for more information: Ask yes or no questions Use simple words to help survivors identify the problem Point to areas that may be painful when asking questions 27

How you can help (cont’d) Ask about pain during or after movement Be patient and take time. Stroke survivors may need more time to explain what they feel Use a pain assessment scale regularly to track a survivor’s pain. Survivors whose pain is being treated may still experience pain 28

How you can help (cont’d) Discuss the survivor’s pain and pain management with the team. Ensure that pain management strategies and medication are adequate 29

Upon reflection Can you recall caring for a person in pain? How did you provide support? Some strokes affect how survivors communicate. Describe some ways they may indicate they have pain. If you find that someone you are caring for is in pain, what should you do? Who would you report it to? What strategies would you use to help someone with pain? 30