Persistent shoulder pain in the first 6 months after stroke: results of a prospective cohort study

Roosink M, Renzenbrink GJ, Buitenweg JR, Van Dongen RT, Geurts AC, IJzerman MJ. Persistent shoulder pain in the first 6 months after stroke: results of a prospective cohort study.

Objective

To identify factors associated with persistent poststroke shoulder pain (pPSSP) in the first 6 months after stroke.

Design

Prospective inception cohort study.

Setting

Stroke units of 2 teaching hospitals.

Participants

Patients (N=31) with a clinical diagnosis of stroke.

Interventions

Not applicable.

Main Outcome Measures

The development of pPSSP within the first 6 months after stroke. Clinical assessment of motor, somatosensory, cognitive, emotional, and autonomic functions, undertaken within 2 weeks (t0), at 3 months (t1), and at 6 months (t2) after stroke.

Results

Patients with pPSSP (n=9) were compared with patients without pPSSP (n=22). Bivariate logistic regression analyses showed that pPSSP was significantly associated with impaired voluntary motor control (t0, t1, t2), diminished proprioception (t0, t1), tactile extinction (t0), abnormal sensation (t1, t2), spasticity of the elbow flexor muscles (t1, t2), restricted range of motion (ROM) for both shoulder abduction (t2) and shoulder external rotation (t1, t2), trophic changes (t1), and type 2 diabetes mellitus (t0).

Conclusions

These findings suggest a multifactorial etiology of pPSSP. The association of pPSSP with restricted, passive, pain-free ROM and signs indicative of somatosensory sensitization may implicate a vicious cycle of repetitive (micro)trauma that can establish itself rapidly after stroke. Intervention should therefore be focused on maintaining and restoring joint ROM as well as preventing injury and somatosensory sensitization. In this perspective, strategies that aim to intervene simultaneously at various levels of function can be expected to be more effective than treatment directed at merely 1 level.     

High prevalence of pain in patients with cancer in a large population-based study in The Netherlands

At present, no definite conclusions can be drawn about the real extent of the pain suffered by cancer patients. A population-based study was conducted to obtain reliable information about the prevalence and severity of pain in cancer patients (all phases) and about predictors of pain. A representative sample of cancer patients was recruited in the area from a cancer registry. Pain was assessed by the Brief Pain Inventory (BPI). Adequacy of pain treatment was assessed with the Pain Management Index (PMI). We found that 55% of the 1429 respondents had experienced pain past week; in 44% (n=351), the pain was moderate to severe (BPI score>or= 4). Total prevalence of pain/moderate to severe pain was present in 49%/41% in patients with curative treatment >or=6 months ago, 57%/43% in patients with current curative treatment or treatment <6 months ago, 56%/43% in patients with current palliative anti-cancer treatment and in 75%/70% in patients for whom treatment was no longer feasible. Positive predictors of the prevalence of pain were lower education level, more advanced disease and haematological (excluding (non)-Hodgkin lymphoma), gastro-intestinal, lung, or breast malignancies. According to the PMI, analgesic treatment was inadequate in 42% of the patients. Negative predictors of adequate treatment were current curative anti-cancer treatment and low education level. CONCLUSION: A substantial proportion of cancer patients does suffer from moderate to severe pain and does not receive adequate pain treatment.     

Central poststroke pain: a population-based study

Central poststroke pain (CPSP) is a specific pain condition arising as a direct consequence of a cerebrovascular lesion. There is limited knowledge about the epidemiology and clinical characteristics of this often neglected but important consequence of stroke. In this population-based study, a questionnaire was sent out to all (n = 964) stroke patients identified through the Danish National Indicator Project Stroke Database in Aarhus County, Denmark, between March 2004 and February 2005. All surviving patients who fulfilled 4 questionnaire criteria for possible CPSP (n = 51) were selected for further clinical examination, and their pain was classified by using stringent and well-defined criteria and a detailed, standardized clinical examination. The minimum prevalence of definite or probable CPSP in this population is 7.3% and the prevalence of CPSP-like dysesthesia or pain is 8.6%. Pinprick hyperalgesia was present in 57%, cold allodynia in 40%, and brush-evoked dysesthesia in 51% of patients with CPSP. Because of its negative impact on quality of life and rehabilitation, pain is an important symptom to assess in stroke survivors.     

Characteristics of the Frenchay Activities Index one year after a stroke: A population-based study

Purpose.?To further describe the properties of Frenchay Activities Index (FAI) with special emphasis on relationships with stroke severity and cognition.

Methods.?Survivors from a population-based first-ever stroke cohort (n = 246) were assessed with FAI one year post-stroke. At the same time patients were asked about their status pre-stroke. Stroke severity was assessed at baseline with the NIH stroke scale (NIHSS). Cognition was assessed at one year with the Mini Mental State Examination (MMSE).

Results.?Pre-stroke and post-stroke FAI averaged at 40.1 and 32.4, respectively. There was a floor effect post-stroke, where 17% had the lowest possible score. The sum score was related to age, but not to gender. Individual items, however, were gender-related. NIHSS was clearly related to the difference FAI pre-stroke – post-stroke, but individual variations were large. Individual NIHSS items differed regarding their impact on post-stroke FAI. MMSE post-stroke also has a clear relationship with FAI, but there are large individual variations.

Conclusions.?This study establishes a population-based standard for FAI scores one year after a stroke. The effects of stroke severity and cognition have been demonstrated. FAI gives useful information that is not obtained from basic ADL scales, such as the Barthel Index.     

Characteristics of the Frenchay Activities Index one year after a stroke: a population-based study

Purpose. To further describe the properties of Frenchay Activities Index (FAI) with special emphasis on relationships with stroke severity and cognition.

Methods. Survivors from a population-based first-ever stroke cohort (n = 246) were assessed with FAI one year post-stroke. At the same time patients were asked about their status pre-stroke. Stroke severity was assessed at baseline with the NIH stroke scale (NIHSS). Cognition was assessed at one year with the Mini Mental State Examination (MMSE).

Results. Pre-stroke and post-stroke FAI averaged at 40.1 and 32.4, respectively. There was a floor effect post-stroke, where 17% had the lowest possible score. The sum score was related to age, but not to gender. Individual items, however, were gender-related. NIHSS was clearly related to the difference FAI pre-stroke - post-stroke, but individual variations were large. Individual NIHSS items differed regarding their impact on post-stroke FAI. MMSE post-stroke also has a clear relationship with FAI, but there are large individual variations.

Conclusions. This study establishes a population-based standard for FAI scores one year after a stroke. The effects of stroke severity and cognition have been demonstrated. FAI gives useful information that is not obtained from basic ADL scales, such as the Barthel Index.     

Prevalence and predictors of pain and fatigue after stroke: a population-based study

Pain and fatigue are two often overlooked symptoms after stroke. Their prevalence and determinants are not well understood. In this study patients with first-ever stroke (n=377) were examined at baseline and after 1 year. General characteristics of the patients, as well as stroke type, stroke severity and risk factors were registered at baseline. After 1 year survivors (n=253) were examined with respect to residual impairment, disability, cognition and depression. They were asked whether they had experienced pain and/or fatigue which had started after the stroke, and which the patient felt to be stroke related. Twenty-eight patients (11%) had stroke-associated pain and 135 (53%) had stroke-associated fatigue. Pain was associated with depression and different manifestations of stroke severity, especially degree of paresis at baseline. Fatigue was more associated with physical disability. In univariate analysis, fatigue was also associated with sleep disturbances. In conclusion, it is important to be aware of the occurrence of pain and fatigue after stroke, because these symptoms are common, they impair quality of life and they are potentially treatable. Post-stroke depression may coexist with pain and fatigue. The detection of one symptom should lead to consideration of the others. Follow-up and individual assessment of stroke patients is crucial.     

Arm motor control as predictor for hypertonia after stroke: a prospective cohort study

de Jong LD, Hoonhorst MH, Stuive I, Dijkstra PU. Arm motor control as predictor for hypertonia after stroke: a prospective cohort study.

Objectives

To analyze the development of hypertonia in the hemiparetic elbow flexors, and to explore the predictive value of arm motor control on hypertonia in a cohort of first-ever stroke survivors in the first 6 months poststroke.

Design

A prospective cohort study.

Setting

A cohort of stroke survivors from a large, university-affilliated hospital in The Netherlands.

Participants

Patients (N=50) with first-time ischemic strokes and initial arm paralysis who were admitted to a stroke unit.

Interventions

Not applicable.

Main Outcome Measures

At 48 hours, 10 to 12 days, 3 and 6 months poststroke, hypertonia and arm motor control were assessed using the Modified Ashworth Scale and the Fugl-Meyer Assessment arm score.

Results

The incidence rate of hypertonia reached its maximum before the third month poststroke (30%). Prevalence was 42% at 3 and 6 months. Participants with poor arm motor control at 48 hours poststroke were 13 times more likely to develop hypertonia in the first 6 months poststroke than those with moderate to good arm motor control. These results were not confounded by the amount of arm function training received.

Conclusions

Hypertonia develops in a large proportion of patients with stroke, predominantly within the first 3 months poststroke. Poor arm motor control is a risk factor for the development of hypertonia.     

Addictive behaviors related to opioid use for chronic pain: A population-based study

The growing body of research showing increased opioid use in patients with chronic pain coupled with concerns regarding addiction encouraged the development of this population-based study. The goal of the study was to investigate the co-occurrence of indicators of addictive behaviors in patients with chronic non-cancer pain in long-term opioid treatment. The study combined data from the individual-based Danish Health Survey in 2010 and the official Danish health and socio-economic, individual-based registers. From a simple random sample of 25,000 adults (16 years or older) living in Denmark, 13,281 individuals were analyzed through multiple logistic regression analyses to assess the association between chronic pain (lasting ?6 months), opioid use, health behavior, and body mass index. Six potential addictive behaviors were identified: daily smoking; high alcohol intake; illicit drug use in the past year; obesity; long-term use of benzodiazepines; and long-term use of benzodiazepine-related drugs. At least 2 of the 6 addictive behaviors were observed in 22.6% of the long-term opioid users with chronic pain compared with 11.5% of the non-opioid users with chronic pain and 8.9% of the individuals without chronic pain. Thus, a strong association was demonstrated between long-term opioid use and the clustering of addictive behaviors. An intricate relationship between chronic pain, opioid use, and addictive behaviors was observed in this study, which deserves both clinical attention and further research.     

Self-reported urinary incontinence in noninstitutionalized long-term stroke survivors: A population-based study

OBJECTIVES: To compare the prevalence of self-reported incontinence among noninstitutionalized long-term stroke survivors with population controls without stroke and to identify risk factors associated with urinary incontinence in the stroke survivors. DESIGN: Community-based, cross-sectional study. SETTING: Municipality of Tronso. PARTICIPANTS: A total of 213 noninstitutionalized stroke survivors (mean time poststroke, 9y) and 242 control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Self-reported presence of urinary incontinence. RESULTS: Urinary incontinence was present in 17% of the stroke survivors and in 7% of the control subjects (odds ratio [OR]=2.8; 95% confidence interval [CI], 1.5-5.2) and more prevalent among the stroke survivors than among the control subjects until 10 years poststroke. In the stroke survivors, urinary incontinence was associated with signs of depression (OR=3.0; 95% CI, 1.3-7.1) and tended to be associated with motor function of the leg (OR=3.1; 95% CI, 0.9-10.4) and cognitive function (OR=2.8; 95% CI, 0.9-8.6). Urinary incontinence was strongly related to the number of these risk factors present ( P trend, <.001; OR=7.2; 95% CI, 2.1-24.6) in subjects having 2 or more of the risk factors, compared with subjects with none of these risk factors). CONCLUSIONS: The prevalence of urinary incontinence is high among long-term stroke survivors, especially in subjects in whom paresis, depressive symptoms, and impaired cognition cluster.     

Video education for critical care nurses to assess pain with a behavioural pain assessment tool: A descriptive comparative study

AimTo evaluate the impact of video education on critical care nurses’ knowledge and skills in using a behavioural pain assessment tool for intensive care patients and to explore the nurses’ experiences with video education.MethodsForty-eight nurses in one intensive care unit watched an educational video on the use of the Critical-Care Pain Observation Tool, then assessed pain in two patients with the tool and took a knowledge test. The researcher made parallel pain assessments. Interrater reliability of patients’ pain assessment between nurses and the researcher was determined to examine nurses’ skills in using the tool after education. Twenty nurses were interviewed about their experiences with the video education. Interviews were analysed with deductive thematic analysis.ResultsThe knowledge test scores indicated that the nurses learned the principles of how to use the tool. The interrater reliability of pain assessments reached a moderate level of agreement during the painful procedure, with a weighted kappa coefficient value of 0.48, CL [0.37, 0.58]. The nurses perceived video education positively, but requested additional interaction.ConclusionsVideo education is useful in teaching the principles of using a pain assessment tool. Additional clinical training is required for nurses to reach adequate skills in using the tool.     

Dry needling for the management of spasticity,pain, and range of movement in adults after stroke: A systematic review

ObjectiveTo summarise the available evidence about the effectiveness of deep dry needling (DN) on spasticity, pain-related outcomes, and range-of-movement (ROM) in adults after stroke.DesignA computer search of Web of Science, Scopus, Medline, Cochrane Library, Cinahl, and Physiotherapy Evidence Database (PEDro) was conducted. A hand search of the reference lists of the selected studies and other relevant publications was also undertaken. Studies were assessed by two independent reviewers and included if they complied with the following criteria: (1) participants were adults after a stroke, (2) use of DN alone or within a multimodal approach, compared to no intervention or other treatments; (3) assessment of spasticity, pain, or joint ROM as a primary or secondary outcome. We included randomised controlled trials (RCTs), case series, and case reports. Data were extracted using a standardised protocol. The methodological quality of the studies was assessed with the Checklist for Measuring quality.ResultsA total of sixteen studies, 7 of which were RCTs, were selected. All studies generally reported an improvement of spasticity level, pain intensity, and ROM after the use of DN, alone or combined with other interventions, in stroke survivors.ConclusionThe management of adults after stroke with DN may impact positively on spasticity, pain, and ROM. However, there was significant heterogeneity across trials in terms of sample size, control groups, treated muscles, and outcome measures, and a meta-analysis was not feasible. Further research should include proper blinding, sham placebo DN as control intervention, and investigate long-term effects.     

Musculoskeletal pain associated with recreational yoga participation: A prospective cohort study with 1-year follow-up

Background

Yoga is a popular complementary therapy for musculoskeletal pain. There are few studies however, that have examined the risks of recreational participation for causing musculoskeletal pain.

Association between glenohumeral subluxation and hemiplegic shoulder pain in patients with stroke

Abstract

Background: Glenohumeral subluxation (GHS) and hemiplegic shoulder pain (HSP) are the most common musculoskeletal complications reported in patients with stroke. These secondary problems present considerable challenges to the rehabilitation of the upper limb.

Objective: The aim of this review was to evaluate the evidence on the association between shoulder subluxation and pain in patients with stroke.

Method: A systematic online search was conducted of MEDLINE, EMBASE, CINAHL, AMED, Biomed Central, and the Cochrane Library. The search was supplemented by hand searching of relevant journals and citation tracking of the retrieved papers. All primary studies published in English language fulfilling the review’s inclusion criteria were included. Five reviewers independently appraised the methodological quality of the selected studies. Any discrepancies were resolved following discussions.

Results: Of the 148 articles that were identified by the search, 14 studies met the criteria to be included in the review. Seven studies found an association and seven studies did not find an association between subluxation and pain. The methodological quality of the studies varied considerably and studies used a wide range of outcome measures to assess both subluxation and pain.

Conclusions: Irrespective of any association, both subluxation and pain can independently have an impact on functional rehabilitation. Management of these clinical outcomes is critical in clinical practice and clinicians should continue to prevent and reduce these post-stroke secondary complications to enhance upper limb function.     

Prevalence of pain in adults admitted to Catalonian hospitals: A cross-sectional study

OBJECTIVE: To survey the prevalence of pain in patients admitted to different hospitals of Catalonia and to describe which factors are related to pain. METHODS: A cross-sectional study was performed in 1675 patients from fifteen hospitals in Catalonia (Spain). Clinical and demographic data, as well as the existence of pain intensity evaluations and analgesic therapy, were obtained from medical charts. Characteristics of pain were given by patients after being interviewed by trained interviewers. The main-outcome measure was the existence of pain (at the interview, in the previous 24h, at the admission and at any time after admission) that was assessed by a visual analogue scale (VAS). The relationship of prevalence of pain to patients' characteristics was carried out by means of a multiple-logistic-regression model with pain presence as the dependent variable of interest. RESULTS: A great variability in the prevalence and intensity of pain among different hospitals was observed. At the time of the interview, 48.5% (95% CI: 46.1-50.9%) of the patients had pain and the median VAS was 40mm (range: 10-100mm), and the prevalence of pain during the previous 24h was similar (47.6%; 95% CI: 45.2-50%). At admission, 26.7% (95% CI: 24.6-28.8%) of patients were in pain, whereas 62% (95% CI: 59.7-64.3%) reported having pain at some time during their stay. Pain intensity annotations were absent in 51.3% (95% CI: 47.9-54.7%) of the medical records of the patients with pain. The factors associated with pain were younger age, female gender, presence of surgery, orthopaedic surgery wards, large hospital and prescribed analgesics. CONCLUSION: A high prevalence of clinically relevant pain in in-patients was found as well as a great variability according to type of patients, clinical wards and hospitals. This study gives clear evidence of the lack of adequate management of pain in the majority of the hospitals and calls for the implementation of organisational and educational measurements that may settle this epidemic problem.