Management of Central Poststroke Pain

Abstract

C entral poststroke pain (CPSP) is a chronic (≥3 months) neuropathic disorder that can occur after a lesion or disease affecting the central somatosensory system. 1 The pain may be spontaneous, occurring either constantly or intermittently, or evoked in response to external stimuli.1 It may develop immediately after a stroke, or years later. [2][3][4][5] To date, the largest prospective study, which enrolled 15 754 participants with ischemic stroke from 35 countries, found that 2.7% of patients developed CPSP at 1 year after stroke.6 Because CPSP case definition is complex, 1 however, its reported prevalence is variable, and dependent on the site of lesion: 1 study, for instance, found that 25% of patients with brain stem infarcts developed CPSP within 6 months. 4 Individuals with CPSP commonly experience sensory abnormalities, including increased tactile and thermal sensitivities, which impair their quality of life. [7][8][9] The underlying mechanisms of CPSP are poorly understood, 1 contributing to challenges in its management.There are several pharmacological and nonpharmacological therapies available for patients with CPSP; few systematic Background and Purpose-Central poststroke pain is a chronic neuropathic disorder that follows a stroke. Current research on its management is limited, and no review has evaluated all therapies for central poststroke pain. Methods-We conducted a systematic review of randomized controlled trials to evaluate therapies for central poststroke pain. We identified eligible trials, in any language, by systematic searches of AMED, CENTRAL, CINAHL, DARE, EMBASE, HealthSTAR, MEDLINE, and PsychINFO. Eligible trials (1) enrolled ≥10 patients with central poststroke pain; (2) randomly assigned them to an active therapy or a control arm; and (3) collected outcome data ≥14 days after treatment. Pairs of reviewers, independently and in duplicate, screened titles and abstracts of identified citations, reviewed full texts of potentially eligible trials, and extracted information from eligible studies. We used a modified Cochrane tool to evaluate risk of bias of eligible studies, and collected patient-important outcomes according to recommendations by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. We conducted, when possible, random effects meta-analyses, and evaluated our certainty in treatment effects using the Grading of Recommendations Assessment, Development, and Evaluation System. Results-Eight eligible English language randomized controlled trials (459 patients) tested anticonvulsants, an antidepressant, an opioid antagonist, repetitive transcranial magnetic stimulation, and acupuncture. Results suggested that all therapies had little to no effect on pain and other patient-important outcomes. Our certainty in the treatment estimates ranged from very low to low. Conclusions-Our

Nonpharmacological therapies for central poststroke pain

“…[ 31 – 33 ] However, a recent systematic review found no evidence that anticonvulsants or tricyclic antidepressants are effective for CPSP. [ 13 ] In addition, evidence-based studies have indicated that, for most CPSP patients, pharmacological treatment is insufficient to relieve pain, even with high doses of different drugs. [ 2 , 34 – 37 ] Thus, the aim of the present study was to assess all evidence-based nonpharmacological therapies, in the hope that an effective treatment option for CPSP would be identified.…”

“…[ 10 ] Several nonpharmacological therapies have also been demonstrated to be effective for patients with CPSP in clinical trials; [ 9 , 11 , 12 ] however, few systematic reviews have summarized their effectiveness and safety. [ 10 , 13 ] Hence, this systematic review was conducted to evaluate the efficacy and safety of nonpharmacological therapies for controlling CPSP, based on scientific evidence.…”

Meta-Analysis: A Review Article

“…This should demonstrate the identification and screening of available studies and also determines the final number of studies included for statisti-cal analysis. As an example, Mulla et al performed a meta-analysis of randomized controlled trials to evaluate therapies for central post stroke pain (10) . The study flow chart can be seen in Figure 1.…”

Gabapentin and pregabalin in the pain setting: All you need to know

“…A large systematic review conducted by Mulla et al (2015) suggested over-statement of many studies regarding the effect(s) of all interventions for central neuropathic pain, including for the anti-convulsants. Publication bias is also acknowledged by Finnerup et al (2015) regarding drugs used in neuropathic pain by up to 10%.…”