Chronic pain after brain injury

Introduction

Chronic pain during and after brain injury is common.

This not only concerns headaches, but also pain throughout the body.
Chronic pain means constant pain. On this page we discuss most of the pain syndromes that can occur after brain injury.

The links on this page refer to more information on this page or on another page of this website.

After a stroke / CVA, for example, about half of those affected have chronic pain. About 70% of these people are in pain every day. Specific pain syndromes are known after a stroke. We discuss these on this page.

After traumatic brain injury, more than half of people have chronic pain complaints.

In people with traumatic brain injury, headache is the most commonly mentioned complaint. Followed by pain in the neck, shoulder, back, arms and legs. Headache complaints and irritability are often signals that the load capacity has been exceeded.

The most common pain syndromes after brain injury

Click on the link of the topic of your choice:

• central pain syndrome after a stroke/CVA (post stroke pain)
  
  • Déjerine-Roussy syndrome or thalamic pain
  • central pain syndrome in Wallenberg syndrome
• complex regional pain syndrome (CRPS)
  
  • shoulder-hand syndrome with half-sided failure
• pain due to spasticity
• headache/neck pain
• neuropathic pain, pain in damaged nerve pathways, numbness, prickling, tingling, intense stabbing, shooting or burning pain or a 'freezing' feeling.
  • hyperesthesia/hyperalgesia Hypersensitivity to pain, feeling too much pain due to changes in nerve pathways. For example when touching the paralyzed half of the body.
• pain in bones, muscles and tendons (musculoskeletal pain):
  • shoulder pain
    • shoulder subluxation With a subluxation of the shoulder joint, the upper arm partially dislocates. This is common shortly after a stroke. The weakened muscles and low muscle tone (tonus) cause a gradual overload of the joint capsule. This can then lead to an incorrect position of the head of the upper arm (humerus). This can cause the arm to dislocate.
  • tense muscles of the shoulder girdle. pain between shoulder
  • blades forced position of joint or muscles/contractures.  In case a person cannot move or cannot move with difficulty due to the brain injury, joints and muscles can become very stiff. The muscles shrivel and therefore become shortened. This can cause a forced position or contracture, a restriction of movement in the joint or in the muscles. Over time, a person can no longer use the muscles properly or stretch the arm or fingers.
    A contracture or forced position is very painful. It hinders normal functioning. Examples: a hand that is in a forced fist position can no longer be used. A stuck shoulder means getting dressed and grabbing something no longer possible.
  • bone fractures at the time of the injury, such as a broken neck.
  • Fibromyalgia is a condition that causes pain in connective tissue and muscles. This concerns the parts of the musculoskeletal system. A study using brain scans has shown that patients with fibromyalgia have abnormalities blood flow in the brain can be seen. Researchers from the University Medical Center in Marseille believe that fibromyalgia is associated with a problem with processing pain in the brain, or a dysfunction of cerebral pain processing. There is no evidence yet that brain injury is a cause.

Pain syndromes highlighted

We discuss some pain syndromes from the menu above.

Central pain syndrome / Post stroke pain

Post stroke pain is chronic nerve pain after a cerebral infarction or cerebral hemorrhage (stroke / CVA). It is also called central pain syndrome or 'central post stroke pain' (CPSP). It is a neuropathic pain syndrome.

Characteristics

The nerve pain (neuropathic pain/neuropathy) can be constant or variable in a small or larger area of the body. There may also be changes in sensory perception such as numbness, pricking, tingling, or severe sensations stabbing, shooting or burning pain or a 'freezing' feeling.
Normal touch can also be experienced as painful, as can feeling pressure from clothing or duvet or even the feeling cold. When normal pricks are experienced painfully, this is called 'allodynia' or increased pain sensitivity: 'hyperalgesia/hyperesthesia'. This sensitivity to pain is due to changes in nerve pathways.
Changes in the weather or certain movements or activities can further worsen the pain.

Pain as a direct result of the brain injury

After a cerebral hemorrhage or a cerebral infarction, long-term (chronic) pain complaints may occur on the opposite side of where
the injury is located. The medical term for the side opposite to where the injury is located is contralateral. If the stroke ocurred in the left hemisphere of the brain, the pain on the right side can be felt in the body.

Vice-versa: a stroke in the right hemisphere can cause pain in the left side of the body.
Only with injuries to the medulla oblongata does the pain usually occur on the same side as the injury. This is called ipsilateral pain complaints.
Sometimes the pain is present immediately after the brain injury, sometimes it appears after a while.
The sensory nerves may be affected, but the pain-relieving nerve pathways may also be damaged.
If nerve pathways and nerve fibers are damaged, they can also become hypersensitive (denervation sensitivity). This is how the central pain syndrome can arise.

Treatment

It is difficult to treat this pain with medication, which is why a special rehabilitation program is often recommended for these pain complaints.
Medicinal neuropathic pain control can be divided into:

• antiepileptic drugs (medications originally intended to treat epileptic seizures)
  
• anti-depressants (medications used for depression)
  
• opiates
• medicinal cannabis (specifically: bediol granules). However, this is very expensive and is not reimbursed by the health insurer.

Side effects of medications

Most of these medications have serious side effects such as concentration problems, drowsiness, alienated feelings, weight gain, dry mouth and problems urinating. Driving a car is not recommended during the first period.
In general, people with brain damage are not better off when they become more drowsy or have concentration problems exacerbated by medication.

Alternatives to medications

Sometimes pain relieving creams such as Phenytoin cream and capsaicin cream/capsaicin patch help. Capsaicin prevents pain
sensory stimuli are passed on to the brain. Sometimes there is the possibility of deep brain stimulation (deep brain stimulation/DBS). Then a tiny electrode is placed in the brain that sends electrical signals to the cell ends sends, who perceive pain. These are the so-called pain receptors or nociceptors. The perception of pain may then decrease. This doesn't help everyone.

Déjerine-Roussy syndrome - Thalamic pain syndrome

If the central pain syndrome occurs after a cerebral hemorrhage or cerebral infarction in the thalamus, it is called Déjerine-Roussy syndrome or thalamic pain syndrome.
The thalamus is an important brain nucleus. There are numerous connections to and from the cerebral cortex.
The often intense pain is palpable on the opposite side of the body (contralateral) to where the stroke occurred, i.e. one half of the body. The pain can be local or felt in a larger area in the legs, arms, or face.
As the initial symptoms of a stroke (numbness and tingling) disappear, a burning pain, or tingling, often remains a tingling sensation or shooting pain. Sometimes the pain changes during the day.

The syndrome is characterized by two forms:
allodynia in which the slightest touch or pressure (for example from a sock or a sheet) causes pain
dysesthesia where the neuropathic pain may be a combination of itching, tingling or burning sensation.

Central pain syndrome after stroke in the medulla oblongata - lateral medullary infarction of Wallenberg

Central pain syndrome can also occur after a stroke (CVA) in the medulla oblongata. This is also called 'central post stroke pain/CPSP in Wallenberg syndrome'. The Wallenberg syndrome is also called the PICA syndrome or lateral medullary syndrome. 

The lateral medulla is the medical term for the medulla oblongata. PICA refers to the abbreviation of the name of the artery: posterior inferior cerebellar artery. That is a branch of the vertebral artery.
The central pain syndrome in Wallenberg syndrome was found in 44% of patients in a specific study to occur. Some people developed this pain in the acute phase within a few days after the stroke. Other people had this pain syndrome in the subsequent phase (within 10 days to months after the stroke). Some had severe stabbing pain.
Most people had this pain syndrome on the affected side. That's called ipsilateral pain. So in the body half where people actually have less feeling in the arm, leg and half of the face.
We have a specific page about Wallenberg syndrome.

Complex regional pain syndrome (CRPS)

In complex regional pain syndrome (CRPS), there is a dysregulation of the nervous system that is accompanied by inflammatory symptoms. This causes severe, constant, burning pain in the affected arm or leg.

CRPS is a result of a variety of diseases including brain injury. CPRS used to be called 'post-traumatic or Sudeck dystrophy' in case it occurred after injury, for example after a bone fracture or limb contusion.

Causes of complex regional pain syndrome

CRPS can be caused by changes in movement of the upper arm in the shoulder socket after a stroke/CVA. The head of the upper arm can also quickly dislocate (subluxation). The less a person can move his or her shoulders, the greater the chance of developing CRPS. The joint between the shoulder blade and the upper arm (glenohumeral joint) normally ensures that the upper arm can move in the shoulder socket.

With CPRS there is no damage to the tendon, nerve or muscle tissue that can explain the pain. However, microdamage to nerve tissue in people with brain damage cannot be ruled out, but it is difficult to diagnose.
An increased sensitivity of the brain to pain may be a cause. The pain pathways in the brain that are supposed to dampen pain stimuli function less well in CRPS patients. Patients with complex regional pain syndrome (CRPS) also had changes in tactile sensitivity. There is clear evidence that chronic pain can alter the processing of sensation and movement. One study showed that blood flow to the thalamus undergoes changes during the course of this neurological disorder.
There are other causes of CRPS, including genetic causes, inflammation with increased inflammatory values in the blood and as yet unknown causes.

Two types of the complex regional pain syndrome

There are two types of complex regional pain syndrome:

• without nerve damage (type I)
  
• with nerve damage (type II)

As mentioned before, microdamage to nerve tissue in people with brain damage cannot be ruled out.

Characteristic symptoms of complex regional pain syndrome

• pain (sensory component)
• a changed feeling (sensory component)
  
• hypersensitivity to touch (sensory component)
  
• edema/swelling (vasomotor component)
  
• change in temperature (vasomotor component)
  
• change in skin color (vasomotor component)
  
• change in sweating (sudomotor component) The neurological system that controls the sweat secretion of the human body is changed.
  
• changes in the growth of hair, nails or skin
  
• osteoporosis in an arm or leg
  
• movement disorder such as weakness, stiffness or tremors

It varies from person to person whether there are mild complaints or permanent serious limitations.

The International Association for the Study of Pain (IASP) has adopted a set of clinical diagnostic criteria for CRPS that includes both sensory and sudomotor/vasomotor symptoms.
In most cases, the most appropriate treatment will be determined in a multidisciplinary team. Physiotherapy takes the most important place in this. Sometimes medication can be administered or with a local anesthetic nerve block placed. Sometimes administering electrical signals to nerve endings via electrodes on the skin helps.
This is called transcutaneous electrical nerve stimulation (TENS). Psychological guidance to learn to deal with chronic illness pain (cognitive behavioral therapy) is sometimes useful.

Shoulder-hand syndrome (SHS)

A specific form of complex regional pain syndrome (CRPS) occurs after half-sided paralysis after brain injury.
This is also called shoulder-hand syndrome. Poor posture of the arm, drooping arm, overextension of the arm or hand while lying down, improper pulling of the arm when dressing and undressing or when moving the patient can cause shoulder-hand syndrome.

The first symptoms of shoulder-hand syndrome are pain, redness, warmth and swelling, which indicates inflammation.
The hand may be swollen and this may be accompanied by stiffening and therefore limitation of movement of the shoulder and shoulder
fingers. Then the skin of the arm becomes colder and clammy. The increased sensitivity to pain begins. There may be local bone decalcification (osteoporosis) may occur.

• Shoulder pain
  
• Hand pain
  
• Numbness
  
• Elbow pain
  
• Pain in the wrist
  
• Tingling
  
• Burning feeling
  
• Stiffness
  
• Swelling, edema
  
• Discoloration of the hand

If no action is taken, the joint can stiffen permanently. The wrist may be permanently bent. The hand can be moved with great difficulty. Bone deformities can even occur.

Prevention is better than cure

Mobilization (movement) and good positioning are the key words. Good physiotherapeutic and occupational therapy help is possible
prevent a lot of pain. Information for partners and informal caregivers on how to properly position a paralyzed arm (positioning) or how to dress and undress is also important.
Give changeover position; change the position of the arm every three hours. If there is swelling in the hand, place the hand higher on a pillow so that the fluid can flow back to the heart. Place a pillow under the arm and under the head of the shoulder to provide good support. Remove rings and bracelets to prevent engorgement (swelling of the hand). To encourage someone to use their arm and hand, the bedside table can be placed on a different side, unless someone also has hemispatial neglect. Then the person does not perceive one half of the body. Make sure that the chair or wheelchair offers good arm support, for example with a work surface.

Exercises
If the patient is not paralyzed on one side but has partial incomplete paralysis (hemiparesis) with loss of strength,
that he or she is encouraged to practice. Otherwise, a therapist or caregiver can passively exercise the arm:

• Squeeze with the affected hand
  
• Move the fingers in and out of the palm as much as possible
  
• Try raising and lowering the arm and shoulder
  
• Try touching the other shoulder with one hand
  
• Try moving the arm and shoulder up and down with the elbow forward. No further than a 90° angle
  
• Bring the affected hand to the mouth
  
• Make cycling movements with your hands.

Pain due to spasticity

Spasticity is increased tension in the paralyzed or weakened muscles of the arms or legs. The muscles in the arms or legs can contract alternately or permanently due to high muscle tension. There may be involuntary contractions (spasms). The muscles can no longer move smoothly, but become stiff and tight.
The cause of spasticity is damage to the nerve tissue in the central nervous system (brain, brain stem and spinal cord).
After a stroke, muscle tension (muscle tone) can increase rapidly. This often happens within a week.

The muscle groups in which it occurs
Spasticity can occur in the muscles or muscle groups of arms, elbows, wrist, shoulders, hands, thumbs, legs, hip, knee, foot and toes. Spasticity in the arm and hand is most common and results in an inability to open the hand, move the wrist or extend the arm.

Risk factors

Risk factors for developing spasticity appear to be associated with: a history of smoking, left-sided weakness, half-sided paralysis/disability (hemiplegia) and a low score on a specific scale: Barthel Index. With the Barthel Index the degree of (physical or verbal) help that a person needs to perform activities of daily living (ADL) can be determined.

Pain
72% of people with spasticity experience pain. Patients with a higher degree of spasticity and a low Barthel Index score appear to have a lower quality of life and more pain. A continuously contracted muscle causes pain, similar to a cramp.
Spasticity can cause changes in muscle properties, leading to fibrosis and atrophy.
Fibrosis is connective tissue formation; small scars where normal muscle tissue would be. The muscles then become hard and stiff. Atrophy in the muscles is a decrease in muscle mass. This causes the muscles to become less strong.
The abnormal strain on muscles and tendons due to spasticity can activate the pain nerve cells.
In addition, spasticity can cause a joint to be in a forced position. Pain can also be a result of the fact that the arm or foot is used differently or is in a different position (functional pain).

Pain treatment
Little is known about pain management of spasticity after a stroke. Well-known pain treatments for spasticity include other neurological conditions, such as multiple sclerosis and cerebral palsy.
The practitioner may opt for a local neuromuscular blockade or treatment with medications (for example Lioresal, Diazepam) that can reduce muscle tension. There are disadvantages to reduced function that the doctor must weigh against the advantages. Mild spasticity can be treated with physiotherapy.
Sometimes treatment is possible with neuromodulation. The drug Baclofen is introduced through a thin tube into the fluid surrounding the spinal cord (intrathecally). This therapy is called intrathecal administration of baclofen, abbreviated as ITB therapy. Baclofen relaxes muscles. It reduces muscle cramps. It also works against nerve pain and spastic muscle cramps.