Pain after stroke

Following their stroke, many people develop “new” pains, often in the weeks to months following stroke (but can develop at any time) [1]. Pain after stroke often persists and can become chronic (this just means that it persists for more than three months). Experiencing chronic pain has an added impact on people with stroke: making it more difficult to perform physical tasks, but also on mood and overall quality of life. Effective management of chronic pain is often identified as an unmet need by stroke survivors.

Individuals with stroke can experience pain in any area, however pain is most frequently reported as occurring in the arm, in particular the shoulder and hand [2]. The pain can be quite varied for each individual, but common descriptions of pain symptoms include: burning, electric shocks, stabbing, squeezing and hot/cold. Pain is also commonly associated with feelings of “pins and needles” and “tingling”.

Often, pain after stroke can occur without an “injury” to the body part. It was commonly thought that weakness around the shoulder joint was the reason for shoulder pain being so common, however recently this been challenged: many people with shoulder weakness don’t have pain, and many people with good shoulder strength do have pain. Similarly, treatments trying to “fix” the joint haven’t had great success [3].

A lot has been happening in the world of pain in the last ten years, and our understanding of pain is continually increasing. There are no ‘pain nerves’ or ‘pain receptors’, or even a ‘pain centre’. Pain is a protective strategy to try and protect the you from threatening information related to the body and the environment that it’s in (i.e. your brain weighs up each situation and determines if it feels ‘safe’ or not) [4]. If it determines that a body part is injured, or at risk of being injured, then it can make sense to experience ‘pain’ as a means to do things differently (such as avoid movement) and try to reduce the risk. It is now accepted that there can be many factors that contribute to whether someone has pain or not, and the nature of the pain that they feel.

If the ‘risk’ is sustained over a period of time, people’s brains can become more sensitive (often called ‘sensitised’). This can result in some information becoming ‘turned up in volume’, and things that normally wouldn’t be painful can then become painful, even though they present no risk of injury (such as being lightly touched, or a sudden change in temperature).

Assessment by skilled clinicians with good pain knowledge can help to identify the unique combination of contributions towards someone’s pain after stroke. They can outline a plan that can help to address the pain. Usually these plans will involve a ‘coming together’ of many things to produce an overall treatment strategy. This often involves a team of health professionals working with the individual. A well-balanced approach of meaningful exercise (this means it will be different for each person based on what they enjoy or find satisfying), good psychological-based techniques such as meditation or mindfulness, in addition to more specific therapies (such as specific strengthening exercises or sensory retraining) can all be utilised to ‘restore’ and ‘refresh’, and help reduce pain while also improving function and quality of life. Medications can also be helpful to ‘turn down’ the system. It’s important to remember that just as each person is different, their pain is also different. It’s worth taking the time to be able to identify all the contributions towards their pain and coming up with a plan that addresses these. Importantly, the plan needs to be achievable and meaningful for each person.

Brendon Haslam

Research Fellow, La Trobe University and Florey Institute of Neuroscience and Mental Health

Faculty, Neuro Orthopaedic Institute

Physiotherapist, Inner North Physiotherapy and Clifton Hill Physiotherapy

Member of Australian College of Physiotherapy

Titled Pain and Neurological Physiotherapist

1. Klit, H., et al., Pain following stroke: a population-based follow-up study. PLoS One, 2011. 6(11): p. e27607.
2. Treister, A.K., et al., Demystifying Poststroke Pain: From Etiology to Treatment. PM R, 2017. 9(1): p. 63-75.
3. Haslam, B.S., et al., Chronic pain following stroke: Current treatment and perceived effect. Disabil Health J, 2021. 14(1): p. 100971.
4. Moseley, G.L. and D.S. Butler, Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain, 2015. 16(9): p. 807-13.