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STROKE AND RNAO BEST PRACTICES: PAIN
Presented by:
Stefan Pagliuso, B.A. Kin(Hon.), MPT
Central South Regional Stroke Rehabilitation and Community Coordinator
Central South Regional Stroke Network
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Acknowledgements
• Janine Theben, Maggie Traetto and Megan Sousa, West GTA Stroke Network
• Rebecca Fleck, Central South Stroke Network
• Shaila Aranha, RNAO
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Objectives
To understand:
Types of post stroke pain
Prevention
Assessment
Management
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Case Study: Bernie
Bernie is a thin 80 year old gentleman who experienced a Left MCA stroke. This left him with weakness in his right upper and lower extremity, impaired ability to sense touch on that side and trouble planning his movements as well as difficulty communicating. Bernie has trouble paying attention and lacks insight into his actual capabilities post-stroke. He suffers from shoulder pain on his right side after an improper transfer from the bed to the chair while his weaker side was not supported properly.
Bernie completed 6 weeks of in-patient rehab. He is now moving in to a LTC facility.
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Post-Stroke Pain
“a sensation in your body that causes acute discomfort or suffering”
( Heart & Stroke Foundation, 2013, p 4.2)
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Duration of Pain
Pain can be either:
Acute Pain
Chronic Pain
(Heart & Stroke Foundation, 2013)
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Sources of Pain
Pain can be due to tissue or nerve damage:
Tissue damage leads to a pain that can be sharp, dull, or aching.
Nerve damage can be described as sharp, burning, aching, tingling, cutting, piercing, stabbing, or numbness.
(Heart & Stroke Foundation, 2013)
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Post-Stroke Pain: Facts
Pain is very common in stroke survivors
(Heart & Stroke Foundation, 2013)
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Post-Stroke Pain Facts
Pain affects quality of life
(Heart & Stroke Foundation, 2013)
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Types of Post-Stroke Pain
Central Post-stroke Pain
Spasticity (High Tone)
Shoulder or Hand Syndrome
Orthopaedic Conditions
Hemiplegic shoulder pain
Shoulder subluxation
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Central Post-Stroke Pain
“Burning/tingling/stabbing/acid under skin”
Pain can be constant or intermittent
Caused by damage to the brain or spinal cord from a stroke
Less than 10%
(Heart & Stroke Foundation, 2013)
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Central Post-Stroke Pain
Worsened by: • Physical Activity
• Light touch
• Stress
• Cold
• Change in weather
May complain of pain: • Where there is no visible tissue damage
• From light touch
• That is unusually severe (Heart & Stroke Foundation, 2013)
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Managing Central Post-Stroke Pain
Difficult to treat
Prescribed medications
Early identification
Watch for symptoms
Acknowledge their pain
Report pain to the appropriate person (Heart & Stroke Foundation, 2013)
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Spasticity
Abnormally high muscle tone
Shortens muscles
Prevents normal movement
Results in stiff and painful joints
‘Muscle cramp’
(Heart & Stroke Foundation, 2013)
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Spasticity Management
Doctor, Physiotherapist, Occupational Therapist
(Heart & Stroke Foundation, 2013)
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Shoulder or Hand Syndrome
May begin with shoulder pain
Develop stiff, swollen, and painful hand and wrist
Decreased range of motion in shoulder and hand
(Heart & Stroke Foundation, 2013)
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Shoulder or Hand Syndrome Management
Pain management specialist consult
Use recommended positioning to protect
Use prescribed exercises
Team approach (Doctor/PT/OT)
(Heart & Stroke Foundation, 2013)
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Orthopaedic Conditions
Rotator Cuff Tear
Muscles that hold the shoulder in place
Tendonitis
Inflammation of the tendon
Bursitis
Inflammation of a bursa
(Heart & Stroke Foundation, 2013)
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Risk Factors of Post-Stroke Shoulder Pain
Functional status
Self-perceived health
Arm motor function
Sensory Disturbance
Subluxation (Lindgren et al., 2007)
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Shoulder Subluxation
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Shoulder Subluxation Cont’d
How can you help:
Handle the shoulder carefully
Support the shoulder joint.
Talk to members of the interdisciplinary team (Heart & Stroke Foundation, 2013)
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Best Practice Guidelines: Prevention
Joint protection strategies
No overhead pulleys
No movement past 90 degrees flex/abduction unless the scapula and humerus are mobilized
Education regarding correctly handling the involved arm
(Dawson et al., 2013)
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Best Practice Guidelines: Assessment
“The assessment of the painful hemiplegic shoulder should include evaluation of tone, strength, changes in length of soft tissues,
alignment of joints of the shoulder girdle and orthopedic changes in the shoulder”
(Dawson et al., 2013: http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/part-two-providing-stroke-rehabilitation-to-maximize-participation-
in-usual-life-roles/management-of-shoulder-pain-following-stroke/)
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RNAO’s related Best Practice Guidelines
www.rnao.ca
Evidence Based Recommendations for: •Assessment • Planning Goals of Care and Treatment strategies with the resident, family and Interdisciplinary team. • Implementing the Care • Monitoring and Evaluation of the effectiveness of the pain management strategies • Educational Resources
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RNAO’s related Best Practice Guidelines
www.rnao.ca
Client Centred Care 2002
Revised Supplement 2006
Stroke Assessment Across the Continuum: developed in partnership with the Heart and Stroke Foundation of Ontario. 2005 Revised Supplement 2011
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Best Practice Guidelines: Management
Consult with Interdisciplinary Team (PT/OT/Physician)
Consult with a pain consultant in your area
Medications as prescribed (Dawson et al., 2013)
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Identifying Pain in Persons Post-Stroke
Verbally “Pain Words” – burning/itching/throbbing Sounds – moans/groans, cries Exclaiming/Cursing – “Ouch!”
Physically Rubbing, bracing, holding or gaurding Frequent shifting, restlessness
Through Facial Expressions Frowning/wincing
Through Behaviour Changes Change in appetite
(Heart & Stroke Foundation, 2013)
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How you can help
Ask yes or no questions
Use simple words to help identify the problem
Point to areas that may be painful when asking questions
Ask about pain during or after movement
Be patient and take time
Use a pain assessment scale regularly
Discuss the pain and management with the team (Heart and Stroke Foundation, 2013)
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Case Study
Bernie’s shoulder pain could potentially have been prevented by:
Utilizing joint protection strategies
Providing education to resident, family and interdisciplinary team members regarding handling the involved arm
“Treatment is difficult and may be even more difficult after the pain is established”
Best form of treatment is prevention!
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Questions and Discussion
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References
• Dawson AS, Knox J, McClure A, Foley N, and Teasell R, on behalf of the Stroke RehabilitationWriting Group. (2013). Chapter 5: Stroke Rehabilitation. In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian StrokeBest Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care: 2013; Ottawa, Ontario Canada: Heart and StrokeFoundation and the Canadian Stroke Network.Canadian Best Practice Recommendations for Stroke Care: 4th edition. http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/part-two-providing-stroke-rehabilitation-to-maximize-participation-in-usual-life-roles/management-of-shoulder-pain-following-stroke/
• Heart and Stroke Foundation. (2013). Tips & Tools for Everyday Living: A Guide for Stroke Caregivers.
• Lindgren, I., Jonsson, A., Norrving, B & Lindgren, A. (2007). Shoulder Pain After Stroke A Prospective Population-Based Study. Stroke, 38: 343-348.
• Registered Nurses’ Association of Ontario. Third Edition (2013). Assessment and Management of Pain. Toronto, Canada: Registered Nurses’ Association of Ontario.
• Registered Nurses’ Association of Ontario. Stroke Assessment across the Continuum of Care, Supplement. (2011). Toronto, ON: Registered Nurses’ Association of Ontario.
• Registered Nurses’ Association of Ontario. Client centred care, supplement. (2006). Toronto, ON: Registered Nurses’ Association of Ontario.