national-clinical-guidelines-for-stroke-fourth-edition

D Any patient who has developed, or is developing, shoulder subluxation should be
considered for functional electrical stimulation of the supraspinatus and deltoid
muscles.
E In the absence of inflammatory disorders, intra-articular steroid injections should not
be used for post-stroke shoulder pain.
6.19.2.2 Sources
A–C Consensus
D Fil et al 2011; Koyuncu et al 2010
E Kalita et al 2006; Lakse et al 2009
6.19.3 Neuropathic pain (central post-stroke pain)
Stroke is one cause of pain following damage to neural tissues (so-called neuropathic
pain, or central post-stroke pain). The incidence of neuropathic pain is uncertain, with
estimates varying between 5% and 20%. However, if present it is unpleasant and warrants
treatment. There may be some overlap with both spasticity which can cause pain, and
with sensory loss which can be associated with unpleasant sensory phenomena. It is, in
principle, separate from musculoskeletal pain, which is considered in the next section
(6.19.4).
Evidence to recommendations
There is very little trial evidence on the management of neuropathic pain specific to
post-stroke patients, and it may well be that post-stroke neuropathic pain is different
from neuropathic pain resulting from other conditions such as peripheral neuropathies
or spinal cord pathology. The recommendations below are largely taken from the NICE
guidance on neuropathic pain. The group that developed the guidance considered that
pregabalin was preferable to gabapentin because evidence from indirect comparisons of
meta-analyses of the two treatments showed that pregabalin has lower number needed
to treat (NNT) values for at least 30% pain reduction and at least 50% pain reduction
compared with gabapentin, with a similar adverse-effect profile. Pregabalin also has
simple dosing and titration compared with gabapentin. Cost-effectiveness analysis
conducted by NICE also suggested that pregabalin should be the initial treatment of
choice. There is no evidence to show that simple or opioid analgesics have any role in
the treatment of neuropathic pain.
6.19.3.1 Recommendations
6 Recovery phase from impairments and limited activities: rehabilitation
A Every patient whose pain has been diagnosed by someone with appropriate expertise
in neuropathic pain should be given oral amitriptyline, gabapentin or pregabalin as
first-line treatment:
● amitriptyline: start at 10 mg per day, with gradual upward titration to an effective
dose or the person’s maximum tolerated dose of no higher than 75 mg per day
(higher doses could be considered in consultation with a specialist pain service)
● gabapentin: use 300 mg twice daily increasing to a maximum of 3.6 g per day
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