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Zakel J, Chae J, Wilson RD. Innovations in Stroke Recovery and Rehabilitation: Poststroke Pain. Phys Med Rehabil Clin N Am 2024; 35:445-462. [PMID: 38514229 DOI: 10.1016/j.pmr.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Pain can be a significant barrier to a stroke survivors' functional recovery and can also lead to a decreased quality of life. Common pain conditions after stroke include headache, musculoskeletal pain, spasticity-related pain, complex regional pain syndrome, and central poststroke pain. This review investigates the evidence of diagnostic and management guidelines for various pain syndromes after stroke and identifies opportunities for future research to advance the field of poststroke pain.
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Affiliation(s)
- Juliet Zakel
- MetroHealth Rehabilitation Institute, MetroHealth System, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA.
| | - John Chae
- MetroHealth Rehabilitation Institute, MetroHealth System, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
| | - Richard D Wilson
- MetroHealth Rehabilitation Institute, MetroHealth System, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
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Greenway MRF, Robinson MT. Palliative care approaches to acute stroke in the hospital setting. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:13-27. [PMID: 36599505 DOI: 10.1016/b978-0-12-824535-4.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.
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Affiliation(s)
| | - Maisha T Robinson
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States; Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States.
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Goss AL, Creutzfeldt CJ. Neuropalliative Care in the Inpatient Setting. Semin Neurol 2021; 41:619-630. [PMID: 34619785 DOI: 10.1055/s-0041-1731071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, San Francisco, California
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Hospital-based Buprenorphine/Naloxone Initiation in a Patient With Limited Communication Abilities: A Case Report. J Addict Med 2021; 15:519-521. [PMID: 33560693 DOI: 10.1097/adm.0000000000000803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
North America's opioid crisis highlights the profound need for low-barrier access to opioid agonist therapy (OAT) for the treatment of opioid use disorder (OUD). This case describes a 33-year-old female with a history of opioid and stimulant use disorder admitted to hospital after a left middle cerebral artery ischemic stroke with resulting aphasia. After medical stabilization, she consented to buprenorphine/naloxone through limited verbal and written communication. After 14 days of titration, she was stabilized on 14 to 3.5 milligrams of buprenorphine/naloxone daily. Buprenorphine/naloxone initiation and titration is patient-based and symptom guided, typically requiring active communication between the patient and care provider. This case illustrates successful buprenorphine/naloxone initiation in a patient with limited receptive and expressive language abilities, emphasizing the feasibility of offering this medication to individuals with limited communication to ensure timely access to evidence-based OUD treatment.
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Haslam BS, Butler DS, Kim AS, Carey LM. Chronic pain following stroke: Current treatment and perceived effect. Disabil Health J 2020; 14:100971. [PMID: 32830081 DOI: 10.1016/j.dhjo.2020.100971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Chronic pain is common following stroke, however there is little known about the treatments for pain that are being accessed by stroke survivors, nor their perceived effectiveness. OBJECTIVES The objectives were to: i) identify the number and type of treatments for pain currently used by stroke survivors with chronic pain; and ii) examine the self-perceived effectiveness of medication and non-medication treatments for pain. METHODS Cross-sectional survey. Participants with stroke and self-reported chronic pain completed an online survey that measured demographics, stroke related factors, intensity of pain, treatments for pain, and perceived effect of medication and non-medication treatments for pain. RESULTS Of 322 stroke survivors who completed the survey, the majority (90.1%) reported current use of pain treatment(s). Medications were accessed by 257 (79.8%), with the most common being anti-inflammatories (39.8%), anticonvulsants (29.5%) and antidepressants (24.8%). Paracetamol (12.1%) was the most common non-prescribed medication used. Polypharmacy was high, with 129 (40.1%) reporting taking 2 or more medications. Medication treatments were self-reported to be effective in 47.1% of those taking medication. Non-medication treatments were accessed by 208 (64.6%), with Physical Therapy/Physiotherapy being most common (48.1%), followed by Occupational Therapy (15.5%) and Psychology (11.8%). Use of multiple non-medication treatments was reported by 85 (26.4%). Non-medication treatments were reported to be effective by 52.4% of those receiving them. CONCLUSIONS Survey findings indicate that stroke survivors with chronic pain demonstrate high utilization of pain treatments, despite the perception that treatment is often ineffective. This highlights the need to develop effective pain interventions for stroke survivors.
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Affiliation(s)
- Brendon S Haslam
- Neurorehabilitation and Recovery, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia; Occupational Therapy, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia.
| | - David S Butler
- School of Health Sciences, University of South Australia, Adelaide, Australia; Neuro-Orthopaedic Institute, Adelaide, Australia.
| | | | - Leeanne M Carey
- Neurorehabilitation and Recovery, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia; Occupational Therapy, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia.
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Taylor BL, O'Riordan DL, Pantilat SZ, Creutzfeldt CJ. Inpatients with neurologic disease referred for palliative care consultation. Neurology 2019; 92:e1975-e1981. [PMID: 30918095 DOI: 10.1212/wnl.0000000000007364] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 01/03/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To compare characteristics and needs of inpatients with neurologic disease to those with cancer referred for palliative care (PC) consultation. METHODS This prospective cohort study used data collected by the Palliative Care Quality Network from January 2013 until December 2016. We compared demographics, reasons for consultation, discharge disposition, Palliative Performance Scale (PPS) score, and outcomes of care among patients with a primary diagnosis of neurologic disease vs cancer. RESULTS The most common reason for PC consultation in all patients was assistance with goals of care and advanced care planning. PC consultation was less often requested for pain and symptom management in patients with neurologic disease compared to patients with cancer (13.7% vs 43%, odds ratio 0.3) and more often for assistance with transition to comfort measures only and withdrawal of life-sustaining treatment (19.1% vs 7.1%, odds ratio 1.3). Patients with cancer had higher PPS scores (42.1% vs 23.4%) and were more likely to be discharged home from the hospital, while patients with neurologic disease were more likely to die in hospital. CONCLUSIONS Patients with neurologic disease as a reason for PC consultation are more in need of end-of-life care planning and more likely to die in the hospital than those with cancer, suggesting that targeted approaches may best address the needs of each patient population. Our results can direct further research and education in neuropalliative care.
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Affiliation(s)
- Breana L Taylor
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco.
| | - David L O'Riordan
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco
| | - Steven Z Pantilat
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco
| | - Claire J Creutzfeldt
- From the Department of Neurology (B.L.T., C.J.C.), University of Washington, Seattle; and Department of Medicine (D.L.O., S.Z.P.), Division of Palliative Medicine, University of California San Francisco
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Schutz REC, Creutzfeldt CJ. Three big things in neuropalliative care: Communication, personhood and uncertainty. J Neurol Sci 2017; 385:232-233. [PMID: 29241840 DOI: 10.1016/j.jns.2017.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Rachael E C Schutz
- Department of Neurology, University of Washington, Harborview Medical Center, Box 359775, Seattle, WA 98104, United States
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, Harborview Medical Center, Box 359775, Seattle, WA 98104, United States.
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Smith JH, Bottemiller KL, Flemming KD, Cutrer MF, Strand EA. Inability to self-report pain after a stroke: A population-based study. Pain 2013; 154:1281-6. [DOI: 10.1016/j.pain.2013.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/19/2013] [Accepted: 04/01/2013] [Indexed: 10/27/2022]
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Creutzfeldt CJ, Holloway RG, Walker M. Symptomatic and palliative care for stroke survivors. J Gen Intern Med 2012; 27:853-60. [PMID: 22258916 PMCID: PMC3378740 DOI: 10.1007/s11606-011-1966-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 10/13/2011] [Accepted: 11/30/2011] [Indexed: 11/29/2022]
Abstract
Stroke is the leading cause of disability and one of the most common causes of death worldwide. Outside the setting of acute management, secondary prevention and stroke rehabilitation, little has been written to address the ongoing symptomatic and palliative needs of these patients and their families. In this literature review, we look beyond secondary prevention with the aim of providing evidence-informed management guidelines for the myriad and often under-recognized symptomatic and palliative care needs of stroke survivors. Some of the most common and disabling post-stroke symptoms that are reviewed here include central post-stroke pain, hemiplegic shoulder pain, painful spasticity, fatigue, incontinence, post-stroke seizures, sexual dysfunction, sleep-disordered breathing, depression and emotionalism. We review the role of caregivers and explore ways to support them and, lastly, remind the reader to be perceptive to the patient's spiritual needs. The literature is most robust, including controlled trials, for central post-stroke pain and depression. Synthesis and discussion outside these areas are frequently limited to smaller studies, case reports and expert opinion. While some data exists to guide informed decision-making, there is an urgent need to document best practice and identify appropriate clinical standards for the full spectrum of symptoms experienced by stroke survivors. We present the current and established data to aid health care providers in symptomatic and palliative management of stroke survivors.
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Affiliation(s)
- Claire J Creutzfeldt
- Department of Neurology, University of Washington Harborview Medical Center, Seattle, WA 98104-2499, USA.
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Mazzocato C, Michel-Nemitz J, Anwar D, Michel P. The last days of dying stroke patients referred to a palliative care consult team in an acute hospital. Eur J Neurol 2009; 17:73-7. [DOI: 10.1111/j.1468-1331.2009.02744.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Wormland B, Nacimiento W, Papadopoulos R, Spyrou M, Borasio GD. [Changes in therapy aims and palliative treatment for severe stroke]. DER NERVENARZT 2008; 79:437-43. [PMID: 18299813 DOI: 10.1007/s00115-007-2404-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recent years have seen considerable advances in acute stroke treatment. Patients who survive the acute phase following major stroke often retain severe limitations of motor, cognitive, and communicative functions. In such patients whose death is imminent, curative therapies should be avoided. Instead, the goal of any therapy should shift to palliative treatment and concentrate on reducing causes of suffering. Palliative methodologies and concepts are already well established in neurology, e.g. for amytrophic lateral sclerosis. Particularly those stroke patients who remain stable for a long period with massive neurological deficits require interdisciplinary palliative care that goes beyond mere reduction of symptoms and seeks a response to possible complications and the question of maintaining life-preserving measures. Not only medical indications but also the expressed or presumed will of the patient must be included in such considerations. This article describes and elucidates basic questions of palliative medicine and symptomatic palliative treatment concepts for stroke patients.
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Affiliation(s)
- B Wormland
- Neurologische Klinik, Klinikum Duisburg, Zu den Rehwiesen 7-9, 47055, Duisburg, Deutschland.
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Kim JS, Choi-Kwon S, Kwon SU, Lee HJ, Park KA, Seo YS. Factors affecting the quality of life after ischemic stroke: young versus old patients. J Clin Neurol 2005; 1:59-68. [PMID: 20396472 PMCID: PMC2854931 DOI: 10.3988/jcn.2005.1.1.59] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2004] [Accepted: 02/28/2005] [Indexed: 11/21/2022] Open
Abstract
Background Factors affecting the quality of life (QOL) may be different between young and old stroke patients. However, these issues have not yet been properly investigated. Methods We identified 170 young-onset stroke patients (onset between 15 and 45 years of age) who were admitted to the Asan Medical Center. Three hundred and forty follow-up period matched, old-onset stroke patients (onset >45 years of age) were chosen as a control group. A follow-up interview was performed 1~5 years after the onset of stroke in 96 young patients and 160 old patients. With the use of standardized questionnaire, we assessed physical disabilities, activity of daily living (Barthel Index Score, modified Rankin scale), the presence of depression (using DSM IV criteria and Beck Depression Inventory) and socio-economic/job status. The QOL was assessed using the Stroke Specific QOL developed by Williams et al. Results The QOL scores were significantly higher in young patients than in old ones. Univariate analysis showed that factors related to low QOL included unemployment, motor impairment, aphasia, dysarthria, dysaphagia and severe modified Rankin score in young patients while poor economic status, unemployment, supratentorial (vs. infratentorial) stroke, anterior (vs. posterior) circulation stroke, the presence of diabetes mellitus, motor impairment, aphasia, dysarthria, dysphagia, visual field defect, severe modified Rankin score, the presence of post-stroke seizures and depression were related to the low QOL in old patients. Cigarette smoking (in old patients) and alcohol drinking (in both young and old patients) were related to high QOL. Multiple regression analysis showed that modified Rankin score was the most important factor explaining low QOL in both groups, while other important factors included depression, visual field defect and anterior circulation stroke in old patients, and the motor dysfunction and dysarthria in young patients. Conclusions We conclude that aside from modified Rankin scale, factors affecting the quality of life are different between these two groups. Recognition of these differences may allow us to develop different strategies to improve the quality of life in stroke patients.
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Affiliation(s)
- Jong S Kim
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Pomeroy VM, Frames C, Faragher EB, Hesketh A, Hill E, Watson P, Main CJ. Reliability of a measure of post-stroke shoulder pain in patients with and without aphasia and/or unilateral spatial neglect. Clin Rehabil 2000; 14:584-91. [PMID: 11128732 DOI: 10.1191/0269215500cr365oa] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the inter/intra-rater reliability of expert physiotherapists (PTs) measuring post-stroke shoulder pain with 100 mm vertical visual analogue scales (VAS; intensity, frequency and affective response) and a categorical site-of-pain scale. DESIGN Three PTs independently rated subjects (normal clinical procedure but with a standardized starting position) on three days, at the same time of day, during one week in a randomized order determined by a nested latin square. Reliability for VAS scores was determined with the intraclass correlation coefficient (ICC) and for site-of-pain with the kappa statistic (kappa). Acceptable reliability was set at 0.75. The limits of agreement were also calculated. SETTING Community. SUBJECTS Thirty-three patients, mean time post stroke 42 months (range 7-360). RESULTS Mean inter-rater reliability was 0.79 for intensity, 0.75 for frequency and 0.62 for affective response (ICC). The limits of agreement were wide and rater bias was significant for 6/27 ratings. Mean intra-rater reliability was 0.70 for intensity, 0.77 for frequency and 0.69 for affective response (ICC). For site-of-pain inter-rater reliability ranged from 0.156 (kappa) to 0.385 (kappa) and intrarater reliability ranged from 0.300 (kappa) to 0.559 (kappa). CONCLUSIONS Although inter-rater reliability was acceptable for intensity and frequency there was a consistently large systematic bias between pairs of raters. Agreement might be improved if a standardized assessment procedure was used and/or if training in pain behaviour interpretation was provided.
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Affiliation(s)
- V M Pomeroy
- The Stroke Association's Therapy Research Unit, The University of Manchester, Salford Royal Hospitals NHS Trust, UK.
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