Efficacy and safety of different antidepressants and anticonvulsants in central poststroke pain: A network meta-analysis and systematic review

Functional magnetic resonance imaging and diffuse tensor imaging diagnostic values in central post-stroke pain

Purpose

This review aims to emphasize the diagnostic value of functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) tractography in detecting and diagnosing central post-stroke pain (CPSP).

Views

CPSP is a debilitating form of chronic neuropathic pain that develops in patients with a history of stroke. CPSP has a wide range of onset and non-specific clinical presentations, making it difficult to detect. Until now, CPSP has been considered a diagnosis of exclusion, often leading to delays in the initiation of the appropriate treatment plan. fMRI and DTI tractography are valuable tools for assessing cerebral metabolic activity and the structural characteristics of the spinothalamic tracts, respectively. By combining these sets of information, physicians can detect CPSP early and implement more effective treatment strategies.

Conclusion

Diagnosing CPSP has been challenging for physicians due to its complex nature. However, fMRI and DTI have the potential in enabling earlier detection of CPSP, giving physicians more time to initiate treatment. This review highlights the capacities of fMRI and DTI in identifying alterations in the spinothalamic pathways associated with CPSP.

Management of Central Poststroke Pain: Systematic Review and Meta-analysis

Central poststroke pain (CPSP) is a neuropathic pain condition prevalent in 8 to 35% of stroke patients. This systematic review and meta-analysis aimed to provide insight into the effectiveness of available pharmacological, physical, psychological, and neuromodulation interventions in reducing pain in CPSP patients (PROSPERO Registration: CRD42022371835). Secondary outcomes included mood, sleep, global impression of change, and physical responses. Data extraction included participant demographics, stroke etiology, pain characteristics, pain reduction scores, and secondary outcome metrics. Forty-two original studies were included, with a total of 1,451 participants. No studies providing psychological therapy to CPSP patients were identified. Twelve studies met requirements for a random-effects meta-analyses that found pharmacological therapy to have a small effect on mean pain score (SMD = -.36, 96.0% confidence interval [-.68, -.03]), physical interventions did not show a significant effect (SMD = -.55 [-1.28, .18]), and neuromodulation treatments had a moderate effect (SMD = -.64 [-1.08, -.19]). Fourteen studies were included in proportional meta-analysis with pharmacological studies having a moderate effect (58.3% mean pain reduction [-36.51, -80.15]) and neuromodulation studies a small effect (31.1% mean pain reduction [-43.45, -18.76]). Sixteen studies were included in the narrative review, the findings from which largely supported meta-analysis results. Duloxetine, amitriptyline, and repetitive transcranial magnetic stimulation had the most robust evidence for their effectiveness in alleviating CPSP-induced pain. Further multicenter placebo-controlled research is needed to ascertain the effectiveness of physical therapies, such as acupuncture and virtual reality, and invasive and noninvasive neuromodulation treatments. PERSPECTIVE: This article presents a top-down and bottom-up overview of evidence for the effectiveness of different pharmacological, physical, and neuromodulation treatments of CPSP. This review could provide clinicians with a comprehensive understanding of the effectiveness and tolerability of different treatment types.

Advancements in Modern Treatment Approaches for Central Post-Stroke Pain: A Narrative Review

PURPOSE OF REVIEW

Central post-stroke pain (CPSP) poses a multifaceted challenge in medical practice, necessitating a thorough and multidisciplinary approach for its diagnosis and treatment. This review examines current methods for addressing CPSP, highlighting both pharmacological and non-pharmacological therapies. It covers the mechanisms and clinical effectiveness of these treatments in managing CPSP and emphasizes the importance of personalized treatment plans, given the varied causes of CPSP.

RECENT FINDINGS

Recent advancements have illuminated diverse treatment modalities for CPSP. Pharmacotherapy spans from conventional analgesics to anticonvulsants and antidepressants, tailored to mitigate the neuropathic characteristics of CPSP. Non-pharmacological interventions, including physical therapy and psychological strategies, are pivotal in managing CPSP's chronic nature. For cases resistant to standard treatments, advanced interventions such as nerve blocks and surgical procedures like deep brain stimulation (DBS) or motor cortex stimulation (MCS) are considered. Additionally, innovative technologies such as neuromodulation techniques and personalized medicine are emerging as promising avenues to enhance therapeutic outcomes and improve quality of life for individuals grappling with CPSP.

SUMMARY

Modern approaches in managing CPSP require an interdisciplinary and patient-centric approach. Customizing treatment plans to address the specific etiology and symptoms of CPSP is crucial. Pharmacotherapy remains fundamental, encompassing medications such as anticonvulsants and antidepressants tailored to manage neuropathic pain. Integrating non-pharmacological interventions is crucial for providing comprehensive care. Additionally, investigating innovative technologies and personalized medicine presents promising opportunities to enhance treatment results and elevate the quality of life for those suffering from CPSP. Ultimately, an integrated approach that acknowledges the multifaceted nature of CPSP is essential for effective management and patient well-being.

Neuropharmacology of Neuropathic Pain: A Systematic Review

Neuropathic pain, a debilitating condition, remains challenging to manage effectively. An insight into neuropharmacological mechanisms is critical for optimizing treatment strategies. This systematic review aims to evaluate the role of neuropharmacological agents based on their efficacy, involved neurotransmitters, and receptors. A manual literature search was undertaken in PubMed including Medline, Cochrane Library, Google Scholar, Plos One, Science Direct, and clinicaltrials.gov from 2013 until 2023. Out of the 13 included studies, seven evaluated the role of gabapentinoids. Two main drugs from this group, gabapentin and pregabalin, function by binding voltage-gated calcium channels, lowering neuronal hyperexcitability and pain signal transmission, thereby relieving neuropathic pain. Four of the pooled studies reported the use of tricyclic antidepressants (TCAs) including amitriptyline and nortriptyline which work by blocking the reuptake of norepinephrine and serotonin, their increased concentration is thought to be central to their analgesic effect. Three articles assessed the use of serotonin-norepinephrine reuptake inhibitors (SNRIs) and reported them as effective as the TCAs in managing neuropathic pain. They work by augmenting serotonin and norepinephrine. Three studies focused on the use of selective serotonin reuptake inhibitors (SSRIs), modulating their effect by increasing serotonin levels; however, they were reported as not a highly effective treatment option for neuropathic pain. One of the studies outlined the use of cannabinoids for neuropathic pain by binding to cannabinoid receptors with only mild adverse effects. It is concluded that gabapentinoids, TCAs, and SNRIs were reported as the most effective therapy for neuropathic pain; however, for trigeminal neuralgia, anticonvulsants like carbamazepine were considered the most effective. Opioids were considered second-line drugs for neuropathic pain as they come with adverse effects and a risk of dependence. Ongoing research is exploring novel drugs like ion channels and agents modulating pain pathways for neuropathic pain management. Our review hopes to inspire further research into patient stratification by their physiology, aiding quicker and more accurate management of neuropathic pain while minimizing inadvertent side effects.

Innovations in Stroke Recovery and Rehabilitation: Poststroke Pain

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.

Pain in the Context of Sensory Deafferentation

Pain that accompanies deafferentation is one of the most mysterious and misunderstood medical conditions. Prevalence rates for the assorted conditions vary considerably but the most reliable estimates are greater than 50% for strokes involving the somatosensory system, brachial plexus avulsions, spinal cord injury, and limb amputation, with controversy surrounding the mechanistic contributions of deafferentation to ensuing neuropathic pain syndromes. Deafferentation pain has also been described for loss of other body parts (e.g., eyes and breasts) and may contribute to between 10% and upwards of 30% of neuropathic symptoms in peripheral neuropathies. There is no pathognomonic test or sign to identify deafferentation pain, and part of the controversy surrounding it stems from the prodigious challenges in differentiating cause and effect. For example, it is unknown whether cortical reorganization causes pain or is a byproduct of pathoanatomical changes accompanying injury, including pain. Similarly, ascertaining whether deafferentation contributes to neuropathic pain, or whether concomitant injury to nerve fibers transmitting pain and touch sensation leads to a deafferentation-like phenotype can be clinically difficult, although a detailed neurologic examination, functional imaging, and psychophysical tests may provide clues. Due in part to the concurrent morbidities, the physical, psychologic, and by extension socioeconomic costs of disorders associated with deafferentation are higher than for other chronic pain conditions. Treatment is symptom-based, with evidence supporting first-line antineuropathic medications such as gabapentinoids and antidepressants. Studies examining noninvasive neuromodulation and virtual reality have yielded mixed results.

Efficacy and safety of eszopiclone combined with drug therapy in the treatment of insomnia after stroke: A network meta-analysis and systematic review

OBJECTIVE

To evaluate the efficacy and safety of multi-drug therapy based on eszopiclone in the treatment of insomnia after stroke using a network meta-analysis method and to provide evidence for clinical practice.

METHOD

Computer searches of PubMed, Excerpt Medica Database (Embase), Cochrane Library Central Register of Controlled Trials, APA PsycInfo, CNKI, WanFang, Sinomed and other databases were performed to search for clinical randomized controlled studies (RCTs) on multi-drug therapy based on eszopiclone in the treatment of insomnia patients after stroke. The search time was from the establishment of each database until July 2023. The bias risk assessment tool recommended by Cochrane was used to evaluate the quality of the included RCTs. Stata 14.0 was applied to perform network meta-analysis using Review Manager 5.3 software for traditional meta-analysis.

RESULT

Eighteen RCTs and 1646 patients were ultimately included, involving 11 treatment options. The results of the network meta-analysis showed that the ranking of Pittsburgh Sleep Quality Index (PSQI) decline was eszopiclone combined with sweet dream oral liquid (ESZ+SDOL)>eszopiclone combined with a shugan jieyu capsule (ESZ+SGJYC)>eszopiclone combined with agomelatine (ESZ+AGO)>eszopiclone combined with flupentixol and melitracen tablets (ESZ+FMT)>eszopiclone combined with yangxue qingnao granules (ESZ+YXQNG)>eszopiclone combined with mirtazapine (ESZ+MIR)>ESZ>FMT; the modified Edinburgh Scandinavia Stroke Scale (MESSS) decline ranking was ESZ+SDOL>ESZ+AGO>ESZ; and the clinical total effective rate ranking was eszopiclone combined with a xuefu zhuyu capsule (ESZ+XFZYC)>ESZ+MIR>ESZ+SGJYC>ESZ+SDOL> ESZ+FMT>ESZ+YXQNG>ESZ>FMT. In terms of clinical adverse reactions, in addition to ESZ therapy, ESZ+ESC had the highest number of adverse reactions, with abdominal pain being the most common. ESZ+YXQNG had the most types of adverse reactions, with 8 types.

CONCLUSION

Multi-drug therapy based on eszopiclone can effectively improve the sleep quality of patients with insomnia after stroke, and ESZ+SDOL has significant efficacy and safety. However, due to the limitations of this study, efficacy ranking cannot fully explain the superiority or inferiority of clinical efficacy. In the future, more multicentre, large sample, double-blind randomized controlled trials are needed to supplement and demonstrate the results of this study.