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Rajamanickam G, Lee ATH, Liao P. Role of Brain Derived Neurotrophic Factor and Related Therapeutic Strategies in Central Post-Stroke Pain. Neurochem Res 2024:10.1007/s11064-024-04175-z. [PMID: 38856889 DOI: 10.1007/s11064-024-04175-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/08/2024] [Accepted: 05/22/2024] [Indexed: 06/11/2024]
Abstract
Brain-derived neurotrophic factor (BDNF) is vital for synaptic plasticity, cell persistence, and neuronal development in peripheral and central nervous systems (CNS). Numerous intracellular signalling pathways involving BDNF are well recognized to affect neurogenesis, synaptic function, cell viability, and cognitive function, which in turn affects pathological and physiological aspects of neurons. Stroke has a significant psycho-socioeconomic impact globally. Central post-stroke pain (CPSP), also known as a type of chronic neuropathic pain, is caused by injury to the CNS following a stroke, specifically damage to the somatosensory system. BDNF regulates a broad range of functions directly or via its biologically active isoforms, regulating multiple signalling pathways through interactions with different types of receptors. BDNF has been shown to play a major role in facilitating neuroplasticity during post-stroke recovery and a pro-nociceptive role in pain development in the nervous system. BDNF-tyrosine kinase receptors B (TrkB) pathway promotes neurite outgrowth, neurogenesis, and the prevention of apoptosis, which helps in stroke recovery. Meanwhile, BDNF overexpression plays a role in CPSP via the activation of purinergic receptors P2X4R and P2X7R. The neuronal hyperexcitability that causes CPSP is linked with BDNF-TrkB interactions, changes in ion channels and inflammatory reactions. This review provides an overview of BDNF synthesis, interactions with certain receptors, and potential functions in regulating signalling pathways associated with stroke and CPSP. The pathophysiological mechanisms underlying CPSP, the role of BDNF in CPSP, and the challenges and current treatment strategies targeting BDNF are also discussed.
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Affiliation(s)
- Gayathri Rajamanickam
- Calcium Signalling Laboratory, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Andy Thiam Huat Lee
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore, Singapore
| | - Ping Liao
- Calcium Signalling Laboratory, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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Lizi H, Jiaojiao K, Dan W, Shuyao W, Qingyuan W, Zijiang Y, Hua K. Non-invasive brain stimulation improves pain in patients with central post-stroke pain: a systematic review and meta-analysis. Top Stroke Rehabil 2024:1-16. [PMID: 38828896 DOI: 10.1080/10749357.2024.2359341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/18/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Central post-stroke pain (CPSP) significantly interferes with the quality of life and psychological well-being of stroke patients. Non-invasive brain stimulation (NIBS) has attracted significant attention as an emerging method for treating patients with CPSP. OBJECTIVE To compare the clinical efficacy of noninvasive brain stimulation on pain, and psychological status of patients with central post-stroke pain using meta-analysis. METHODS A computerized search of multiple databases was performed for identification of randomized controlled trials involving NIBS-led treatment of CPSP patients. Two researchers worked independently on literature screening, data extraction, and quality assessment. Research was conducted from inception of the database until October 2023. RevMan 5.0 and Stata 15.0 software were used to conduct statistical analysis. RESULTS Sixteen papers with 807 patients were finally included. The results showed that NIBS reduced patients' pain intensity [SMD = -0.39, 95% CI (-0.54, -0.24), p < 0.01] and was more effective in short-term CPSP patients. However, the included studies did not show a significant impact on psychological status, particularly depression. Subgroup analysis suggested that the M1 stimulation point was more effective than other stimulation points [SMD = -0.45, 95% CI (-0.65, -0.25), p < 0.001]. Other stimulation modalities also demonstrated favorable outcomes when compared to rTMS [SMD = -0.67, 95% CI (-1.09, -0.25), p < 0.01]. CONCLUSION NIBS has a positive impact on pain relief in patients with CPSP, but does not enhance patients' psychological well-being in terms of anxiety or depression. Furthermore, large-sample, high-quality, and multi-center RCTs are needed to explore the benefits of different stimulation durations and parameters in patients with CPSP. The current study has been registered with Prospero under the registration number CRD42023468419.
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Affiliation(s)
- Hu Lizi
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Kou Jiaojiao
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wang Dan
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wang Shuyao
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wang Qingyuan
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yang Zijiang
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Kang Hua
- College of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Xu H, Guan M, Chen Y, Qin H, Huang S. Efficacy and safety of pregabalin vs carbamazepine in patients with central post-stroke pain. Neurol Res 2024; 46:291-296. [PMID: 38192206 DOI: 10.1080/01616412.2024.2302269] [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] [Received: 06/02/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To compare the efficacy and safety of pregabalin and carbamazepine in patients with central post-stroke pain (CPSP). METHODS Patients included in the study were randomly assigned to either flexible-dose pregabalin treatment group or carbamazepine treatment group. The primary efficacy variable was face visual analog scale (F-VAS), the second efficacy assessment was used to assess the effect of treatment on mental health by Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD). RESULTS The mean baseline pain score F-VAS was 6.47 in the pregabalin group and 6.58 in carbamazepine treatment group. F-VAS was significantly lower in the pregabalin group (1.64) than (3.94) carbamazepine treatment group after treatment. Pregabalin was significantly superior to carbamazepine in endpoint assessments on the HAMA and HAMD after treatment. F-VAS and HAMD were showed efficacy as early as week 2 and maintained for whole duration of the study. The average pregabalin dose in the 12-week study was 214.6 (150-375) mg/day. The mean dose (range) of carbamazepine received by the patients was 275.0 (200-400) mg/day. Mild or moderate, typically transient, somnolence and dizziness were the most common adverse events (AES). The differences of the side effects between the two groups were not significant. CONCLUSIONS Pregabalin, but not carbamazepine, may be effective in improving F-VAS, HAMA and HAMD in patients with CPSP.
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Affiliation(s)
- Hongyan Xu
- Department of Neurology, People's Hospital of Wuzhou, Wuzhou, Guangxi, China
- Wuzhou Hospital Affiliated to Youjiang Medical University for Nationalities, Wuzhou, Guangxi, China
| | - Mingjian Guan
- Department of Neurology, People's Hospital of Wuzhou, Wuzhou, Guangxi, China
- Wuzhou Hospital Affiliated to Youjiang Medical University for Nationalities, Wuzhou, Guangxi, China
| | - YuFeng Chen
- Department of Neurology, People's Hospital of Wuzhou, Wuzhou, Guangxi, China
- Wuzhou Hospital Affiliated to Youjiang Medical University for Nationalities, Wuzhou, Guangxi, China
| | - Haoqiang Qin
- Department of Neurology, People's Hospital of Wuzhou, Wuzhou, Guangxi, China
- Wuzhou Hospital Affiliated to Youjiang Medical University for Nationalities, Wuzhou, Guangxi, China
| | - Shuilan Huang
- Department of Neurology, People's Hospital of Wuzhou, Wuzhou, Guangxi, China
- Wuzhou Hospital Affiliated to Youjiang Medical University for Nationalities, Wuzhou, Guangxi, China
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Mayor RS, Ferreira NR, Lanzaro C, Castelo-Branco M, Valentim A, Donato H, Lapa T. Noninvasive transcranial brain stimulation in central post-stroke pain: A systematic review. Scand J Pain 2024; 24:sjpain-2023-0130. [PMID: 38956966 DOI: 10.1515/sjpain-2023-0130] [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] [Received: 11/13/2023] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The aim of this systematic review is to analyze the efficacy of noninvasive brain stimulation (NBS) in the treatment of central post-stroke pain (CPSP). METHODS We included randomized controlled trials testing the efficacy of transcranial magnetic stimulation (TMS) or transcranial direct current stimulation versus placebo or other usual therapy in patients with CPSP. Articles in English, Portuguese, Spanish, Italian, and French were included. A bibliographic search was independently conducted on June 1, 2022, by two authors, using the databases MEDLINE (PubMed), Embase (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science Core Collection. The risk of bias was assessed using the second version of the Cochrane risk of bias (RoB 2) tool and the certainty of the evidence was evaluated through Grading of Recommendations Assessment, Development and Evaluation. RESULTS A total of 2,674 records were identified after removing duplicates, of which 5 eligible studies were included, involving a total of 119 patients. All five studies evaluated repetitive TMS, four of which stimulated the primary motor cortex (M1) and one stimulated the premotor/dorsolateral prefrontal cortex. Only the former one reported a significant pain reduction in the short term, while the latter one was interrupted due to a consistent lack of analgesic effect. CONCLUSION NBS in the M1 area seems to be effective in reducing short-term pain; however, more high-quality homogeneous studies, with long-term follow-up, are required to determine the efficacy of this treatment in CSPS.
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Affiliation(s)
- Rita Sotto Mayor
- Anesthesiology Department, Hospitais da Universidade de Coimbra, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Natália R Ferreira
- Institute of Occlusion and Orofacial Pain, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Camile Lanzaro
- Anesthesiology Department, Local Unit of Health in Alto Minho, Viana do Castelo, Portugal
| | - Miguel Castelo-Branco
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, Coimbra, Portugal
| | - Ana Valentim
- Anesthesiology Department, Hospitais da Universidade de Coimbra, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Helena Donato
- Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - Teresa Lapa
- Anesthesiology Department, Hospitais da Universidade de Coimbra, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
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Wilkinson AJ, Yang A, Chen GH. Stellate ganglion block to mitigate thalamic pain syndrome of an oncological origin. Pain Pract 2024; 24:231-234. [PMID: 37485837 DOI: 10.1111/papr.13275] [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] [Received: 08/18/2022] [Revised: 05/25/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Thalamic pain syndrome (TPS) is an enigmatic and rare condition. Thalamic pain syndrome is under the umbrella of central pain syndrome, which is classically associated with multiple sclerosis, spinal cord injury, postamputation, epilepsy, stroke, tumor, and Parkinson's disease. The mainstay treatment of TPS is polypharmacy. There is uncertainty about the intermediate options to manage medication-resistant TPS before resorting to invasive, and often expensive, intracranial therapies. Stellate ganglion block (SGB) has shown promise in reducing TPS symptoms of the upper extremity and face following a thalamic ischemic event. AIMS Discuss the effect and potential utility of SGB on ipsilateral headache, facial, and upper extremity neuropathic pain due to thalamic malignancies. MATERIALS AND METHODS A review of two patient records that underwent SGB for treatment of TPS of oncologic origin. RESULTS We present two cases of the successful use of SGB for the treatment of oncologic-related TPS for patients who had failed other conservative pharmacologic measures. DISCUSSION Chronic pain is a complex experience that often simultaneously involves psychosocial, neuropathic, and nociceptive constituents. Among advanced cancer patients, factors such as an individual's spirituality, psychological stressors, and views on their mortality add layers of intricacy in addressing their pain. While TPS has been characterized in both stroke populations and oncologic populations, the treatment of SGB for pain relief in TPS has been limited to the stroke population. Repeated SGB worked to alleviate the ipsilateral headache, facial, and upper extremity pain in these two patients. The benefits of utilization of SGB, with the possibility of pain relief, within the thalamic malignancy population cannot be understated. CONCLUSION In summary, ultrasound-guided SGB may be considered in patients with TPS due to thalamic cancer, before pursuing more invasive intracranial surgeries to treat pain.
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Affiliation(s)
- Alex J Wilkinson
- McGovern Medical School at UTHealth Houston, Houston, Texas, USA
| | - Ajax Yang
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Grant H Chen
- Department of Anesthesiology, Chronic Pain, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
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Mohanan AT, Nithya S, Nomier Y, Hassan DA, Jali AM, Qadri M, Machanchery S. Stroke-Induced Central Pain: Overview of the Mechanisms, Management, and Emerging Targets of Central Post-Stroke Pain. Pharmaceuticals (Basel) 2023; 16:1103. [PMID: 37631018 PMCID: PMC10459894 DOI: 10.3390/ph16081103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 08/27/2023] Open
Abstract
The incidence of stroke plays the foremost role in the genesis of central neuropathic pain. Central post-stroke pain (CPSP) is a central pain arising from a vascular lesion in the central nervous system that elicits somatosensory deficits, often contralateral to stroke lesions. It is expressed as continuous or intermittent pain accompanied by sensory abnormalities like dysesthesia and allodynia. CPSP remains de-emphasized due to the variation in onset and diversity in symptoms, besides the difficulty of distinguishing it from other post-stroke pains, often referred to as a diagnosis of exclusion. Spinothalamic dysfunction, disinhibition of the medial thalamus, and neuronal hyperexcitability combined with deafferentation in thalamocortical regions are the mechanisms underlying central pain, which play a significant role in the pathogenesis of CPSP. The treatment regimen for CPSP seems to be perplexed in nature; however, based on available studies, amitriptyline and lamotrigine are denoted as first-line medications and non-pharmacological choices may be accounted for cases intractable to pharmacotherapy. This review attempts to provide an overview of the mechanisms, existing management approaches, and emerging targets of CPSP. A profound understanding of CPSP aids in optimizing the quality of life among stroke sufferers and facilitates further research to develop newer therapeutic agents for managing CPSP.
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Affiliation(s)
- Anugeetha Thacheril Mohanan
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| | - Sermugapandian Nithya
- Department of Pharmacology, Sri Ramachandra Faculty of Pharmacy, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Porur, Chennai 600116, Tamilnadu, India
| | - Yousra Nomier
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| | - Dalin A. Hassan
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| | - Abdulmajeed M. Jali
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| | - Marwa Qadri
- Department of Pharmacology and Toxicology, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
- Inflammation Pharmacology and Drug Discovery Unit, Medical Research Center (MRC), Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| | - Shamna Machanchery
- Department of Clinical Pharmacy, College of Pharmacy, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
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Zhou L, Jin Y, Wu D, Cun Y, Zhang C, Peng Y, Chen N, Yang X, Zhang S, Ning R, Kuang P, Wang Z, Zhang P. Current evidence, clinical applications, and future directions of transcranial magnetic stimulation as a treatment for ischemic stroke. Front Neurosci 2023; 17:1177283. [PMID: 37534033 PMCID: PMC10390744 DOI: 10.3389/fnins.2023.1177283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/28/2023] [Indexed: 08/04/2023] Open
Abstract
Transcranial magnetic stimulation (TMS) is a non-invasive brain neurostimulation technique that can be used as one of the adjunctive treatment techniques for neurological recovery after stroke. Animal studies have shown that TMS treatment of rats with middle cerebral artery occlusion (MCAO) model reduced cerebral infarct volume and improved neurological dysfunction in model rats. In addition, clinical case reports have also shown that TMS treatment has positive neuroprotective effects in stroke patients, improving a variety of post-stroke neurological deficits such as motor function, swallowing, cognitive function, speech function, central post-stroke pain, spasticity, and other post-stroke sequelae. However, even though numerous studies have shown a neuroprotective effect of TMS in stroke patients, its possible neuroprotective mechanism is not clear. Therefore, in this review, we describe the potential mechanisms of TMS to improve neurological function in terms of neurogenesis, angiogenesis, anti-inflammation, antioxidant, and anti-apoptosis, and provide insight into the current clinical application of TMS in multiple neurological dysfunctions in stroke. Finally, some of the current challenges faced by TMS are summarized and some suggestions for its future research directions are made.
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Affiliation(s)
- Li Zhou
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Yaju Jin
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Danli Wu
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Yongdan Cun
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Chengcai Zhang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Yicheng Peng
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Na Chen
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Xichen Yang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Simei Zhang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Rong Ning
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Peng Kuang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Zuhong Wang
- Kunming Municipal Hospital of Traditional Chinese Medicine, Kunming, Yunnan, China
| | - Pengyue Zhang
- Key Laboratory of Acupuncture and Massage for Treatment of Encephalopathy, College of Acupuncture, Tuina and Rehabilitation, Yunnan University of Traditional Chinese Medicine, Kunming, China
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Rahmatian A, Bastani E, Shokri F, Karbasfrushan A. Prevalence of Hemiplegic Shoulder Pain in Iran: A Systematic Review and Meta-analysis. Anesth Pain Med 2023; 13:e136423. [PMID: 38021328 PMCID: PMC10664159 DOI: 10.5812/aapm-136423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 12/01/2023] Open
Abstract
Context Hemiplegic shoulder pain (HSP) is one of the complications of a stroke. Objectives This study aimed to determine shoulder pain prevalence in cerebrovascular accident (CVA) patients. Methods This meta-analysis study searched English and Persian descriptive or descriptive-analytical full-text studies on CVA patients. The search was carried out in all databases by two researchers using keywords such as stroke, pain, CVA, hemiplegic, and shoulder pain. Data analysis was done with the software CMA3. Results In the initial search, 109 articles were found, and finally, the data from four articles were analyzed. The prevalence of HSP was 23% (confidence interval (CI) = 10.3% - 43.5%). Conclusions Considering the HSP prevalence (28.1%) among CVA patients, it is necessary to carry out rehabilitation interventions to prevent such pain in these patients. It is also suggested that rehabilitation interventions be included in the patient education of the healthcare system.
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Affiliation(s)
- Aryoobarzan Rahmatian
- Shahid Mostafa Khomaeini Hospital, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Elham Bastani
- Department of Internal Medicine, Shahid Mostafa Khomaeini Hospital, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Fariba Shokri
- Department of Internal Medicine, Shahid Mostafa Khomaeini Hospital, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Ali Karbasfrushan
- Department of Anesthesiology, Imam Khomeini Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Department of Anesthesiology, Imam Reza Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
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