F30 Pain after stroke - referenced

After a stroke you might experience various physical effects, such as weakness, paralysis or changes in sensation. Unfortunately you may also experience pain. This factsheet will help you to understand some of the causes of pain after stroke and the treatments that may be available. It also gives details of useful organisations that can provide you with further information and support. There are many different types of pain you may experience after having a stroke. Weakness on one side of your body is one of the most common effects of stroke. This can lead to painful conditions such as muscle stiffness spasticity! and shoulder problems. "ome people also experience central post#stroke pain, headaches, and sore swollen hands after stroke. As with many effects of stroke, pain may persist for some time, but treatments such as medication and physiotherapy are often successful in relieving pain. $any people also benefit from attending pain management clinics and learn coping techni%ues to help them to manage long#term pain see page & for details!. controls your muscles.iv If you have spasticity you will have increased muscle tone.v $uscle tone is the amount of resistance or tension in your muscles, and it is what enables us to hold our bodies in a particular position. vi This increased muscle tone can make it difficult to move your limbs.vii "pasticity may also cause your muscles to tense and contract abnormally, causing spasms,viii which can be very painful.ixxxi "pasticity can also damage your tissue and (oints and can sometimes cause painful night cramps.xii It is important to treat spasticity as soon as possible because your (oints and muscles may become so stiff that it is impossible to move them this is called a contracture!.xiii

Spasticity and contractures

After stroke you may find that you have muscle tightness or stiffness ' this is called spasticity. i It is a common problem and affects over a third of stroke survivors.ii Usually it occurs on the weaker side of your body.iii "pasticity happens when there is damage to the area of your brain that

ow is spasticity treated!
If you have weakness after your stroke you should be assessed for spasticity. xiv A team of specialists will decide on the best treatment for you.xv This may include a combination of physiotherapy, medication and )otox. Physiotherapy

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If you have spasticity you should have physiotherapy every day to move your (oints.xvi This will help to stretch your muscles, keeping them flexible and reducing the possibility of contractures.xvii /our physiotherapist will gently place your affected limb into as many different positions as possible. This is called passive stretching and should be taught to your family and carers so that they can help you to practise your exercises.xviii "ee our factsheet F16, Physiotherapy after stroke for more information. "oto# If spasticity affects only one or two specific parts of your body, you may be given botulinum toxin A "oto#! as an in(ection directly into your muscle.xixxx )otox works by blocking the action of the nerves on the muscle,xxi reducing your muscle0s ability to contract.xxii It reduces muscle tone, which can help you to straighten out your limbs.xxiii )otox is only useful for small muscles, such as those in the hands.xxiv The muscle#relaxing effects of )otox usually last for about three months and you should not notice any changes in sensation in your muscles.xxv )otox treatment should be given with further rehabilitation such as physiotherapy, or other treatments like splinting or casting. /ou should also have an assessment three to four months after the treatment, and be

offered further )otox treatments if helpful. $edication If you find that you are still experiencing muscle stiffness, you may be prescribed medicationxxvi to help reduce this stiffness and the pain that often accompanies muscle spasms.xxvii There are different types of drugs that you could be given. They all work in slightly different ways, but they all help to relax your muscles. When your muscles are relaxed they can move more easily and you can stretch them further.xxviii /ou may also find that it becomes easier to straighten or bend your affected limbs, and you may notice fewer muscle spasms.xxix /ou will usually be prescribed baclofenxxx or ti1anidinexxxi first. If these drugs do not work, there are other drugs that may help, but they should only be prescribed by someone who speciali1es in managing spasticity. xxxii
xxxiii

ow are contractures treated!

Splinting and casting If your spasticity is not fully controlled and you develop contractures, your physiotherapist may use a splint or a cast that moulds to or lies along your affected limb and holds it in place.xxxiv This treatment helps to stretch out the muscles in your tight limbs and is
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usually combined with physiotherapy. xxxv "ometimes this treatment is used to try to prevent contractures from formingxxxvi by making sure that your body is not in an abnormal position.xxxvii Unfortunately sometimes splints and casts can be uncomfortable. Talk to your physiotherapist about what would be best for you. Surgery If you have severe contractures, you may need surgery to lengthen your tendons.xxxviii Tendons are the bands that connect your muscle to the bone, and lengthening your tendons allows the (oint to be stretched out. This procedure is performed under anaesthetic. "urgery is always a last resort.xxxix

in place. There is a layer of tissue that surrounds this (oint which is called a capsule. If your arm muscles are very weak, stiff or paralysed, the effect of gravity puts a strain on your ligaments and your capsule. This can cause these parts of your shoulder (oint to become inflamed,xli stretched and damaged. -aving weakness in your arm muscles may contribute to this pain in your shoulder.xlii Sublu#ation Another cause of shoulder pain is shoulder subluxation. This means partial dislocationxliii # where the bone of the upper arm and the shoulder blade have moved apart.xliv This might be because the muscles that normally hold this (oint in place are too weak to do this properly. xlv

Shoulder pain ow is shoulder pain treated!

"houlder pain is common after a stroke, and usually affects the side of your body that is affected by the stroke. There are different types of shoulder pain that you might experience and experts do not yet fully understand the exact causes.xl Fro%en shoulder After a stroke you may find that your shoulder is very stiff and that it hurts when you move it. This is called fro1en shoulder or capsulitis. $uscles and ligaments around our shoulder (oints hold the bone in our upper arms Prevention If you have weakness in your arm following your stroke, your medical team will try to prevent shoulder pain developing.xlvi They will make sure that anyone who handles your arm knows how to do so with care and without causing strain on your shoulder (oint. xlvii They should also ensure that your arm and shoulder are positioned correctly.xlviii &orrect positioning is vital because it can help to reduce the strain on your ligaments and capsule,
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helping to prevent fro1en shoulder from developing. It may also help to prevent your shoulder blade and upper arm bone from moving apart subluxation!.xlix /our medical team may use foam supports to make sure that your shoulder is supported in the correct position.l /our arm can also be supported using a pillow.li 'verhead arm slings should not be usedliiliii because there is not enough evidence that they workliv and they may increase your risk of developing shoulder pain or contractures.lv /our physiotherapist may use cuffs or straps to keep your arm and shoulder in the correct position, but for some people this may lead to spasticity.lvi /our physiotherapist may also use electrical stimulation on the muscles around your shoulder to help prevent or treat subluxation.lvii "ee page 2 for further information about electrical stimulation.! (educing pain /ou may be given painkillers such as paracetamol or codeine to help relieve the pain in your shoulder.lviii 3or more severe pain you may be given a non# steroidal anti#inflammatory drug 4"AI5!lix such as diclofenac or ibuprofen.lx These types of drug help to relieve pain and can also help to reduce swelling in your shoulder capsule.lxi If you have an inflamed shoulder a steroid) such as triamcinolone, may be

in(ected into your (oint to help reduce the pain.lxii "oto# can sometimes be in(ected into specific muscles around your shoulder to help reduce pain and increase fle#ibility, particularly where the pain is associated with spasticity. lxiii $oving your shoulder It is important to keep the muscles in your shoulder and arm active so that any stiffness does not get worse. /our physiotherapist may use stretching e#ercises to move your shoulder (oint in all directions.lxiv They can also provide you with advice about how to protect your shoulder during everyday movements such as reaching for something or getting dressed.

&entral post-stroke pain &PSP!

Up to ,* per cent of people who have a stroke will develop a particular type of pain called central post#stroke pain 67"7!.lxv This is also known as 5e(erine 8oussy "yndrome,lxvi or central pain syndrome.lxvii There are different types of painlxviii you might experience if you have 67"7. $any people describe it as an icy burning sensation, or a throbbing or shooting pain. "ome people also experience pins and needles or numbness in the areas affected by the pain. 3or most stroke survivors with 67"7, the pain occurs in the side of their body that has been affected by the stroke.lxix The pain may begin
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immediately after your stroke but more often it begins several months later.lxxlxxi "ome people find this pain becomes worse because of other factors such as movement or a change in temperature.lxxii The exact cause of 67"7 is unknown, but it is thought to be due to damage to certain parts of the brain and body. 67"7 is a form of neuropathic pain) which means that the painful sensation does not occur because your body is in*ured or because something is making it hurt. The pain may be caused by damage to the brain, brainstem and spinal cord together, these are called the central nervous system!lxxiii or be due to damage to the sensory pathways. These are pathways between the brain and the bodylxxiv which carry messages about pain.lxxv In some cases, 67"7 is due to damage to the thalamus, which is the brain0s pain centre.lxxvi When this part of the brain is damaged it can sometimes cause feelings of pain when you are feeling a sensation that is not normally painful.

created for treating other conditions are helpful for some people.lxxviii lxxix They include amitriptyline)lxxx which is a drug used to treat depression, and gabapentin and pregabalin) which are used to treat epilepsy. lxxxi /ou will usually be started on a low dose, which is then gradually increased. If the first medication you try does not work, you should be offered another drug to try either with, or instead of, the first one. In rare cases, if your pain is severe and other treatments have been unsuccessful, your medical team may offer you deep brain stimulation. This is a procedure where small electrical leads are placed deep within your brain and are connected to a battery#powered machine, which sits under your skin. This procedure can only be carried out in specialist centres and it is not suitable for everyone.lxxxii 8esearch shows that deep brain stimulation is effective in reducing pain for some people, though only a small number of people have taken part in the studies.

'ther painful conditions ow is &PSP treated!

Swollen hand Unfortunately there is no cure for 67"7, but around +0 per cent of stroke survivors with &PSP find that medication helps to relieve their pain.lxxvii :rdinary painkillers are not usually helpful in relieving 67"7, but some drugs which were originally /ou might find that after your stroke your hand swells up and becomes painful. This usually happens if you are not moving your hand very much, for example, if it is paralysed. The swelling happens because the fluid in the tissue
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"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

in your hand cannot circulate properly because the muscles are not moving. When your muscles are not moving regularly, this fluid can collect, causing swelling and discomfort.lxxxiii This can get worse if your hand is often hanging downwards.lxxxiv This painful swelling can make it even more difficult to move your hand and arm, which can make spasticity worse.lxxxv To overcome this problem it is best to raise your hand and place it on a pillow or a cushion, and to get your hand moving again gently with the help of your physiotherapist. Wearing a tight#fitting glove can sometimes help to push the fluid out of your hand ' this is called an oedema glove. This will need to be fitted correctly to avoid causing too much pressure.lxxxvi /our physiotherapist should be able to make a referral for you to have this done. /ou might find that painkillers such as paracetamol help to relieve the pain caused by this swelling in your hand.lxxxvii eadache There are many reasons why you might experience headaches following your stroke. "ome reasons might be the same as before your stroke, such as stress, depression or lack of sleep.lxxxviii If you are having headaches after your stroke, they could be a side effect of medication that you have started taking. 6ommon examples include

nifedipine Adalat!,lxxxix which is given for high blood pressure, dipyridamole 7ersantin!,xc a blood#thinning medication, and glyceryl trinitrate,xci which is given for angina and to lower blood pressure. ,alk to your doctor, because if you are experiencing headaches or any other side effects from medication, there may be an alternative drug you can try instead. :ccasionally, headaches may be a direct after#effect of your stroke if there is swelling of the brain.xcii This swelling, which can be caused by a stroke, can irritate the membrane that covers the brain, resulting in a headache.xciii This is more common if you have had a stroke caused by a bleed in the brain. -eadaches can also occur because of a change to the levels of cerebrospinal fluid 6"3!. This is the fluid that fills the space between our brain and our skull. If there is an increased or reduced amount of 6"3, this can cause headaches.xciv The pain from the headaches you are experiencing should lessen over time and can usually be controlled by painkillers such as paracetamol. -ou should not take aspirin if your stroke was caused by a bleed. .rinking plenty of water two to three litres per day! and avoiding caffeine and alcohol which cause dehydration! may help to reduce these headaches.
2

"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

Increasing the amount of fluid in your body will improve the blood circulation to your brain.xcv "ometimes taking painkillers for headaches too often for more than about ,+ days a month! can cause headaches. Treatment usually involves stopping all pain relief medication for one month, but talk to your <7 first if you think this is the cause of your headaches. 5o not stop taking any medication without getting medical advice. /f you ever e#perience a sudden) severe headache or a persistent headache) you should seek medical attention urgently to find out what is causing it. :ne of the symptoms of a stroke caused by bleeding on the surface of the brain subarachnoid haemorrhage! is a very sudden and severe headache, as if you have been hit on the back of the head. 3or more information about strokes caused by bleeding, please see our factsheet F25, Bleeding in the brain - haemorrhagic stroke.

yoga)xcvi or speaking to a counsellor may also help you to cope.xcvii A pain clinic can give you more advice about your options see page &!. ,ranscutaneous electrical nerve stimulation 2,e1S3 If you have severe and persistent pain, your medical team may consider treating this with transcutaneous electrical nerve stimulation Te4"!.xcviii Te4" treatment uses electrical impulses to reduce pain. "ticky pads are attached to your skin close to the area that hurts. These pads are linked to leads called electrodes, which are attached to a battery#operated machine. ?lectrical impulses are then sent from the machine, through the electrodes and onto your skin. These impulses can help to block the pain signals from travelling along the nerve pathways xcix to your brain. At a low fre%uency, Te4" can help your body to release natural painkillers called endorphins.c There is not enough evidence to say definitively whether Te4" is an effective and reliable way of reducing pain. 6linical trials have shown that it works well for some people but not for others, and that the amount of pain relief and the length of time that this lasts for varies from person to person.ci The ma(ority of people who have found Te4" to be effective noticed benefits whilst the machine was switched on, but found the pain relief did not last.cii
&

0lternative methods of treating pain

If you find that medication and=or physiotherapy has not helped to relieve your pain, you may wish to try some alternative techni%ues. /ou may gain temporary relief from ,e1S, massage or acupuncture. >earning a relaxation techni%ue, such as meditation or

"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

This form of pain management is widely used by hospitals and pain clinics throughout most of the U@ see the section on Pain clinics and pain management programmes!. Te4" could be a helpful way to manage your pain but it is important to check with your doctor first before trying this treatment. This is because there are lots of different causes of pain and types of pain, and Te4" has not yet been recommended for all of them.ciii There are no side effects to Te4" and you can use it alongside other medication. Te4" is unsuitable for some people, for example people fitted with a cardiac pacemaker,civ so if you are interested in trying Te4" to manage your pain, it is important to check with your doctor first. Te4" treatment may be available from your physiotherapist, or alternatively you can buy the machines from some pharmacies.

At a pain clinic, you can have an assessment to determine the cause of your pain and they can provide treatment and advice to help you to manage this pain. The kinds of treatment that are available from pain clinics vary across the U@. $ore information about what pain services are available for you can be obtained from your local health service, for example your <7.cviii "ome pain clinics run pain management programmes. They use physical) psychological and practical methods to deal with managing your pain and the effects that it has on your life. 6arried out in groups, the programmes usually run for a set amount of time over a number of weeks. 5octors, nurses, psychologists, physiotherapists and occupational therapists will be there to carry out the programme.cix 3or example, a physiotherapist might help you to work on the physical difficulties that the pain causes by strengthening your musclesA a psychologist might help you to manage the emotional effects that pain can have, such as depression and frustration.cx

Pain clinics and pain management programmes

/ou should be referred to a specialist pain service if you are still in pain despite initial treatment, and it is causing you distress or significantly limiting what you are able to do. If this has not happened, ask your doctor to refer you to one.cvcvi 7ain clinics and pain management programmes can help you to find ways to manage your pain in the longer#term to improve your %uality of life.cvii

Useful resources
Pain relief audio tapes4&.s A series of simple and effective audio resources for home use, describing techni%ues used on the pain
B

"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

management programme at the Walton 6entre for 4eurology and 4eurosurgery. They are available from the 7ain 8elief 3oundation see Useful organisations!. TitlesC oping !ith Pain, oping !ith Back Pain, oping !ith "eadache and #igraine, $n%iety all priced at DB.;+ inc. 7E7!, &he 'ela%ation (it, and, Feeling )ood D,..FF inc 7E7!. "ooks &he Pain 'elief "andbook* +elf-help methods for managing pain, )y 5r 6hris Wells E <raham 4own Germilion, >ondon ,FF2. Available from book shops. &aking ontrol of your Pain, )y Toni )attison. Age 6oncern )ooks *++;! Available from book shops. Pain 'elief !ithout -rugs, )y Han "adler. *++&! -ealing Arts 7ress price D,*.FF!. Available from The 7ain 8elief 3oundation.

0ction on pain ,el5 +B9; 2+. ,;F. 7ebsite5 www.action#on#pain.co.uk 7rovides information and advice about pain. 6ampaigns and raises awareness of those living with chronic pain. ,he "ritish Pain Society ,el5 +*+ &*2F &B9+ 7ebsite5 www.britishpainsociety.org -as various publications for patients and information about pain management. &entral Pain Syndrome 0lliance 7ebsite5 www.centralpain.org International internet resource with online information and a discussion forum for support. &hronic Pain Policy &oalition ,el5 +*+ &*+* B;B+ 7ebsite5 www.policyconnect.org.uk=cppc A forum uniting professionals, members of parliament and patients to campaign for improved strategies on chronic pain
issues. Information about pain is available on the website.

Useful organisations
All organisations are U@ wide unless otherwise stated. Stroke 0ssociation Stroke elpline5 +.+. .+.. ,++ 6mail5 infoIstroke.org.uk 7ebsite5 www.stroke.org.uk 6ontact us for information about stroke, emotional support and details of local services and support groups.

Pain 0ssociation Scotland ,el5 +B++ &B. 2+;F 7ebsite5 www.painassociation.com 7rovides information about pain and runs self#management programmes across "cotland for people living with chronic pain. Pain &oncern
F

"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

elpline5 +.++ ,*. +&BF 7ebsite5 www.painconcern.org.uk Information and advice about pain is available through a range of publications and their helpline. 8uns a radio programme called Airing 7ain. They also have an online forum. ,he Pain (elief Foundation ,el5 +,;, ;*F ;B*+ 7ebsite5www.painrelieffoundation.org. uk 7rovides information about pain and pain management and supports research into treatments. PainSupport 7ebsite5 www.painsupport.co.uk 7rovides information about pain relief and advice about treatments. :ffers an online forum and a contact club so that people suffering from pain can contact each other. S&'P6 elpline5 +B+B B++ .... 7ebsite5 www.scope.org.uk 7rovides information sheets about spasticity, splinting and )otox treatment. ,alking 8ife ,el5 +,;, 2.* +22* 7ebsite5 www.talkinglife.co.uk 8uns training courses and produces materials for professionals. ,e1S $edical Services 8td ,el5 +B9; +F++ B++ 7ebsite5 www.tens.co.uk

7roduces and sells Te4" machines. .isclaimer5 The "troke Association provides the details of other organisations for information only. Inclusion in this factsheet does not constitute a recommendation or endorsement.

9lossary of terms
&apsulitis J see K3ro1en shoulder0. &entral nervous system J the name for the system in the body containing the brain, brainstem and spinal cord. &ontracture J abnormal shortening of a muscle that results in deformity. &PSP J central post#stroke pain. &erebrospinal fluid &SF! J fluid that fills the space between the brain and skull. Fro%en shoulder J a very stiff shoulder which can be painful. 8umbar puncture J a procedure to take a sample of cerebrospinal fluid, which can be used to diagnose conditions such as a subarachnoid haemorrhage. 'edema J an increase of fluid in the tissues which can cause swelling. Spasticity J a form of muscle tightening.
,+

"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

Subarachnoid haemorrhage J a type of stroke caused by bleeding in the space between the brain and skull. Subarachnoid space J the space between the membranes that surround the brain and protect it from the skull.

Sublu#ation J partial dislocation of the shoulder, where the bone of the upper arm and the shoulder blade have moved apart. ,e1S J Transcutaneous electrical nerve stimulation a treatment that uses electrical impulses to block pain signals!.

7roduced by the "troke Association0s Information "ervice. 3or sources used, visit stroke.org.uk L "troke Association 3actsheet .+, version +, published "eptember *+,* next review due "eptember *+,9!.
"troke Association is registered as a charity in ?ngland and Wales 4o *,,+,;! and in "cotland "6+.&&BF!. Also registered in 4orthern Ireland MT..B+;! Isle of $an 4o F9;! and Hersey 47: .2F!.

(eferences

"troke Association "eptember *+,* "troke -elpline +.+. .+ .. ,++ website www.stroke.org.uk

,,

8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;& ii Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;&F iii 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.B,C 2.*+. iv $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&2 v The )ritish $edical Association *++F!, /llustrated #edical -ictionary "econd edition!, 5orling @indersley >imitedC >ondon, p.;;9 vi About 6erebral 7alsy, #uscle &one httpC==www.about#cerebral# palsy.org=definition=muscle#tone.html accessed ,2th Huly *+,*! vii $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&2 viii $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&2 ix $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&2 x Genes, 5 et al. *++;!. &aber0s yclopedic #edical -ictionary. 3.A. 5avis 6ompany, p.*+.* xi -arwood, 8. et al *++;!, +troke are a practical manual 3irst edition!, :xford University 7ressC 4ew /ork, p.,&* xii 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*B xiii 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;&#;B xiv 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.B, 2.*+ xv 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.;C 9.,B., ). xvi 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.; ..,.., xvii Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;B, xviii $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&B xix )ritish $edical Association, *+,, reprint!, .e! )uide to #edicines and -rugs ?ighth edition!, 5orling @indersley >imitedC >ondon, p.,&2 xx "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html p...A p.&; accessed *+th Huly *+,*! xxi 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;B xxii $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*B+ xxiii Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;B,#* xxiv 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;F xxv "tein, H. et al *++F!, +troke 'eco1ery and 'ehabilitation 3irst edition!, 5emos $edical C 4ew /ork, p.99&. xxvi 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.B,A 2.*+., ?
i

Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;B, xxviii $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&F xxix $arler, H. *++;!, +troke for -ummies 3irst edition!, Wiley 7ublishingC Indiana, p.*&F xxx )ritish $edical Association, *+,, reprint!, .e! )uide to #edicines and -rugs ?ighth edition!, 5orling @indersley >imitedC >ondon, p.,2& xxxi )ritish $edical Association, *+,, reprint!, .e! )uide to #edicines and -rugs ?ighth edition!, 5orling @indersley >imitedC >ondon, p.&B=9BF xxxii 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.BC 2.*+., 3. xxxiii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p.., accessed *+th Huly *+,*! xxxiv 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.& 2.,9.,.5 xxxv 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;F xxxvi 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.&C 2.,9.,C 5 xxxvii 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.&BA 2.,9 xxxviii -arwood, 8. et al *++;!, +troke are a practical manual 3irst edition!, :xford University 7ressC 4ew /ork, p.,&* xxxix -arwood, 8. et al *++;!, +troke are a practical manual 3irst edition!, :xford University 7ressC 4ew /ork, p.;B* xl "tein, H. et al *++F!, +troke 'eco1ery and 'ehabilitation 3irst edition!, 5emos $edical C 4ew /ork, p.99*. xli The )ritish $edical Association *++F!, /llustrated #edical -ictionary "econd edition!, 5orling @indersley >imitedC >ondon, p.,+& xlii 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*; xliii The )ritish $edical Association *++F!, /llustrated #edical -ictionary "econd edition!, 5orling @indersley >imitedC >ondon, p.;., xliv 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;; xlv 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;; xlvi 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;; xlvii 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.B xlviii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+!, httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html p..& accessed *+th Huly *+,*! xlix 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.;;
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8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.B and "t <eorge0s Trust httpC==www.slcsn.nhs.uk=files=stroke=events=,9,++F=,9,++F#gawned.pdf li -arwood, 8. et al *++;!, +troke are a practical manual 3irst edition!, :xford University 7ressC 4ew /ork, p.;* lii 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.,.BA 2.**., A liii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+!, httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p..& accessed *+th Huly *+,*! liv "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+!, httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p..9 accessed *+th Huly *+,*! lv "tein, H. et al *++F!, +troke 'eco1ery and 'ehabilitation 3irst edition!, 5emos $edical C 4ew /ork, p.99+ lvi Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;BF lvii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, section 9.,+.. p..; accessed *+th Huly *+,*! lviii 4-" 6hoices, Fro2en +houlder 3 &reatment April *+,*! httpC==www.nhs.uk=6onditions=3ro1en#shoulder=7ages=Treatment.aspx accessed ,2th Huly *+,*! lix "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p.9, accessed *+th Huly *+,*! lx 4-" 6hoices, $nti-inflammatories, non-steroidal Hune *+,*! httpC==www.nhs.uk=conditions=anti#inflammatories#non#steroidal=pages=introduction.aspx accessed ,9th August *+,*! lxi 4-" 6hoices, Fro2en +houlder 3 &reatment April *+,*! httpC==www.nhs.uk=6onditions=3ro1en#shoulder=7ages=Treatment.aspx accessed ,2th Huly *+,*! lxii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, section 9.,..F, p.9, accessed *+th Huly *+,*! lxiii "ingh H.A., 3it1gerald 7.$. *+,+! )otulinum toxin for shoulder pain. ochrane -atabase of +ystematic 'e1ie!s. lxiv 4-" 6hoices, Fro2en +houlder 3 &reatment April *+,*! httpC==www.nhs.uk=6onditions=3ro1en#shoulder=7ages=Treatment.aspx accessed ,2th Huly *+,*! lxv "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, section 9.,,.*, p..; accessed *+th Huly *+,*! lxvi 6entral 7ain "yndrome Alliance, 4hat is entral Pain +yndrome5 httpC==centralpain.org= accessed ,2th Huly *+,*!
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4ational Institute of 4eurological 5isorders and "troke, ./.-+ entral Pain +yndrome /nformation Page Han *+,,! httpC==www.ninds.nih.gov=disorders=centralNpain=centralNpain.htm accessed ,2th Huly *+,*! lxviii "tein, H. et al *++F!, +troke 'eco1ery and 'ehabilitation 3irst edition!, 5emos $edical C 4ew /ork, p.**. lxix "tein, H. et al *++F!, +troke 'eco1ery and 'ehabilitation 3irst edition!, 5emos $edical C 4ew /ork, p.*** lxx 4ational Institute of 4eurological 5isorders and "troke, ./.-+ entral Pain +yndrome /nformation Page Han *+,,! httpC==www.ninds.nih.gov=disorders=centralNpain=centralNpain.htm accessed ,2th Huly *+,*! lxxi 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*. lxxii Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;B& lxxiii 4ational Institute of 4eurological 5isorders and "troke, ./.-+ entral Pain +yndrome /nformation Page Han *+,,! httpC==www.ninds.nih.gov=disorders=centralNpain=centralNpain.htm accessed ,2th Huly *+,*! lxxiv )eers, $ et al, *++.!, &he #erck #anual of #edical /nformation "econd edition! 7ocket )ooksC 4ew /ork, p.9.B lxxv Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;B& lxxvi 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*. lxxvii 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,** lxxviii 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,** lxxix 4ational Institute of 4eurological 5isorders and "troke, ./.-+ entral Pain +yndrome /nformation Page Han *+,,! httpC==www.ninds.nih.gov=disorders=centralNpain=centralNpain.htm accessed ,2th Huly *+,*! lxxx "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p..2 accessed *+th Huly *+,*! lxxxi "tein, H. et al *++F!, +troke 'eco1ery and 'ehabilitation 3irst edition!, 5emos $edical C 4ew /ork, p.**.#**9 lxxxii :wen, ".>.3., <reen, A.>., "tein, H.3., A1i1, T.O., *++&! 5eep brain stimulation for the alleviation of post#stroke neuropathic pain. In -enry, H.>., 7an(u, A., /ashpal, @. *++&! 6entral 4europathic 7ainC 3ocus on 7ost#stroke 7ain. IA"7 7ress "eattle p.*,F#**B. lxxxiii 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*B lxxxiv 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, 7,*B. lxxxv Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;F+ lxxxvi 7rofessor Anthony 8udd. ?xpert Advisory 7anel. *&th Huly *++F!. Painful, s!ollen hand. (anine.bennettIstroke.org.uk
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8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*F lxxxviii 4ational Institute of 4eurological 5isorders and "troke, "eadache* "ope through 'esearch Huly *+,*! httpC==www.ninds.nih.gov=disorders=headache=detailNheadache.htmP,F.*&.,.B accessed ,2th Huly *+,*! lxxxix )ritish $edical Association, *+,, reprint!, .e! )uide to #edicines and -rugs ?ighth edition!, 5orling @indersley >imitedC >ondon, p.... xc )ritish $edical Association, *+,, reprint!, .e! )uide to #edicines and -rugs ?ighth edition!, 5orling @indersley >imitedC >ondon, p.**; xci )ritish $edical Association, *+,, reprint!, .e! )uide to #edicines and -rugs ?ighth edition!, 5orling @indersley >imitedC >ondon, p.*2; xcii -ankey, <. *++*!, 6our 7uestions $ns!ered* +troke 3irst edition!, -arcourt 7ublishers >imitedC >ondon, p.;B. xciii -ankey, <. *++*!, 6our 7uestions $ns!ered* +troke 3irst edition!, -arcourt 7ublishers >imitedC >ondon, p.;B xciv 3uller, <. et al *++2!, .eurology* an illustrated colour te%t "econd edition!, ?lsevier >imitedC >ondon, p..F xcv )rain and "pine 3oundation. *++F!. +ubarachnoid "aemorrhage. httpC==www.brainandspine.org.uk=information=publications=brainNandNspineNbooklets=subar achnoidNhaemorrhage=index.html created April *++F, accessed ,2th Huly *+,*!, p.*, xcvi 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*9 xcvii Warlow, 6. et al *++B!, +troke Practical management Third edition!, )lackwell 7ublishingC :xford, p.;BB xcviii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+!, httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p..; accessed *+th Huly *+,*! xcix 4-" 6hoices, "o! Physiotherapy 4orks 3eb *+,*! httpC==www.nhs.uk=6onditions=7hysiotherapy=7ages=-ow#does#it#work.aspx accessed ,2th Huly *+,*! c 4-" 6hoices, &8.+ 9&ranscutaneous 8lectrical .er1e +timulation: 5ec *+,,! httpC==www.nhs.uk=conditions=tens=7ages=Introduction.aspx accessed ,2th Huly *+,*! ci 4-" 6hoices, &8.+ 9&ranscutaneous 8lectrical .er1e +timulation: 5ec *+,,! httpC==www.nhs.uk=conditions=tens=7ages=Introduction.aspx accessed ,2th Huly *+,*! cii 4-" 6hoices, &8.+ 9&ranscutaneous 8lectrical .er1e +timulation: 5ec *+,,! httpC==www.nhs.uk=conditions=tens=7ages=Introduction.aspx accessed ,2th Huly *+,*! ciii "cottish Intercollegiate <uidelines 4etwork "I<4!, #anagement of patients !ith stroke* rehabilitation, pre1ention and management of complications and discharge planning Hune *+,+! httpC==www.sign.ac.uk=guidelines=fulltext=,,B=index.html, p.9,.; accessed *+th Huly *+,*! civ 4-" 6hoices, &8.+ 9&ranscutaneous 8lectrical .er1e +timulation: 5ec *+,,! httpC==www.nhs.uk=conditions=tens=7ages=Introduction.aspx accessed ,2th Huly *+,*! cv 8oyal 6ollege of 7hysicians and the 6linical ?ffectiveness E ?valuation Unit. *++B! .ational linical )uidelines for +troke. .rd ?dn. >avenham 7ress >tdA "uffolk, p.B. cvi 8udd, A. et al *++2 reprint!, +troke at your Fingertips "econd edition!, 6lass 7ublishingC >ondon, p.,*9 cvii )ritish 7ain "ociety, Pain linics httpC==www.britishpainsociety.org=patientNpainNclinics.htm accessed ,2th Huly *+,*! cviii )ritish 7ain "ociety, Pain linics httpC==www.britishpainsociety.org=patientNpainNclinics.htm accessed ,2th Huly *+,*!
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)ritish 7ain "ociety, Pain management Programmes for $dults *++&! httpC==www.britishpainsociety.org=bookNpmpNpatients.pdf accessed ,2th Huly *+,*! cx )ritish 7ain "ociety, Pain management Programmes for $dults *++&! httpC==www.britishpainsociety.org=bookNpmpNpatients.pdf accessed ,2th Huly *+,*!
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