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G.B. Abassova, G.A. Mustapayeva, G.A. Dihanbayeva,

S.K. Erkebayeva, B.O. Alauova, D.B. Orazaliyeva

H.A. Yasawi International Kazakh Turkish University

Department of nerve diseases

THE PROPBLEM OF POST-STROKE PAIN AND FIND WAYS TO SOLVE IT

Insult is one of the main mortality cause and disability the world's population nowadays taking in most of the 2-3 places in the structure of total mortality. Restoration of former ability to work is very difficult for many post cerebral stroked patients. Only 10-20% of them are employed, 8% retain their vocational abilities, 20-43% need the outside care, 33-48% suffer from hemiparesis, and 18-27% have speech disorders. Insult places as a special obligation on members of the family and as a heavy socio-economic burden on society. From 3 till 5% of budget in developed countries is spent for cerebral stroked patients. Therefore, insult is the problem of emergency medical and social significance [1].

The Ischemic stroked patients suffer from pain of different localization and etiopathogenesis. Post Ischemic stroke pain syndrome is often a significant independent problem which impairs the quality of life of the patient [2,3].

According to contemporary investigations Post Ischemic stroke pain syndromes are divided conditionally into three types: 1) central Post Ischemic stroke pain (CPISP); 2) pain syndrome with paretic limb joint disease, - “shoulder pain”, Post-stroke arthropathy; 3) pain syndrome, spasm with painful spastic muscle paretic limb. Post Ischemic stroke pain (CPISP) meets an average of 6-8% of cases of stroke. As Bowsher says, annually in USA 20000-30000 patients after insult suffer from CPISP. 15-20% patients with post-stroke hemiparesis suffer from Post-stroke arthropathy. Relief therapeutic approaches to Post-stroke pain syndrome should be differential depending on the etiology and pathogenesis. Thereby, the acute disorders cerebral blood flow, post-stroke pain syndrome (as one of frequent complications of cerebral stroke) is one of actual problems. It is of scientific interest in developing informed, differentiated therapeutic approach in the correction of this complication [4,5,6,7].

So, the aim of the research is a scientific search of Post Ischemic stroke pain syndrome solving problem.

The scientific research was held in Kazakhstan, Shymkent, the H.A. Yasawi International Kazakh- Turkish University, Department of nerve diseases and Oriental Medicine on the basis of Neurology Clinic.

Principle cohort consists of 37 patients in recovery period of acute cerebrovascular accidents with Post Ischemic stroke pain syndrome. In individual medical record there were reflected patient’s complaints, medical history and life, data of the objective status of a detailed study of neurological status.

7 (19%) patients from 37 ones suffered a hemorrhagic stroke, 30 (81%) - Ischemic stroke. Age of patients was from 52 till 68 (mean age is 59,5). All the patients were examined in magnetically resonance tomographic (ÌRÒ) investigation of brain in order to clarify the nature of stroke, size and location of the lesion.

In the results of analyses of the basic cohort patients with Post Ischemic stroke pain syndrome 37 patients were divided into three groups for clinical and pathogenetic criteria. 12 patients (32%) with central poststroke pain included the first group. 13 patients (36%) with poststroke arthropathy included the second group. 12 patients (32%) with painful muscle spasms paretic limb included the third group. The patients with combined options of Post Ischemic stroke pain syndrome were removed for purposeful learning and development clinical-pathogenetic reasonable therapeutic approach.

To quantify the perception of pain there was used the visual analogue scale – VAS, to assess the severity of functional impairment associated with pain and limitation of joint movement there was held a simple Test for Shoulder (S.B. Lippitt, 1993.), the degree of spasticity in paretic limbs was evaluated on Ashfort spasticity scale. Hamilton scale was used for patients’ anxiety and depressive disorders. Quality of life of patients assessed on European Quality of Life Questionnaire (1990).

In accordance with objective of the study, based on personal experience and analysis of published data, there was developed a differentiated approach to Post Ischemic stroke pain syndrome treatment depending on the clinical variant and pathogenesis. Patients with central post insult pain were prescribed the combined use of antiepileptic drug Pregabalin (Lirika) with antidepressant from the group of selective inhibitor of return capture of serotonin (SIRCS) of Sertralin (Zoloft). Day's dose of Lirika in one-two reception is 75-300 mg, of Zoloft in one-two reception is 50-150 mg. Course of treatment is one month.

Combined use of nonsteroidal anti-inflammatory drug (NAID) from the group lornoxikamov (Xefokam) with muscle relaxant was prescribed for treatment of post-stroke arthropathies (Mydocalm). Day’s dose of Xefokam is 16 mg, scheme for speed: injection form for 3-5 days (8 mg in/m), then oral form for two times. Day’s dose of Midokalm is 100-450 mg, scheme for speed: injection form for 10 days (100-300 mg in/m), then oral form. Course of treatment is one month.

Patients with painful muscle spasms were prescribed Midokalm, day’s dose of Midokalm was 100-450 mg, scheme for speed: injection form for 10 days (100-300 mg in/m), then oral form. Course of treatment was one month. Drug therapy combined with physiotherapy, massage and physical training.

Control group consisted of 36 patients in the recovery period of cerebral stroke. This group was subdivided into three subgroups (per 12 patients in each group) depending on post-stroke pain syndrome. Patients from the control group were treated with standard pain therapy as NAID and non-pharmacological therapy as well. In one, four weeks of treatment as a doctor as a patient got overall assessment of treatment effectiveness.

In comparison with the control group the results of differential treatment of post-stroke pain in the main group of patients with central post-stroke pain syndrome showed the significant positive clinical dynamics. According to ÂÀØ scale the severity of pain before treatment in the main group 8,8 points, in the control group 8.3 points after treatment these figures were 2.3 and 3.9 points respectively (Figure 1).

Figure 1 – The dynamics of the central post-stroke pain treatment

(scale ÂÀØ)

Also in the main group patients had clinical regression of anxiety and depressive disorders (according to Hamilton scale), before treatment was 45 points, and after treatment 12 points. Other situation in the control group: before treatment was 46 points, and after treatment 32 points (Figure 2).

Figure 2 – Dynamics of treating anxiety and depressive disorders in the central post-stroke pain (according to Hamilton scale)

According to the scale VASH the analysis of the results of treatment of patients with post-stroke arthropathy also showed a positive clinical dynamics in the main group in comparison with the control group (in the main group before treatment - 8.6 points, and 2.4 points after treatment; respectively, in the controls group: 8.5 points before treatment, and after treatment - 3.7 points). Also, the dynamics of treatment was assessed by a simple test for the shoulder. Results of the test showed the efficiency of the combined use of Movalis Mydocalm in the main group.

Figure 3 – Dynamics of treating post-stroke arthropathies (a simple test for the shoulder)

During the treatment in the main and control groups of patients with painful spasms of muscles spastic paretic limb spasticity was assessed the dynamics of pain according to the VAS scales and spasticity of Ashfort.

Good clinical regression of pain was observed in the main group patients receiving step scheme Mydocalm (Fig. 4).

Figure 4 – The dynamics of the treatment of painful spasms of muscles spastic paretic limb (Ashfort scale)

The effectiveness of a differentiated approach in the treatment of patients with post-stroke pain syndrome was assessed by the European Quality of Life Questionnaire (1990). Analysis of results showed significant improvement in quality of life of patients receiving differential treatment based on clinical-pathogenic variant of post-stroke pain. In the main group of patients the quality of life prior to treatment was assessed at 42 points. After the differential treatment of post-stroke pain syndrome quality of life improved significantly, and was rated at 73 points. In the control group indicated a moderate improvement in quality of life of patients during standard treatment: 45 and 58 points respectively (Fig. 5).

Figure 5 – Evaluation of treatment results post-stroke pain syndrome in the European Quality of Life Questionnaire

According to the results of research work the following conclusions:

1. Must take into account different pathophysiological mechanisms of post-stroke pain syndrome in the differential approach to the diagnosis of this pathology.

2. The therapeutic approach to the correction of post-stroke pain syndrome should be differentiated depending on the clinical-pathogenic variant.

3. In the result of the research there was proposed the following scheme of differential treatment of post-stroke pain syndrome:

a) with the central post-stroke pain, it combined use of antiepileptic drug pregabalin (Lyrica) with an antidepressant of the SSRI sertraline (Zoloft);

b) in post-stroke arthropathy recommended the combined use of nonsteroidal

anti-inflammatory drug (NSAID) in the group lornoksikamov (Ksefokama) with a muscle relaxant (Mydocalm);

c) for painful muscle spasms muscle relaxant is recommended (Mydocalm).

References:

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3. G.N. Kryzhanovsky. The central mechanisms of pathological pain. // Journal of Neuropathology and psychiatrist, ¹3, 2003, P. 4-7.

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