Clinical challenges

Complex regional pain syndrome (otherwise known as central pain syndrome, shoulder-hand syndrome, thalamic pain syndrome or Dejerine Roussy) following stroke appears as a painful, oedematose limb with altered heat and tactile sensations, dystrophic skin and is prone to non-use and psychological implications such as anxiety and depression (see Chapter 5). Onset following stroke may occur in the shoulder or hand (or both) in the first 5 months and one-third of these patients may resolve within 1 year (Pertoldi and di Benedetto, 2005). Onset seems to be related to aetiology of stroke (frequently involving the thalamus), severity, motor recovery, spasticity, sensory disorders and glenohumeral subluxation. Although the mechanisms are unclear, the hypersensitivity and interpretation of non-noxious stimuli to be noxious appears to arise from neurogenic inflammation leading to sensitisation of peripheral and central sensory neurones and variable involvement of the sympathetic nervous system. Interventions include pharmacology (non-steroidal anti-inflammatories, tricyclic antidepressants, botulinum toxins), regional anaesthesia, neuromodulation, sympathectomy (sympathetic blocks), TENS and electrotherapy, nighttime resting splints (not recommended for daytime), counselling, biofeedback, relaxation techniques, group therapy and psychotherapy. Exercise and a graded desensitisation programme within perceived pain thresholds may be helpful to gradually habituate patients to stimuli perceived as noxious. However, there is little evidence to support the efficacy of these interventions (Pertoldi and di Benedetto, 2005) and referral to specialised pain clinics is recommended.

Other clinical challenges to somatosensory assessment and intervention include cognitive difficulties, particularly where severe attention impairments such as unilateral neglect are evident. Here, it may be more beneficial to focus on the cognitive aspects to sensory processing and adaptive (compensatory/functional) strategies.

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