When pain symptoms begin, for example in the shoulder, the pain is usually localized to one area of the shoulder joint. If not addressed in a timely manner, it can become a severe, generalized pain.

The paralyzed hand is particularly at risk of developing permanent limitations in mobility due to pain symptoms. Here, the typical signs of inflammation such as swelling, redness and heat are initially evident. To prevent pain, the hand is moved even less and the limitation in mobility increases. A vicious cycle begins.

If pain is already occurring in the wrist or shoulder, affected patients should consult medical advice. Medications can help to disrupt the pain process.

To prevent pain symptoms, correct positioning of the arm or hand affected by paralysis should be started as early as possible.

The correct positioning in the wheelchair:

• Even for short distances, use a wheelchair table or arm support upon which the affected arm or hand can be rested.
• Provide a soft support surface (e.g. a towel).
• Place the affected hand palm down on the table.
• Some individuals find that a rolled-up towel or soft stuffed animal in the affected hand to be comfortable. If the fist involuntarily closes tightly around the fabric, it might be better to choose another object or talk to your therapist about suitable support materials, like splints.
• Make sure to sit up straight. This ensures a physiological joint position in the shoulder joint.
• The affected hand should be positioned in the patient’s field of vision.

If you are a wheelchair user, avoid long periods of poor sitting posture as best as possible.  Be cognizant of positions that put your shoulder at risk of becoming painful. 

The correct positioning while lying: 

Even when lying down, care must be taken to ensure that neither the hand nor arm is trapped.

• Stretch the arm at a 90-degree angle at the side of the body.
• The wrist should be elevated to approximately the same level as the heart to prevent blockages in the arm and ensure lymphatic return.
• A pad under the arm can be helpful. 

Splints are particularly important in the early stages after a stroke. On the one hand, they enable safe positioning of the affected hand, and on the other, they can protect the wrist during active movements. Occupational therapists and orthopaedic technicians can make splints which are individually tailored to the patient’s needs.

Orthopedic specialty markets also offer ready-made splints in various sizes.

Active or passive movement is an important factor in preventing pain in the upper limbs after a stroke. In occupational therapy or physical therapy, therapists assist patients with specific movements. In addition, the affected arm or hand should be moved carefully outside of therapy time.

Patients can try to move the affected hand themselves with their healthy hand:

• Move the fingers of your healthy hand and observe what movements the fingers can make.
• Hold the affected fingers in the healthy hand and try to guide them through the observed movements carefully and slowly.
• Move the fingers individually and then several together.
• Movements must only ever be made in the pain-free range of motion.

As soon as you can move the fingers of your affected hand yourself, try to actively perform movements in the pain-free range several times a day.

Preventive measures are more difficult when patients suffer from “neglect” as a result of a stroke. Patients with neglect ignore the affected half of the body or one half of the room. This increases the risk of injury.

If, for example, the patient sits on the neglected handtrapping it, the patient may perceive pain, but may not localize it or react to it. The hand can remain trapped for hours. This can lead to inflammation with severe swelling.

These patients in particular are dependent on support from relatives, caregivers, and therapists. Care must be taken to ensure that the positioning is closely monitored.

Neuropathic pain is a nerve pain that occurs even without visible reason. The cause of this pain is associated with damage to the nerve tissue in certain parts of the brain or spinal cord. This pain is often described by patients as burning, stabbing, and shooting, but can also present as dull and pressing. It is usually excruciating pain.

If a diagnosis of neuropathic pain is made, medication is started early. Successful treatment requires interdisciplinary cooperation between doctors, therapists, and psychologists.

Injury-related pain in the upper limb after a stroke is not inevitable. Stroke patients, caregivers, and therapists should be particularly careful with the affected arm or hand in the initial period following the stroke.

Auhtor: Hannes Aftenberger

Sources:

Diagnostik und Therapie komplexer regionaler Schmerzsyndrome (CRPS) (2018)

Kumar, P. (2019). Hemiplegic shoulder pain in people with stroke: Present and the future. Pain Management, 9(2), 107–110. https://doi.org/10.2217/pmt-2018-0075