Pain after stroke

Shoulder pain

Shoulder pain usually happens on the side of your body that is affected by the stroke. There are many different conditions that cause shoulder pain and while some improve with targeted treatment, it sometimes becomes a long-term condition.

Frozen shoulder

After a stroke you may find that your shoulder is very stiff and that it hurts when you move it. This is called frozen shoulder, or capsulitis. 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 joint to become inflamed, stretched and damaged.

Subluxation

Subluxation means partial dislocation, when the rounded end of the upper arm bone moves slightly out of its socket. This happens because the muscles that normally hold this joint in place are weakened due to the stroke, and the weight of the arm can pull and stretch the soft tissues.

How is shoulder pain treated?

Prevention

If you have weakness in your arm following your stroke, your therapist will try to prevent shoulder pain developing. They will make sure that anyone who handles your arm knows how to do so with care and without causing strain on your shoulder joint.

They should also ensure that your arm and shoulder are positioned correctly. Correct positioning is vital because it can help to reduce the strain on your ligaments and capsule, helping to prevent frozen shoulder from developing. It may also help to prevent your shoulder blade and upper arm bone from moving apart (subluxation). You may need to use foam supports to make sure that your shoulder is supported in the correct position. Your arm can also be supported using a pillow.

Reducing pain

You may be given painkillers such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen. NSAIDs can also help to reduce swelling. You should only take painkillers on the advice of a doctor as they can increase the risk of bleeding if you are on a blood-thinning medication such as aspirin. If you also have inflammatory arthritis, a steroid may be injected into your joint to help reduce the pain.

Moving your shoulder

It is important to keep the muscles in your shoulder and arm active so that any stiffness does not get worse. Your physiotherapist may use stretching exercises to move your shoulder joint in all directions. They can also provide you with advice about how to protect your shoulder during everyday movements such as reaching for something or getting dressed.

Spasticity and contractures

A stroke can damage the way the nerves control your muscles. This can lead to muscles contracting for long periods or going into spasm, which can be painful. This muscle tightness is known as spasticity, or hypertonia. A stroke can cause muscle weakness down one side, also known as hemiparesis.

If it’s not treated, spasticity can lead to the muscles being permanently shortened. The joints and muscles can become so stiff that it is impossible to move them, causing a contracture.

How is spasticity treated?

Treatments may include a combination of physiotherapy, injections of botulinum toxin type A, and other medications.

Physiotherapy

If you have spasticity you should be given physiotherapy exercises to do. This will help to keep muscles and joints flexible and reduce the possibility of contractures. Your physiotherapist will give advice and pictures for positioning your arm when in bed or sitting up. They will also give you stretches and exercises to build strength.

See our guide ‘Physiotherapy after stroke’ for more information.

Botulinum toxin type

Botulinum toxin type A is given as an injection directly into your muscle. Botulinum treatment is only effective as part of a programme including rehabilitation such as physiotherapy, or other treatments like splinting or casting to ensure that any range gained in the muscle is maintained.

The main brand names used for this treatment are Botox, Dysport and Xeomin. Botulinum toxin type A works by blocking the action of the nerves on the muscle, reducing your muscle’s ability to contract. This makes the muscle less tight), which can help you to straighten out your limbs. This treatment is mainly used for post-stroke spasticity in the hands, wrists and ankles.

Medication

If you have generalised spasticity, or if botulinum toxin type A treatment doesn’t reduce spasticity in the injected muscle, other types of medication can help reduce the stiffness and pain that often comes with spasticity. Muscle relaxants can help you move and stretch more easily and may reduce muscle spasms.

There is a range of medication available for spasticity, and you may need to try more than one or take a combination that works for you. Each type of drug has different benefits and side effects. Your doctor and pharmacist can support you with practical advice on the best way of taking them.

How are contractures treated?

Contractures are treated with splinting and casting. If you develop contractures, your therapist may use a splint or a cast that moulds to or lies along your affected limb and holds it in place. This treatment helps to stretch out the muscles in your tight limbs and is usually combined with physiotherapy.

Sometimes this treatment is used to try to prevent contractures from forming by making sure that your body is not in an abnormal position. Unfortunately, splints and casts can sometimes be uncomfortable. Talk to your physiotherapist about what would be best for you.

Central post-stroke pain (CPSP)

Central post-stroke pain (CPSP) is also known as neuropathic pain, or central pain syndrome. It usually starts within three to six months after a stroke, but it can begin earlier. CPSP happens when areas of the brain that interpret pain are affected by the stroke. This is also known as neuropathic pain, or central pain syndrome.

Many people describe it as a burning or burning cold sensation, or a throbbing or shooting pain. Some people also experience pins and needles or numbness in the areas affected by the pain. For most stroke survivors with CPSP, the pain occurs in the side of their body that has been affected by the stroke.

How is CPSP treated?

Ordinary painkillers such as paracetamol or ibuprofen don’t help with CPSP. Some types of drug that change the chemicals in the brain can be helpful. The main drugs that are used are amitriptyline, and the anti-epilepsy drugs gabapentin and pregabalin. Your doctor and pharmacist will support you to find the right dose or combination of drugs that work for you.

Other approaches to reducing pain include pain clinics and TENS (transcutaneous electrical nerve stimulation).

If treatments have been unsuccessful, you might be able to access a pain clinic. Contact your GP for help.

Swollen hand

Developing a swollen hand can happen if you are not moving your hand very much, or are unable to move it. Older people and those who have experienced more severe strokes are most likely to experience this condition.

The swelling may happen because fluid builds up in the tissue if the muscles are not moving around. It’s more likely to happen if the hand is hanging downwards. The painful swelling can make it more difficult to move your hand and arm, which can make spasticity worse.

How are swollen hands treated?

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.

Headache

There are many reasons why you might experience headaches following your stroke. Some reasons might be the same as before your stroke, such as migraines, stress, or lack of sleep.

If you had a stroke due to a bleed in the brain (haemorrhagic stroke or brain haemorrhage), it can take a while for the headache to reduce while you are recovering.

If you have a persistent headache, you should seek medical attention urgently. If you have any of the signs of a stroke, including a sudden, severe headache, call 999.

How are headaches treated?

If you are having headaches after your stroke, they could be a side effect of medication. If you think that a medication may be causing your headaches, visit your GP. They can find out what could be behind your headaches, and can give you alternative medications if necessary. Don’t stop any treatments before talking to your doctor, as some types of drug depend on being taken regularly.

Headaches can usually be controlled by painkillers such as paracetamol. You should check with your doctor or pharmacist before taking aspirin or a non-steroidal anti-inflammatory such as ibuprofen, as these can cause bleeding.

Drinking plenty of water (around two litres a day) and avoiding caffeine and alcohol helps you to stay hydrated and may reduce headaches. Migraines may be triggered by fatigue, which is common after stroke.

Sometimes, taking painkillers for headaches too often (for more than about 10 days a month) can cause medication over-use headaches. Treatment usually involves stopping all pain relief medication for about 12 weeks. However, you should contact your GP before doing so, as some painkillers contain codeine which can cause withdrawal symptoms if you stop taking it suddenly.

Alternative ways of managing pain

If you find that medication and or physiotherapy has not helped to relieve your pain, there are some other approaches you can try.

Pain clinics and pain management programmes

Pain clinics and pain management programmes can help you find ways to manage your pain in the longer-term to improve your quality of life. If you are in pain despite initial treatment, and it is causing you distress or significantly limiting what you are able to do, ask your GP to refer you to a pain clinic.

Pain clinics provide different treatments and advice to help you manage your pain. The kinds of treatment that are available from pain clinics vary across the UK.

Some pain clinics run pain management programmes. They use psychological and practical methods to deal with managing your pain, and the effect that it has on your life. Doctors, nurses, psychologists, physiotherapists and occupational therapists may be involved with the programme.

Transcutaneous electrical nerve stimulation (TENS)

TENS treatment uses electrical impulses to reduce pain. Sticky pads are attached to your skin and linked to electrodes, which are attached to a battery-operated machine.

Electrical impulses are then sent through the electrodes onto your skin. These impulses can help to block the pain signals from travelling along the nerve pathways to your brain. At a low frequency, TENS can help your body to release natural painkillers called endorphins.

There is not enough evidence to say definitively whether TENS is an effective and reliable way of reducing pain. It provides temporary pain relief with no side effects, other than possible skin redness. You should ask your doctor before using it if you have a heart pacemaker or other type of electrical or metal implant in your body. It may not be suitable early in pregnancy, or for people with epilepsy or heart problems.

Complementary therapies

Although there is limited evidence on using complementary therapies after stroke, it’s possible that massage or acupuncture and relaxation techniques like meditation or yoga may be helpful.

Alternatively, you can also read our short article about cannabis-based products such as CBD oil.

Information guides

• Download Pain after stroke (PDF)
• Download Physiotherapy after stroke (PDF)
• Download Physical effects of stroke guide (PDF)

Where to get help and information from the Stroke Association

Helpline
Call us on 0303 3033 100,from a textphone 1800 0303 3033 100
Email: helpline@stroke.org.uk
Our Helpline offers information and support for anyone affected by stroke, including family, friends and carers.

Read our information
Call the Helpline to ask for printed copies of our guides.

Other sources of help and information

Action on pain
Phone: 0345 603 1593
Provides information and advice about pain, campaigns and raises awareness of those living with chronic pain.

The British Pain Society
Phone: 020 7269 7840
Has various publications for patients and information about pain management.

Pain Association Scotland
Phone: 0800 783 6059
Provides information about pain and runs self-management programmes across Scotland for people living with chronic pain.

Pain Concern
Phone: 0300 123 0789
Information and advice about pain are available through a range of publications and their helpline. Runs a radio programme called 'Airing Pain', they also have an online forum.

The Pain Relief Foundation
Phone: 0151 529 5820
Provides information about pain and pain management, they also support research into treatments for chronic pain relief.

PainSupport
Provides information about pain relief and advice about treatments. Offers an online forum and a contact club so that people suffering from pain can contact each other.

SCOPE
Phone: 0808 800 3333
Provides information sheets about spasticity, splinting and Botox treatment.

TeNS Medical Services Ltd
Phone: 0121 355 6555
Produces and sells TeNS machines.

Apps from MyTherappy
App recommendations from the NHS for survivors and carers ranging from communication, eating and drinking, healthy lifestyle, vision and more..

Disclaimer: The Stroke Association provides the details of other organisations and apps for information only. Inclusion on My Stroke Guide does not constitute a recommendation or endorsement.