Joint Pain And Stroke: Is There A Link?

Joint pain is a common complication after a stroke, affecting about 30% to 40% of stroke survivors. This pain can manifest in the shoulder, arm, or hand, and it can range from irritating to crippling in severity. While joint pain itself does not cause a stroke, certain conditions like rheumatoid arthritis (RA) that trigger joint pain can increase the risk of stroke. RA is an autoimmune disease where the body's immune system attacks the joints, releasing inflammatory chemicals that damage not only the joints but also blood vessels, increasing the likelihood of a stroke. Therefore, while joint pain does not directly cause a stroke, addressing underlying conditions that cause joint pain, such as RA, can help mitigate stroke risk.

Rheumatoid arthritis and stroke risk

Rheumatoid arthritis (RA) is an autoimmune disease that primarily affects the joints. It is well-established that RA can independently increase an individual's risk of experiencing a stroke, with recent evidence drawing attention to the association between the two conditions. This heightened risk affects both young and adult patients with RA.

Mechanisms and Risk Factors

RA is characterised by chronic inflammation, primarily within the synovial tissue in joints. This inflammation triggers the release of enzymes, pro-inflammatory factors, and cytokines, which can enter the bloodstream and contribute to atherosclerosis—the build-up of plaques on artery walls. Atherosclerosis increases the likelihood of blood clots and blocked blood vessels, which can lead to a stroke.

In addition, RA has been linked to vasculitis, an inflammation of blood vessels, particularly impacting the medium and small cerebral vessels in the brain. This condition further elevates the risk of stroke.

Other mechanisms that potentially contribute to the increased risk of stroke in individuals with RA include:

• Cardiac valve injury and atrial fibrillation, which significantly increase the risk of blood clots.
• Immune-driven atherosclerosis, an inflammatory process accelerated by RA.
• Endothelial dysfunction, often associated with elevated levels of TNF-alpha, which is also linked to increased cardiovascular risk.
• Neuroinflammation, increased arterial stiffness, and disruption of the blood-brain barrier, all of which are associated with RA.

Early Detection and Treatment Implications

The identification of diagnostic markers and early detection tools is essential for the diagnosis, prevention, and management of stroke in RA patients. This includes the utilisation of disease-modifying anti-rheumatic drugs (DMARDs) in conjunction with standard therapy when necessary.

Furthermore, the management of RA severity and control of cardiovascular risk factors are crucial in reducing the risk of stroke. This includes focusing on lifestyle changes such as a nutritious diet, regular physical activity, and quitting smoking.

Additionally, certain medications used to treat RA, such as non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, may also increase the risk of stroke and other cardiovascular events. Therefore, it is important for healthcare providers to carefully assess the risks and benefits of these treatments on a case-by-case basis.

Post-stroke pain treatment

Non-steroidal anti-inflammatory drugs (NSAIDs)

These include aspirin, ibuprofen, and naproxen, as well as acetaminophen and opioids. NSAIDs should be avoided if the patient had a hemorrhagic stroke due to the high risk of bleeding.

Narcotic painkillers

These can cause sedation and impair cognitive ability. There is also a risk of addiction.

Antidepressants

Tricyclic antidepressants such as amitriptyline (Elavil) have proven efficacy in addressing constant pain.

Anti-seizure medications

Anti-seizure medications such as gabapentin (Neurontin) and carbamazepine (Tegretol) can provide relief from stabbing pain.

Surgical treatment

Surgical treatment can help reduce pain by 50% or more, and some patients find excellent or even complete pain relief. Surgical options include deep brain stimulation and motor cortex stimulation.

Psychological treatment

Depression and anxiety can worsen pain, and pain can cause patients to become depressed and anxious. Seeking treatment from a mental health provider with experience in caring for patients with chronic pain can help break this cycle.

Physical therapy

Physical therapy and early mobility are vital for reducing long-term disability and improving symptoms. Range-of-motion exercises should be done gently to avoid further trauma. Stretching is essential for maintenance and improvement of functioning.

Complementary therapies

Complementary therapies such as massage, acupuncture, meditation, or yoga may be helpful.

Shoulder pain after stroke

Shoulder pain is the most common source of pain for stroke survivors, affecting 16% to 72% of patients. It usually occurs on the side of the body affected by the stroke.

There are two types of shoulder pain that can follow a stroke:

• Limited range of motion: The resulting immobility can cause "frozen shoulder", which is scar tissue that forms in the joint.
• Shoulder subluxation: This is a partial dislocation of the shoulder joint, caused by weak rotator cuff muscles, which connect the upper arm bone to the shoulder blade. These muscles are responsible for maintaining shoulder joint alignment during arm movement. When the rotator cuff is weak, gravity pulls the arm down and away from the shoulder blade, causing shoulder subluxation. This can also be caused by slumped posture due to weak back muscles, or by muscle stiffness that places uneven stress on the shoulder joint.

Prevention and management strategies for shoulder subluxation include:

• Constraint-induced movement therapy: This involves forcing the use of the affected arm by restraining the unaffected arm with a sling.
• Mental practice with motor imagery: Rehearsing a physical activity by memory without body movement.
• Task-specific training: Relearning a given task by training specifically for that task.
• Slings and other support devices: Slings that support the weight of the arm while allowing the elbow to straighten are the best option for reducing subluxation while promoting use of the arm, which is vital to recovery.
• Foam supports or shoulder strapping: These may be used to prevent shoulder pain.
• Electrical stimulation: A low-level electric current may be used to manage shoulder pain.
• Medicines: Your doctor may recommend paracetamol, non-steroidal anti-inflammatories like aspirin or ibuprofen, or opioids.

Central post-stroke pain

The symptoms of CPSP include a combination of sensations such as hot and cold, burning, tingling, numbness, sharp stabbing, and underlying aching pain. The pain is often felt on the side of the body affected by the stroke and can be triggered or worsened by touch, movement, water, changes in temperature, or emotional distress.

CPSP can have a significant impact on a person's quality of life, affecting their ability to perform daily activities, sleep, and overall well-being. It is important to note that CPSP is distinct from other types of post-stroke pain such as shoulder pain, painful spasticity, persistent headache, and other musculoskeletal conditions.

The treatment for CPSP can vary, and finding the right medication regimen may take time. Common analgesic drugs such as ibuprofen are often the first line of treatment, followed by tricyclic antidepressants or anti-convulsants if the pain persists. In more severe cases, stronger analgesics, narcotics, or even neurosurgery may be considered. An interdisciplinary team of healthcare professionals, including mental health experts, is crucial in managing CPSP and providing patient-centred care.

Headaches after stroke

Headaches are a common complication after a stroke, with 23% of people experiencing persistent headaches. They can be more severe than the pain during the stroke itself and may be caused by medication side effects, dehydration, or changes in the brain.

Headaches after a stroke can be treated with painkillers such as paracetamol, and staying hydrated by drinking plenty of water. However, it is important to consult a doctor before taking aspirin or ibuprofen, as these can increase the risk of bleeding.

If you are experiencing headaches after a stroke, it is important to seek medical advice. A doctor can help diagnose the headache, identify underlying causes, and recommend appropriate treatments. Sudden, severe headaches require urgent medical attention and should be treated as a medical emergency.

Frequently asked questions