Repairing Nerve Damage From A Stroke: Is It Possible?

Stroke is a serious, life-changing injury that can result in a wide variety of secondary effects, including nerve damage. The nervous system is a complex network of nerve cells called neurons, and their connections are called synapses. The nervous system is fragile and can be damaged, healing with great difficulty, if at all. This affects the brain's ability to communicate with muscles and sensory organs.

Injuries to the central nervous system (CNS) typically do not regenerate. However, the CNS can reorganise in response to an injury, a process known as 'plasticity'. The brain has a lot of built-in redundancy, meaning that when one area loses function, other undamaged areas can take over. For example, if a stroke causes brain damage, other parts of the nervous system can take over the lost function of the damaged area.

There are several treatments for nerve damage caused by stroke, including pain medication, anticonvulsants, topical pain relievers, antidepressants, corticosteroids, physical therapy, electroacupuncture, deep brain stimulation, and repetitive transcranial magnetic stimulation.

Central neuropathy treatment

A combination of treatments is usually required to manage central neuropathy, which may include:

• Medication: Over-the-counter pain relievers, antiseizure medications, antidepressants, and topical treatments such as lidocaine or capsaicin creams.
• Surgery: In some cases, surgery can help repair or remove certain nerves to reduce pain.
• Physical therapy: This can help relieve pain and soreness, improve range of motion, and encourage the body to produce more natural pain-relieving chemicals.
• Psychological counselling: Therapy can help patients cope with the emotional stress associated with central neuropathy.

In addition to these treatments, patients may benefit from spinal cord stimulation, peripheral nerve stimulation, or brain stimulation.

Lifestyle changes can also help prevent and manage central neuropathy:

• Regular exercise
• Healthy diet with fresh fruits, vegetables, whole grains, and lean proteins
• Limiting alcohol intake
• Managing diabetes and monitoring blood sugar levels

Peripheral neuropathy treatment

Peripheral neuropathy is a type of damage to the nervous system, specifically the peripheral nervous system. This is the network of nerves that sends information from the brain and spinal cord (central nervous system) to the rest of the body. Peripheral neuropathy has many different causes, including diabetes, injury, kidney conditions, hormone imbalances, and inherited disorders. There are more than 100 types of peripheral neuropathy, each with its own symptoms and prognosis. Symptoms can include tingling, numbness, burning pain, paralysis, loss of muscle and bone, changes in skin, hair, or nails, loss of balance, emotional disturbances, and loss of bladder control.

Treatment for peripheral neuropathy may include treating any underlying causes or symptoms. For example, controlling diabetes through lifestyle changes such as stopping smoking, cutting down on alcohol, maintaining a healthy weight, and exercising regularly may help improve neuropathy. Vitamin B12 deficiency, a common cause of peripheral neuropathy, can be treated with B12 injections or tablets. If peripheral neuropathy is caused by medication, stopping the medication may improve symptoms. In some cases, medication or surgery may be required to treat nerve pain or repair nerve injuries.

• Medications: Certain medications can be used to treat nerve pain associated with peripheral neuropathy. Common options include amitriptyline, duloxetine, pregabalin, and gabapentin. Antidepressants and anti-seizure medications may also be prescribed.
• Capsaicin cream and patches: Capsaicin is the substance that gives chilli peppers their heat and can help block pain messages to the brain.
• Lifestyle changes: Lifestyle choices can play a role in preventing and managing peripheral neuropathy. This includes avoiding alcohol, correcting vitamin deficiencies, eating a healthy diet, losing weight, avoiding toxins, and exercising regularly. Quitting smoking and caring for wounds, especially on the feet, are also important.
• Physical therapy: Physical therapy can help improve muscle strength and mobility. Hand and foot braces or orthotics can also be used to compensate for muscle weakness and improve walking ability.
• Alternative therapies: Some people may find relief from benfotiamine (a form of vitamin B1) or alpha-lipoic acid (an antioxidant) supplements. However, the evidence for these treatments is not always clear, and it is important to speak to a doctor before trying them.

While there is no cure for peripheral neuropathy, these treatments can help manage symptoms and prevent further deterioration. It is important to work with a healthcare provider to determine the best treatment approach based on the underlying cause and specific type of peripheral neuropathy.

Shoulder pain treatment

Shoulder pain is the most common source of pain for stroke survivors. It can be caused by shoulder subluxation, which is a partial dislocation of the shoulder joint. This is usually caused by weak rotator cuff muscles, which connect the upper arm bone to the shoulder blade and 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. Slumped posture caused by weak back muscles can increase shoulder subluxation. Shoulder subluxation can also be caused by muscle stiffness, which places uneven stresses on the shoulder joint, pulling the joint out of alignment.

To prevent and treat shoulder pain, proper shoulder support is key. This can be achieved through the use of slings, arm boards, troughs, and lap trays. However, it is important to select the correct type of sling, as some slings can promote stiffness that can lead to shoulder pain. Physical therapists can help choose the most appropriate style and teach how to wear it correctly. Other positioning devices, such as wheelchair devices such as lap trays and arm troughs, may also be used to support the shoulder.

Exercises can also help improve shoulder pain. Physiotherapists or occupational therapists may recommend repeating a movement or task, exercising with weights, and correct positioning to ensure joints are comfortable and safe. Electrical stimulation may also be used to manage shoulder pain.

Medications can also be prescribed to help with shoulder pain. Paracetamol, non-steroidal anti-inflammatories like aspirin or ibuprofen, and opioids can be recommended. For pain caused by muscle spasticity, injections of local anaesthetic, steroids, or botulinum toxin A may be prescribed.

Spasticity treatment

Spasticity is a common complication after a stroke, affecting 25% to 43% of people in the first year. It causes muscles to become stiff and tight, making it difficult to stretch, move, and perform everyday tasks.

Treatment Options

Exercises and Stretching

Regularly exercising and stretching the affected areas can help ease tightness, prevent muscles from shortening, and maintain your full range of motion. A physical therapist or occupational therapist can recommend specific exercises to help with post-stroke spasticity.

Injections

Injections of certain medications, such as botulinum toxin (Botox), can help reduce spasticity.

Oral Medications

Oral medications, such as baclofen, diazepam, tizanidine, and dantrolene sodium, can be prescribed to reduce spasticity. However, they may have adverse side effects, and their efficacy is limited by small sample sizes and a lack of quality-of-life measures in clinical studies.

Intrathecal Baclofen Therapy (ITB)

ITB has been shown to effectively manage PSS, enhance functional recovery, and improve quality of life. It involves administering baclofen directly into the intrathecal space, requiring much lower doses than oral baclofen, resulting in fewer side effects.

Surgery

In cases where spasticity has caused muscle or tendon shortening, and less invasive procedures have not been successful, surgical interventions may be considered. These include tendon transfers and tendon lengthening procedures.

Central post-stroke pain treatment

Central post-stroke pain (CPSP) is a central neuropathic pain syndrome that can occur after a stroke in the part of the body corresponding to the cerebrovascular lesion. CPSP is characterised by pain and sensory abnormalities localised to the affected area. CPSP can be difficult to characterise, as it can be described in a variety of ways, from aching, dull and throbbing to sharp, stabbing, shooting or burning pain. The onset of CPSP can be quite variable, but most commonly begins 1-3 months after a stroke, with the majority of affected patients developing symptoms by 6 months.

CPSP is a diagnosis of exclusion, so careful elimination of other potential causes of pain after a stroke must occur before diagnosing CPSP. These potential causes include complex regional pain syndrome, radiculopathy, plexopathy, peripheral mononeuropathy, hemiparetic shoulder pain, and deep venous thrombosis.

The treatment of CPSP is challenging and must incorporate pharmacological and non-pharmacological interventions to maximise the potential for success. Treatment benefits only a fraction of patients diagnosed with CPSP, and response to treatment is often incomplete. Goals of treatment should therefore be focused on reducing, not eliminating, symptoms and returning to functional activity. Treatment algorithms typically follow a trial-and-error approach, and the use of various treatments in one patient is common.

Pharmacological Management

• Antidepressants: Tricyclic antidepressants (specifically amitriptyline) have traditionally been considered first-line pharmacological management for CPSP. Fluvoxamine may be beneficial, particularly if concomitant depression is present. Other SSRIs such as citalopram have not been shown to be beneficial.
• Anticonvulsants: Gabapentinoids including gabapentin and pregabalin are considered first or second-line treatments. Carbamazepine has limited data supporting its use as a treatment of CPSP.
• Opioids: Opioids are generally not considered to have a positive risk-benefit ratio in the treatment of CPSP.
• NMDA antagonists: Ketamine may possess some efficacy, however, side effects and administration route limit its utility.
• Antiarrhythmics: Mexiletine and lidocaine may transiently reduce pain in CPSP. Their utility is limited, however, given poor patient tolerance and need for intravenous administration, respectively.
• GABA agonists: Intrathecal baclofen has been reported to be effective in a case series of patients with CPSP, however, this has not been more widely studied.

Non-pharmacological Management

• Psychological treatment, exercise therapy, and desensitisation techniques may be beneficial in CPSP.
• Transcutaneous electrical nerve stimulation (TENS) is likely not effective and may actually increase pain symptoms in some patients.
• Acupuncture was found in one randomised control trial to significantly reduce pain in CPSP.
• Repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and vestibular caloric stimulation have demonstrated efficacy in the treatment of CPSP, however, they are not widely accessible in the clinical setting.
• Deep brain stimulation (DBS) and motor cortex stimulation via implanted stimulators show variable efficacy and should be reserved for patients with significant symptomatology who have exhausted pharmacological and less invasive non-pharmacological treatment strategies.
• Spinal cord stimulation has preliminarily been utilised in patients with intractable pain with some finding significant pain relief, however, studies are thus far limited.
• Mirror therapy and virtual reality have also shown promise in CPSP.

Frequently asked questions