Original Paper
Cerebrovasc Dis 2003;16:27–30
DOI: 10.1159/000070111

Received: December 17, 2001
Accepted: July 30, 2002

An East-West Approach to the
Management of Central Post-Stroke
Pain
Hwee Ling Yen William Chan
Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore

Abstract
The development of neuropathic pain following stroke is
not uncommon. The consequences include significant
disabilities and depression. Treatment can often be difficult and responses unsatisfactory. We report a patient
with severe central post-stroke pain (CPSP) of the right
leg benefiting from a combination of Western multidisciplinary therapies and acupuncture. A literature search
has revealed that relatively few studies have been done
on the management of CPSP, compared with other types
of neuropathic pain. Amitriptyline and carbamazepine
were found to produce positive effects on post-stroke
pain in one small study; lamotrigine and gabapentin are
two newer drugs which appear promising. To the best of
our knowledge, the use of acupuncture for the treatment
of CPSP has not been previously reported.
Copyright © 2003 S. Karger AG, Basel

ABC

© 2003 S. Karger AG, Basel
1015–9770/03/0161–0027$19.50/0

Fax + 41 61 306 12 34
E-Mail karger@karger.ch
www.karger.com

Accessible online at:
www.karger.com/ced

Introduction

In the early twentieth century, Dejerine and Roussy [1]
described the phenomenon of neuropathic pain in the
contralateral body part following a thalamic stroke [1–3].
For decades, this was known as the ‘thalamic syndrome’.
In recent years, modern radiological techniques and postmortem studies have found many cases with lesions in
extrathalamic sites [4, 5]. These findings, together with
pathophysiological considerations, have resulted in the
condition being now known as ‘central post-stroke pain’
(CPSP).
CPSP can be defined as a neuropathic pain syndrome
occurring after stroke, in which the patient experiences
constant or intermittent pain on the affected side of the
body with associated sensory abnormalities [2, 3]. This
complication can compound the already devastating effects of stroke and further impede functional recovery.
Current medical literature has indicated that responses to
standard Western medical treatment may often be incomplete and unsatisfactory [2, 5, 6]. Acupuncture, a healing
art that originated in China several thousand years ago,
has been used to treat various types of chronic pain with
reports of favourable outcome. However, as far as we
know, there has not been any published study on the
application of this therapeutic modality specifically for

Hwee Ling Yen, MD
Department of Rehabilitation Medicine, Tan Tock Seng Hospital
c/o Ang Mo Kio Community Hospital, 17 Ang Mo Kio Avenue 9
Singapore 569766 (Singapore)
Tel. +65 64505164, Fax +65 64590414, E-Mail hlyen@excite.com

Downloaded by:
Univ.of Adelaide
129.127.145.240 - 11/29/2017 3:09:45 PM

Key Words
Central post-stroke pain W Pharmacology W Drugs W
Acupuncture

Fig. 1. CT scan of the brain showing a haematoma in the left putamen with mild mass
effect.

CPSP. We report a patient with severe post-stroke neuropathic pain benefiting from a combination of Western
and traditional Chinese medical therapies.

thrice weekly physio- and occupational therapies. However, his
symptoms persisted, pain-free periods became shorter and the VAS
maximum score increased to 9–10. In addition, he manifested
increased dynamic tone of his right upper and lower limbs, which
impaired hand function and made walking difficult and unsafe. Tone
was scored as 3 on the Modified Ashworth Scale (MAS). Two weeks
after starting medications, the dosages of carbamazepine and fluoxetine were increased to 200 mg three times daily and 40 mg once a day,
respectively. Amitriptyline 75 mg at night was added for the pain,
and baclofen 10 mg three times a day to control his hypertonia.
Unfortunately, the patient failed to experience any significant pain
reduction and continued to complain of daily severe pain with the
peak VAS score remaining at 9–10.
Due to the poor response to pharmacological treatment, we
decided to add acupuncture therapy 4 weeks after initiation of his
medications. The following classical acupuncture points were used:
GV20, GB20, LI11, LI4, TE5, PC6, BL23, BL24, ST36, ST40, GB34,
BL60 and LR3. The limb points were needled on the affected (right)
side. Twice weekly treatment sessions were performed, lasting 30 min
each. No adverse events occurred from the acupuncture therapy. His
symptoms gradually improved and by 3 months after starting acupuncture, he experienced only occasional episodes of pain. The peak
VAS score was 5 1 month after initiating acupuncture and decreased
to 3 at 3 months. The painful episodes became shorter, function
increased to previous levels and his mood elevated. A reduction of the
dynamic tone of his limbs was also noted to an MAS score of 1.
As his symptoms improved, the medications were gradually
tapered and 6 months after initiating pharmacological treatment, his
drug regime consisted of fluoxetine 20 mg once a day and amitriptyline 25 mg at night. He continued to receive acupuncture therapy
once a week. Right thigh pain was experienced occasionally but peak
VAS remained at 3 and the pain symptoms did not affect his function.

Case Report

28

Cerebrovasc Dis 2003;16:27–30

Discussion

As our case illustrates, CPSP can have a profound
adverse impact on a patient’s function and subsequent
recovery after a stroke. Although there are no local statistics, several reports have estimated an incidence of 2–6%
of all stroke cases [4, 5]. Previously, dysfunction of the
thalamus was believed to be the main cause of such central pain but more recent investigations have found that a
lesion anywhere in the spino-thalamic pathway, its relays
or projections may cause this syndrome [4, 5].
Pharmacological treatment of CPSP has been notoriously complex and difficult. A literature search on the
management of neuropathic pain revealed a dearth of
studies on central pain. Traditional primary analgesics,
such as paracetamol and non-steroidal anti-inflammatory
drugs, are relatively ineffective in pure neuropathic pain
[6]. There is evidence that opioids are effective in some
cases of neuropathic pain but with reduced efficacy compared with nociceptive pain. At high doses, opioid drug
tolerance and other side-effects are a problem [6]. Tra-

Yen/Chan
Downloaded by:
Univ.of Adelaide
129.127.145.240 - 11/29/2017 3:09:45 PM

Mr. K. suffered a haemorrhagic stroke, which resulted in mixed
dysphasia and right hemiplegia. The intracerebral heamorrhage involved the left putamen with extension to the left corona radiata;
there was associated mild mass effect but no midline shift (fig. 1). He
underwent a comprehensive rehabilitation programme, made significant neurological and functional improvements and planned to return
to work. However, 9 months following stroke, he developed a deep,
aching pain in his right thigh, which increased in severity and frequency over a 1-week period, became almost constant and affected him
daily. The Visual Analogue Scale (VAS) score ranged from 2 (minimum) to 8 (maximum). The pain was aggravated by exertion such as
walking, and by emotional changes like anxiety and frustration. On
examination, no significant tenderness was elicited in the area of pain
and the patient did not experience any allodynia or hyperalgesia. The
power of his right upper and lower limbs was graded as 4/5 proximally
and 3/5 distally. Sensations were reduced to light touch, pinprick and
temperature over his right arm and leg compared with the contralateral limbs. These neurological findings were essentially unchanged from
those prior to the onset of pain. His function deteriorated as a result
and he became frustrated and depressed.
The patient was treated with the following medications: tramadol
for its analgesic effects at a dose of 50 mg three times a day, carbamazepine to treat neuropathic paint at 100 mg three times a day and
fluoxetine for depression (and possibly neuropathic pain) at 20 mg
once a day. His out-patient rehabilitation programme consisted of

madol has weak opioid action, but most of its analgesic
effect is thought to be via inhibition of re-uptake of 5hydroxytryptamine and noradrenaline.
Tricyclic antidepressants and sodium channel blockers, particularly carbamazepine, are currently considered
to be the pharmacological treatments of choice for neuropathic pain [6, 7]. However, most of the studies have been
performed on patients with postherpetic neuralgia, diabetic neuropathy and trigeminal neuralgia. We could find
only one small study by Leijon and Boivie [8] that examined the efficacy of amitriptyline and carbamazepine in
15 patients with CPSP. Amitriptyline produced a statistically significant reduction of pain, compared with placebo, in 10 of the 15 patients. Five of 14 patients treated
with carbamazepine reported some pain relief, but the
effect did not reach statistical significance when compared with placebo.
Two new anticonvulsant drugs hold promise for the
treatment of this difficult condition. Lamotrigine acts by
stabilising the conformation of a subtype of sodium channels, and thereby suppresses the neuronal release of glutamate. A recent randomised controlled trial has demonstrated a moderate effect of lamotrigine in reducing pain
in 12 of 30 patients (44%) with CPSP [9]. Gabapentin is a
novel anticonvulsant that may have a unique effect in voltage-dependent calcium channel currents at postsynaptic
dorsal horn neurons. Two large multicentre trials, one in
postherpetic neuralgia and the other in diabetic peripheral neuropathy, have demonstrated the efficacy of this
drug. However, the effectiveness of gabapentin for CPSP
has not been documented [7, 10].
Our patient was treated with a conventional regime of
tramadol, carbamazepine and fluoxetine initially, with
amitriptyline and baclofen added on subsequently. When
his symptoms persisted despite these medications, a trial
of acupuncture was instituted.
Acupuncture, one of the oldest forms of therapy, originated in China in prehistoric times and has its roots in
ancient Chinese philosophy. It was disseminated to the
West several hundred years ago and over the past two
decades, various researchers had applied Western scientific techniques to evaluate the effectiveness (or not) of
this modality for the treatment of chronic pain. However,
many studies were found to be flawed methodologically;
the study design was inadequate, the number of cases
small and the choice of control acupuncture points controversial [11, 12]. At the Consensus Development Conference held by the United States National Institutes of
Health in November 1997, the consensus panel reviewed
existing clinical research data and concluded that needle

acupuncture is effective for postoperative dental pain
(among other conditions), and may be effective for headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain and low back pain [13]. To the best of our
knowledge, the use of acupuncture specifically for CPSP
has not been previously studied or reported in any Western medical journal.
It is still not exactly clear what mechanisms underlie
the action of acupuncture and how it relieves pain. Western scientific research has proposed several theories for
the basis of acupuncture analgesia. One is that acupuncture works on the principle of the gate control theory of
pain (local and segmental effects) [14, 15]. Needling produces input that blocks the transmission of nociceptive
afferent impulses from the painful area to the central nervous system. Other theories explain the heterosegmental
effects of acupuncture via the release of various neurochemicals, such as serotonin, endorphins and noradrenaline [15–17]. Hui et al. [18] applied functional magnetic
resonance imaging techniques to investigate the effects of
acupuncture in normal subjects and found that needle
manipulation modulated the activity of the limbic system
and subcortical structures in the brain. It would be interesting to perform similar imaging studies for patients with
various painful conditions and compare the results of subjects who experience pain relief with those of patients who
do not respond to acupuncture [18].
Clearly, further well-designed research of sufficient
power is required to determine the efficacy of acupuncture for the treatment of chronic painful conditions, such
as CPSP, as well as to elucidate the underlying mechanisms of action.

East-West Approach to Central Post-Stroke
Pain

Cerebrovasc Dis 2003;16:27–30

Conclusion

There is no doubt that CPSP poses a big challenge to
clinicians and scientists alike in terms of effective management and the underlying pathophysiology. On the part
of the patient, CPSP leads to or aggravates any pre-existing disabilities and becomes a further major impediment
to recovery of independence after stroke. It would appear
from current medical literature that the tricyclic antidepressants and carbamazepine are the most effective medications available. However, treatment often remains unsatisfactory and side-effects troubling. We used a combination of multidisciplinary Western medical approaches
and traditional acupuncture therapy for our patient with
CPSP and found the combination effective in bringing
about pain relief and functional improvement.

Downloaded by:
Univ.of Adelaide
129.127.145.240 - 11/29/2017 3:09:45 PM

29

References

30

8 Leijon G, Boivie J: Central post-stroke pain – A
controlled trial of amitriptyline and carbamazepine. Pain 1989;36:27–36.
9 Vestergaard K, Andersen G, Gottrup H, Kristensen BT, Jensen TS: Lamotrigine for central
poststroke pain: A randomized controlled trial.
Neurology 2001;56:184–190.
10 Nicholson B: Gabapentin use in neuropathic
pain syndromes. Acta Neurol Scand 2000;101:
359–371.
11 Lee TL: Acupuncture and chronic pain management. Ann Acad Med Singapore 2000;29:
17–21.
12 Hammerschlag R: Methodological and ethical
issues in clinical trials of acupuncture. J Altern
Complement Med 1998;4:159–171.
13 Acupuncture. NIH Consensus Conference.
JAMA 1998;280:1518–1524.

Cerebrovasc Dis 2003;16:27–30

14 Melzack R, Wall PD: Pain mechanisms: A new
theory. Science 1965;150:971–979.
15 Bowsher D: Mechanisms of acupuncture; in
Filshie J, White A (eds): Medical Acupuncture:
A Western Scientific Approach. London, Churchill Livingstone 1998, pp 69–82.
16 Pomeranz B: Basic research into acupuncture
for the relief of pain. J Altern Complement
Med 1996;2:53–59.
17 Han JS, Terenius L: Neurochemical basis of
acupuncture analgesia. Ann Rev Pharmacol
Toxicol 1982;22:193–220.
18 Hui KK, Liu J, Makris N, Gollub RL, Chen AJ,
Moore CI, Kennedy DN, Rosen BR, Kwong
KK: Acupuncture modulates the limbic system
and subcortical gray structures of the human
brain: Evidence from fMRI studies in normal
subjects. Hum Brain Mapp 2000;9:13–25.

Yen/Chan
Downloaded by:
Univ.of Adelaide
129.127.145.240 - 11/29/2017 3:09:45 PM

1 Dejerine J, Roussy G: Le syndrome thalamique. Rev Neurol 1906;14:521–532.
2 Jensen TS, Lenz FA: Central post-stroke pain:
A challenge for the scientist and the clinician.
Pain 1995;61:161–164.
3 Andersen G, Vestergaard K, Ingeman-Nielsen
M, Jensen TS: Incidence of central post-stoke
pain. Pain 1995;61:187–193.
4 Bowsher D: The management of central poststroke pain. Postgrad Med J 1995;71:598–604.
5 Bowsher D: Central pain: Clinical and physiological characteristics. J Neurol Neurosurg Psychiatry 1996;61:62–69.
6 Smith TE, Chong MS: Neuropathic pain. Hosp
Med 2000;61:760–766.
7 Sindrup SH, Jensen TS: Efficacy of pharmacological treatments of neuropathic pain: An update and effect related to mechanism of drug
action. Pain 1999;83:389–400.