Management of Central Poststroke Pain: Systematic Review and Meta-analysis

Abstract

Central poststroke pain (CPSP) is a neuropathic pain condition prevalent in 8 to 35% of stroke patients. This systematic review and meta-analysis aimed to provide insight into the effectiveness of available pharmacological, physical, psychological, and neuromodulation interventions in reducing pain in CPSP patients (PROSPERO Registration: CRD42022371835). Secondary outcomes included mood, sleep, global impression of change, and physical responses. Data extraction included participant demographics, stroke etiology, pain characteristics, pain reduction scores, and secondary outcome metrics. Forty-two original studies were included, with a total of 1,451 participants. No studies providing psychological therapy to CPSP patients were identified. Twelve studies met requirements for a random-effects meta-analyses that found pharmacological therapy to have a small effect on mean pain score (SMD = -.36, 96.0% confidence interval [-.68, -.03]), physical interventions did not show a significant effect (SMD = -.55 [-1.28, .18]), and neuromodulation treatments had a moderate effect (SMD = -.64 [-1.08, -.19]). Fourteen studies were included in proportional meta-analysis with pharmacological studies having a moderate effect (58.3% mean pain reduction [-36.51, -80.15]) and neuromodulation studies a small effect (31.1% mean pain reduction [-43.45, -18.76]). Sixteen studies were included in the narrative review, the findings from which largely supported meta-analysis results. Duloxetine, amitriptyline, and repetitive transcranial magnetic stimulation had the most robust evidence for their effectiveness in alleviating CPSP-induced pain. Further multicenter placebo-controlled research is needed to ascertain the effectiveness of physical therapies, such as acupuncture and virtual reality, and invasive and noninvasive neuromodulation treatments. PERSPECTIVE: This article presents a top-down and bottom-up overview of evidence for the effectiveness of different pharmacological, physical, and neuromodulation treatments of CPSP. This review could provide clinicians with a comprehensive understanding of the effectiveness and tolerability of different treatment types.

Keywords: Central poststroke pain, neuropathic pain, thalamic pain, pharmacological review, neuromodulation review.