Publications
APS Bulletin • Volume 18, Number 1, 2008
Resource Reviews
John D. Loeser, MD, Department Editor
Central Neuropathic Pain: Focus on Poststroke Pain
Reviewed by Misha Backonja, MD
James L. Henry, Akbar Panju, Kiran Yashpal (Eds.), Seattle, IASP Press, 2007. Hard cover, 281 pages, ISBN 978-0931092-66-4, $65 (IASP members), $80 (nonmembers).
This book represents a collaborative effort by the participants at the Fifth International Association for the Study of Pain (IASP) Research Symposium held in Toronto, Canada, in June 2006. It provides a solid summary of the current status of the field of central post-stroke pain (CPSP). After reading this book, one is left with strong impressions about this area of neurological and pain research and practice, which is characterized by a lack of animal models (models would lead to a better understanding of mechanisms, and the book presents one model); the absence of CPSP-specific symptoms and signs measurement tools; and the grave paucity of therapeutic randomized clinical trials. Many chapters discussed mechanisms that may or may not be relevant to CPSP.
For a reader who is new to the field of CPSP, chapter 4, which reviews the clinical characteristics of CPSP, will be most helpful. There are two chapters on neurostimulation for CPSP—the deep brain and motor cortex stimulation chapters. Both provide interesting information about these two invasive and expensive methods that require a high level of technical neurosurgical experience. Unfortunately, both of these techniques are out of reach for most patients with CPSP.
The book’s chapter Differential Diagnosis and Management of Pain After Stroke does not serve as a sufficient source on overall strategy for managing CPSP. For recommendations about the care of patients with this condition, the reader must turn to a chapter at the end of the book titled Best Practice Guidelines for Treatment of Central Pain After Stroke, which documents the consensus of the panel participants at the 2006 IASP symposium. The chapter starts with recommendations to treat patients using “five pillars of pain management.” The first pillar, “universal precautions of pain management,” discusses precautions developed to address fears of opioid addiction. This is an inappropriate recommendation because patients with CPSP face more pressing issues, such as receiving an appropriate CPSP-specific evaluation and an evaluation of cognitive and other neurological defects resulting from stroke that often interfere with care. The book’s other “pillars” are appropriate for the care of patients with complex pain problems such as CPSP. Another serious concern presented by this chapter’s author is the recommendation to use amitriptyline as first-line treatment. The American Geriatrics Society and the American Academy of Family Physicians contend amitriptyline should never be prescribed to elderly patients. This is especially an issue for patients who have had strokes and have cardiac disease. In many cases, these are contraindications for the use of a tricyclic antidepressant (TCA). If one has no option but to use a TCA, the medication chosen should have similar efficacy and much lower potential for adverse effects (nortriptyline would be one such option).
In summary, this is a timely book that provides a snapshot of the current state of CPSP; gaps in our knowledge still need to be filled, however, if care for patients with CPSP is to improve.
Dr. Backonja is Associate Professor of Neurology at the University of Wisconsin, Madison.