Post stroke pain is very challenging to manage and should involve a holistic approach with physiotherapy and rehabilitation being a mainstay of treatment. Anti-neuropathic pain medication including tricyclic antidepressants, SNRIs and antiepileptic drugs can play a role in the management of pain. Our patient had been started on a low dose of Gabapentin in primary care. His renal function was normal and the dosage was increased incrementally to 600mg tds with some benefit. The expressive dysphasia made it difficult to measure levels of anxiety and depression but it was evident that the patient was struggling both physically and mentally. He was commenced on an SNRI in the form of Duloxetine 60mg once daily and had several sessions with a neuropsychologist, which helped with acceptance and adjustment to the devastating effects the stroke had had on him. Taping of muscles and appropriate physiotherapy can also be useful in both preventing and managing dropped shoulder syndrome. Our patient had multiple physiotherapy sessions both in the acute phase and in the longer term with neurophysiotherapists working conjointly with specialist pain physiotherapists.
Neurostimulation therapy including deep brain stimulation has also been used in resistant cases. This was discussed with our patient but he declined a referral.