PAIN in MS —

Stuart SchlossmanMS Pain and Side Effects, Multiple Sclerosis (MS) Symptoms

Pain – factsheet

Date of revision: April
2012
Updated with revised NICE guidelines – March 2014
This factsheet will be reviewed within three years


 

Pain in MS

Pain can be
defined as “unpleasant sensory experiences”1. For people
with MS this may encompass both ‘painful’ feelings and also altered sensations
such as pins and needles, numbness, or crawling, burning feelings. Estimates
vary as to how common these symptoms are2,3 with some reports
suggesting that up to 80% of people with MS may experience pain at some stage4.
The management
of pain in MS is not always easy and some types of pain will never go away
entirely. In this case, the aim of treatment is to minimise the level of pain
and to develop coping strategies so that the individual can carry out normal
day-to-day living. Treatment options may include drugs, non-drug treatments
such as physiotherapy or a combination of the two.
As well as the
direct causes of pain, a number of factors can make pain feel worse for people
with MS. These include heat, cold, poor sleep, fatigue, mobility problems,
feelings of low self-esteem, loneliness or isolation, and depression
or anxiety.
Dealing with some of these other issues can help to improve pain levels.
It also needs
to be remembered that people can experience pain for reasons other than their
MS.
Different types
of pain are managed in different ways, so a careful assessment of the factors
that may be contributing to the symptom is necessary in order to find
appropriate treatments.
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Describing pain

Pain is very
subjective and is best described by the person experiencing it. No two people
will experience pain in the same way.
Pain is often
categorised in terms of how long it lasts. Acute pain is generally described as
an intense, sharp, burning or shooting feeling. It is usually experienced
intermittently, with very sudden onset and either improving or disappearing
equally quickly.
Chronic pain is
long-lasting or persistent pain. The intensity of chronic pain may fluctuate
over a period of time without ever fully disappearing.
There are two
broad types of pain that result from MS:

  • neuropathic
    or nerve pain is caused by damage to the nerves in the brain and spinal
    cord
  • nociceptive
    or musculoskeletal pain is caused by damage to muscles, tendons, ligaments
    and soft tissue

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Neuropathic (nerve) pain

Neuropathic
pain is caused by disruption in how the nerves carry messages within the brain
and spinal cord. In MS damage occurs to the myelin sheath, a layer of fatty
protein that protects the nerves and aids transmission of messages. Nerve
messages can be interrupted or delayed, interfering with the body’s normal
ability to function. Sometimes the brain interprets these disrupted messages as
pain, even though there is no physical cause of pain.
The National
Institute for Health and Care Excellence (NICE) has issued clinical
guidelines for neuropathic pain. This indicates amitriptyline
(Triptafen), duloxetine (Cymbalta), gabapentin
or pregabalin
(Lyrica) as first-line treatments. Treatment should be reviewed regularly
and should the chosen drug not be effective, one of the others should be tried5.
Treatment usually starts with low doses that are built up slowly.
These drugs
affect the chemical transmission of pain signals resulting in a reduction of
symptoms. They often cause side effects such as drowsiness, dizziness, nausea
and blurred vision although these will eventually wear off.
The guidelines
also suggest agreeing a treatment plan that takes into account the individual’s
concerns and expectations. Referral to a specialist pain service can be
considered at any stage5.

Examples of neuropathic pain

Dysaesthesia
or paraesthesia (altered sensation)
These are common symptoms in MS, but they are experienced differently from
person to person. The pain can be described in a variety of ways including:

  • pins and
    needles
  • burning
  • tightness
  • numbness
  • prickling
  • dull
    ache
  • itching
  • crawling
  • nagging

Usually experienced
in the extremities, these changes can occur anywhere in the body. These
sensations can be uncomfortable and unsettling and may be painful and
distressing.
Banding,
sometimes called the ‘MS hug’
This is a feeling of constriction, tightness or being squeezed around the
chest.
Altered
sensations are generally treated with one of the standard drugs, although
symptoms such as numbness and loss of sensation may not be treated unless they
are causing particular distress.
L’hermitte’s
sign
A sudden sensation resembling an electric shock, which passes down the back of
the neck and into the spinal column and can radiate out to the fingers and
toes. The pain is sharp but passes quickly so treatment is not usually
considered.
Optic
neuritis
A sharp, knifelike pain behind the eyes caused by inflammation of the optic
nerve, sometimes also causing disruption to vision. Optic neuritis is a common
early symptom of MS, though can occur at any time. It usually responds
successfully to treatment with steroids.
Trigeminal
neuralgia
An intense, severe stabbing and burning sensation down the side of the face
that can ease to an ache or burn. Pain follows the path of the trigeminal
nerve, which provides feeling in the side of the face and controls chewing and
swallowing. It is thought that the pain, which normally only affects one side
of the face at a time, is caused by damage where the nerve connects to the
brain. The pain can be excruciating and can be set off by something as simple
as eating, talking or smiling. It is usually sudden in onset and can reduce or
disappear over a period of time. However it can become chronic.
Trigeminal
neuralgia can be difficult to treat. First line treatment is with a standard
drug for neuropathic pain. It is also useful to identify whether the pain has
any triggers, for example eating ice cream, and avoiding them or reducing their
likelihood. In extreme cases, surgery can be carried out to cut the nerve’s
connection to the brain, but this may leave the face numb.
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Musculoskeletal (nociceptive) pain

Musculoskeletal
or nociceptive pain is the type of pain experienced when someone has an injury.
It results from damage to muscles, tendons, ligaments and soft tissue.
Musculoskeletal
pain is generally more successfully managed than neuropathic pain. Common pain
relieving drugs such as paracetamol, ibuprofen or aspirin can be used.
The NICE
Clinical Guideline for the management of multiple sclerosis state that
specialist therapists should assess every person with MS who has
musculoskeletal pain6. For instance, a physiotherapist could
identify changes in posture and offer exercises to strengthen certain muscle
groups to improve function and help to reduce pain. An occupational therapist
could determine whether any new equipment might be required to help relieve
pain, such as an appropriate walking aid or wheelchair, or equipment to make
tasks in the home or workplace easier.

Examples of musculoskeletal pain

Pain in
the hips and lower back
Many people with MS experience lower back pain. This can be caused by alterations
in the way someone walks, possibly as a result of spasticity
or weakness.
This puts extra stress on the back or hips, leading to pain. Similarly, someone
who spends much of the day sitting down, possibly due to mobility problems or
fatigue may be prone to back pain.
Pain in
the muscles, tendons or ligaments
This can occur if the limbs are stiff and kept in a fixed position for long
periods of time. Muscles that aren’t exercised can become stiffer and shorter,
known as a contracture, restricting the range of movement possible. Ligament
damage can also occur in MS, for instance if changes in how someone walks
causes them to over extend their knee, leading to swelling and pain.
Spasms and
spasticity can also cause pain in the soft tissues. When a muscle contracts,
suddenly in the case of spasms or over a longer period of time in the case of
spasticity, this can cause pain in the affected limb.
The NICE
Clinical Guideline recommends the drugs baclofen
or gabapentin as the first line of treatment for spasticity6. Other
treatment options include tizanidine,
diazepam,
clonazepam
or sodium
dantrolene. The cannabis based drug Sativex
is licensed for use as an add-on treatment for spasticity when people have
shown inadequate response to other treatments or found their side effects
intolerable.
A combined
approach to treating spasticity, using both drug treatment and exercise, is
often employed. Physiotherapy is used alongside medication to improve muscle
function through a range of exercises and thus reduce painful sensations.

More information is
available in our factsheet Spasticity and spasms

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Further treatment options

Pain clinic

If pain does
not respond to treatment, it is possible to get a referral from a GP or
neurologist to a specialist pain clinic. Services vary in the treatments offered
and not all areas will have a specific pain clinic. Usually input is from a
multidisciplinary team of doctors, nurses and therapists using a combination of
drugs, therapy and coping strategies to help the person with MS minimise the
effects of pain and to allow them to carry on with normal day-to-day living.

TENS

TENS
(transcutaneous electrical nerve stimulation) is a machine that applies a small
electrical current to the area of pain, producing a slight tingling, prickling
sensation. The tingling sensations are transmitted along nerves more quickly
than the pain sensations, reducing the effect of pain. It has also been
suggested that TENS encourages the body to produce chemicals that have a pain
relieving effect7,8.
TENS is
included in the NICE Guideline as a treatment for musculoskeletal pain that
doesn’t respond to medication6.

Complementary therapies

There is
limited scientific evidence to support the use of acupuncture9 and
aromatherapy10 as treatments to alleviate pain, if only for short
periods of time.
Some people
with MS have reported benefits from the following therapies, possibly due to
their relaxing effects. There may be others that are helpful:

SOURCE



Links and references

Pain organisations

  • Pain
    Concern
    A charity offering information and support for people who experience pain
    by people who experience pain. Provides a ‘listening ear’ helpline.

    Helpline: 0300 123 0789
    [email protected]
    www.painconcern.org.uk

References

  1. IASP
    Task Force on Taxonomy. Merskey H, Bogduk N, editors.
    Classification of chronic pain. 2nd ed.
    Seattle;IASP Press:1994.
  2. Ehde DM,
    et al.
    The scope and nature of pain in persons with multiple sclerosis.
    Multiple Sclerosis 2006;12(5):629-638.
    abstract
  3. Hirsh
    AT, et al.
    Prevalence and impact of pain in multiple sclerosis: physical and
    psychologic contributors.
    Archives of Physical Medicine and Rehabilitation 2009;90(4):646-651.
    read online
  4. Archibald
    CJ, et al.
    Pain prevalence, severity and impact in a clinic sample of multiple
    sclerosis patients.
    Pain 1994;58(1):89-93.
    abstract
  5. National
    Institute for Health and Care Excellence.
    Neuropathic pain – pharmacological management: The pharmacological
    management of neuropathic pain in adults in non-specialist settings. NICE
    clinical guideline CG173.
    London:NICE;2013.
    read on the NICE website
  6. National
    Institute for Clinical Excellence.
    Understanding NICE guidance – information for people with multiple
    sclerosis, their families and carers, and the public.
    London: NICE; 2003.
    download
  7. Warke K,
    at al.
    Efficacy of transcutaneous electrical nerve stimulation (TENS) for chronic
    low-back pain in a multiple sclerosis population: a randomized,
    placebo-controlled clinical trial.
    Clinical Journal of Pain 2006;22(9):812-819.
    abstract
  8. Sluka
    KA, Walsh D.
    Transcutaneous electrical nerve stimulation: basic science mechanisms and
    clinical effectiveness.
    Journal of Pain 2003;4:109-121.
    abstract
  9. Wang Y,
    et al.
    A pilot study of the use of alternative medicine in multiple sclerosis
    patients with a special focus on acupuncture.
    Neurology 1999;52:A550.
  10. Howarth
    AL, Freshwater D.
    Examining the benefits of aromatherapy massage as a pain management
    strategy for patients with multiple sclerosis.
    Nursing Times Research 2004;9(2):120-128.

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