MS Symptoms: Pain

Pain is a common symptom in MS. It’s a very personal experience , one can feel but others cannot see. Those who experience pain feel its effects on their daily life activities, such as work and recreation, and in their mood and enjoyment of life. Many clinical features of pain are often unrecognized by clinicians, and it may be difficult for many people with MS to find the right words to describe the pain they experience. At the same time, scales for evaluating pain rely on subjective reports and may be biased by any combination of circumstances, making the evaluation of pain severity and its impact on daily living difficult. Pain is often present with other symptoms, such as depression, spasticity, and mobility difficulties, underlining the importance of addressing MS comprehensively. The situation is complicated further by the fact that a person with MS may also have other illnesses, making the diagnosis and treatment of pain very complex. Another concern is that in some cases the side effects of pain medication can be as distressing as the pain itself and therefore cannot be used at an optimal level. Considering it has a significant influence on a person’s quality of life, unmanaged or ineffectively managed pain can have consequences that go beyond issues of symptom management. Therefore, involvement of the MS team, including the person with MS and his or her family, is fundamental for the identification, assessment, and optimal treatment of pain. “My treatment is hit and miss as my doctor and nurses don’t view pain as part of MS.” Why does pain happen in MS Pain is a sensory symptom directly related to two occurrences – the disruption of central nervous system myelin and the effects of disability. Myelin speeds nerve conduction, aiding smooth motor activity, integration and interpretation of sensory stimuli and effortless cognition. When pain is the result of a disruption or alteration of nerve conduction, it is termed neurogenic, or having its genesis or roots in the central nervous system. Pain that comes from weakness, stiffness or other mobility problems from MS is considered musculoskeletal pain-Nociceptive pain. Both types of pain can be acute, having a rapid onset and short duration, or chronic, starting gradually and persisting daily or almost every day. The key is to identify the type of pain and treat the source of it. Some questions that help your MS team better understand the pain experience Location of pain, which part of the body How long does it last & frequency How would you describe the pain experience (burning, stabbing, throbbing .. etc) How intense the pain is (scale 0-10) Does the pain alter your lifestyle Have you noticed anything that make it worse or improves it If using any pain treatment, how does it improve the pain Tools to measure pain Numerical scale rating: scale 0-10 where 0 is no pain and 10 is extreme pain Visual analogue scale Pain body map: to help locate the MS related pain “I often wake up at night because of pain.” Neurogenic/neuropathic pain: Neurogenic pain is described as continuous and steady or spontaneous and intermittent and is reported in varying degrees of severity. One large North American study found that half of those reporting pain said their pain was continuous and severe. Intermittent, spontaneous pain is characterized as shooting, stabbing, electric shock-like, or searing and is often evoked by stimulus that normally do not cause pain, for example touch, the weight of bed covers, chewing or a cold breeze can all bring about spontaneous neurogenic pain. Steady neurogenic pain is often worse at night, worse during temperature change and could be worsened by exercise. Dysesthesia: Several studies have reported dysesthesia to be among the most common pain syndromes associated with MS. Dysesthesia is described as a constant symmetric or asymmetric burning sensation, usually affecting a person’s lower limbs, more frequently distally (meaning farther away from the body, such as in the feet and lower legs) than proximally (meaning closer to the body, such as in the upper part of the legs). A degree of sensory loss associated with dysesthesia can be detected during a neurological examination. First line treatment for dysesthesia related to MS are tricyclic antidepressants, e.g.: amitriptyline Anticonvulsant medications are commonly used e.g.: carbamazepine, lamotrigine and gabapentin In general, anticonvulsant medications, as well as tricyclic antidepressants, may be useful in some MS patients, although unfortunately there is not enough data available from studies with large numbers of participants, which is necessary for drawing conclusions as to the best choice of medication. Trigeminal neuralgia (TN): Also known as Tic Doloureux (French for “painful twitch”) Is probably the most widely recognized neurogenic pain in PwMS . It affects the trigeminal nerve, one of the largest nerves in the head. The trigeminal nerve sends impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead and around the eyes. TN in people with MS has been widely studied, with prevalence ranging from 1.9 percent to 4.4 percent. TN is characterized by paroxysmal (sudden), episodic facial pain which occurs in the fifth cranial or trigeminus nerve, often triggered by touch, chewing, shaving or even a light breeze. It can usually be treated successfully with medications such as gabapentin or carbamazepine. In severe cases that do not respond to medication, a surgical procedure called rhizotomy can be performed. This procedure severs the nerve roots that carry sensation. Painful tonic spasms (PTS): Often described as cramping, pulling pain and can affect both the upper and lower limbs, although they are more common in the lower extremities. The spasms are triggered by movements or sensory stimuli, often occurring during the night. PTS are estimated to occur in approximately 11 percent of PwMS. Antispasticity medications, such as baclofen is largely used in treatment of PTS. Lhermitt’s sign: It’s a short-lasting paroxysmal (sudden) pain radiating down the spine to the lower extremities triggered by flexing or extending the neck forward, is strongly linked to MS. It is experienced by approximately 40 percent of PwMS at some point throughout the disease. If the phenomenon becomes persistent, small doses of carbamazepine have been used for reducing the frequency and severity. Often PwMS who experience this symptom do not require medication. Optic Neuritis (ON): Painful optic neuritis is not neurogenic in nature and is probably a unique kind of pain. It is characterized by inflammation of the optic nerve, with pain occurring behind the eyes which is intensified with eye movement. In addition to pain, optic neuritis can be accompanied by blurred vision, visual acuity loss, impaired colour vision and complete or partial loss of vision. Corticosteroids (oral prednisone and intravenous methylprednisolone) may increase the rate of recovery from optic neuritis. Allodynia: Hypersensitivity to touch. A painful response to normally non-painful things such as stroking with a soft brush, getting dressed, or going out in the wind. MS hug: a squeezing sensation around the torso that feels like a blood pressure cuff when it tightens. This too is from damage to the spine from MS and could be a first symptom of MS or a relapse. “The kind thing about my MS pain is that it travels and does not stay in the same place for too long!” Other medications that are used in MS-related pain: THC/CBD, Pregabalin, Botulinum toxin, and NSAIDs. Achieving relief for neurogenic pain in MS may require trying different medications and dosages before identifying the most effective solution. Since many types of pain common in MS are difficult to treat effectively with standard medications, clinicians should also be open to discussing non-standard strategies for improving pain relief. Non-pharmacological pain relief options Acupuncture: Traditional Chinese medicine involving the insertion of extremely fine needles into precise nerve stimulation points in the skin and muscle. It is thought to work by increasing the body’s release of natural painkillers – endorphin and serotonin – in the pain pathways of the spinal cord and brain. Transcutaneous Electrical Nerve Stimulation (TENS): Using the same principle as acupuncture, TENS uses an electrode on the skin to produce a weak current to stimulate a painful muscle or skin. The current causes endorphins to be released into the cerebrospinal fluid. Exercise: Exercise can be very helpful to prevent and treat pain from musculoskeletal causes. A regular stretching program can help the discomfort from spasticity. Optimizing weight and core strength can help prevent and treat back, neck and joint pain. Exercise has been shown to help pain from many different conditions, partly through the enhanced release of the body’s own pain-relieving chemicals. Massage: Massage stimulates blood flow around the body, which may promote relaxation and pain relief. However, it may also send muscles into spasm, so should be used with caution. PwMS develop, among other ailments, chronic neuropathic pain. Unfortunately, there is a lack of adequate controlled trials in MS patients to assess the efficacy of established pain-relieving agents. Hence, treatment recommendations for MS-related pain largely rely on experience from other diseases with associated neuropathic pain. Currently, the number of medications for the treatment of MS-mediated chronic neuropathic pain is limited, and their use is often associated with severe adverse evets. Therefore, there is an urgent medical need to identify novel drug targets which may lead to the development of therapeutics with improved tolerability, low toxicity, and enhanced efficacy for the management of MS-associated chronic neuropathic pain. The influence of pain on quality of life The relationship between MS pain and health-related quality of life is complex due to other health issues PwMS may be experiencing. Several research have shown that in MS, mental health correlated with pain, and that anxiety and depression were significantly related to chronic pain. Unpublished British data suggests that people with MS with pain have less energy than those without pain. In summary, the available data suggests that in MS, health-related quality of life may be worse in terms of physical function and energy and, if chronic pain is experienced, mental health may be adversely affected. It is important to acknowledge the complexities of analysing the causes of pain, its relation to MS, measuring pain and relating pain to quality of life. Apart from understanding the difficulties of measuring quality of life over time, research suggests that if quality of life is used as an outcome measure for an intervention, anxiety and depression must also be assessed as they influence the relationship between disability and quality of life. Pain may also directly influence an individual’s participation in life. This may be because physical discomfort causes social withdrawal, or because pain worsens mental health (or poor mental health worsens pain and participation). Needless to say , careful studies are needed to unravel these relationships. Conclusion: Pain is seen by many as a major part of their MS and a symptom that can adversely affect quality of life. The wide variety of pain-related symptoms and treatments listed by people gives an indication of the individual nature of pain in MS and the difficulty respondents and their health care team have in effectively treating pain. To be continued. 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