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MS information for health and social care professionals Pain

Pain is a symptom of MS that may be experienced by up to 80% of people at some stage[1] and it is often one of the presenting symptoms[2]. Pain is recognised as a symptom of MS that requires managing and is addressed in the NICE guidelines[3].

The pain experienced by people with MS is usually chronic in nature, which means that it is longstanding and cannot usually be cured. The aim with chronic pain is to help people to manage it. Not surprisingly, pain can be difficult to cope with and those who experience it may also be more prone to poorer mental health. Pain may well lead to depression and depression in turn may contribute to the experience of pain.

The pain experienced by people with MS can be either as primary, a direct result of nerve damage, or secondary, due to disability, for example low back pain from prolonged wheelchair use or poor posture.

There are two broad types of pain: neuropathic (neurogenic) and nociceptive.

Neuropathic pain

Neuropathic pain or 'nerve' pain is usually described as burning, shooting, tingling, stabbing and/or hypersensitivity. People with MS often experience neuropathic pain due to demyelination of the nerves and plaques in the brain and spinal cord. An example of this is trigeminal neuralgia, a severe facial pain, which occurs 300 times more frequently in people with MS than in the general population[4]. In extreme cases surgery may be performed to alleviate the pain but this may leave the face numb. Lhermitte's sign is another example: an unpleasant sensation similar to an electric shock that shoots down the spine into the legs, often triggered by head movement and attributed to demyelination in the cervical area. Apart from drug therapies, a support collar may be an effective control method for this symptom.

Neuropathic pain cannot be cured. It is a symptom of the condition that needs managing with the use of anti-convulsants and antidepressants. These two groups of drugs can affect the chemical transmission of pain signals resulting in a reduction of symptoms, but they often cause unpleasant side effects such as drowsiness, dizziness, nausea and blurred vision. Some people find the side effects of the drugs intolerable and therefore choose not to take them, but with controlled titration of the dose and support from health care professionals, the side effects can often be tolerated and will eventually wear off.

Other treatments for neuropathic pain include TENS (see below) and complementary therapies such as acupuncture and aromatherapy[5].

Nociceptive pain

Nociceptive pain, commonly referred to as musculoskeletal pain, is the type of pain experienced when someone hurts himself or herself, has an accident, or surgery. Damage to muscles, tendons, ligaments and soft tissue results in nociceptive pain. Muscle spasm and spasticity, common symptoms of MS, can also be a source of nociceptive pain.

Many people with MS experience lower back pain, especially if immobility or fatigue means that they are sitting down for much of the time. Sitting places the lower back under more strain than standing and nerves can easily become compressed or pinched. Equally, an alteration of gait may place unusual stresses on the discs between the vertebrae. Such stress can cause damage to the discs and nerves to be trapped which results in pain in whichever part of the body is served by those nerves.

Heavy lifting and awkward turning and bending can also contribute to back and leg pain. These movements may irritate the spinal nerves causing the muscles at the side of the spine to go into spasm; these muscle flexor spasms can be very painful and disabling.

Ligament damage can also occur in MS because of hyperextension of the knee when walking; the subsequent swelling of the knee can cause significant pain.

Nociceptive pain is generally more successfully managed than neuropathic pain. A variety of analgesic drugs ranging from paracetamol and codeine-based preparations, through to antiinflammatory drugs and opiates can be used, in combination with drugs such as Baclofen and Tizanidine for spasm if indicated. Other treatments indicated include physiotherapy to strengthen muscles and correct poor posture, trigger point injections and nerve blocks, TENS[6], and complementary therapies such as acupuncture and aromatherapy[5].

Use of TENS for the management of pain

Transcutaneous electrical nerve stimulation (TENS) is the application of electricity to relieve pain. It is not a new treatment; carvings from Egypt dating back to 2500BC illustrate the use of electric fish for the treatment of pain[7]. TENS units deliver a small electrical current to the sensory cutaneous nerve endings through electrically conductive pads. A buzzing, prickling, tingling sensation is experienced when the machine is switched on. TENS is recommended in the NICE guideline3 for people with musculoskeletal pain who have not responded to medication, but it can be used in conjunction with medication and also for neuropathic pain.

TENS machines are battery powered, usually by a regular 9 volt battery. Machines should have the facility for a constant mode (also known as continuous or conventional), a burst mode (also known as acupuncture TENS), and a modulation mode. On the constant mode (high frequency/low intensity) a constant tingling sensation is felt, on burst mode (low frequency/high intensity) a pulsing sensation, and on modulation mode (variation of pulse duration and frequency in a cyclical pattern) an increase and decrease in the tingling sensation is felt. To accommodate these three modes the machine should have the facility to alter the pulse rate (frequency) and pulse width. TENS units either have one or two channels allowing the use of either 2 or 4 pads. The dual channel machines are preferable to allow coverage of a larger area or treatment of 2 separate areas. The self-adhesive pads are recommended if the machine is to be used over a long period of time, as they are much easier to use.

It is thought that TENS relieves pain by several mechanisms. The main principle behind the effect of TENS is the Gate Control Theory of Pain[8]. Electrical impulses are conducted more quickly than pain impulses and subsequently provide a competitive barrage of sensory input in the dorsal horns. This enhanced sensation inhibits the activity of the spinal cord pain neurons. Researchers hypothesise that TENS may stimulate the production of endorphins and encephalins, the body's own natural analgesics at spinal cord level especially if used at low frequency when sharper and more intense pulses are experienced[9].

Assessment and treatment of pain

Pain is a complex, multidimensional phenomenon. It is an unpleasant experience, particularly when combined with the other symptoms of MS. It impacts upon many aspects of an individual's psychosocial and spiritual well-being and can be difficult to cope with.

This needs to be remembered when developing pain management strategies for people with MS. Loss of sleep, mobility problems, financial insecurity, feelings of low self-esteem, all result in people finding it hard to manage their pain. The importance of developing coping strategies is paramount and these can include relaxation, distraction, exercise regimes and the use of therapies that can be self-administered such as TENS and massage.

It also needs to be remembered that people with MS can experience pain due to problems other than their MS. 7% of the general population have experienced pain for three months or more[10] so other factors such as arthritis, rheumatism, previous injuries and surgery need to be taken into consideration.

Simply acknowledging that the pain is real is reassuring for some people with MS, particularly when many of them will have been told, sometimes by health professionals, that MS is not associated with pain.

When people with MS present with pain they need to be assessed to identify its cause. This, along with its impact on their life, needs to be taken into consideration when devising a treatment plan. If pain remains unresolved, where possible, it is advisable to refer them onto a specialist multidisciplinary pain team[3].

References

  1. Archibald CJ, McGrath PJ, Ritvo PG et al. Pain prevalence, severity and impact in a clinic sample of multiple sclerosis patients. Pain 1994;58(1):89-93.
  2. Miller D, Compston A. The differential diagnosis of multiple sclerosis. In: Compston A, Confavreux C, Lassmann H editors McAlpine's multiple sclerosis. 5th ed. London: Churchill Livingstone; 2005. p389-436.
  3. National Institute for Clinical Excellence. Multiple Sclerosis- Management of multiple sclerosis in primary and secondary care. NICE Clinical Guideline 8. London: NICE;2003.
  4. Thompson AJ. Multiple sclerosis: symptomatic treatment. J Neurol 1996;243(50):559-565.
  5. Howarth AL, Freshwater D. Examining the benefits of aromatherapy massage as a pain management strategy for patients with multiple sclerosis. Nurs Times Res 2004;9(2):120-128.
  6. Mattison PG. Transcutaneous electrical nerve stimulation in the management of painful muscle spasm in patients with multiple sclerosis. Clin Rehabil 1993;7:45-48.
  7. Walsh DM. TENS: Clinical applications and related theory. New York: Churchill Livingstone; 1997.
  8. McMahon S, Koltzenburg M editors. Wall and Melzack's textbook of pain. 5th ed. Edinburgh: Churchill Livingstone; 2005.
  9. Sjolund BH, Eriksson M, Loeser JD. Transcutaneous nerve stimulation of peripheral nerves. In: Bonica JJ. The management of pain. 2nd edition. Philadelphia: Lea & Febiger; 1990. p1852-1861.
  10. Bowsher D. In: Carroll D, Bowsher D, editors. In: Pain: management and nursing care. Oxford: Butterworth-Heinemann; 1993.

Bibliography

  • Kerns RD, Kassirer M, Otis J. Pain in multiple sclerosis: a biosocial perspective. J Rehabil Res Dev 2002;39(2):225-233.
  • The British Pain Society. Recommended guidelines for pain management programmes for adults a consensus statement prepared on behalf of the British Pain Society. London: British Pain Society; 2007.