MS Pain and What To Do About It
By Laurie Long
Twenty years ago doctors used to say that there was no pain with MS. But these days there is no question from any of the medical community that pain associated with MS is real. Most of the recent studies show that neuropathic pain - pain caused by problems in the nervous system - is experienced by 50% or more of MS patients sometime during the course of the disease.
So what causes this pain? Demyelinated axons may cause neural impulses to leak out and spread to other adjacent demyelinated fibers. If the adjacent fibers belong to the sensory pathway, these misdirected neural impulses give rise to pain. Trigeminal neuralgia (sharp facial pain brought on by chewing or touch) is an example of this pain, where the motor and sensory branches of the trigeminal nerve short circuit. Nerve cells can also become overstimulated or misfire. This means that an overabundance of pain messages are sent to the brain, causing severe and often long-lasting agony. These types of pain do not respond to ordinary pain medications, which should be avoided, as they are not only ineffective, but addictive. Muscular and skeletal pain is also prevalent and can be due to muscular weakness, spasticity and imbalance.
Pain associated with MS is divided into different areas, but the most common classifications are acute, subacute, and chronic pain.
Acute Pain
Acute pain syndromes are sudden attacks of pain, often repetitive and lasting anywhere from seconds to hours. Acute pain is usually caused by abnormal conduction or 'short circuit' along demyelinated nerve fibers. Trigeminal neuralgia (see above) is the most recognized acute pain syndrome. Trigeminal neuralgia occurs about 300 times more frequently in people with MS than in the general population. Lhermittes sign (electric-shock sensation passing down the back when the head is flexed forward) and paroxysmal (brief) pain in the arms and legs are also known pain syndromes found in MS. These symptoms can be triggered by touch, movement, or even rapid breathing. Acute pain syndromes often occur at the beginning of the disease and are less frequent than the chronic pain syndromes (less than 15% according to Moulin at al, 1988).
Treatment
The preferred drug for treating acute pain syndromes in MS is anticonvulsant medication. Carbamazepine (Tegretol) is the drug of choice. Gabapentin (Neurontin) and phenytoin (Dilantin) are also used. These medications block abnormal nerve conduction at the demyelinated site. These drugs can have side effects, and may also cause the worsening of other MS symptoms such as weakness or tremor because they block nerve conduction. Capsaicin, a topical cream made from hot chili peppers, is also used to treat Trigeminal Neuralgia.
Subacute Pain
Subacute pain can also be caused by demyelination, or from a secondary source, such as the swelling of the nerve. The most common subacute syndrome is optic neuritis. Optic Neuritis is an aching, throbbing pain around or behind the eye and is provoked by eye movement. It is often the first symptom of MS. Optic Neuritis usually resolves in 7-10 days.
Treatment
Treatment of Optic Neuritis is generally with corticosteriods like Solumedrol or Prednisone to reduce optic nerve swelling.
Chronic Pain
Chronic neurogenic pain is the most common, and the most intractable of the pain syndromes in MS. Chronic pain syndromes make up 50 to 80% of all pain experienced in MS. Chronic pain syndromes include paresthesias and dysesthesias .
Paresthesias include pins and needles, tingling, shivering, burning pains, feeling of pressure, and areas of skin with heightened sensitivity.
Dysesthesias include burning, aching or girdling around the body.
Treatment
Treatment for neuropathic pain is with antidepressants called tricyclics. Amitriptyline (Elavil) has been the most commonly used tricyclic, but newer antidepressants such as bupropion (Wellbutrin) are replacing the older tricyclics because of reduced side effects.
If these medications do not work anticonvulsants, narcotics or the anti-spasticity drug baclofen can be tried. Combinations of these drug therapies can also be tried, although the risk of side effects rises with increased medication.
In addition to the drug therapies, other therapies such as physiotherapy, relaxation, meditation, deep breathing, yoga, chi gung, biofeedback, massage, chiropractic, hydrotherapy, acupuncture, etc. can help to alleviate and control chronic pain. Transcutaneous nerve stimulation (TENS) which is actually a variant of acupuncture, is also sometimes used to provide relief.
Other MS Pain
Other MS pain is often not directly related to demyelination and neuropathic pain. Chronic pain syndromes such as backache and leg spasms affect many people with MS. Reduced mobility, poor posture in walking and sitting can cause lower back pain. Spasms (intense cramping) are often due to increased disability and immobility.
Treatment
Back pain can be treated with non-steriodal anti-inflammatory medication (NSAIDS), physiotherapy, chiropractic, massage, yoga and other stretching and strengthening exercises. Treatment for spasms is generally anti-spasticity medication such as baclofen (Lioresal).Tizanidine (Zanaflex), diazepam (Valium) and dantrolene (Dantrium) are also used. This treatment is combined with physiotherapy - stretching and strengthening exercises, which should be done on a daily basis.
Multidisciplinary Pain Programs
For some people, even these pain relief therapies may not be sufficient to help control their pain. Pain clinics and accredited pain programs may be the answer. Such programs use a multidisciplinary approach to combating and controling pain. They tailor their program to the individual's needs. The Commission on Accreditation of Rehabilitation Facilities [telephone: (800) 281-6531] can provide you with a listing of accredited pain programs in your area (your health insurance may require that the unit be CARF accredited in order for you to receive reimbursement). You can also contact the American Pain Society , an organization for health care providers, at (847) 375-4715 additional information about pain units in your area.
Conclusion
It is critical that a correct diagnosis of the cause of any type of pain be made to ensure that it is properly treated. There are more available drugs and other therapies today for MS pain than ever before, and new discoveries are giving people more choices to combat that pain. But the most important point is that you don't "just have to live with" MS pain! Never assume that new pain is "just my MS". Have it evaluated by your health care provider and get the proper therapy to alleviate it. Take control of your pain - don't let it take control of you!
PAIN CHART
Type of Pain |
Drug Therapies |
Other Therapies |
Acute: |
Carbamazepine (Tegretol), Gabapentin (Neurontin), Phenytoin (Dilantin), Capsaicin |
Meditation, deep breathing, relaxation, chi gung, |
Subacute: |
Solumedrol, Prednisone |
Meditation, deep breathing, relaxation, chi gung, |
Chronic Pain: |
Amitriptyline (Elavil), Bupropion (Wellbutrin), |
Physiotherapy, relaxation, meditation, deep breathing, yoga, chi gung, biofeedback, massage, chiropractic, hydrotherapy, acupuncture, TENS |
Other Pain: |
Non-steriodal anti-inflammatory medication (NSAIDS), |
Physiotherapy, chiropractic, massage, yoga and other stretching and strengthening exercises |
Pain Websites:
http://www.theacpa.org The American Chronic Pain Association
http://www.tna-support.org Trigeminal Neuralgia Association
http://www.paincare.org The National Foundation for the Treatment of Pain
http://www.painmed.org American Academy of Pain Medicine
http://www.painfoundation.org The American Pain Foundation
http://www.ampainsoc.org The American Pain Society
http://www.painsupport.co.uk/ Pain Support - Natural Pain Relief
http://www.mayoclinic.com/invoke.cfm?objectid=3454D91F-85AA-4775-8AACF811D6C5723A The Mayo Clinic on Trigeminal Neuralgia
MSA Articles on Alternative Therapies for Pain Relief:
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References and Bibliography
Pain in MS , The World of Multiple Sclerosis
McEwan, Lynn, RN, MScN, MS Pain: It's Real and It Can be Treated , The World of Multiple Sclerosis
Sourcebook - Pain , From The MS Information Sourcebook, Information Resource Center and Library of the National Multiple Sclerosis Society
O'Neil, John, Treatments: Easing Pain Rooted in Nervous System , New York Times, 11/20/01
Vaney, Claude, MD, Understanding Pain Mechanisms in Multiple Sclerosis , From The World of Multiple Sclerosis
Bushnell, Catherine, MD, Picturing Your Pain , From http://www.eurekalert.org , 17/5/02
Kraft, George, MD and Cantanzaro, M., Living with Multiple Sclerosis - A Wellness Approach 2 nd Ed. 2000.Demos Medical Publishing, NY
Kalb, Rosalind C., MD, Multiple Sclerosis: The Questions You Have - The Answers You Need 2 nd Ed. 2000.Demos Medical Publishing, NY
Schapiro, Randall T., MD, Symptom Management in Multiple Sclerosis 3 rd Ed. 1998.Demos Medical Publishing, New York
Sibley, WA Therapeutic Claims in Multiple Sclerosis 4 th Ed., Demos Medical Publishing, New York
Lechtenberg, Richard, MD, Multiple Sclerosis Fact Book 2 nd Ed. 1995FA David Co., Philadelphia