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Pain - factsheet

Date of revision: August 2007

Contents

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Pain in MS
  • Causes of pain in MS
  • Pain symptoms
  • Acute pain versus chronic pain
  • Management of pain
Neuropathic (nerve) pain
  • Standard drug therapies
  • Treating acute neuropathic pain
  • Treating chronic neuropathic pain
  • Treating chronic neuropathic pain
Musculoskeletal (nociceptive) pain
  • Standard therapies
  • Treating acute musculoskeletal pain
  • Treating chronic musculoskeletal pain
Further treatment options
  • Pain clinic
  • Complementary therapies
Useful references and further reading
  • Guidelines
  • Books
  • Websites and addresses

1. Pain in MS

Causes of pain in MS

Until recently MS was considered to be a painless disease. However, it is now recognised that over half of people with MS will experience pain at some stage. MS is a chronic disease of the central nervous system (the brain and spinal cord). For reasons that are not fully understood, damage occurs to the myelin sheath that protects the nerves and aids transmission of messages. The myelin sheath can be compared to the insulation material around electrical wires. When myelin is damaged, the transmission of messages from the brain and spinal cord to the rest of the body is disrupted, interfering with the body's normal ability to function. One of the results of this disruption may be pain.

There are two broadly recognised types of pain:

  • Neuropathic pain – also known as nerve pain. This arises as a direct result of the damaged myelin interfering with the normal functioning of the central nervous system. Nerve pain can occur as a result of impulses jumping between nerves – similar to short-circuiting electrical wires. However, the origin of most nerve pain is not fully understood.
  • Musculoskeletal pain – also known as nociceptive pain. Nociceptors are pain receptors found throughout the body that respond to injury and inflammation. They send messages to the brain that are perceived as pain, usually in the joints or muscles. This type of pain is not directly related to MS, but may be exacerbated by it; for example, musculoskeletal pain can arise as the result of spasms or abnormal pressure on the muscles and joints due to changes in posture.

It is important to remember that not all pain experienced by people with MS is due to MS; many other things such as an infection or an accident could be the cause. Treating the symptom normally relieves this type of pain; therefore other possible causes should always be thoroughly investigated.

Pain symptoms

A wide range of MS symptoms may be classed as pain, including:

  • numbness
  • feelings of constriction, tightness or being squeezed around the chest
  • tingling
  • pins and needles
  • burning sensations
  • sudden stabbing pains
  • chronic gnawing pains
  • changes in sensation, eg very sensitive patches of skin

No two people will experience pain in the same way; it is very subjective and is best described by the person experiencing it.

Acute pain versus chronic pain

Pain can be sub-divided into two categories, acute and chronic pain. Acute pain (also known as paroxysmal pain) is generally described as an intense, sharp, burning or shooting pain. It is usually experienced intermittently, with very sudden onset, and in some cases it can disappear equally quickly. Some types of acute pain, particularly that resulting from spasms, can become chronic.

Chronic pain is traditionally defined as pain that lasts more than a month. It is described as a deep-seated, continual pain. It differs from acute pain in that its onset is often slow. Chronic pain may fluctuate over a period of time, without ever fully disappearing.

Management of pain

The management of pain in MS is not always easy and may not be successful. Some types of pain will never go away entirely. The body adapts to tolerate a certain level of day-to-day pain and the person with MS may not recognise the pain as a symptom after a while. Treatment depends largely on the cause of the pain; therefore it is important to be open to a range of possible treatment options, which may include drugs, non-drug treatments such as physiotherapy or a combination of the two. The aim of treatment if the pain cannot be eradicated, is to manage the level of pain so that the individual can carry out normal day-to-day living.

It is recognised that many factors can make pain worse. These include heat, cold, poor sleep, extreme fatigue, feelings of loneliness and isolation, and depression or anxiety. Treating all these symptoms is beyond the scope of this factsheet, but it is important to realise that pain may not happen on its own, and that dealing with some of the other issues can help to improve pain levels. However, this may not always be possible, for example, in the 'chicken-and-egg' situation where a person is unable to sleep because of the pain they are experiencing. If possible, it may be helpful to discuss these issues with your MS nurse (where available) or GP.

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Neuropathic (nerve) pain

Standard drug therapies

With the exception of some sudden onset pains, and sometimes the pain that arises from spasticity, the treatment of neuropathic pain is with a range of drugs. They can either be used alone or in combination. They include:

  • carbamazepine (Tegretol)
  • gabapentin (Neurontin)
  • amitriptyline (Triptafen)

Carbamazepine and gabapentin are drugs that are used to treat epilepsy. However, they are used in MS because one of their secondary effects is to provide pain relief, especially from spasms. Amitriptyline is an anti-depressant and trials of this drug showed that a useful side effect is pain relief. It can be prescribed in MS solely to control pain – rather than to treat depression. These agents can all be prescribed by a GP, although your neurologist may also be involved.

Treating acute neuropathic pain

  • Trigeminal neuralgia – an intense, severe stabbing and burning sensation down the side of the face that eases to an ache and burn. This pain follows the path of the trigeminal nerve, and it is thought that the pain arises from damage that occurs where the nerve connects to the brain. It normally only affects one side of the face at a time. The pain can be excruciating and can be set off by something as simple as eating, talking or smiling. This pain is usually sudden in onset and can reduce or disappear over a period of time. However it can become chronic.

    It can be difficult to treat and it is useful to identify whether the pain has any triggers, for example eating ice cream, and learning to avoid them or reduce their likelihood. First-line treatment is with a standard drug therapy for neuropathic pain. Long-term options include surgery to cut the nerve's connection to the brain; but this is only available in specialist centres. More information is available from the MS Trust if required.

  • L'hermitte's sign/syndrome – 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.

    Rarely treated as the pain is so sharp and sudden that it does not usually last long enough for pain treatments to take effect.

  • Lightning-like extremity pain – similar to L'hermitte's sign. Often triggered by moving the head or neck, bending or turning, which results in a sharp, shooting pain that travels through to the fingers and toes. Following the initial shooting pain, it may leave a lingering ache or burning sensation. As with L'hermitte's sign this is rarely treated.

  • Optic neuritis – a sharp, knifelike pain behind the eyes. A common first symptom of MS, caused by inflammation of the optic nerve. Normally responds successfully to corticosteroid treatment such as methyl prednisolone, which resolves the symptom and therefore relieves the pain.

  • Spasms – when muscles seize into an extended, outstretched position it can result in pain. Pain can also occur if the muscles contract into a painful bent position – known as a contracture. Spasms occur most often in the legs and are usually related to muscle stiffness (spasticity). They are caused by the disruption of messages from the brain to the nerves at the bottom of the spinal cord that control the leg muscles. Spasms can be extremely painful, and though sudden in onset, they can become chronic over time.

    Tonic spasms – painful seizures of the arm or leg in an unusual position. They are not related to spasticity and often last less than 90 seconds. However they can occur many times a day.

    Spasms are treated with carbamazepine or gabapentin in the first instance. They may also respond to treatments for spasticity (see below).

Treating chronic neuropathic pain

  • Spasticity – a stiffness of the muscles that occurs most often in the legs and can cause a deep, gnawing, constant pain. Spasticity can be made worse by immobility, which causes changes to muscle and other soft tissues.

    Drug treatments are available specifically for spasticity; the NICE Clinical Guideline (see Useful references below) recommends baclofen or gabapentin as the first line of treatment. Other treatment options include tizanidine, diazepam, clonazepam or sodium dantrolene. A GP can prescribe these drugs, but may choose to refer you to a neurologist or pain clinic. Anti-spasticity drugs can cause 'floppy' legs and reduced mobility. Therefore various doses may be tried before a balance between pain relief and maintaining muscle function is achieved.

    A combined approach to treating spasticity, using both drug treatment and exercise, is normally most successful. Physiotherapy is used in conjunction with anti-spasticity medication to achieve maximum pain relief and improve muscle function through a range of exercises. It can help improve muscle stiffness and reduce painful sensations. Referral to a physiotherapist is through a GP or neurologist.

  • Dysaesthesia/Paraesthesia – the technical terms for altered sensation. The pain can be described in a variety of ways including burning, pins and needles, tightness, numbness, prickling, dull ache, itching and nagging

    Usually experienced in the extremities, but can occur anywhere in the body. These changes in sensation are at best uncomfortable and unsettling, but they may be painful and distressing. These are common symptoms in MS, but they are experienced differently from person to person.

    Generally treated with one of the standard drug therapies. Symptoms such as numbness and loss of sensation may not be treated unless they are causing particular distress.

  • Banding – another form of altered sensation. Described as feelings of constriction, tightness or being squeezed around the chest. Scarring of the spinal cord usually causes this type of pain.

    In the first instance treated with carbamazepine, gabapentin or amitriptyline.

    If initial treatment of neuropathic pain is unsuccessful, a referral may be made to a specialist pain clinic.

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Musculoskeletal (nociceptive) pain

Standard therapies

Musculoskeletal pain is often successfully treated by physiotherapy and exercise. A full assessment by a physiotherapist should be able to identify changes in posture and offer exercises to strengthen certain muscle groups. These are normally beneficial in maximising muscle function and may help to reduce pain as a result.

According to the NICE Clinical Guidelines (see Useful references below), specialist therapists should assess every person with MS who has musculoskeletal pain, in order to identify the cause and how the pain might best be managed. This may include a combined assessment by a physiotherapist and occupational therapist to determine whether any new equipment is required to help relieve pain or improve muscle function. This could be a simple adaptation such as a walking stick to improve balance; or bigger, lighter cutlery to make cooking and eating easier.

Drug treatments for musculoskeletal pain include common painkillers, such as paracetamol or aspirin. Musculoskeletal pain sometimes responds to complementary therapies, for example reflexology or massage (see Complementary therapies below).

Treating acute musculoskeletal pain

  • General muscle cramps/spasms – pain occurs when large muscles suddenly shorten, which can result in severe cramps. This can be as a result of muscle fatigue, muscle strain or a shortage of minerals in the body such as sodium or potassium.

    Treatment can include regular stretching exercises and balancing water intake with adequate sodium and potassium intake.

Treating chronic musculoskeletal pain

  • Pain in the hips and bottom of the spine – can be caused by pressure due to immobility or misalignment of the hip and pelvis, for example if the body is imbalanced by dragging one leg.

    May respond to painkillers, physiotherapy or regular exercise.

  • Pain in the muscles, tendons or ligaments – can occur if the limbs are stiff and kept in a fixed position or, for example, if there is a weaker arm, pain may be experienced in the shoulder caused by the favouring of one side of the body over the other.

    Treatments may include massage, heat therapy or ultrasound.

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Further treatment options

Pain clinic

If pain does not respond to treatment, or remains unbearable, it is possible to get a referral from your GP or neurologist to a specialist pain clinic. At the clinic a range of drug and non-drug treatments can be tried for the pain. If the pain cannot be completely eradicated, the goal will be to achieve a reduction in the pain to a level that is manageable for the person with MS, and enables them to carry on with normal day-to-day living. Pain clinics vary in the treatments offered and not all hospitals may have a specific pain clinic. Details of your nearest pain clinic can be obtained from The Pain Society (see Useful references below).

Complementary therapies

Some people with MS prefer trying a non-drug approach rather than conventional drug therapies, or before approaching a pain clinic. Very few non-drug therapies are backed up by full scientific research trials. However, there is some scientific evidence to support reflexology, massage and magnetic therapy (magnets, available as bracelets or belts, are applied to the area of pain). Some people with MS have reported benefits from the following therapies, and there may be others that are helpful:

  • acupuncture
  • aromatherapy
  • homeopathy
  • yoga
  • reiki
  • TENS (transcutaneous electrical nerve stimulation – a small electrical current is applied to the area of pain)
  • relaxation techniques
  • visualisation techniques
  • distraction techniques
  • cognitive behavioural therapies

Some non-drug treatments may be available via a GP or pain clinic, but provision varies. Many of these therapies are available privately, and it is important that a reputable, qualified practitioner is used. The Prince of Wales's Foundation for Integrated Health is a useful source of information; it maintains a register and contact details for the regulatory bodies for the different therapies. It is also publishing a guide to help people find an appropriate therapy and properly qualified and regulated practitioners (see sectioUseful references below).

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Useful references and further reading

Guidelines

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 the NICE Guideline

Books

Burgess M.
Multiple sclerosis: theory and practice for nurses.
London: Whurr Publishers; 2002.

Robinson I, Rose C.
Managing your multiple sclerosis.
London: Class Publishing; 2004.

Schapiro RT.
Managing the symptoms of multiple sclerosis. 4th edition.
New York: Demos Medical Publishing; 2003.

Bowling AC.
Complementary and alternative medicine and multiple sclerosis. 2nd edition
New York: Demos Medical Publishing; 2006.

Websites and addresses

National MS Society (American): Spotlight on Pain – gives an overview of causes of pain and information on treatments. Please bear in mind that not everything recommended or used in the USA is available in the UK.

The British Pain Society
the representative body for professionals involved in the management of pain in the UK. Can provide details of your nearest pain clinic.
The British Pain Society
Third Floor
35 Red Lion Square
London WC1R 4SG
Tel: 0207 269 7840

Pain Concern
organisation offering information and support for people who experience pain by people who experience pain. Provides a 'listening ear' helpline.
Pain Concern
PO Box 13256
Haddington EH41 4YD
Helpline: 01620 822572

The Prince's Foundation for Integrated Health
33-41 Dallington Street
London
EC1V 0BQ
Tel: 020 3119 3106
email: info@fih.org.uk