Ms and Pain Heidi Maloni, PhD, np, Washington dc vamc, mscoe east Approximately two thirds of people with ms experience pain at some time during the course of the disease



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MS and Pain
Heidi Maloni, PhD, NP, Washington DC VAMC, MSCoE East
Approximately two thirds of people with MS experience pain at some time during the course of the disease. MS pain experts understand that MS pain is difficult to manage, and associated with depression, anxiety, and fatigue. Pain should never be ignored and should always be addressed.
Causes of MS Pain
Pain is a sensory symptom directly related to two events – the disruption of central nervous system myelin and the effects of disability. When pain is a symptom of an MS lesion or plaque it is termed neurogenic pain. The disability that is a result of MS causes a different type of pain originating in muscles, bones, and joints.
Neurogenic pain can be continuous and steady or spontaneous and intermittent, and is reported in varying degrees of severity. Intermittent, spontaneous pain is described as shooting, stabbing, electric shock-like, or searing and is often caused by sensations that normally do not cause pain.
Tightness or band-like sensations, nagging, numbness, tingling in legs or arms, burning, aching, and throbbing pain is categorized as continuous or steady neurogenic pain. Steady pain is often worse at night, worse during temperature change and worsened by exercise. The most common pain syndromes experienced by people with MS include: headache, continuous burning pain in the extremities, back pain, and painful tonic spasms.
Treatment of MS Pain
The sensation of pain is difficult to measure, and it is what the experiencing person says it is. Pain impacts sleep, mood, and the ability to work, play and enjoy life. Pain management is approached medically, behaviorally, physically and in some cases, surgically. A good pain history of the onset, location, duration, characteristics, aggravating factors, relieving factors, and treatments helps providers adequately treat pain. Keeping a pain diary helps patients explain their pain and receive the best care.
Medication: Treatment of neurogenic pain is aimed at down regulating excitatory neurotransmitters and enhancing inhibitory transmitters of pain with topical agents, antiepileptics, antidepressants, antiarrhythmics, NMDA-receptor antagonists, and non-narcotic and narcotic opioids. The use of opioids for MS neurogenic pain remains controversial. Opioids are considered when other agents become ineffective or not well tolerated. Opioids are constipating. A good bowel regimen including fiber, stool softeners, and laxatives is always considered in MS pain managed with opioids.
VA providers and patients are being warned of a recent Food and Drug Administration bulletin reporting an increased rate of suicide in patients receiving antiepileptic drugs (AEDs). AEDs are commonly prescribed to manage MS pain. There is no need to discontinue these medications. Awareness of any behavior changes or depressed mood should be reported to your providers.
Behavioral: Tolerance to pain is decreased with repeated exposure to pain, with stress, fatigue, anger, boredom, and sleep deprivation. Pain tolerance is increased with hypnosis, warmth, distracting activities, and strong beliefs or faith. Competing stimuli such as distraction, socialization, and recreation may act to increase pain tolerance. Relaxation, meditation, imagery, hypnosis, distraction, and biofeedback are strategies that increase the tolerance to pain. Getting involved in work or social activities, joining a support group or even having a good laugh are techniques that can minimize pain. Interesting to note, higher pain severity is reported by people with MS who are unemployed or homebound.
Physical: Physical agents work to enhance or limit pain transmitters and include the application of heat, cold or pressure, physical therapy, exercise, massage, acupuncture, yoga, tai chi, and Transcutaneous Electrical Nerve Stimulation (TENS). Use of physical agents can minimize doses of medication.
Surgical: Surgical pain management interventions are sought when medical, physical, and behavioral options fail. Procedures such as regional nerve blocks are reversible and safe. Neurosurgical options, rhizotomy, cordotomy, and Gamma Knife radiosurgery are known to offer relief, but carry risks.
Summary
Pain is a symptom that demands serious attention, as it has such pervasive impact on role, mood, capacity to work and rest, and interpersonal relationships. MS pain management is an achievable goal. The management of pain in MS is based on the mechanisms of the pain experienced. The goal of pain management is to optimize mood, sleep, and quality of life.
Date posted: April 17, 2008

http://www.va.gov/ms/default.asp?action=article&ID=412&KeyWords=pain%2Cand%2Cms


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