Pain in MS and its Management

1. Pain in MS and its Management

2. Pain in MS • Up to 80% of people with MS will have pain at some stage of the diseasePain occurs equally in relapsing-remitting and progressive disease • Pain is more common : • in women • when disease has been present >5 years • when patients are in their 50s or 60s Archibald CJ et al. Pain, 1994;58:89 Moulin D et al. Neurology,1988;38:1830

3. Pain in MS • Pain in MS is often: • overlooked • misdiagnosed • poorly treated • Patients may not complain about their pain, but 30% consider it to be one of their worst symptoms second only to fatigue Stenager E et al. Acta Neurologica Scandinavica,1991;84:197

4. Pain in MS Pain decreases patient’s and carer’s quality of life It can cause: • sleep disturbances • fatigue • weight loss • low mood, possibly leading to clinical depression • anxiety and agitation • changes in character e.g. becoming withdrawn or irritable, which can cause stress in relationships • decreased social and physical functioning

5. Pain in MS • Patients may have more than one type of pain, due to different underlying pathologies • Pain can be • acute : short-lived (minutes or hours - but may be repetitive), rapid onset. ‘Paroxysmal’ describes a brief, sudden attack • subacute: time-limited (lasting days to weeks) • chronic : lasting >1 month, insidious or subtle onset • Pain is chronic in the majority of patients • Some types of pain are particularly difficult to treat McEwan L. ‘MS Canada’, 2000;29:4 – in: ‘MS Society articles’, www.msif.org National MS Society, MS Information Sourcebook, www.nationalmssociety.org

6. Pain in MS The origin of pain in MS may be: • Neuropathic • Musculoskeletal • Iatrogenic • Co-morbid disorders

7. Neuropathic pain • Directly caused by the underlying disease process • pathological changes in the nerves – demyelination – disrupts neural transmission, resulting in painful sensations • May be acute, sub-acute, chronic • May be continuous or paroxysmal • if continuous: a steady pain described as burning, tingling, aching • if paroxysmal: an intermittent pain described as shooting, stabbing, electric shock-like, searing • Pain can be triggered by benign stimuli e.g. touch of clothing, bath water – this hypersensitivity is termed ‘allodynia’

8. Musculoskeletal pain • Secondary to the disease, as a consequence of immobility, postural and other problems • results in e.g. muscle cramps, joint aches, back pain • Usually chronic • Can lead to muscle weakness, stress on bones and joints due to improper use of compensatory muscles and further immobility

9. Iatrogenic pain Pain related to, or as a side effect of, treatment e.g. • interferon-related ‘flu-type aches, headache, injection-site reactions • osteoporotic pain

10. Co-morbid pain • Pain due to co-morbid medical conditions – other painful disorders from which patients may also be suffering e.g. heartburn, migraine, irritable bowel • Secondary pain from MS-related conditions e.g. pressure sores, bladder infection

11. Acute pain syndromes • Trigeminal neuralgia • neuropathic - follows path of trigeminal nerve • facial pain, usually unilateral. Paroxysms of shooting, stabbing, electric-shock-like pains, which can be repetitive • triggered by movement e.g. talking, chewing, brushing teeth • affects around 10% of people with MS (400x more common than in general population)

12. Acute pain syndromes • Tonic spasms • May be of neuropathic origin or musculoskeletal, due to spasticity • Simple, painful flexor spasms • Triggered by movement or noxious (harmful) stimuli • Managed with anti-spasticity therapies • Brief spasms of upper/lower extremity • Painful muscle spasms – can occur several times per day • Lightening-like extremity pain • Intense, shooting pain • Can occur in any part of the body

13. Acute pain syndromes • Lhermitte’s sign • neuropathic – sign of damage to posterior column of cervical spinal cord • brief, ‘electric shock’ or stabbing pain, running from back of head down spine • triggered by bending forward or head/neck movement • Optic neuritis • neuropathic – sign of inflammation/demyelination around optic nerve • sharp, knife-like pain, or can be deep ache/pressure behind or above the eye

14. Chronic pain syndromes • Can be of neuropathic or musculoskeletal origin • Account for 50-80% of pain experienced in MS • Dysaesthetic extremity pain (dysaesthesia – unpleasant, abnormal or distorted sensation) • neuropathic - commonly due to lesion in thalamic/dorsal spinal cord • most common chronic pain syndrome. • no direct correlation with level of disability • persistent, burning, tingling, dull, nagging, prickling pain in lower extremities • worse later in the day, after exercise, • aggravated by changes in temperature

15. Chronic pain syndromes • Band-like, ‘girdling’ pain and dysaesthesia • neuropathic – due to spinal cord lesions • can be in torso or extremities • burning, aching, squeezing, pressure sensations • pain may be converted to sensations of pressure / warmth by use of pressure garments / heat compresses • Back pain • can be neuropathic due to spinal nerve root compression (radiculopathy), or musculoskeletal

16. Other causes of pain in MS • Pain arising from consequential conditions e.g. pressure sores, bladder infections • Pain caused by MS therapies e.g.: • ‘flu-like aches • injection site reactions associated with injectable therapies • osteoporotic pain which may be steroid induced

17. Management of Pain

18. Goals of pain therapy • Relieve or reduce pain • Improve quality of life • Achieve by: • targeting the causes, where possible • treating the pain • helping patient to develop successful coping strategies to reduce their pain ‘experience’

19. Management steps • Assess and determine cause(s) • Identify any barriers to successful pain management • Treat any underlying cause • Consider multi-disciplinary approach e.g. drug, non-drug and cognitive therapies, Pain Clinic • Monitor progress, side effects, patient satisfaction and adjust management accordingly

20. Barriers to successful pain management • Healthcare professionals: • lack of knowledge in identifying, assessing and managing the problem • lack of time for on-going management • managing side effects • “Silent” symptom often not asked about • Patients: • communication problems • reluctance to report pain • want to appear normal, not complainers • seems insignificant compared to other problems • may think means worsening of underlying disease • unwilling to take more medication • compliance • means more side effects

21. Management of PainNICE Recommendations • Each professional in contact with a person with MS should ask whether pain is a significant problem for the person, or a contributing factor to their current clinical state • All pain, including hypersensitivity and spontaneous sharp pain, should be subject to full clinical diagnosis, including referral to an appropriate specialist, if required

22. Management of PainNICE Recommendations Musculoskeletal pain • Should be seen by specialist therapists to see if exercise, passive movements, better seating or other procedures may benefit • If non-pharmacological means are unsuccessful then appropriate analgesia should be given • For continuous unresolved musculoskeletal pain, consider transcutaneous nerve stimulation (TNS) or antidepressant therapy • Ultrasound, low-grade laser treatment and anticonvulsants should not be used routinely • Cognitive behavioural and imagery treatment methods should be considered if person has well-preserved cognition to actively participate

23. Management of PainNice Recommendations Neuropathic Pain • Treated using anticonvulsants, such as carbamazepine or gabapentin, or antidepressants, such as amitriptyline • If pain remains uncontrolled after initial treatments have been tried, refer to a specialist pain service

24. Take a history: When did it begin? How did it begin? Where is it? How long does it last? Description What relieves it? What triggers / makes it worse? Current medication, including any OTC analgesics? Use pain assessment tools e.g. McGill pain questionnaire (MPQ) Visual analogue scales (VAS) for pain Assessment of pain

25. The McGill Pain Questionnaire

26. The short form McGill Pain Questionnaire Sensory Dimension Affective D.

27. No pain Worst pain possible 0 1 2 3 4 5 6 7 8 9 10 Visual Analogue Scale • The VAS is a simple robust pain measurement tool • Can be used to measure severity and/ or improvement • Usually designed as a 10cm line with descriptors at each end

28. Involving the patient Encourage them to: • Believe that control of their pain is possible • Understand the pain, and why it is happening • Get to know their pain triggers • Use preventative approaches • Explore and understand their treatment options and possible side effects • Use non-drug strategies • Keep a pain diary to monitor their progress and reinforce compliance

29. Pain management options • Pharmacological – drug treatment • e.g. analgesics, anti-spasticity drugs, drugs which affect neural function • oral, topical, injectable, transdermal • Anaesthetic patches • Non-pharmacological therapies e.g. physical therapy, relaxation techniques • Surgical intervention e.g. rhizotomy, epidural • Complementary therapies e.g. aromatherapy • Specialised analgesic technologies e.g. TENS

30. Anticonvulsants • Carbamazepine (Tegretol) -1st line treatment for trigeminal neuralgia • Phenytoin • Valproic Acid • Clonazepam • Gabapentin • Pregabalin • Lamotrigine • Topiramate • Oxcarbazepine - low side effect profile

31. Tricyclic antidepressants (TCAs e.g.amitriptyline) • Still a useful treatment for neuropathic pain, especially at night • Affect neural transmission - inhibit reuptake of neurotransmitters serotonin and noradrenaline • SEs: sedation, dry mouth, weight gain, postural hypotension, cardiovascular effects, seizures, urinary retention McQuay HJ & Moore A. BMJ,1997;314:763

32. Opiates • Although traditionally thought to be ineffective in neuropathic pain, now increasingly recognised as a useful treatment option. • Drugs such as: • Morphine derivatives e.g. oxycodone • Weak opioids e.g. buprenorphine, tramadol hydrochloride • Transdermal patches offer ease of administration and may be more easily tolerated

33. Cannabinoids • As yet unlicensed in the U.K, although can be obtained on a named patient basis • Evidence re: efficacy is still under debate • Patients may have unrealistic expectations of its effectiveness • Concerns re: side effect profile

34. TENS Physiotherapy Acupuncture Aromatherapy Relaxation techniques Hypnosis Pain clinic Behavioural/lifestyle management Cognitive therapy Pain management programme combining a variety of approaches Non-pharmacological options

35. Acupuncture Massage Neurostimulators Tai Chi Hypnotherapy Biofeedback Centering Meditation Yoga CAM

36. Diet Exercise Recreation Laugh therapy Massage Hypnosis CBT Positive attitude /imagery Music Diversional therapy Support groups Socialisation Other non-pharmacological options

37. Treatment titration • Start with a low dose and gradually titrate to efficacy • Partial pain relief with one drug • combine two or more • often yields improved analgesia, with fewer side effects • In general, when pain free for 3 months on treatment, consider a slow taper