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Multiple Sclerosis

It is important to remember that MS is only one part of a person and not the person.

MS does not represent them, it is not their identity, they are as normal as the next person.  

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Pain                                                                                                                                                                                                               

Pain adds to all sorts of other problems, decreased mobility, depression, misery and it is an awful symptom to endure.

Pain is broadly divided into two types                                                                                                                                                     

Nociceptive pain - caused by actual, or potential damage to tissues, a cut, a burn, an injury, pressure or force from outside the body, or pressure from inside the body (for example, from a tumour). The reason pain is felt in these situations is because tiny nerve endings become activated or damaged by the injury, and this sends pain messages to the brain via nerves. Nociceptive pain tends to be described as sharp or aching that may be eased by painkillers such as paracetamol, anti-inflammatory painkillers, codeine, morphine, etc.

Neuropathic pain - caused by a problem with one or more nerves themselves. There is often no injury or tissue damage that triggers the pain, however, the function of the nerve is affected in a way that sends pain messages to the brain.  Neuropathic pain is often described as burning, stabbing, shooting, aching, or like an 'electric-shock'.

 

The perception ('feeling') of pain can vary depending on how a person reacts to pain and their circumstances.

 

Various conditions can affect nerves and may cause neuropathic pain as one of the features of the condition                        

• Trigeminal neuralgia.
• Post herpetic neuralgia (pain following shingles).
• Diabetic neuropathy - a nerve disorder that develops in some people with diabetes.
• Phantom limb pain following an amputation.
• Multiple sclerosis.
• Pain following chemotherapy.
• HIV infection.
• Alcoholism.
• Cancer.
• Atypical facial pain.
• Various other uncommon nerve disorders.

Related Problems                                                                                                                                                                                       

Allodynia - the pain comes on, or gets worse, with a touch or stimulus that would not normally cause pain. For example, a slight touch on the face may trigger pain if you have trigeminal neuralgia, or the pressure of the bedclothes may trigger pain if you have diabetic neuropathy.

Hyperalgesia - severe pain from a stimulus or touch that would normally cause only slight discomfort. For example, a mild prod on the painful area may cause intense pain.

Paresthesia - Dysaesthesia unpleasant or painful feelings even when there is nothing touching, and no stimulus. e.g. painful pins and needles, or electric shock like sensations. Although these are often experienced as affecting the skin, the sensation is caused by interrupted nerve messages in the central nervous system.

The impact that the pain has on a persons life may be just as unpleasant                                                                                        

Pain can cause:

• Anxiety.
• Depression. (Where relevant, treatment for anxiety or depression may help - Pain may effect treatment for depression.)
• Disturbed sleep.

How common is neuropathic pain?                                                                                                                                                          

It is estimated that about 1 in 100 people in the UK have persistent (chronic) neuropathic pain.

It is much more common in older people

 

Treatments include                                                                                                                                                                                    

•  Medicines
• Physical treatments
• Psychological treatments
• Treating the underlying cause - If this is possible, it may help to ease the pain. For example, if you have diabetic neuropathy then good control of the diabetes may help to ease the condition.

 

Medicines used to treat neuropathic pain                                                                                                                                              

The usual 'traditional' painkillers may be tried at first such as:

• Paracetamol.
• Codeine.
• Morphine.

These may help. If they do not, or only partially help, then a antidepressant or anticonvulsant medicine may then be advised.

Antidepressant medicines                                                                                                                                                                         
An antidepressant medicine in the 'tricyclic' group is a common treatment for neuropathic pain. (It is not used here to treat depression).

There are several tricyclic antidepressants such as:

• Amitriptyline.
• Imipramine.
• Nortriptyline.

Tricyclic antidepressants ease neuropathic pain separate to their action on depression. It is thought that they work by interfering with the way nerve impulses are transmitted. A tricyclic antidepressant may ease the pain within a few days, but it may take 2-3 weeks. It can take several weeks before you get maximum benefit. Tricyclic antidepressants sometimes cause drowsiness as a side-effect. This often eases in time. To try and avoid drowsiness, a low dose is usually started at first, and then built up gradually if needed.

A dry mouth is another common side-effect. Frequent sips of water may help with a dry mouth. See the leaflet that comes with the medicine packet for a full list of possible side-effects.

• Anti-epileptic medicines -  (anticonvulsants)                                                                                                                                          
  Carbamazepine.
• Gabapentin.
• Pregabalin.
• Sodium Valproate.

An anti-epileptic medicine is an alternative to an antidepressant. These medicines are commonly used to treat epilepsy but they have also been found to ease nerve pain. An anti-epileptic medicine can stop nerve impulses causing pains separate to its action on preventing epileptic seizures.

As with antidepressants, a low dose is usually started at first and built up gradually if needed. It may take several weeks for maximum effect as the dose is gradually increased. Sometimes both an antidepressant and an anti-epileptic medicine are taken if either alone does not work very well.

Sometimes a traditional painkiller such as codeine is combined with an antidepressant or an anti-epileptic medicine.  As they work in different ways they may compliment each other and have an additive effect on easing pain better than either alone.

 

Other drugs
Some other medicines are sometimes used on the advice of a specialist in a pain clinic.

Physical treatments

Depending on the site and cause of the pain, a specialist in a pain clinic may advise one or more physical treatments. These include:

• Physiotherapy
• Acupuncture
• A TENS machine (Transcutaneous Electrical Nerve Stimulation)
• Nerve blocks with injected local anaesthetics
• Spinal cord stimulation
• Psychological treatments

Pain can be made worse by:

• Stress
• Anxiety
• Depression

Pain management programmes sometimes have a role in helping people with chronic - persistent - neuropathic pain: [1]

• Stress management
• Counselling
• Cognitive behaviour therapy

The severity of the pain often does not correspond with the seriousness of the underlying condition. For example, postherpetic neuralgia (pain after shingles) can cause a severe pain, even though there is no rash or signs of infection remaining.

Capsaicin cream
This is sometimes used to ease pain if medicines do not help, or cannot be used because of problems or side-effects.

Capsaicin is thought to work by blocking nerves from sending pain messages. Capsaicin cream is applied 3-4 times a day. It can take up to 10 days for a good pain relieving effect to occur.

Capsaicin can cause an intense burning feeling when it is applied. In particular, if it is used less than 3-4 times a day, or if it is applied just after taking a hot bath or shower. However, this side-effect tends to ease off with regular use.

Capsaicin cream should not be applied to broken or inflamed skin. Wash your hands immediately after applying capsaicin cream.

 

1. W. Campbell. First and second-line treatments in neuropathic pain. Prescriber Volume 16, Issue 7, 5 April 2005

1. Shingles Prodigy guidance 2005

1. Trigeminal Neuralgia Prodigy guidance 2005

1. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005454.

1. Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD001133

 

 

Other web sites                                                                                                                                                                                           

British Pain Society - A professional organisation, but their website has a lot of information about pain and it's treatment which is aimed at the general public. britishpainsociety.org

Chronic Pain Policy Coalition - A forum for patients, professionals and parliamentarians who operate at policy level to develop an improved strategy for the prevention, treatment and management of chronic pain and its associated conditions. paincoalition.org.uk

Action On Pain - A national charity providing support for people affected by chronic pain.  action-on-pain.co.uk

Pain Concern - Provides information and support for pain sufferers. - Tel: 01620 822572 -  painconcern.org.uk

 

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