Multiple Sclerosis Centers of Excellence
Successfully Managing Pain in Multiple Sclerosis
Heidi Maloni, PhD, APRN, BC-ANP, CNRN, MSCN
Pain is a common MS symptom that can occur at any time in the disease course. Studies show that 60% of people with MS have experienced pain associated with their MS at some time. Pain is important to understand because, if left untreated, it can affect relationships, mood, sleep, work, and the ability to have fun and generally enjoy life. Fortunately, there are many ways to successfully manage pain.
People with MS can experience many kinds of pain. MS tends to cause neuropathic (nerve) pain and/or musculoskeletal (muscle/bone) pain. Neuropathic pain is directly caused by MS. A lesion in the brain or spinal cord can cause nerves to fire inappropriately. This can interfere with smooth nerve transmissions that carry sensations. Neuropathic pain is often either steady and constant or intermittent and spontaneous. Steady pain is described as burning, tight, tingling, nagging, aching, throbbing, or even icy. Steady pain is more common than intermittent pain. Intermittent pain is described as shooting, stabbing, or lightning bolt-like. Other unpleasant sensations, like the feeling of crawling bugs, water running down an arm or leg, or tingling, pins and needles sensations can also be caused by abnormal nerve firing and can become so bothersome these are described and treated as pain.
Musculoskeletal pain in MS may result from living with physical impairments. Muscles, bones, or joints can become painful when stressed due to decreased mobility, prolonged sitting, spasms, and improper use and disuse. For example, if you are using your back muscles to compensate for weak or lost leg muscles, you may overuse those muscles and experience back pain. Sitting or lying in one spot limits blood supply to tissues and increases pressure on bones near the surface. Being immobile may contribute to aches, infections, wounds, numbness, and spasms.
The most common pains in people with MS are burning pain in the legs or arms, back pain, painful spasms, trigeminal neuralgia (stabbing, intermittent facial pain), and Lhermitte’s sign (shock-like sensation down the back and into the arms when dipping your chin to your chest). People with MS are also more prone to migraines than people without MS.
If you have a new onset of these sensations, report this to your healthcare provider. These symptoms may reflect a new MS lesion or an exacerbation.
The kind of pain experienced guides the selection of treatment. Treating pain often requires a multipronged approach.
Medications are just one approach. Anti-seizure medications are frequently used for neuropathic pain. They work by calming inappropriate nerve firing and help make nerve cells more stable. Anti-depressant medications are also used for neuropathic pain. They can stabilize chemicals in the nerve cells and increase the “feel good” neurotransmitters in your brain which soften the perception of pain. Any of these medications may take a while to be effective and can cause side effects. A slow increase in dose over time (as much as a month) can often be needed to get over the side effects so you have the chance to experience the benefit. Muscle relaxants can help control painful spasms. The use of opioids or narcotics remains controversial in MS pain management and are only considered when other agents are ineffective or not well tolerated. Narcotics may help you escape pain in the short-term but can take away choice and true control over pain and function in the long-term.
Physical agents work to limit pain transmission and include the application of heat, cold, or pressure. Physical therapy, exercise, massage, acupuncture, yoga, tai chi, and transcutaneous electrical nerve stimulation (use of electric current to stimulate nerves for therapeutic purposes) may also be helpful.
Pain psychology is becoming a common, well accepted, and important approach to pain management. This approach looks at mental and emotional factors, as well as attitudes, that may affect pain and a person’s pain experience and behaviors. Feelings like anger, fear, boredom, depression, and anxiety, and situations such as loss of sleep, loneliness, and fatigue make a difference in the severity of the pain you feel. It’s important to recognize that how you feel, how you cope, and how you interact with the world greatly influences the severity and intensity of pain. Relaxation, meditation, imagery, strong beliefs or faith, mindfulness, hypnosis, and distraction are strategies that can 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. Managing pain by learning to improve coping is more complicated and effortful than taking a pill but can be much more rewarding. Pain may not disappear but its intensity, frequency, and impact on your life can be reduced by managing emotions and influences in your life.
Your Action Plan
Managing your pain means developing an action plan. Make your plan important to you, be specific, be flexible, be positive, and write it down. Part of your personal pain prescription begins with mastering emotions and reducing stress and environmental pain triggers. You may not be able to do this alone. Seek the help of the pain team at your VA facility or ask for a referral to the mental health team. A mental health professional will be able to fully assess your mood and can offer individual or group counseling. Assess your social situation and your general activity. Make an effort to get out of the house, call a friend to go to the movies or get a bite to eat. Is it time to join a gentle yoga class?
Pain is manageable and can be tackled with an integration of medications, physical agents, interventions to relieve mental and emotional factors, and strategies to enhance social support and help you become more active. Successful management will not happen overnight or with one pill. Set your mind on a positive course. You have the capacity to effect MS pain and your VA healthcare team is here to help.