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MS in Focus 10 Pain English MSIF10 pp01-28 English 12/6/07 15:30 Page 1 MS MSin in Focus focus Issue OneOne •• 20032002 Issue 10 • 2007 ● Pain and MS The Magazine of the Multiple Sclerosis International Federation 1 MSIF10 pp01-28 English 12/6/07 15:30 Page 2 MSin focus Issue 10 • 2007 Editorial Board Editor and Project Leader Michele Messmer Uccelli, Multiple Sclerosis MA, MSCS, Department of Social and Health International Federation (MSIF) Research, Italian Multiple Sclerosis Society, Genoa, Italy. MSIF leads the global MS movement by stimulating research into the understanding Executive Editor Nancy Holland, EdD, RN, MSCN, Vice President, Clinical Programs, National Multiple and treatment of MS and by improving the Sclerosis Society, USA. quality of life of people affected by MS. In Managing Editor Lucy Hurst, BA, MRRP, Information undertaking this mission, MSIF utilises its and Communications Manager, Multiple Sclerosis unique collaboration with national MS International Federation. societies, health professionals and the Editorial Assistant Chiara Provasi, MA, Project Co- international scientific community. ordinator, Department of Social and Health Services, Italian Multiple Sclerosis Society, Genoa, Italy. Our objectives are to: International Medical and Scientific Board ● Support the development of effective Reporting Member Chris Polman, MD, PhD, Professor national MS societies of Neurology, Free University Medical Centre, ● Communicate knowledge, experience and Amsterdam, the Netherlands. information about MS ● Advocate globally for the international MS Editorial Board Members community Martha King, Director of Publications, National Multiple ● Stimulate research into the understanding, Sclerosis Society, USA. treatment and cure of MS Elizabeth McDonald, MBBS, FAFRM, RACP, Medical Director, The Nerve Centre, MS Australia (NSW/VIC). Visit our website at www.msif.org Nicole Mulasits, Editor-in-chief of Neue Horizonte magazine, Austrian MS Society, Austria, member of the Persons with MS International Committee. Izabela Odrobinska,´ President, Polish MS Society, Cover image: Bardi Rosman Koodrin Poland, member of the Persons with MS International Designed and produced by Committee. Cambridge Publishers Ltd 275 Newmarket Road Dorothea Pfohl, RN, BS, MSCN, MS Nurse, Clinical Cambridge Coordinator, Comprehensive MS Center of the CB5 8JE Department of Neurology at the University of UK Pennsylvania Health System, USA. +44 (0)1223 477411 [email protected] Paul Van Asch, Director of Physiotherapy, National MS www.cpl.biz Centre, Melsbroek, Belgium. ISSN1478467X Nicki Ward-Abel, Lecturer Practitioner in MS, University © MSIF of Central England, Birmingham, UK. 2 MSIF10 pp01-28 English 12/6/07 15:30 Page 3 MSin focus Issue 10 • 2007 Letter from the Editor Contents Pain is a common symptom in MS. Those who experience Introduction to pain and MS 4 pain feel its effects on their daily life activities, such as work and recreation, and in their mood and enjoyment of life. Prevalence, classification and The fact that a record number of people responded to measurement of pain 8 our online survey (results on page 24-25) for this edition of the magazine shows how important this problem is for Neurogenic pain in MS 11 the many people who experience pain. Alarmingly, 90 percent of people with MS said they were not completely relieved of pain with treatment. MS pain and quality of life 14 This discrepancy highlights an area that demands attention from health care professionals and researchers. Promising psychosocial treatments for pain and MS 16 Many clinical features of pain are often unrecognised by clinicians and it may be difficult for many people with MS to find the right words to describe the pain they experience. At the same time, scales for evaluating Cannabis as a painkiller in pain rely on subjective reports and may be biased by any combination of MS: real or imaginary? 19 circumstances, making the evaluation of pain severity and its impact on daily living difficult. Your questions answered 21 Pain is often present with other symptoms, such as depression, spasticity Interview: living with pain 22 and mobility difficulties, underlining the importance of addressing MS comprehensively. The situation is complicated further by the fact that a and MS person with MS may also have other illnesses, making the diagnosis and treatment of pain very complex. Another concern is that in some cases the Pain online survey results 24 side effects of pain medication can be as distressing as the pain itself and therefore cannot be used at an optimal level. Reviews 26 Considering it has a significant influence on a person’s quality of life, unmanaged or ineffectively managed pain can have consequences that go beyond issues of symptom management. Therefore, involvement of the MS team, including the person with MS and his or her family, is fundamental for the identification, assessment and optimal treatment of pain. The next issue of MS in focus will look at We hope that this edition of MS in focus will clarify some issues related stem cells and regeneration in MS. to the diagnosis and management of pain and be a useful resource, Please send questions and letters to particularly for health professionals who may not realise the impact [email protected] or marked for the pain has. attention of Michele Messmer Uccelli at the Italian MS Society, Via Operai 40, Michele Messmer Uccelli, Editor Genoa, Italy 16149. Editorial statement The content of MS in focus is based on professional knowledge and experience. The Editor and authors endeavour to provide relevant and up-to-date information. The views and opinions expressed may not be the views of MSIF. Information provided through MS in focus is not intended to substitute for advice, prescription or recommendation from a physician or other health care professional. For specific, personalised information, consult your health care provider. MSIF does not approve, endorse or recommend specific products or services, but provides information to assist people in making their own decisions. 3 MSIF10 pp01-28 English 12/6/07 15:30 Page 4 MSin focus Issue 10 • 2007 Introduction to pain and MS Heidi Wynn Maloni, PhD, RN, Veterans reports of pain in MS emerged. Anticonvulsants were still first-line treatments at the time. It was not Affairs Medical Center, MS Center of until the 1980s that the incidence, prevalence and Excellence East, Washington, DC, USA characteristics of MS pain were described through findings from population-based studies conducted in North America and Europe. Associations of pain Pain in multiple sclerosis? Pain is not a symptom with other symptoms and the psychosocial that is commonly associated with MS. But, when implications were further explored in more recent findings of worldwide MS research studies studies. These studies supported pain as a suggest that pain is a key factor in MS, it is common feature in MS and suggested ways of important that people with MS and their families, managing the symptom. friends, carers, MS society staff and health professionals, take a second look at the symptom Why does pain occur in MS? of pain and its impact on the lives of people with Pain is a sensory symptom directly related to two MS. Such studies have revealed that occurrences – the disruption of central nervous approximately two thirds of people with MS system myelin and the effects of disability. Myelin experience pain at some time during the course of speeds nerve conduction, aiding smooth motor the disease; pain can be an early and presenting activity, integration and interpretation of sensory symptom; pain can be the most debilitating stimuli and effortless cognition. When pain is the symptom, impacting function; pain is under- result of a disruption or alteration of nerve treated; and that pain is associated with conduction, it is termed neurogenic, or having its depression, anxiety and fatigue. genesis or roots in the central nervous system. Some literature also uses the term “neuropathic”. Pain in MS – is this something new? There is currently no agreement on which term is Indeed, knowledge of the experience of pain more correct. associated with the diagnosis of MS existed in the 1800’s as Jean Martin Charcot associated pain Nociceptive pain occurs when bone, muscle or observed in patients with a neurological condition body nociceptors warn of tissue damage which he termed insular sclerosis. In 1853, French neurologist Trousseau noted that pain had epilepsy-type characteristics, guiding scientists’ “Research studies from populations of use of anticonvulsants, also known as antiepileptic people with MS worldwide report that drugs, to treat pain. Phenytoin was used to manage painful tonic spasms in the 1940s, and in approximately two-thirds of people with the 1960s, several case studies and isolated MS experience pain at some time.” 4 MSIF10 pp01-28 English 12/6/07 15:30 Page 5 MSin focus Issue 10 • 2007 may result from disability. This can be secondary to multidisciplinary approach and the skills of pain musculoskeletal changes in MS due to weakness management experts. or incorrect posture for example. If a person walks in a different way than normal then joints may be Medication stressed and become painful as well. One of the If the cause is neurogenic, medications that side effects of steroids is bone loss but this is modulate excitatory neurotransmitters and usually not an issue in MS as they are generally enhance inhibitory transmitters are prescribed. used for short periods. Immobility can result in a Medications used in MS pain management loss of bone density but this is not usually painful include antidepressants and opioids because an unless it results in a fracture. Nociceptive pain can increase in neurotransmitters minimises pain. MS also occur when skin breaks down or is expected pain is modulated with anticonvulsants (see page to bear weight over an extended time without 7) and antiarrhythmics because they calm movement. excited nerve firing. How does MS neurogenic pain present? Neurogenic pain is described as continuous and steady or spontaneous and intermittent, and is reported in varying degrees of severity.
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