Pain in Multiple Sclerosis: An Overview of Its Nature and Management.
Multiple sclerosis (MS) is a chronic inflammatory disease of central nervous system myelin characterized by unpredictable exacerbation and remission as well as unpredictable severity of disease symptoms.
Pain is one of the myriad symptoms that may be generated by MS. Pain and MS have been allied since the earliest disease finding by Charcot in 1872. Yet, it was not until about 20 years ago that pain as a symptom of MS began to be recognized and taken seriously. The incidence of pain in MS is both related to an inflammatory, demyelinating process as well as attributed to the very nature of chronic disease. In addition, pain in MS may be an expected sequelae of immune modulating drugs.
This article looks at the etiology of pain in MS, describes the variety of pain syndromes found in MS, and presents current treatments in pain management.
The character and predilection of pain in MS have been charted and described by several qualitative studies.[Illegible Text] The findings indicate that pain is experienced by two-thirds of all people with MS at some time during the course of theft disease. The most thorough investigation into the prevalence and nature of MS pain was conducted by Moulin et al.[25,26] Moulin described the nature of MS pain as chronic, acute, and subacute. This article utilizes the Moulin classification.
In comparing people with MS who experience pain with those who are pain-free, no distinction is found in age of disease onset, disease duration, disability score, gender, depressive symptoms, or MS subgroups (relapsing-remitting, secondary progressive, primary progressive, or progressive-relapsing). However, individuals with prolonged history of disease, advancing age, and severe symptoms are more likely to experience pain.[1,16]
Assessment of Pain in MS
Because interventions for pain management in MS are specific to the nature of the pain, a thorough assessment is critical for optimum outcome. Pain is subjective. Pain is what the person experiencing the pain says it is. The neuroscience nurse assesses pain by observation, query, and an understanding of the cognitive, psychosocial, emotional, and spiritual aspects of the MS person with pain. Social and family support, culture, religion, age, gender, and responsibilities are factors that influence response to pain. Critical to MS is the unpredictable, uncontrollable, and chronic nature of the disease. Fears, anxiety, and anger may contribute to the intensity of MS pain. Nursing observations include vital signs, restlessness, irritability, depression, withdrawal, changes in sleep pattern, changes in weight, changes in relationships, difficulty concentrating, pinched features, increased muscle tension, and the facial mask of pain. Nursing queries include the onset of the pain, the location, the characteristics (shooting, lancinating, ice-pick-like, electric-shock-like, burning, radiating, sharp, cramping, aching, itching, dull, pressing, nagging), duration, frequency, intensity and severity, aggravating factors, relieving factors, and current methods of coping and treatments used. Use of pain scales, such as the visual analogue scale or a verbal rating scale, offers concrete measurement tools to both assess and evaluate interventions in the management of MS pain.
Acute pain is usually brief and paroxysmal, meaning sharp, intermittent spasms of sudden and spontaneous onset. These paroxysms are described as lancinating, intense, sharp, shooting, electric-shock-like, tic-like, and burning. Acute pain experiences in MS may be trigeminal neuralgia, episodic facial pain, tonic seizures, paroxysmal limb pain, and headache. Any of the acute pain syndromes can be symptomatic of an underlying inflammatory process or attributed to a demyelinating lesion affecting pain pathways.[9,26] Therefore, provider assessment of new onset acute pain is imperative.
Trigeminal neuralgia (TN) involves the second and third divisions of the trigeminal nerve that innervate the face, cheek, and jaw. In MS, this neuralgia occurs as a result of demyelinating lesions along the trigeminal nerve pathway in the root entry zone at the pons. TN pain is characterized by excruciatingly sharp, shock-like attacks of 2-3 seconds or several minutes, with periods of remission. Touching, chewing, smiling, or any facial movement triggers the pain. A person experiencing the pain of TN may be seen holding the face and jaw rigid, talking with teeth clamped shut, and holding the head motionless.
Trigeminal neuralgia affects 2% of all people with MS and is 400 times more common in people with MS than in the general population. It affects men at a greater rate than women and is usually bilateral.[25,33]
Trigeminal neuralgia in MS is often cyclic, and treatment with medication is preferred over invasive surgical procedures. Management strategies include the use of antiepileptic medications (Table 1). The prostaglandin E analogue, misoprostol (Cytotec) has been shown in clinical trials to be effective in reducing TN pain through suppression of inflammation in MS plaques and by increasing the pain threshold. Critical to the successful use of these medications is low-dose induction and slow increase to therapeutic doses in order to minimize side effects and maximize the potential of these drugs. Recent clinical trials of gabapentin (Neurontin) and lamotrigine (Lamictal) indicate efficacy and better tolerability as compared to carbamazepine and phenytoin when used in TN pain syndromes.[6,15,18] Dosing is very person-specific. Treatment choice is based on response and tolerability. Combining medications is one way of reducing the dose of each drug while minimixing the adverse events.
[TABULAR DATA 1 NOT REPRODUCIBLE IN ASCII]
One-fourth of all persons with MS suffering from TN are refractory to medical pain relief or find the medication side effects intolerable. Surgical procedures that interrupt the pain pathway offer an option. Invasive management procedures include radiofrequency rhizotomy, cryotherapy, alcohol or nerve glycerol injection, balloon gangliolysis, and percutaneous thermocoagulation.[19,40,42] The surgical treatment of choice is trigeminal rhizotomy.[14,28,29] The risk of full or partial sensory deficit as a result of trigeminal rhizotomy must be weighed against the intolerance to the medical management of TN pain. Pain relief is 80-90% effective with reported resolution for 6 months to several years. Plaques, seen by autopsy and on surgical exploration of the cerebellopontine angle, at the trigeminal nerve root, suggest that a destructive lesion at the nerve root entry zone of the trigeminal nerve is necessary for the relief of pain in patients with trigeminal neuralgia secondary to MS.[27,29] Such findings support the application of trigeminal rhizotomy. Microvascular decompression is not an adequate or reliable cure for TN pain in MS because of the polycentric nature of the disease.
Episodic Facial Pain
Episodic facial pain is distinguished from trigeminal neuralgia as a burning, dull, aching, or nagging pain. Some clinicians consider it to be a precursor of trigeminal neuralgia. This pain is resistant to analgesics and nonsteroidal anti-inflammatory drugs. Antiepileptic medications, particularly carbamazepine (Tegretol), are the treatment of choice. Gradual increase in the dose of carbamazepine to achieve blood levels of 6-8 [micro]g/ml is often necessary for therapeutic effect. Monotherapies using amitriptyline (Elavil), phenytoin (Dilantin), or baclofen (Lioresol) and combination therapy of amitriptyline and perphenazine (Trilafon) are also helpful.
Tonic seizures were observed in 17% of people with MS in a Japanese study in 1974. Since that time, painful tonic seizures have been well described. These paroxysmal episodes are not seen on electroencephalography (EEG) nor is loss of consciousness, as is typically seen in seizures. Tonic seizures are brief, unilateral muscle twitching, cramping, and spasms usually of the limbs, preceded and accompanied by intense radiating pain, burning, or tingling. These spasms are provoked by a "trigger," such as touch, movement, or hyperventilation. They occasionally occur in the absence of a trigger. In the upper extremity, these seizures usually begin with tetany-like spasm of the hand, flexion of the elbow, and adduction at the shoulder. Transaxonal ephaptic transmission may explain the spinal origin of these sensorimotor seizures. Carbamazepine (Tegretol) is extremely effective in suppressing painful tonic seizures.
Paroxysmal Limb Pain
When not associated with tonic seizures, paroxysmal limb pain is a burning, aching, or itching that lasts several seconds to several minutes. It can affect any part of the body including the perineum. It most often involves the extremities. Carbamazepine (Tegretol) is the cornerstone of treatment for paroxysmal pain. Antiepileptic drugs such as gabapentin (Neurontin) and lamotrigine (Lamictal) have proved effective in treatment of paroxysmal pain.[21,36] Amitryptiline (Elavil), clonazepam (Klonopin), diazepam (Valium), or applications of heat and cold are also useful.
The association between headache and MS is unclear. Headache is seen in people with MS at greater frequency than in the general population. Causal mechanisms are speculative. It is thought to be associated with an inflammatory process.[13,31] Migraine, tension, and cluster headache have been described in people with MS. A recent investigation has hypothesized that lesions on the trigeminal nerve are also responsible for cluster headaches in MS. Treatment of headache is ordained by the nature of the headache.
Subacute pain in MS results from events that occur because of an acute worsening of symptoms or as a result of treatments for MS. These include optic neuritis, infection, influenza, decubitus ulcer, urinary retention, and urinary tract infection. Treating the cause usually alleviates the pain.
Aching and sometimes "ice-pick-like" pain associated with optic neuritis is a result of the traction of the meninges surrounding the swollen optic nerve. Pain can be episodic or constant and associated with movement of the eye. Nonsteroidal anti-inflammatory agents may ease the pain. Inflammation and accompanying eye pain can be alleviated with a single daily dose of 1000 mg methylprednisilone given intravenously over 3-5 days with or without a short oral prednisone taper.
Muscle aches and headache pain associated with interferon therapy can be modulated by induction of half dose over 2-4 weeks. Injections given at bedtime and concomitant use of ibuprofen (Motrin) and acetaminophen (Tylenol) can minimize interferon side effects.
Chronic pain is defined as any pain that persists longer than 1 month. Chronic pain persists regardless of disease duration or disability and has no relationship to depressive symptoms or cognitive deficit. It includes dysesthetic extremity pain, back pain, and painful leg spasms. Of all patients with pain in the course of MS, 70% suffer from chronic pain syndromes.
Dysesthetic Extremity Pain
Dysesthetic extremity pain is the most common chronic pain syndrome seen in MS. It occurs predominantly in people who have greater disability scores and is characterized as a "burning" pain. This persistent pain, most likely affecting the legs and feet, may also occur in the arms and trunk and is described as quivering, prickling, tingling, dull, pressing, tight, and nagging and is associated with warmth. Extremity pain is attributed to demyelinating lesions in the posterior or dorsal column of the spinal cord. This type of pain is of moderate intensity, generally tolerated and considered "nagging." Dysesthetic extremity pain is often worse at night and after exercise. Pain may be aggravated by changes in temperature or weather.[25,26] Low doses of tricyclic antidepressants such as amitriptyline (Elavil), imiprimine (Tofranil), or desiprimine (Norpramin), commonly considered first-line treatments, have outcome study indications of only a 20% efficacy. Capsaicin (Zostrix) reduces the burning and tingling dysesthetic pain by interfering with pain transmission in the periphery. Gabapentin (Neurontin) in doses as high as 2700 mg and lamotrigine (Lamictal) are proving effective in dysesthetic extremity pain.[6,15,18,21,36] Dull aching pain responds best to tricyclics and least well to antiepileptic drugs. Warm or cold compresses or pressure applied by latex leggings or stockings acts in a manner similar to the effect of capsaicin and may interfere with pain transmission in the periphery by altering pain sensation.
Musculoskeletal Pain/Chronic Back Pain
Chronic back pain plagues those with greater progression of MS than those with milder disease. Chronic back pain most often results from mechanical stress on muscles, bones, and joints because of disability. Back pain may result from postural abnormalities, weakness, improper use of compensatory muscles, or immobility.
Back pain may also occur because of a deymelinating lesion in the cervical, thoracic, or lumbar spinal cord. Joint, hip, and back pain can occur from steroid-induced osteoporosis or steroid-induced asceptic necrosis. Radiating pain should be evaulated to rule out disc involvement.
Nonsteroidal anti-inflammatory agents are pharmacological agents of choice in the treatment of chronic back pain. Heat, ice, position change, exercise, and firm support when sitting or sleeping can alleviate pain of structural cause. Aggressive physical therapy becomes critical because issues of gait aids, ankle-foot orthosis, exercises for maintaining posture and strength, and safety considerations all have an impact on back pain.
Assessment of bone mineral density and concomitant behaviors to minimize bone loss offset the effects of osteoporosis. Pain associated with osteoporosis can be minimized or ameliorated by a decrease in steroid use, antiresorptive therapies such as calcitonin (Calcimar), alendronate (Fosamax), and raloxifene (Evista), avoidance of alcohol, smoking cessation, and maintenance of 1200 mg of calcium and 400-800 mg of vitamin D per day.
Flexor and extensor cramping and pulling with subsequent pain characterize painful leg spasms. Painful leg spasms are associated with severe disability and hypertonia. Uninhibited flexor response and spasm are due to a reaction of the spinal cord to an irritative foci (decubitus ulcer, urinary tract infection, full bladder, constipation, or tactile sensation). Pain occurs because the spasm is contracture-like in character and highly exaggerated.
Management of painful spasms includes both pharmacological and nonpharmacological intervention. Pharmacological intervention includes baclofen (Lioresol), diazepam (Valium), dantrolene (Dantrium), and tinazidine (Zanaflex). Aggressive medical treatment includes botulinum toxin (Botox) injections and the use of an intrathecal baclofen pump.[3,34] Intrathecal baclofen is delivered directly into the spinal canal, thereby utilizing the lowest possible dose. This technique minimizes adverse side effects and maximizes the therapeutic effect. Nonpharmacologic intervention includes proper positioning and support of the lower extremities, reduction of irritative foci, massage, use of cryotherapy, and physical therapy for stretching and range of motion. Severe spasms retractable to therapy may need to be managed surgically by tenotomy, peripheral neurotomy, or anterior or posterior rhizotomy.
Alternative and Complementary Therapies
Many people with MS who experience pain use alternative and complementary therapies for pain relief. These include acupuncture, transcutaneous electric nerve stimulation (TENS), massage, and dorsal column stimulation. These therapies act to inerfere with pain conduction, activate analgesia through nociceptive pathways, act as counter irritants, and raise the pain threshold. People with MS who experience pain can exercise some modest control over their pain by optimizing rest, relaxation, stress management, and proper diet. Exercise programs such as Tai Chi, meditation, centering, hypnotherapy, imagery, and biofeedback are techniques that may serve to increase quality of life as well as reduce pain.[10,39]
The person with MS who is experiencing pain should be treated holistically. Treatment plans should incorporate the use of a pain analogue scale. Effective alternative approaches to pain management currently practiced should be included in the plan. The nurse should approach the assessment, planning, and intervention of pain management from a physical, social, psychological, and spiritual dimension.
Pain is a symptom that demands serious attention because it has such a pervasive impact on role, capacity to work and rest, and interpersonal relationships. Untreated pain causes isolation, anger, and depression. Optimum therapeutic treatment involves a commitment to the goal of controlling pain and improving quality of life.
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Questions or comments about this article may be directed to: Heidi Wynn Maloni, MSN RN CNRN ANP, 5 Chevy Chase Circle, Chevy Chase, MD 20085. She is a student in the doctor of nursing science program at The Catholic University of America, Washington, DC.
Copyright [C] 2000 American Association of Neuroscience Nurses 0047-2603/00/3203/00139$1.25
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|Author:||Maloni, Heidi Wynn|
|Publication:||Journal of Neuroscience Nursing|
|Date:||Jun 1, 2000|
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