Sue Barnes - Pain management and Multiple Sclerosis

1. Pain Management &
Multiple Sclerosis
Sue Barnes, Consultant Nurse Pain Management

2. Objectives
• Review the anatomy and physiology of pain
• Gain knowledge of the pathophysiology of pain in
Multiple Sclerosis (MS)
• Understand the types of pain commonly experienced by
people with MS
• Consider the impact of pain on people living with Multiple
Sclerosis
• Neuropathic Pain medications
• Identify the need for specialist assessment

3. What is pain?
Williams, Amanda C. de C.; Craig, Kenneth D. PAIN: November 2016 - Volume 157 - Issue 11 - p 2420–2423

4. MS Symptom Management
NICE 2016

5. Pain in Multiple Sclerosis
• Prevalence 57% to 65%
• At disease onset, pain ranges from 11-23% with
approximately half of patients having pain at any given
point in their disease.
• People with MS are more likely to complain of moderate
to severe pain that has an impact on daily living.
(O’Connor 2008)

6. Common Causes of Pain in MS
• Acute pain due to inflammation
• Chronic or intermittent pain as a result of CNS lesion
• Secondary to spasticity
• Spasm and muscle cramps from higher motor neuron
lesions
• MSK- Maladaptive body positions and general
deconditioning

7. Co-morbidity - Neuropathic pain
18
27
33
36
39
55
60
0 10 20 30 40 50 60 70
Poor appetite
Anxiety
Depression
Concentration difficulties
Drowsiness
Lack of energy
Difficulty sleeping
% patients with moderate to very severe discomfort due to symptoms (n=126)
Meyer-Rosberg K et al. Eur J Pain 2001; 5: 379–389.

8. 8

9. Nociception
• Transduction-
• noxious stimuli converted to electrical signal
in the nerve cell
• Transmission-
• information relayed along A-delta and C
fibres to dorsal horn, spinothalamic tract,
brain stem & thalamus
• Perception-
• conscious awareness of pain
• Modulation-
• Inhibition of ascending pathways-
endogenous opioids, descending pathways
Melzack and Wall 2008

10. Where is the lesion ?
Homunculus

13. The continuum of pain
<1 month
Time to resolution
≥3–6 months
Acute
pain
Chronic
pain
• Usually obvious tissue damage
• Increased nervous system activity
• Pain resolves upon healing
• Serves a protective function
• Pain for 3–6 months or more
• Pain beyond expected period
of healing
• Usually has no protective
function
Degrades health and function
Insult

14. So….. Chronic pain is a complex issue
requiring a different approach

15. Defining Neuropathic Pain
IASP (NeuPSIG) 2008 as
"pain arising as direct
consequence of a lesion or
disease affecting the
somatosensory system,"
–and a grading system of "definite,"
"probable," and "possible"
neuropathic pain
R. -D. Treede, MD, T. S. Jensen, MD, PhD, J. N. Campbell, MD, G. Cruccu, MD, J. O. Dostrovsky, PhD, J. W. Griffin, MD, P.
Hansson, MD, DMSc, DDS, R. Hughes, MD, T. Nurmikko, MD, PhD and J. Serra, MD -Neurology 2008

16. Neuropathic Pain
• Disease of the pain signalling system
• Central or peripheral malfunctioning in the pain
signalling pathway – Neuroplastic changes
• Perception of pain in the absence of
tissue damage
• Serves no useful biological purpose

17. • Peripheral
Neuropathies
• Diabetic Neuropathy
• Phantom Limb Pain
• Herpes zoster
• Ischemic neuropathy
• Vasculitis
• Central Pain
Syndromes
• Vascular- PSP/ Cord Infarct
• Traumatic brain injury
• Spinal Cord Injury
• CVA
• MS
• Tumor
• Inflammatory disorders –Myelitis

18. Symptoms of Neuropathic Pain
• Spontaneous or Evoked
• Shooting, burning,
electric shock
• Allodynia
• Hyperalgesia
• Dysesthesia
Dickenson AH. Brit J Anaesthesia 1995;75:193-200
Dworkin RH et al. Arch Neurol 2003; 60: 1524–1534.

19. Diagnosing neuropathic pain
• Diagnosis is based on:1
–Medical history
–Patient’s description of the pain
–Physical and neurological examination
–Appropriate laboratory tests and investigations
• The LANSS (Leeds Assessment of Neuropathic
Symptoms and Signs)
. 1. Dworkin RH et al. Arch Neurol 2003; 60: 1524–1534. 2. Bennett M. Pain 2001; 92: 147–157.

20. 1. Bennett M. Pain 2001;92:147–157.

21. Types of pain in MS

22. Lhermitte’s Sign- Barbers chair syndrome
• Neuropathic Pain
• Shooting pain from the neck down the spine
–16 in every 100 people with MS
–Sudden, brief
–Buzzing
–Can travel into arms and legs, fingers and toes
• Triggers include heat, stress & fatigue
• Manage triggers as well as symptoms and impact!

23. Central Neuropathic Dysaesthesia
extremity pain
• Caused by lesions in the CNS nociceptive pathway.
• Continuous, burning, pricking or stabbing pain, worse at
night.
• Most commonly presents in lower limbs & feet.
• Can be exacerbated by movement, exercise or
temperature.
• ‘Dante-esque’ – ‘Hells hottest knives’
Osterberg et al 2005

24. The MS Hug
• Neuropathic Pain
• Spasm of the intercostal muscles- MS Girdling
–Squeezing
–Crushing
–Crawling
–Hot/ Cold
–Pins and needles
• Triggers include heat, stress & fatigue
• Manage triggers as well as symptoms and impact!

25. Trigeminal Neuralgia
• Neuralgia refers to nerve pain that’s
brief, electric shock like, lancinating
and stabbing.
• Affects the movement of the jaw
muscles – V3 distribution
• Confused with dental pain.
• Triggered by innocuous stimulation
such as taking, touching the face,
eating and brushing teeth.
• Spontaneous with no trigger.

26. • Can be the first symptom of MS, its 20 times more common than in general
population.
• High suspicion in people under the age of 40yrs.
• Onset commonly 11yrs post onset of MS.
• 18% more likely to be bilateral in MS.
• TGN caused by pressure on the nerve by a blood vessel, causing wearing
of myelin sheath, causing the nerve to become more excitable.
• Usually atypical.
Trigeminal Neuralgia & MS

27. TGN Treatment Options
• MRI scan – Brain
• Carbamazepine (Tegretol),
phenytoin, gabapentin &
pregabalin
• Steroid therapy – inflammation
• Invasive procedures
• Microvascular decompression

28. Neuropathic Pain
Medications

29. Neuropathic Pain Management
Strong-opioid + Non-opioid +/- Adjuvant
Weak opioid + Non-opioid +/-Adjuvant
Non-opioid +/- Adjuvant
Ref: Jadad AR and Bowman JAMA, 1995; 274: p1870-3

30. Tramadol
• Synthetic analogue of Codeine
• Agonist properties at all opioid receptors but particularly at Mu receptor
• Inhibits reuptake of serotonin and noradrenaline
• Absorbed gut, oral bioavailability 70 -90%
• Metabolized liver, excreted in urine
• Max Dose 400mgs daily, IR & MR

31. Tapentadol
• Synthetic analgesic – moderate – severe pain
• Dual mechanism of action, binds to mu opioid receptor &
inhibits the reuptake of norepinephrine. Weak effects on the
reuptake of serotonin.
• Available as Palexia IR & MR 50, 75 & 100mgs
• Dose 50mgs 4- 6 hourly, max 600mgs daily. Onset analgesia
30 mins
• Half life 4 hours

33. Long term effects of opioids
• Nausea
• Sedation
• Cognitive impact
• Chronic constipation
• Immune system compromise
• Sex Hormones
• Opioid induced hyperalgesia
• Long term osteoporosis

34. Neuropathic medications
• Amitriptyline or Nortriptyline
• Duloxetine
• Gabapentin
• Pregabalin
• Carbamazepine (TGN)

35. Amitriptyline Gabapentin
Duloxetine Pregabalin
Tramadol
Capsaicin Cream

36. NICE Recommendations
• Consider contraindications and side effects
• Co-morbid conditions
• Patient preference
• Titrate according to response
• Use one drug at a time
• For localised pain consider 0.075% Axsain
cream

37. Antidepressants
• Originally developed for the treatment of
depression.
• Mode of action:
– Block the re-uptake of serotonin and
noradrenalin, leading to activation of the
body's own descending inhibitory system
• Side effects: drowsiness, dry mouth,
constipation, low blood pressure, fast
heart rate, urinary retention and weight
gain
• Drugs: TCA- amitriptyline / nortriptyline
• SNRI – Duloxetine 60mg OD

38. Anticonvulsants
• Treatment of cerebral seizures
• Mode of action binds to the voltage-
gated calcium channels to blocks
neuronal sodium and calcium channels
Side effects: headache, dizziness,
drowsiness, tiredness, depression,
gastrointestinal symptoms
• Drugs: *gabapentin, pregabalin,
carbamazepine (TGN)

39. Amitriptyline
GabapentinGabapentin
?Opioid
+
SevereModerateMild
Amitriptyline Amitriptyline
+
+
Increasing Neuropathic pain

40. Specialist Protocol Neuropathic Pain

41. Small Localised areas of Neuropathic pain
• Capsaicin cream 0.025% or 0.075%
• Small amount applied 4 times a day
• 6 weeks to gain optimum benefit
• Reduces the release of substance P

42. Lidocaine Plaster

45. Important Factors to Consider
for your patient with Neuropathic pain
• Listen to the patient’s concerns
• Explain the Pain does not equal harm
• REASSURANCE! REASSURANCE!
• Diagnose Neuropathic pain
• Realistic expectations – medication
-30-50% pain relief, may take 4-6
weeks effective.

46. Referral to Specialist Pain Service
• Where pain management needs are complex and cannot
be met by primary care or secondary specialist MS/
Neurology services.
• Where patients have failed to respond to first line
treatment (NICE 2016)
• Where pain is the predominating feature
• Difficult to manage Neuropathic pain

47. Thank you
Susan.Barnes@srft.nhs.uk