Pain and MS by J. Lamar Freed, Psy.D.
			Dr. Freed is a Gero-Psychologist in private practice.  He has been diagnosed with MS since 1993.
A recent email reminded me of an issue often neglected or misunderstood by people with MS: pain. In the past, medical professionals often have said MS does not cause pain. Today, fortunately, neurologists and other physicians are accepting the nasty truth in this matter. MS does cause pain in many different ways, directly, indirectly, and sometimes very subtly.
	Most directly, MS causes pain because it can interfere with the communication between pain receptors in the body and the various  pain centers in the brain.  These areas are connected by long nerve cells covered with a myelin sheath.  In MS the myelin sheath, which works kind of like insulation works on electrical wires, is attacked by the body's own immune system.  Sometimes people with MS get pain
because the nerve signals from one place to another are interrupted by a kind of short circuit due to myelin breakdown. The normal signals from different parts of the body do not arrive at the brain. In the same way signals from the brain cannot make it completely to the more distant parts of the body. Faulty signals to and from the brain can cause pain or fail to calm pain signals normally. For example,missing myelin can mean crossed signals that send an indication of pain back to the brain when nothing painful is actually occurring.  Similarly, the faulty signals can instruct muscles to act in ways that cause pain, tightening up either steadily (spasticity) or suddenly (spasms).   The misfiring of a calming signal from the brain can allow pain to persist or grow.
Sometimes the absence of these calming signals from the brain can allow the pain receptors to get hypersensitized so that even the smallest sensation may be experienced as painful. People with MS have reported this affect with sensations of touch and temperature. Parts of their bodies, or even all of their bodies, can become so sensitive that minor stimulation may feel like a major painful event. As with every other MS symptom, such experiences can worsen during an exacerbation, when fatigued, or when overheated.
In the same way, the absence of crucial signals from the brain and spinal chord can increase the perception of pain. People often don't know that the nerves of the brain and spinal chord conduct signals to the muscles, skin and other body tissue that inhibit, or reduce the sensation of pain. You almost certainly have experienced the way initial sharp pains often are reduced with repetition. For example, the spicy flavors of some foods may become more tolerable as you continue to eat them. Or a sauna that is initially barely tolerable gradually becomes a sensation of mild heat. The reason this happens is that inhibiting or calming signals from the higher centers of the nervous system get sent after the initial pain sensations arrive. These signals calm the nerves involved in pain sensation and reduce the intensity of the signals of pain to the brain.
Pain of this sort is treated with medication and pain management techniques. Baclofen and Neurontin are sometimes prescribed. Simply using Tylenol may reduce discomfort. At other times, or for other people, even prescription medications can have little effect. For this reason, it is important to work patiently with a physician to find an effective approach.
There are also non-medical techniques that help reduce pain. Fatigue management particularly is helpful for pain directly caused by malfunctioning neurons. Since it seems that some MS impaired systems work better when rested than they do after exertion, keeping optimally rested can reduce any resulting pain. Alternately, pushing yourself to do more than you should can result in unnecessary discomfort.
Sometimes pain can worsen because people with MS have to overuse their muscles in order to get a normal amount of work done. We all know that being in good condition means that we can get more physical work done. If the muscles are strong, lifting and moving is not likely to cause a problem. On the other hand, when these muscles are weak or underused, a little bit of work can cause stiffness and pain later. We also know that MS reduces strength and coordination. A normal amount of work, even if it may not be enough to push us over the edge of MS fatigue, may be enough to make us overuse muscles that are poorly conditioned due to MS related weakness or poor coordination. If the muscles are overworked because MS causes them to be out of condition or causes them to be used inefficiently, it can cause pain. This pain, while not caused directly by malfunctioning neurons, is still, without question, MS related pain. Even in those muscles that MS doesn't directly affect,  pain can be related to MS for the simple reason that deficiencies force muscles to do double or triple duty to achieve the normal physical activities of life.
Pain of this sort will respond to the same treatments muscle and joint pains respond to in the rest of the population and can be reduced with simple things like Tylenol or aspirin. Alternative methods such as massage, stretching, Yoga, hypnosis, relaxation, hot baths (when tolerable), rest, and many other non-medical interventions can have a positive effect
Most subtly, MS can lower the pain threshold so that people with MS are more sensitive to pain. Many of us have heard computer advertisers brag about the capacity of new operating systems to multitask. Multitasking means that computers can do several things at once. Our brains have been capable of multitasking since the infancy of our neurological systems. Mothers multitask when they watch children, bake bread, do laundry, and run the vacuum at the same time. Drivers multitask when they watch traffic and talk on the cell phone, eat a sandwich, and drink a soda. We all multitask when we keep our heart beating, breath, walk, and think at the same time.
For people with MS, higher levels of multitasking can be difficult. Multitasking requires a smoothly operating neurological system. MS lesions can slow thought or, because of the interfering quality of lesions, can make the experience of managing multiple mental events more fatiguing. With MS the capacity to multitask is reduced. We can multitask for shorter periods of time, or we can mentally juggle fewer events at a time. Stimulus overload can set in more frequently than with other people.
The sensation of pain is managed in this mental multitasking system. A signal of pain is the way for the body to tell the brain that there is something going on that needs attention. The brain avoids paying attention to pain until it crosses a certain threshold. Pain signals have to be considered sufficiently worthy for us to stop other tasks and pay attention to it. We unconsciously suppress small pain sensations as part of the many mental tasks we do at the same time. This is best shown in athletes. When a basketball player continues to play while hurt, he suppresses the pain and focuses on the game at hand. After the game he lets his brain pay attention to more things and the force of the pain comes through. During the excitement of the game, the pain sensations are ignored or suppressed and often not even noticed.
This squelching of pain signals is something we all do to a certain extent. It is a neurological task, one of the many things brains can do simultaneously in the neurological multitasking system. But if we are fatigued, or if our multitasking system has reduced efficiency, minor pain sensations can appear to be significant. This is greatly marked in more advanced fatigue states. Something as simple as background music can overload the brain's sensory management system and may be experienced as highly annoying. Little pains of modest or even insignificant importance can rage  like deep bruises or lacerations. Pain signals can be over-read and may seem to be more important than they really are.
Paying attention to pain and pain management is an important part of caring for MS. For most of us with MS, simple things are enough for the proper fatigue management needed to keep pain in control: resting regularly and avoiding stress; the use of simple pain relievers such as Tylenol or aspirin; and an increase in comfort measures such as massage or stretching carefully. For others, prescription medications or more aggressive behavioral techniques -- hypnosis or a systematic program of progressive muscle relaxation -- are needed.
Regardless of the level of pain, we do need to pay attention to it. And to complicate matters even more, just because you have MS does not mean you won't get something else. So new pain or patterns of pain need to be addressed with your physician. While chest or back pain can be MS related, it also can be caused by cardiac difficulties. Unusual bumps, bruises, and pain can be related to MS or to blood disorders. Muscle aches and pains can be arthritis or troublesome medication side effects. Good coaching and careful attention to the many signals from our bodies, as well as a physician who can tolerate this kind of hyper-vigilance, are essential in managing this disease