Non-pharmacological management of chronic pain in multiple sclerosis and rehabilitation outcomes

Abstract

Multiple sclerosis (MS) is a chronic, inflammatory and demyelinating autoimmune condition which affects the central nervous system. Multiple sclerosis can present with a wide variety of symptoms and can affect a patient’s mobility, sensory and cognitive functions. Pain in multiple sclerosis is common and can present as either acute or chronic pain. Chronic pain is pain which lasts greater than 3-6 months and has significant implications on a patient’s health, disability and quality of life. Causes for chronic pain in MS can range from nociceptive somatic pain to neuropathic pain and specific chronic pain syndromes which include trigeminal neuralgia and peripheral neuropathy. Currently, there is a lack of literature on chronic pain in multiple sclerosis.

Given the prevalence of pain, its significant impact on patients and the need for greater evidence for non-pharmacological interventions, further information is required to help with improving identification, assessment and management of chronic pain in multiple sclerosis. In this thesis, four studies address current gaps in the literature and help progress evidence-based practice.

Study 1 is a systematic review of the effectiveness of non-pharmacological management of chronic pain in multiple sclerosis. Despite there being very low quality of evidence, it remains unknown what type of non-pharmacological interventions reduce the intensity of chronic pain and improve quality of life and function in multiple sclerosis. This study acknowledges the gaps in the current research, the inherent difficulties associated with the review of non-pharmacological interventions, methodological limitations and appropriate study designs.

Study 2 is a 10-year longitudinal study on chronic pain in multiple sclerosis in an Australian cohort. This study showed that over time there was a greater representation of bilateral bodily pain, greater subjective worse pain and deterioration in the quality of life and increase in carer burden. This study suggests that over-time chronic pain is persistent and has a significant impact on people with multiple sclerosis.

Study 3 is a retrospective study on the effectiveness of interdisciplinary management of chronic pain in multiple sclerosis and central nervous system disorders. This study accessed clinical data from an Australian and New Zealand-based electronic pain clinic database. From this database; patient outcomes were compared between those with multiple sclerosis and central nervous system disorders and those without these comorbidities. This study showed that those with multiple sclerosis and central nervous system disorders could also benefit from interdisciplinary management and have improvements pain severity scores, catastrophisation, depression, anxiety and stress scores and improvement in pain self-efficacy.

Study 4 is a prospective single-blinded randomised controlled trial using transcranial direct stimulation for chronic neuropathic pain in multiple sclerosis. This study showed that those who had received transcranial direct stimulation compared to sham treatment had an improvement in pain visual analogue scale but no change in affective outcome measures, quality of life scores and depression, anxiety and stress scores. In addition to this; the most common adverse effect was mild tingling which was only during stimulation. This study suggests that transcranial direct stimulation is a safe and feasible non-pharmacological intervention for chronic neuropathic pain in multiple sclerosis.

This work was completed to test the hypothesis that non-pharmacological interventions can improve patient outcomes. The study conclusions can help with evidence-based recommendations, future-research directions and clinical implementation of non-pharmacological interventions.