Daisy Cam. MS Specialist Nurse, Sheffield Teaching Hospitals NHS Foundation Trust

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1 Daisy Cam. MS Specialist Nurse, Sheffield Teaching Hospitals NHS Foundation Trust

2 Pain in MS Until 20 years ago pain was not recognised as a common symptom of MS Up to 68% of people with Multiple Sclerosis (MS) in the UK suffer with pain (MS Trust 2011) Central pain and neuropathic pain are commonplace in MS (kaliv, O Connor 2005) Despite new medications and drug regimes there does not seem to be any single treatment that works for all MS related pain (Finnerup et al 2005)

3 Neuropathic Pain Urch and Dickinson (2008) described Neuropathic pain as: Pain that has no protective function and is a result of nerve lesion damage or dysfunction of the nervous system It can be superficial or deep, intermittent or constant, and can be spontaneous or triggered by various stimuli. It causes burning, stabbing, pins and needles, numbness and allodynia (pain caused by light touch)

4 Treatments for Neuropathic Pain Conventional management involves the combined use of a range of pharmacological approaches eg. Amitriptyline, Gabapentin, Pregabalin, Opioid s, NSAIDs and topical treatments such as Capsaicin (chilli pepper) and Lignocaine. Non drug approaches can also be effective - Acupuncture, TENS, and aromatherapy/massage (Sykes 1997). Psychological treatments can benefit some.

5 Acupuncture Techniques resembling acupuncture have been used for over 5000 years Because of increasing public interest in the subject over the last forty years, considerable scientific research has been carried out, though much remains to be done. Modern imaging techniques have demonstrated changes in brain activity particularly those areas responsible for the processing of pain.

6 Chinese Acupuncture Chinese Acupuncture dates back 3000 years and is recognised as an integral part of traditional Chinese medicine. It derives from the philosophy that we all have Yin and Yang. Qi is the life energy that accumulates in the body s organs &flows around the body in channels or meridians By needling points along the meridians it is possible to influence the flow of Qi and exert a therapeutic effect on the organs. There are 14 meridians in total

7 The body also has five phases (elements) - wood, fire, earth, metal and water.

8 Acupuncture Points

9 Western Medical Acupuncture (WMA) A Western Acupuncturist makes a diagnosis in the conventional way and uses needles to treat the problematic area alongside conventional medicine. The needles stimulate nerve fibres in the skin and muscles = blood vessels dilate = increase in the blood flow. =The body produces its own analgesic hormones: endorphins and encephalin. =decreases the pain messages travelling to the brain. WMA has shown to inactivate myofascial trigger points The sensation of needling is also registered in the cerebral cortex which can produce feelings of wellbeing on the patient.

10 WMA does not claim to treat every medical condition, nor every individual. Acupuncturists need to know when it is appropriate, and when not appropriate to use acupuncture.

11 My Journey Funding to undertake training, study leave, Pain nurse, clinic space I trained with The British Medical Acupuncture Society (BMAS) in 2009 All members of the British Medical Acupuncture Society are registered healthcare professionals. ENB N53: Principles of Effective Pain management

12 Procedure Explain Possible contraindications Treatment Side Effects

13 Evidence NICE guidelines 2012 recommend acupuncture for migraine and headache, to date this is proving effective and is used as common practice in Neurology Centres. One systematic review of randomised controlled trials comparing acupuncture with carbamazepine for trigeminal neuralgia found acupuncture to be as effective as the drug treatment, but to cause fewer unwanted effects (Liu 2011) Cummings in 1996 found that in a primary care setting 90% of patients with myofascial pain responded well to WMA compared to 40% of patients with other sorts of analgesics.

14 Project Earlier this year the Pain Specialist Nurse and myself undertook a service evaluation titled Review of Acupuncture in the management of Pain associated with Multiple Sclerosis Here are the results

15 53 Responses over 6 months Questionnaire given to patient to fill out during appointment 40 patients had relapsing remitting MS 9 patients had secondary progressive MS 3 patients were unsure of their type of MS The average duration they had been receiving Acupuncture was 4.4 years

16 Type of pain -14 Descriptors Neuropathic Spasm, burning, shooting, sensitive, lancing, crawling, pins and needles, numbness, tightness. Muscular skeletal Deep, nagging, aching, throbbing, dull 40 patients described Neuropathic symptoms, they all had between 5-9 different descriptive symptoms 30 patients had between 1-5 descriptors that included mechanical or muscular skeletal symptoms

17 Sites of Pain Back 26/53 Legs 37/53 Shoulders 15/53 Face 1/53 Head 5/53 Arms 17/53 Hands 13/53 Feet 20/53 Only 2 people had pain in one site/area only

18 Response to Treatment Average percentage of relief of pain symptoms 68% Average duration of relief 4.7 weeks

19 Amitriptyline Baclofen Drugs that patients are taking Number of patients Pregabalin Gabapentin Naproxen Co codamol Dihydrocodiene Duloxitine Maloxicam Morphine Nefopam Number of patients

20 Changes to Medication Regime 26 patients no change 6 reduced a lot 11 reduced a little 5 increased their medication

21 Changes to sleep and feeling of well being SLEEP 20 patients had improved sleep 33 slept the same FEELING OF WELL BEING 48 patients had an improved feeling of well being 3 had no change MOOD Gad 7 scores = average was 8 PHQ9 scores = average was 9.1

22 Patients Impression of Change Very much improved Much Improved Mininmally Improved No change Minimally worse Much worse Very much worse

23 Patients Comments Acupuncture gives your body a relaxed and pain free period Hope this isn t a study to cut back, I was very low and depressed. I was on MST now stopped, back at work. Improved mood and mind-set Acupuncture doesn t provide instant pain relief but I know when I am due for it as my symptoms increase

24 Finally.. Collaborative working across two specialities has proven to be effective, offering a unique service to our patients. The majority of patients I treat find acupuncture to be effective, many still need conventional medication but their pain symptoms have improved due to the treatment. Acupuncture is cost effective and as shown to improve patient s sleep and feelings of well being There is a clear need to undertake more research, particularly comparative studies to look at the effectiveness of acupuncture for MS related pain if it has any hope in continuing to be funded by the NHS. It is still a postcode lottery.

25 Thank you.