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Disclaimer: 'MS Views and News' DOES NOT endorse any products or services found on this blog. It is up to you to seek advice from your healthcare provider. The intent of this blog is to provide information on various medical conditions, medications, treatments, for your personal knowledge and to keep you informed of current health-related issues. It is not a substitute for the advice of your physician. Should you or your family members have any specific medical problem, seek medical care promptly.


Saturday, March 28, 2015

ABOUT LDN (Low Dose Naltrexone)

Many have asked about the efficacy of LDN to treat patients with Multiple Sclerosis for decades now.   Finally, here is an article that looks at the various clinical trials that have been done over the years and the outcomes of those.

Please be aware that LDN needs to be prepared at a formulating pharmacy and is not covered by any insurances currently.  A three month supply is around $60-$80 USD and people who will be responders to this therapy generally report noticing a difference (even if only a greater sense of well being) within the first week of dosing.  The first study noted in the article found at the above link looked at 40 patients with Primary Progressive Multiple Sclerosis (PPMS) for which we currently do not have any good ways to treat.  It noted that spasticity was less in those in the trial when the trial concluded than in those not on the active medicine.

This drug as a considerable amount of anecdotal information (patient stories of how they have been helped) but very few clinical trials looking at symptom management or actual disease modification with this drug.  If you have used LDN or would like to see more extensive clinical trials involving this, please log into www.iConquerMS.org and let them know that you want to see trials developed that will bring this into the main line treatment arena if it actually belongs there.

Be well,

Cherie C. Binns RN BS MSCN

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Friday, March 27, 2015

New law to guarantee access for service dogs

Pam Andrews has multiple sclerosis so her service dog Cyber helps her pick up things – such as the crutch Cyber is clutching – and pull open doors, among other duties. She’s thrilled at proposed new legislation that will include provisions to provide her and her dog access to businesses and other places, and fine those caught pretending their pets are service dogs. - Wanda Chow/NewsLeader
Pam Andrews has multiple sclerosis so her service dog Cyber helps her pick up things – such as the crutch Cyber is clutching – and pull open doors, among other duties. She’s thrilled at proposed new legislation that will include provisions to provide her and her dog access to businesses and other places, and fine those caught pretending their pets are service dogs.
— Image Credit: Wanda Chow/NewsLeader

Pam Andrews and her daughter-in-law had driven an hour to take her then-two-year-old grandson to a regional tourist attraction from her home in Richmond.
Andrews lives with multiple sclerosis and uses a scooter to get around. After they paid for their tickets, she was told her golden retriever service dog Cyber wouldn't be allowed inside.
She said the staff there questioned her need for the dog and didn't care that she had government identification showing Cyber is a certified service dog. She called the Burnaby-based Pacific Assistance Dogs Society (PADS), which trained Cyber, and even they weren't able to reason with the staff.
Andrews, 53, got their money refunded but to make matters worse, when she asked to use the restroom before the long drive home, she was denied access again until the staff agreed to escort her to the washroom and back.
It's situations like these that are all too common for people with disabilities who rely on the support of service dogs. It's also one that's about to change, thanks to new provincial legislation introduced to guarantee service dogs access to anywhere the public is allowed.
"With these changes we can make sure that a fully certified dog will be appropriately recognized and won’t result in someone with a disability being turned away from a service," Social Development Minister Michelle Stilwell said when the legislation was introduced recently.
Violators such as stores and restaurants who refuse entry to service dogs will also face stiffer fines of as much as $3,000.
Disability Alliance BC executive director Jane Dyson said tougher penalties were long overdue and the current maximum fine of $200 was "grossly inadequate."
The proposed Guide Dog and Service Dog Act, if passed in the legislature, will replace the Guide Animal Act which is about 30 years old.

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European Medicines Agency Validates Marketing Authorisation Application for ZINBRYTA™ (Daclizumab High-Yield Process) for Treatment of MS

Today Biogen (BIIB) and AbbVie (ABBV) announced that the European Medicines Agency (EMA) has validated the companies’ Marketing Authorisation Application (MAA) for ZINBRYTA™ (daclizumab high-yield process) for the treatment of relapsing forms of multiple sclerosis (MS) in the European Union (EU). Validation confirms that the submission is complete and signifies the initiation of the review process by the EMA’s Committee for Medicinal Products for Human Use (CHMP).
“The submission and validation of the MAA are important milestones for ZINBRYTA and mean this investigational treatment is one step closer to potentially becoming available to MS patients who may benefit from its novel profile,” said Gilmore O’Neill, vice president, Multiple Sclerosis Research and Development at Biogen.
The MAA included results from two clinical trials, DECIDE and SELECT, in which ZINBRYTA 150 mg was administered subcutaneously every four weeks in people with relapsing-remitting MS.
“We are committed to bringing to market medicines that may provide remarkable impact for patients, and the EMA validation of the MAA for ZINBRYTA is an important step in accomplishing that mission for MS patients,” said Michael Severino, M.D., executive vice president of research and development and chief scientific officer, AbbVie.
About ZINBRYTA™ (daclizumab high-yield process)
ZINBRYTA (daclizumab high-yield process) is an investigational drug and a new form of a humanized monoclonal antibody that selectively binds to the high-affinity interleukin-2 (IL-2) receptor subunit (CD25) that is expressed at high levels on T-cells that become abnormally activated in multiple sclerosis (MS). ZINBRYTA modulates IL-2 signaling without causing general immune cell depletion. ZINBRYTA is believed to work by decreasing abnormally-activated T-cells and pro-inflammatory lymphoid tissue inducer cells, and increasing CD56bright natural killer (NK) cells, which are important cells that help regulate the immune system.
Biogen and AbbVie are jointly developing ZINBRYTA.

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Thursday, March 26, 2015

Drug Successfully Restores Myelin in Phase 2 Trial

Mar 26, 2015    |    Rachel Lutz

 A Phase 2 acute optic neuritis (AON) trial has met its primary efficacy endpoints which included medication that restores myelin, according to information released by Biogen Idec.   Researchers determined that anti LINGO 1, the medication tested to restore myelin, could help repair the damaged visual system for patients. 

Anti LINGO 1 was tested in the RENEW trial, which is part of a larger Biogen Idec trial for multiple sclerosis (MS) patients. The study examined effects on remyelination in 82 patients in 33 European sites by measuring the latency of nerve conduction between the retina and the visual cortex in the brain using full field visual evoked potential (FF VEP) for a period of 24 weeks. The patients received 6 intravenous infusions of 100 mg/ kg anti LINGO 1 or placebo once every 4 weeks. The larger SYNERGY trial should produce results in 2016, the company expects.  

 Anti LINGO 1 showed improvement in the recovery of optic nerve latency when measured by FF VEP, which is the time for a signal to travel from the retina to the visual cortex, when compared to a placebo group. The researchers from the study also noted there was no effect on secondary endpoints – including change in thickness of the retinal layers, visual function, and low contrast letter acuity. - 
See more at: http://www.hcplive.com/news/Drug-Successfully-Restores-Myelin-in-Phase-2-Trial-#sthash.14NfQP1F.dpuf

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MS Treatment Using Stem Cells Better Than Medication

March 26th, 2015                     Alisa Woods, PhD

New research from Italy and Spain demonstrated that intense immunosuppression followed by autologous hematopoietic stem cell transplantation (AHSCT) was better than the medication mitoxantrone in treating severe cases of multiple sclerosisThe study appeared in the February 11, 2015, online issue of Neurology.
 MSMS is characterized by an immune system attack on the body’s own nerve cells. The fatty substance myelin degenerates in MS, causing problems with nerve cell communication. Mitoxantrone is an intravenous medication that inhibits immune system cells, including T-cells, B-cells, and macrophages. It can slow the progression of MS, but does not cure the disease. In contrast to the approach of using medication to inhibit the immune system, AHSCT attempts to replace the immune system. Lead author Giovanni Mancardi, MD of the University of Genoa in Italy explained “This process appears to reset the immune system. With these results, we can speculate that stem cell treatment may profoundly affect the course of the disease.”
Over 800 patients with MS have undergone stem cell treatments in small studies.
Dr. Mancardi and co-workers from the Autoimmune Disease Working Party of the European Group for Blood and Marrow Transplantation studied 21 patients with an average age of 36 years. All of the study participants had secondary progressive or relapsing-remitting MS and had an increased MS disability within the last year, even though they were taking standard MS treatments.
Nine of the study participants received intense immunosuppression followed by stem cell transplantation and 12 received mitoxantrone 20 mg every month for 6 months. To determine whether MS was progressing, the scientists performed magnetic resonance imaging (MRI).
The researchers studied the subjects for up to 4 years. The intense immunosupression with stem cell transplantation reduced apparent multiple sclerosis activity more than the mitoxantrone treatment. This was a statistically significant effect. People who underwent stem cell transplants had 79% fewer regions in which lesions appeared (brain damage) compared to those who received mitoxantrone. The study authors noted that “This effect was already evident in the first year and was sustained through the 4-year follow-up.”

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Ninth grader's brain experiment takes 2nd in national contest; seeks cure for MS

While many of his 14-year-olds counterparts are worrying about acne, Christian Gonzalez is looking to cure multiple sclerosis.
Christian Gonzalez.jpgChristian Gonzalez, 14, placed second in a national contest to design a brain experiment. His entry seeks to find a cure for multiple sclerosis. (Paul Huggins/phuggins@al.com) 
The ninth-grade homeschool student from Harvest came up with a scientific experiment that finished second in the national"Design a Brain Experiment" contest by advancing the field of neuroscience with an original idea.
"It's pretty much the most interesting part of biology," Gonzalez said of his interest in neuroscience. "The brain is the most important part of the human body. It controls everything."

he Dana Foundation sponsored the annual competition that invites entries from high school students across America. They are asked to develop innovative theories that challenge knowledge about the brain. The proposed experiments are judged on originality, 

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Researchers Develop First Accurate Method to Assess Important Protein in MS, Other Diseases

shutterstock_245479576Researchers at the University of Copenhagen and Rigshospitalet in Denmark have for the first time developed an accurate method to measure apolipoprotein M (apoM), a protein that is involved in several diseases like diabetes but also arteriosclerosis and sclerosis, disorders characterized by the stiffening of structures usually by replacement of the normal tissue by connective tissue. The study is entitled “Protein unfolding allows use of commercial antibodies in an apolipoprotein M sandwich ELISA” and was recently published in the Journal of Lipid Research.
The protein apoM circulates in the plasma attached to high-density lipoprotein (HDL) particles. ApoM is important for cholesterol metabolism and has been recently shown to transport the signaling lipid sphingosine-1-phosphate (S1P), which has been implicated in various inflammatory diseases such as rheumatoid arthritis and multiple sclerosis.
“We know that apoM is of importance to the development of arteriosclerosis and cardiovascular diseases. Previously, we have discovered that apoM carries a small fatty molecule, S1P, which plays a part in both diabetes and sclerosis. Whether or not apoM is of importance, remains to be seen, however, our new and secure measuring methods open up completely new perspectives on the research being conducted in these areas” said the study’s senior author Dr. Christina Christoffersen in anews release.
To establish an accurate, reliable and efficient method to measure apoM has been a challenge for researchers worldwide. “The protein is attached to the good cholesterol, HDL, which makes measuring it difficult. It is folded like a small funnel, but expressed in popular terms, we have managed to unfold it, which makes it much easier to identify” explained Dr. Christoffersen
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Wednesday, March 25, 2015

Low Dose Naltrexone Review for MS Reveals High Safety Profile, Mixed Results on Benefits in Multiple Studies

Low Dose Naltrexone Review for MS Reveals High Safety Profile, Mixed Results on Benefits in Multiple Studies

March 25, 2015

One of the most widely disputed treatments for multiple sclerosis is low dose naltrexone (LDN). While a plethora of patient testimonies and anecdotal evidence suggest immense benefits of LDN for multiple sclerosis, many clinicians are wary due to the lack of FDA approval outside of treating heroin and alcohol addiction.
Starting with the basic biology of LDN, the opiod antagonist drug is suggested to protect oligodendrocytes from cell death by reducing inflammation in the brain as a result of inducible nitric oxide synthase (iNOS) inhibition. In other words, less oligodendrocyte apoptosis means a greater potential for myelination, the key activity that could restore myelin damaged in multiple sclerosis. An alternative explanation for LDN activity is that low doses (less than 5 mg/day) of naltrexone cause the drug to act as an opiate agonist to regulate neurotransmitter activity between neurons.
Regardless of the mode of action, “Low Dose Naltrexone Therapy in Multiple Sclerosis,” published in the journal Medical Hypotheses, reports that over 70,000 LDN capsules are dispensed from a single pharmacy in only 8 months. Such a high demand for LDN resulted in the first trial for LDN initiated in December 2006 (completed in August 2007 and published in September 2008).
Led by researchers in Milan, Italy, the trial was a six-month, multi-center pilot Phase 2 trial that treated 40 patients with primary progressive multiple sclerosis (PPMS), a more severe form of the disease. “A significant reduction of spasticity was measured at the end of the trial,” wrote Dr. Gironi, lead author of the study “A Pilot Trial of Low-Dose Naltrexone in Primary Progressive Multiple Sclerosis,” published in the journal Multiple Sclerosis. Dr. Gironi further described, “Our data clearly indicate that LDN is safe and well tolerated in patients with PPMS.”
In this study, patients were dosed with 2 mg oral LDN at bedtime for four weeks. Patients were monitored by their clinicians via phone call, and the dose was increased to 4 mg if warranted. In-person follow-up visits allowed clinicians to track the progress of patients. Only one patient experienced a progression of neurological disability, and adverse events did not interfere with daily living for the patients who remained in the study.
Around the same time as the study in Milan, psychologist David Pincus announced a study to treat patients with either PPMS or relapsing-remitting multiple sclerosis. This trial was a 16-week trial with 36 patients. Unfortunately, at the close of the study, Dr. Pincus acknowledged problematic outcomes in the study. “We did not exclude patients on existing immunosuppressants,” stated Dr. Pincus. “The existing immunosuppressants may have inhibited the LDN effects in this population.” There was no apparent difference between placebo-treated and LDN-treated patients in terms of symptoms or energy levels.
The first placebo-controlled trial for LDN in multiple sclerosis was conducted by the University of California, San Francisco in early 2007 with neurological researcher Bruce Cree, MD as the lead. “A Randomized Placebo-Controlled, Crossover-Design Study of the Effects of Low Dose Naltrexone” was a Phase 3 study that dosed 80 patients with either 4.5 mg of naltrexone or placebo for eight weeks before treatment was crossed-over.

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Tuesday, March 24, 2015

State of MS Report

March 2015

When it comes to information about living with multiple sclerosis (MS), more is better. More than nine in 10 patients say – and neurologists tend to agree – that they like to know everything about their MS, whether it’s good or bad.

How do we know? We asked.

As part of a comprehensive State of MS initiative, an international survey sought to understand MS care by surveying those in the trenches: people living with and treating the disease.

Commissioned by Biogen and conducted online by Harris Poll, the survey focused on a key aspect of MS care: communication between patients and their doctors.

When communication is done well, it reinforces a healthy partnership between clinicians, patients and others actively involved in MS care. And for truly successful treatment regimens to be developed and maintained, patient participation is fundamental.

Our commitment to improving the lives of MS patients – an effort that extends well beyond medication – prompted this timely analysis.

What did we learn? In short, despite the generally positive assessment of current practice in MS, certain aspects of communication between doctors and patients could be better. It’s our fervent hope that the survey will serve as a catalyst for improvement – not only in doctor-patient dialogue, but also in information more precisely targeted to the answers patients and neurologists still seek about MS.
The study was conducted by The State of MS Consortium, an international steering committee of treating neurologists from five countries and representatives from patient advocacy groups.

Source Link

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Monday, March 23, 2015

PAIN in MS --

Pain – factsheet

Date of revision: April 2012
Updated with revised NICE guidelines - March 2014
This factsheet will be reviewed within three years


Pain in MS

Pain can be defined as "unpleasant sensory experiences"1. For people with MS this may encompass both 'painful' feelings and also altered sensations such as pins and needles, numbness, or crawling, burning feelings. Estimates vary as to how common these symptoms are2,3 with some reports suggesting that up to 80% of people with MS may experience pain at some stage4.
The management of pain in MS is not always easy and some types of pain will never go away entirely. In this case, the aim of treatment is to minimise the level of pain and to develop coping strategies so that the individual can carry out normal day-to-day living. Treatment options may include drugs, non-drug treatments such as physiotherapy or a combination of the two.
As well as the direct causes of pain, a number of factors can make pain feel worse for people with MS. These include heat, cold, poor sleep, fatigue, mobility problems, feelings of low self-esteem, loneliness or isolation, and depression or anxiety. Dealing with some of these other issues can help to improve pain levels.
It also needs to be remembered that people can experience pain for reasons other than their MS.
Different types of pain are managed in different ways, so a careful assessment of the factors that may be contributing to the symptom is necessary in order to find appropriate treatments.
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Describing pain

Pain is very subjective and is best described by the person experiencing it. No two people will experience pain in the same way.
Pain is often categorised in terms of how long it lasts. Acute pain is generally described as an intense, sharp, burning or shooting feeling. It is usually experienced intermittently, with very sudden onset and either improving or disappearing equally quickly.
Chronic pain is long-lasting or persistent pain. The intensity of chronic pain may fluctuate over a period of time without ever fully disappearing.
There are two broad types of pain that result from MS:
  • neuropathic or nerve pain is caused by damage to the nerves in the brain and spinal cord
  • nociceptive or musculoskeletal pain is caused by damage to muscles, tendons, ligaments and soft tissue
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Neuropathic (nerve) pain

Neuropathic pain is caused by disruption in how the nerves carry messages within the brain and spinal cord. In MS damage occurs to the myelin sheath, a layer of fatty protein that protects the nerves and aids transmission of messages. Nerve messages can be interrupted or delayed, interfering with the body's normal ability to function. Sometimes the brain interprets these disrupted messages as pain, even though there is no physical cause of pain.
The National Institute for Health and Care Excellence (NICE) has issued clinical guidelines for neuropathic pain. This indicates amitriptyline (Triptafen), duloxetine (Cymbalta), gabapentin or pregabalin (Lyrica) as first-line treatments. Treatment should be reviewed regularly and should the chosen drug not be effective, one of the others should be tried5. Treatment usually starts with low doses that are built up slowly.
These drugs affect the chemical transmission of pain signals resulting in a reduction of symptoms. They often cause side effects such as drowsiness, dizziness, nausea and blurred vision although these will eventually wear off.
The guidelines also suggest agreeing a treatment plan that takes into account the individual's concerns and expectations. Referral to a specialist pain service can be considered at any stage5.

Examples of neuropathic pain

Dysaesthesia or paraesthesia (altered sensation)
These are common symptoms in MS, but they are experienced differently from person to person. The pain can be described in a variety of ways including:

  • pins and needles
  • burning
  • tightness
  • numbness
  • prickling
  • dull ache
  • itching
  • crawling
  • nagging
Usually experienced in the extremities, these changes can occur anywhere in the body. These sensations can be uncomfortable and unsettling and may be painful and distressing.
Banding, sometimes called the 'MS hug'
This is a feeling of constriction, tightness or being squeezed around the chest.

Altered sensations are generally treated with one of the standard drugs, although symptoms such as numbness and loss of sensation may not be treated unless they are causing particular distress.
L'hermitte's sign
A sudden sensation resembling an electric shock, which passes down the back of the neck and into the spinal column and can radiate out to the fingers and toes. The pain is sharp but passes quickly so treatment is not usually considered.

Optic neuritis
A sharp, knifelike pain behind the eyes caused by inflammation of the optic nerve, sometimes also causing disruption to vision. Optic neuritis is a common early symptom of MS, though can occur at any time. It usually responds successfully to treatment with steroids.

Trigeminal neuralgia
An intense, severe stabbing and burning sensation down the side of the face that can ease to an ache or burn. Pain follows the path of the trigeminal nerve, which provides feeling in the side of the face and controls chewing and swallowing. It is thought that the pain, which normally only affects one side of the face at a time, is caused by damage where the nerve connects to the brain. The pain can be excruciating and can be set off by something as simple as eating, talking or smiling. It is usually sudden in onset and can reduce or disappear over a period of time. However it can become chronic.

Trigeminal neuralgia can be difficult to treat. First line treatment is with a standard drug for neuropathic pain. It is also useful to identify whether the pain has any triggers, for example eating ice cream, and avoiding them or reducing their likelihood. In extreme cases, surgery can be carried out to cut the nerve's connection to the brain, but this may leave the face numb.
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Musculoskeletal (nociceptive) pain

Musculoskeletal or nociceptive pain is the type of pain experienced when someone has an injury. It results from damage to muscles, tendons, ligaments and soft tissue.
Musculoskeletal pain is generally more successfully managed than neuropathic pain. Common pain relieving drugs such as paracetamol, ibuprofen or aspirin can be used.
The NICE Clinical Guideline for the management of multiple sclerosis state that specialist therapists should assess every person with MS who has musculoskeletal pain6. For instance, a physiotherapist could identify changes in posture and offer exercises to strengthen certain muscle groups to improve function and help to reduce pain. An occupational therapist could determine whether any new equipment might be required to help relieve pain, such as an appropriate walking aid or wheelchair, or equipment to make tasks in the home or workplace easier.

Examples of musculoskeletal pain

Pain in the hips and lower back
Many people with MS experience lower back pain. This can be caused by alterations in the way someone walks, possibly as a result of spasticity or weakness. This puts extra stress on the back or hips, leading to pain. Similarly, someone who spends much of the day sitting down, possibly due to mobility problems or fatigue may be prone to back pain.

Pain in the muscles, tendons or ligaments
This can occur if the limbs are stiff and kept in a fixed position for long periods of time. Muscles that aren't exercised can become stiffer and shorter, known as a contracture, restricting the range of movement possible. Ligament damage can also occur in MS, for instance if changes in how someone walks causes them to over extend their knee, leading to swelling and pain.

Spasms and spasticity can also cause pain in the soft tissues. When a muscle contracts, suddenly in the case of spasms or over a longer period of time in the case of spasticity, this can cause pain in the affected limb.
The NICE Clinical Guideline recommends the drugs baclofen or gabapentin as the first line of treatment for spasticity6. Other treatment options include tizanidine, diazepam, clonazepam or sodium dantrolene. The cannabis based drug Sativex is licensed for use as an add-on treatment for spasticity when people have shown inadequate response to other treatments or found their side effects intolerable.
A combined approach to treating spasticity, using both drug treatment and exercise, is often employed. Physiotherapy is used alongside medication to improve muscle function through a range of exercises and thus reduce painful sensations.
More information is available in our factsheet Spasticity and spasms
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Further treatment options

Pain clinic

If pain does not respond to treatment, it is possible to get a referral from a GP or neurologist to a specialist pain clinic. Services vary in the treatments offered and not all areas will have a specific pain clinic. Usually input is from a multidisciplinary team of doctors, nurses and therapists using a combination of drugs, therapy and coping strategies to help the person with MS minimise the effects of pain and to allow them to carry on with normal day-to-day living.


TENS (transcutaneous electrical nerve stimulation) is a machine that applies a small electrical current to the area of pain, producing a slight tingling, prickling sensation. The tingling sensations are transmitted along nerves more quickly than the pain sensations, reducing the effect of pain. It has also been suggested that TENS encourages the body to produce chemicals that have a pain relieving effect7,8.
TENS is included in the NICE Guideline as a treatment for musculoskeletal pain that doesn't respond to medication6.

Complementary therapies

There is limited scientific evidence to support the use of acupuncture9 and aromatherapy10 as treatments to alleviate pain, if only for short periods of time.
Some people with MS have reported benefits from the following therapies, possibly due to their relaxing effects. There may be others that are helpful:

Links and references

Pain organisations

  • Pain Concern
    A charity offering information and support for people who experience pain by people who experience pain. Provides a 'listening ear' helpline.

    Helpline: 0300 123 0789


  1. IASP Task Force on Taxonomy. Merskey H, Bogduk N, editors.
    Classification of chronic pain. 2nd ed.
    Seattle;IASP Press:1994.
  2. Ehde DM, et al.
    The scope and nature of pain in persons with multiple sclerosis.
    Multiple Sclerosis 2006;12(5):629-638.
  3. Hirsh AT, et al.
    Prevalence and impact of pain in multiple sclerosis: physical and psychologic contributors.
    Archives of Physical Medicine and Rehabilitation 2009;90(4):646-651.
    read online
  4. Archibald CJ, et al.
    Pain prevalence, severity and impact in a clinic sample of multiple sclerosis patients.
    Pain 1994;58(1):89-93.
  5. National Institute for Health and Care Excellence.
    Neuropathic pain - pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings. NICE clinical guideline CG173.
    read on the NICE website
  6. National Institute for Clinical Excellence.
    Understanding NICE guidance - information for people with multiple sclerosis, their families and carers, and the public.
    London: NICE; 2003.
  7. Warke K, at al.
    Efficacy of transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain in a multiple sclerosis population: a randomized, placebo-controlled clinical trial.
    Clinical Journal of Pain 2006;22(9):812-819.
  8. Sluka KA, Walsh D.
    Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness.
    Journal of Pain 2003;4:109-121.
  9. Wang Y, et al.
    A pilot study of the use of alternative medicine in multiple sclerosis patients with a special focus on acupuncture.
    Neurology 1999;52:A550.
  10. Howarth AL, Freshwater D.
    Examining the benefits of aromatherapy massage as a pain management strategy for patients with multiple sclerosis.
    Nursing Times Research 2004;9(2):120-128.

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