Here is My Question:
Having MS for almost 30 years, I know very well the importance of PT, exercising and stretching. Due to some health problems I have not been doing my calf stretches. My calf muscles are very, very tight. I was just getting back to my stretching routine, when I started getting pains in my right inner upper leg. It is now also in my lower back. Can this be from lack of stretching? I have had tests, and it is not my hip nor a bladder-kidney infection. Can it possibly be muscle related from tightness ? Thanks

Answer: 
The pains you are feeling can definitely be related to muscle tightness in the muscles of the inner thigh and in the back; especially if you spend the majority of the day sitting. Also, if you are altering the way you walk because of the stiffness in your legs, that could also be a potential cause of the increase in tightness. If you are someone who has spasticity, you may also be experiencing an increase in spasticity to those regions. If any of  these are the reason for your pain, stretching will help!
 
​Sarah Frank, PT, DPT, MSCS
Outpatient Rehab
Mt. Sinai Rehabilitation Hospital
490 Blue Hills Ave.
Hartford, CT 06112

Here is My Question:
I'm looking for a non opioid non weight gain pain control medication.  

Answer:
This topic is a little more complicated because there are different causes (and sources) of pain.  In MS, we focus on neuropathic pain (i.e., pain originating from a scar of multiple sclerosis).  

Unfortunately, medications to treat this type of pain can encourage weight gain.  Depending on the type of neuropathic pain, medications such as trike oral, topiramate, or keppra could be used, but they have to be used appropriately.  If the pain is not neuropathic in nature but is related to musculoskeletal pain, physical therapy can be helpful.  

As you can see, more information is needed to determine a treatment strategy.  In complicated situations, pain centers can be utilized which use a multifaceted approach of of medication, physical therapy, and wellness approach to tailor care.

A. Scott Nielsen, MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
I've been told by my neurologists that I have a significant number of lesions in my C-spine area. I generally tend to sleep on my back at night, as my legs get tingly and cramp when sleeping on my side. However, after a few hours I'm awakened by pain and soreness in the back of my neck. Do you know of a device that can help and am I inflicting more damage by putting pressure in the area? Thank you. Sleepless in San Diego.

Answer:
The pain in your neck while sleeping is almost certainly not related to your MS. You need to find a better pillow. If you go on-line you will find an entire cottage industry devoted to the relief of neck pain while sleeping. It will require some experimentation on your part but you should find something that offers relief. 
Good luck

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Director of Hillcrest Neurology
Professor of Clinical Neurosciences
University of California San Diego

Here is My Question:
I have a question from my pediatric MS group for you :

For our kids that have lingering pain post attack: Is it possible that the kind of intense PT/OT that children who have been diagnosed with (AMP) Amplified Musculoskeletal Pain receive be beneficial to our MS kids who experienced post attack pain?


Answer:
Unfortunately there is no good data for this technique in pediatric MS. We encourage patients to have a detailed exam with their neurologist and physiatrist to determine the cause of the pain (neuropathic versus musculoskeletal versus spasticity) as this can dictate the best course of action.
 
Benjamin M. Greenberg, MD, MHS
Vice Chair of Translational Research and Ambulatory Care
Department of Neurology and Neurotherapeutics
Director, Transverse Myelitis, Neuromyelitis Optica Programs
Co-Director, Pediatric CONQUER Program
UT Southwestern Medical Center
Childrens Health
Dallas, Texas

Here is My Question:
My GP prescribes 'Sifrol' for me. I have pain in my right leg and arm and hand and behind my eye. I know this is for restless leg syndrome but honesty I have nerve pain so how will this help me? I have taken it for one week now with no results. My problem is finding a MS Neurologist.

Answer:
This is an excellent question. We do not usually use a dopamine agonist like pramipexole (Sifrol is a brand) to treat neuropathic pain. You may want to suggest a trial of gabapentin or pregabalin to your general doctor. Good luck.

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Question:
My question is how long will 'Cymbalta'60 mg, for neuro pain take to work? I asked my doctor and he told me for pain it takes longer. I have been taking them now 18 days and getting desperate to know if I am wasting my time. My doctor is away and my neurologist and I feel helpless.....pain is not getting any less. My mood is changing not for the better, but not sure if its this medication or just me feeling down from the pain, my husband has his operation next week and my boys have exams...meaning at home all the time. I lost hope.......Thank you in advance. I appreciate this web site very much. I feel I have someone I can ask.

Answer:
Tim Vollmer in Denver published a placebo controlled study on the use of Cymbalta (duloxetine) for MS related Neuropathic pain in 2014. Those patients who responded began to see benefits at 1 week and definitely noticed benefits by 2 weeks. The numbers need to treat to achieve a 30 % reduction in pain (what is considered meaningful) was 8. This means that 8 people must be treated with this drug to achieve a 30 % reduction in pain for 1 person.

I usually add pregabalin (Lyrica) if a patient is not beginning to respond by 2 to 4 weeks. Talk to your doctors about adding another medication. If you are not tolerating the Cymbalta you should also discuss stopping it with your doctors.

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Question:
Is Cymbalta used for MS patients for pain? At the moment I take 30 mg but my doctor suggested 60 mg after one week.

Answer:
Cymbalta is used to treat depression and chronic pain. I find it particularly useful for patients with disrupted sleep and depression co-existing with their chronic pain. It is usually started at the 30 mg dose and increased to the 60 mg dose. Ask your doctor about potential side effects and good luck.

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Question:
I just got Cymbalta prescribed for my MS nerve pain, but this is an antidepressant medication. Is this the best for nerve pain? I tried Lyrica and it did not work. In fact it made my symptoms worse (side effects) The problem is I almost always get the side effects. My other option was Neurotin. Reading these side effects scared me. Which is more suitable for MS pain with the least amount of side effects?

Answer:
I have written several responses in the past related to the treatment of neuropathic pain in MS. Please search the site for a more detailed response (just type "neuropathic pain" in the search box that is in the upper corner of this page).

I have found that Cymbalta can be effective and is approved by the FDA for neuropathic pain. Often we need to use Cymbalta in combination with lower doses of medications like gabapentin (neurontin) and lamotrigine or older medications like phenytoin and carbamazipine

Ask your doctor about all these medications.

Good luck

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Question:
I was diagnosed with RRMS in 2011. About three years ago I began developing pain in my neck. I am fine except when I bend my neck down and either right or left. I feel a sharp shooting pain. My neurologist told me it could be Lhermittes Sign. I was placed on Lyrica to help with the pain. A year later I suffered from memory loss and discontinued the Lyrica. I have now been prescribed Tramadol for neck pain and severe back stiffness/soreness. Does this seem like a good recommendation? Is there another avenue that I should discuss with my neurologist in regards to pain management? Thank you.

Answer:
Lhermitte’s phenomenon is an electrical or tingling shock like sensation that radiates down the spine or sometimes to the right or left arm with forward neck flexion. Sharp shooting pain could represent Lhermitte’s but is more often related to compression of a nerve root by arthritis or disc herniation or both. The fact that you now have chronic neck pain supports this hypothesis. 

You may want to ask your doctor to evaluate you for cervical spondylosis or another process that causes sharp jabbing pain with neck movement. The treatment will depend upon what is found.

Revere (Rip) Kinkel MD
Director of the Multiple Sclerosis Program
Professor of Clinical Neurosciences
University of California San Diego

Here is My Question:
I was diagnosed with MS (lesions on brain MRI) in Feb 2014. I had a Lumbar Puncture. Since that time I have a very uncomfortable feeling at the base of my neck in the center or the top of my spine (I think) that feels like pressure. It even get painful at times. What can I do, without medicine to relieve that feeling that won't cause damage to my spine?

Answer:
Your symptom is not one I can diagnose over a blog, but requires a face-to-face visit with your doctor.  Occasionally, an unusual headache can occur after a spinal tap that is only present when sitting or standing up, but goes away when you lay down.  This pain can be reflected in the neck as well.  Usually this is self-limited and goes away on its own.  Your symptoms sound different and require a formal evaluation in clinic.  Once the cause is suspected/known, then your doctors can offer a course of therapy.
-ASN

It is not possible to interpret potential adverse effects of a treatment in isolation; you must contact your doctor and get evaluated to determine if the breast pain is at all related to any drug. Asking other patients if they’ve experienced similar symptoms will not resolve your question. Hope the pain goes away soon.

Rip Kinkel, MD

Here is My Question:
I stopped taking Tefidera two days ago because my stomach pain was so severe and I had a fever, chills and nausea. Today I still feel like I have a virus and severe stomach pain even though my doctor put me on Singulair for stomach pain. Is it possible I have a virus together with reactions from the drug?

Answer:
The constellation of symptoms you describe—fever, chills, nausea and abdominal pain— would be unusual for Tecfidera and suggest a viral gastroenteritis. You should contact your doctor and see him or her. In the meantime, you made the correct choice to stop Tecfidera until your problem is sorted out by your physician.

By the way, I do not think your doctor put you on Singulair for stomach pain. Singulair is used as a treatment for asthma and one of its main side effects is stomach pain.

Hope you feel better soon.
-Rip Kinkel

Question:
I have been having persistent lower right pelvic pain for more than month now. I had a pelvic ultrasound, CT scan, and everything looked normal. They said it's probably IBS (which is basically anything that can't be explained) or food intolerance (unlikely because I have changed nothing recently). While it's good to know there's nothing serious going on, I still have to live with this pain. Is there any possible way that this could be due to MS?
 
Answer:
This depends on the nature of the pain; lancinating, burning, or needle-like superficial pain following sensory dermatomes could be related to MS or even a condition called zoster sine herpete (shingles pain without the rash). A tight squeezing sensation that can be intermittently painful may also occur with spinal cord involvement by MS.

Non MS related causes are far more numerous and more common for pelvic pain even in MS patients.

Rip Kinkel

This really depends on the part of the back involved; I will confine my response to lower back pain, also called lumbar back pain.

In my experience low back pain in MS patients is infrequently a direct effect of Multiple Sclerosis but often a secondary complication of MS.

Remember, most of strain on your body from either prolonged sitting or standing is transmitted through the lumbar spine region. This make people in general very susceptible to mechanical low back pain.

Patients with MS are specially prone to this type of pain because of abnormal walking patterns, asymmetric truncal weakness, and  improper seating support. These are the types of problems best evaluated by a rehabilitation specialists and an adaptive seating and technology specialist.

Rip Kinkel, MD

Spasms in the legs often do not respond to the same dose of medication used to treat overall spasticity even though they are related phenomenon. If the spasms do not respond to higher doses of Baclofen, tizanidine, gabapentin, Lyrica or a more standard muscle relaxer or if these doses cause too many side effects, we often add a benzodiazepine like diazepam or clonazepam at bedtime. This usually does the job for most people since cramps and spasms are more common at night while lying supine.

Cramps are a slightly different phenomenon causes by muscle irritability and will sometimes respond to magnesium oxide supplements (250 to 500 mg). But beware, higher doses of magnesium oxide can cause loose stools.

Q: Some neurologists classify symptoms as either gain of function (for example paresthesia), and loss of function ones (like trouble walking, numbness, etc). In your opinion, where does pain belong in this classification? Is it also a sign of healing? Thanks!

Answer: I am not sure I like the term, “gain of function”, since there is nothing really gained by the acquisition of pain. I would say that neuropathic pain, which is usually described as sharp, jabbing, stabbing, electric or burning, is caused by the generation of abnormal electrical signals in areas of the nervous system responding to injury. Chronic pain is more complex and likely involves a maladaptive response to injury. Please see my most recent blog (http://www.healthcarejourney.com/10/post/2014/02/what-causes-abnormal-sensations-and-pain-in-multiple-sclerosis.html) for a more thorough explanation of abnormal sensations in people with MS.