All About Multiple Sclerosis

More MS news articles for January 2004

Invisible Symptoms: Fatigue and Pain

December 2003
Elida J. Greinel, MSN, RN
MS Nursing - Introduction to Multiple Sclerosis Nursing Care
The National Multiple Sclerosis Society


After reading this article, nurses who are new to the care of people with MS will be able to the following:


In addition to the other, more obvious challenges associated with treating a chronic, progressive autoimmune disease, are those posed by the “invisible” symptoms of MS. The diagnosis and treatment (including both medical and educational interventions) depend on accurate information about these elusive symptoms, as well as effective communication between people with MS and their healthcare team. Nurses play a pivotal role in this process. Because they tend to spend the most time with patients, they are often in the best position to recognize the invisible symptoms a patient is experiencing, assess their impact on day-to-day functioning, interpersonal relationships, and quality of life, and provide support and management recommendations. Invisible symptoms can be defined as any that are not obvious to others—even the healthcare professional.

The invisible symptoms of MS can include parasthesias, cognitive dysfunction, depression or other mood changes, sexual dysfunction, pain, fatigue, and even elimination problems. Too often, patients will neglect to mention symptoms like these, either because they are unaware of their relationship to MS or because they are too embarrassed to talk about them. An essential component of every office visit is a careful review of any new or uncomfortable problems the person is experiencing; this will help to ensure that the invisible symptoms of MS get the attention they require.

To illustrate the challenges associated with the invisible symptoms of MS, this module focuses on the diagnosis and management of fatigue and pain in MS.


Fatigue has been defined by the Multiple Sclerosis Council for Clinical Practice Guidelines as “a subjective lack of physical and/or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities” (Multiple Sclerosis Council, 1998). The underlying cause(s) of this unique type of fatigue or lassitude remains unclear, in spite of the high prevalence of this symptom among people with MS. The research indicates that 75–95 percent of people with MS experience fatigue, and 50–60 percent consider it one of their most debilitating symptoms (Fisk, 1994; Freal et al., 1984; Murray, 1985). The impact on an individual’s quality of life is significant, given that:

Characteristics of MS-Related Fatigue Assessment Strategies

The first step in managing MS-related fatigue is to identify and address possible contributory factors (Krupp & Elkins, 2000; Schapiro, 2003; Multiple Sclerosis Council, 1998).

Management Strategies

Management of MS-related fatigue begins by addressing (and eliminating, if possible) each of the possible contributory factors.


Although the association between MS and pain was made by Charcot as long ago as 1872 (Charcot, 1872), the common belief among healthcare professionals until fairly recently was that pain was not a significant problem for people with MS. We now know that pain syndromes are quite common in MS, affecting approximately 45–65 percent of patients. (Indaco et al., 1994; Moulin et al., 1988; Stenager et al., 1991). With 32 percent reporting continuous, unremitting pain for at least one month, pain may in fact be one of the most troubling symptoms of the disease (Vermote et al., 1986). MS patients can experience various types of pain, many of which are quite challenging to control.

Types of MS-Related Pain

MS-related pain can be generally divided into acute syndromes with paroxysmal onset (lasting less than one month) and chronic syndromes with insidious onset (that last more than one month).

Acute syndromes include:

Paroxysmal pain tends to resolve on its own after four to six weeks and may not require prolonged therapy. If medication is needed, the general recommendation is to initiate treatment with low-dose (100–200 mg bid) carbamazepine. For persistent pain, the dosage of antiseizure medication can be gradually raised, and/or a second medication can be added (Jeffery, 2000).

Chronic pain syndromes include

Managing Refractory Pain

Some pain syndromes in MS, particularly the more chronic ones, can be quite refractory to treatment. Several medications may need to be tried before an effective one is found, and more than one may be needed at any given time. Once the pain is brought under control, an attempt should be made to stop the first medication since treatment with only one medication at a time produces fewer side effects. In the case of severe, breakthrough pain, narcotics may be necessary. Because patients with unremitting pain are at risk for depression, supportive counseling and/or psychiatric intervention may be required (Indaco et al., 1994; Vermote et al., 1986; Jeffery, 2000).


Nurses play an integral, active, and dynamic role in the management of invisible symptoms like fatigue and pain. As the member of the healthcare team who is likely to spend most time with a patient, the nurse is ideally situated to identify these challenging symptoms and provide education and support, and implement management strategies designed to meet the unique needs of each individual.


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1. Invisible symptoms of MS may include

a. Cognitive dysfunction
b. Depression
c. Pain
d. Sexual dysfunction
e. All of the above
2. Current pharmacological agents used to reduce symptoms of fatigue include all of the
following except
a. Amantadine (Symmetrel®)
b. Pemoline (Cylert®)
c. Diazepam (Valium®)
d. Modafenil (Provigil®)
3. A careful assessment of all of the following factors is important when dealing with
MS fatigue-related complaints, except
a. Presence of a bacterial or viral infection
b. Age and gender of patient
c. Concomitant medications
d. Depression
4. Dysesthetic pain is characterized by burning or aching sensation.
a. True
b. False
5. MS-related pain includes
a. Dysesthetic pain
b. Trigeminal neuralgia
c. Optic neuritis
d. All of the above

Answers: 1 e; 2 c; 3 b; 4 a; 5 d

Copyright © 2004, The National Multiple Sclerosis Society