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Reappraisal of Lhermitte's sign in multiple sclerosis
Abstract
Lhermitte's sign (LS) is strongly linked to multiple sclerosis (MS). Our aim is to reassess its frequency, natural history, various characteristics and neuroradiological correlation in a cohort of MS patients attending our specialized MS clinic and to propose a working definition. Consecutive patients with CDMS and normal controls were interviewed using a structured questionnaire. Cervical MRIs were reviewed when available. There were 300 MS patients and 100 normal controls. Forty-one per cent of the patients and none of the controls reported having LS during the course of their illness. In 53% of those who reported LS, it started in the first three years of the illness and began as an isolated symptom in 64% and was polysymptomatic in 36%. In all patients LS was a short-lasting sensation in all patient who experienced it and was mostly stereotyped in individual patients. Characteristics varied widely between patients. Forty-three patients had cervical MRIs; 17 out of 18 patients who reported LS had abnormalities, whereas only 13 out of the 25 with no LS had abnormalities. The results indicate that LS is highly prevalent in MS, is commonly stereotyped in individual patients, has a variable natural course and correlates significantly with cervical MRI abnormalities. A working definition is proposed.
... Показники розповсюдженості ФЛ при РС у нечисельних дослідженнях з даної проблематики мають досить великі відмінності [6,7,8,9,10]. Більше того, до теперішнього часу немає жодного лонгітюдного дослідження щодо частоти виникнення ФЛ у пацієнтів з РС -усі вищезгадані епідеміологічні дослідження мають кроссекційний або ретроспективний характер. ...
... На теперішній час це єдине проспективне дослідження щодо показників виникнення ФЛ у пацієнтів з РС. В крос-секційних та ретроспективних роботах частота ФЛ у пацієнтів з РС мала наступні значення: на момент огляду -9% [10], 55% [7]; протягом усього періоду захворювання -16% [8], 33,18% [9], 41% [6], 70% [7]. Значна розбіжність показників розповсюдженості ФЛ може пояснюватися як відмінностями популяцій пацієнтів, так і різними методиками опитування (очне, поштою, тощо). ...
... Можливо, якісна варіабельність відчуттів при ФЛ також може частково пояснювати значні розбіжності показників розповсюдженості ФЛ за даними літератури (частота виявлення ФЛ визначається способом опитування пацієнтів). До теперішнього часу, тільки в одній роботі досліджувалися якісні характеристики ФЛ при РС: у 80% випадків пацієнти опису-вали їх як «електричний струм», у 10% -як «поколювання», у 3% -як «вібрацію», у 2,5% -як «повзання мурашок», у 2,5% -як «розтягування», у 2% -як «інші відчуття» [6]. З 7 випадків, коли пацієнти з ФЛ, що виник, погодилися з'явитися в Центр, тільки у 1 пацієнта (14,3%) було діагностовано загострення РС. ...
Neuropathic pain in multiple sclerosis can manifest itself in the form of the Lhermitte phenomenon, short-term unpleasant sensations along the spine that occur when the head is bent. The purpose of this study is to investigate the factors that act as predictors of the Lhermitte phenomenon and their frequency in multiple sclerosis. 308 patients with multiple sclerosis were involved in the study, 258 of them agreed to follow-up, of them there were 67 men (26.0%) and 191 women (74.0%), aged 21 to 60 years. Out of the total cases, 187 (72.5%) patient had the relapsing-remitting type of multiple sclerosis, 2 (0.8%) had primary progressive type, and 69 (26.7%) showed secondary progressive type. Among the 258 patients who initially agreed to participate in the study at the Centre, 18 (7.0%) individuals discontinued their involvement during the first year, and 13 (5.0%) individuals prematurely withdrew from the study during the second year due to various reasons. Among the characteristics of multiple sclerosis, the age of the patient when diagnosed, the duration and the type of course, and the overall assessment of neurological deficit were determined. Psychopathological and cognitive states, socio-demographic factors, and comorbid pathology were assessed using appropriate scales. Statistical research methods were employed to analyze the collected data. The results indicate that the risk of developing the Lhermitte phenomenon remains relatively consistent over a two-year period: 2.5% in the first year and 2.3% in the second year. Pain associated with the Lhermitte phenomenon is most commonly experienced in the neck (63.6%), followed by the upper back (54.6%), lower back (72.7%), and least frequently in the upper limbs (18.2%) and lower limbs (36.4%). The Lhermitte phenomenon typically spreads to two or three affected areas of the body in 33.3% and 48.2% of cases, respectively. The most commonly used descriptors for the Lhermitte phenomenon are "shooting" (72.7%), "tingling" (18.2%), and "crawling ants" (9.1%). No significant differences in social, demographic, neuropsychological, and neurocognitive characteristics were observed between patients with and without Lhermitte phenomenon. According to the results of univariate Cox regression analysis, we has found that during the 2-year period, an increase in the duration of the disease for each subsequent year is associated with a decrease in the relative risk of Lhermitte phenomenon by 1.15 times (1.02-1.29, p=0.02). In patients with multiple sclerosis, the average risk of experiencing the Lhermitte phenomenon remains consistent at approximately 2.3-2.5% per year throughout the course of the disease. Patients who have a short history of multiple sclerosis are a risk group for the occurrence of the Lhermitte phenomenon. It is quite difficult to explain the regularity we have identified, for its clarification a detailed study of a special additional study is necessary. But, in any case, from a practical point of view, patients in the early stages of multiple sclerosis can be considered as a group of increased risk for the occurrence of the Lhermitte phenomenon.
... As a result of focal demyelination of ascending sensory pathways, areas of depolarization and hyperexcitability of axon membranes are formed, which in turn become a source of pathological ectopic impulsion and cause paroxysmal neuropathic sensations, and neck movement activates ascending demyelinated spinal thalamic pathways at the cervical level [50]. Magnetic resonance imaging data confirms this hypothesis, namely, lesion formation in the cervical spine was detected in 95% of patients with Lhermitte's phenomenon compared with52% of patients without this symptom [51]. Current studies on the pathogenesis of Lhermitte's phenomenon have revealed dysfunction of GABAergic systems, microglial activation, and proinflammatory cytokines, as well as molecular mechanisms of CREB phosphorylation and other transcription factors in the CNS, which increase hyperexcitability and pain. ...
... It should be noted that Lhermitte's phenomenon is not specific to MS; it occurs under many other conditions [49]. It is temporary, manifesting for a few weeks, and it disappears spontaneously; therefore, a careful differential diagnosis should be made, especially with pathological processes at the cervical level [10,51]. The current diagnosis of Lhermitte's phenomenon is mainly based on the characteristic clinical picture and anamnesis, as there are no routine objective tests for its evaluation or treatment. ...
Multiple sclerosis is a chronic infammatory disease that afects the central nervous system and can cause various types of
pain including ongoing extremity pain, Lhermitte’s phenomenon, trigeminal neuralgia, and mixed pain. Neuropathic pain is
a major concern for individuals with multiple sclerosis as it is directly linked to myelin damage in the central nervous system
and the management of neuropathic pain in multiple sclerosis is challenging as the options available have limited efcacy and
can cause unpleasant side efects. The literature search was conducted across two databases, PubMed, and Google Scholar.
Eligible studies included clinical trials, observational studies, meta-analyses, systematic reviews, and narrative reviews.
The objective of this article is to provide an overview of literature on pharmacological and non-pharmacological strategies
employed in the management of neuropathic pain in multiple sclerosis. Pharmacological options include cannabinoids,
muscle relaxants (tizanidine, baclofen, dantrolene), anticonvulsants (benzodiazepines, gabapentin, phenytoin, carbamazepine,
lamotrigine), antidepressants (duloxetine, venlafaxine, tricyclic antidepressants), opioids (naltrexone), and botulinum toxin
variants, which have evidence from various clinical trials. Non-pharmacological approaches for trigeminal neuralgia may
include neurosurgical methods. Non-invasive methods, physical therapy, and psychotherapy (cognitive behavioral therapy,
acceptance and commitment therapy and mindfulness-based stress reduction) may be recommended for patients with
neuropathic pain in multiple sclerosis. The choice of treatment depends on the severity and type of pain as well as other
factors, such as patient preferences and comorbidities. There is a pressing need for healthcare professionals and researchers
to prioritize the development of better strategies for managing multiple sclerosis-induced neuropathic pain.
... Цей синдром не є специфіч ним для РС і проявляється й при інших патологічних станах, що включають компресію або ураження шийного від ділу хребта. При РС синдром Лермітта може бути зумовлений демієлініза цією в дорсальних стовпах на шийному рівні [40]. ...
... Незважаючи на те що специфічні механізми, які лежать в основі виникнення ди зестетичного болю, не з'ясовані, передбачається, що ураження СМ можуть призводити до порушення передачі болю спиноталаміч ним трактом або розвиватися внаслідок дисфунк ції ГАМКергічних інтернейронів [41]. При РС у людей з дизестетичним болем у кінців ках при магнітнорезонансній томогра фії часто виявляють вогнища демієлінізації у шийному та грудному відділах СМ [40]. ...
Multiple sclerosis (MS) is a multifaceted, complex chronic neurological disease that leads to motor, sensory and cognitive impairment.
The symptoms of MS are unpredictable and extremely variable. Pain is
a frequent symptom of MS and is manifested by nociceptive or neuropathic pain (NP), even in the early stages of the disease. MS is one of the
most debilitating symptoms that reduces the quality of life and interferes
with daily activities, especially because conventional pharmacotherapeutic drugs do not adequately alleviate NP. Despite the achievements,
the mechanisms underlying NP in MS remain unclear. Most studies examining the pathophysiology of NP associated with MS have been
performed on experimental animal models that reproduce some of the
clinical and neuropathological features of MS. Experimental allergic
encephalomyelitis (EAE) is one of the most studied and most frequently
used experimental models of MS. As in patients with MS, rodents affected by EAE have an increased sensitivity to pain, which can be assessed
using well-proven tests. EAE studies have provided valuable information
on the pathophysiology of NP. However, further research is needed to
better understand the events that lead to and maintain NP in order to
identify targets that may contribute to the development of more effective therapeutic interventions. The aim of this article is to review several
mechanisms associated with NP in MS and EAE by summarizing published
literature data.
Key words: multiple sclerosis, experimental allergic encephalomyelitis, glia, neuroinflammation, neuropathic pain.
... Lhermitte's sign (LS) is a common manifestation of MS occurring in about a third of MS patients, however, it can also be seen in a variety of other conditions involving the spine. LS commonly starts in the early stages of the disease and can be the first clinical manifestation of MS in 10% [54]. It is defined as a short-lasting electric-like sensation felt at the back of the neck radiating to the lower parts of the body following neck flexion and disappearing on resuming normal posture [54]. ...
... LS commonly starts in the early stages of the disease and can be the first clinical manifestation of MS in 10% [54]. It is defined as a short-lasting electric-like sensation felt at the back of the neck radiating to the lower parts of the body following neck flexion and disappearing on resuming normal posture [54]. Most MS patients cope well with this symptom, when problematic, neck braces/collars have been used to decrease neck movements that provoke LS [55]. ...
Paroxysmal symptoms are well-recognized manifestations of multiple sclerosis (MS). These are characterized by multiple, brief, sudden onset, and stereotyped episodes. They manifest as motor, sensory, visual, brainstem, and autonomic symptoms. When occurring in the setting of an established MS, the diagnosis is relatively straightforward. Conversely, the diagnosis is significantly more challenging when they occur as the initial manifestation of MS. The aim of this review is to summarize the various forms of paroxysmal symptoms reported in MS, with emphasis on the clinical features, radiological findings and treatment options.
... However, smaller studies have described a much broader range of estimates. Two studies found Lhermitte's sign to have been present at some point during the course of MS in 40 % of patients [1,8,10]. The reason for this discrepancy might be attributed to varying descriptions of Lhermitte's sign and to the design of the clinical studies. ...
... The reason for this discrepancy might be attributed to varying descriptions of Lhermitte's sign and to the design of the clinical studies. It was reported that Lhermitte's sign commonly starts in the early years of the disease and can start as the first clinical manifestation of MS [10]. The current study has shown no correlation between Lhermitte's sign and age, gender, EDSS and disease duration. ...
The reliability and diagnostic value of Lhermitte's sign in multiple sclerosis (MS) has not been fully established. The purpose of this study was to determine the clinical, neurophysiological and neuroradiological correlations of Lhermitte's sign in a cohort of MS patients and reassess the relevance of this phenomenon in the clinical history of the disease. A prospective study of 694 patients with MS and 110 age-matched healthy adults was evaluated by a structured questionnaire that included basic demographic data, age of onset, clinical characteristics of the disease, and the inquiry of Lhermitte's sign. Cranial and spinal magnetic resonance imagings (MRI) and median and tibial somatosensory evoked potentials (SSEP) were performed at the same time. One hundred and twelve (16 %) patients were reported to have Lhermitte's sign; 582 (84 %) patients did not experience Lhermitte's sign during their disease duration (P < 0.026). No correlation was found between Lhermitte's sign and age, gender, EDSS, and disease duration; 88 % of patients with Lhermitte's sign had a demyelinating lesion on the cervical MRI. In negative Lhermitte's sign group, 64 % patients had a positive MRI. SSEP conductions were delayed in 92 % of patients with positive Lhermitte's sign and in 70 % of patients with negative Lhermitte's sign. Regarding the data, a significant correlation was found between MRI lesion and Lhermitte's sign (P < 0.001), and between SSEP abnormality and Lhermitte's sign as well (P < 0.001). This study underlines the relevance of this phenomenon with neuroradiological and neurophysiological abnormalities.
... Another paroxysmal pain syndrome in MS patients is Lhermitte's sign, described as a painful, electric-current-like sensation in the spine when the patient flexes the neck. In 95% Life 2024, 14, 87 8 of 12 of the patients presenting this sign, cervical demyelinating lesions were detected during MRI examination [54]. ...
Multiple sclerosis is a chronic and progressive neurological disease, with an important socio-economic burden. Over time, an increased incidence of headaches like migraines and tension headaches has been observed among these patients. Headaches have not been considered as multiple sclerosis-related symptoms, even representing a red flag for multiple sclerosis diagnosis. It is uncertain whether the headache–multiple sclerosis association could be explained by the presence of common triggers or a common physiopathological mechanism (involvement of tertiary B-cell follicles). An important differential diagnosis is between multiple sclerosis attacks and migraines with aura, which can also be associated with neurological deficits. Another important aspect is the occurrence or exacerbation of the cephalalgic syndrome after the initiation of therapy for multiple sclerosis (DMTs), or the improvement of headache after the initiation of certain DMT drugs. In addition to headaches, individuals diagnosed with multiple sclerosis often report experiencing diverse pain syndromes, contributing to an additional decline in their overall quality of life. These syndromes are frequently neglected, the focus being on slowing down the progression of neurological deficits. This review aims to evaluate the characteristics of multiple-sclerosis-related headaches (frequency, possible correlation with attacks, and disease-modifying therapies) and the key distinctions in imaging characteristics between demyelinating lesions in multiple sclerosis and those observed in cases of primary headaches.
... Notably, MS patients have distinctive pain syndromes that can mimic CNP. The Lhermitte sign is a paroxysmal descending electric-like sensation triggered by neck flexion associated with a cervical spine demyelinating plaque in the posterior column [71]. Another common manifestation of MS is painful tonic spasms that are paroxysmal posturing resulting from pyramidal tract lesions [72]. ...
Neuropathic pain, traditionally considered a chronic condition, is increasingly encountered in the emergency department (ED), accounting for approximately 20% of patients presenting with pain. Understanding the physiology and key clinical presentations of neuropathic pain is crucial for ED physicians to provide optimal treatment. While diagnosing neuropathic pain can be challenging, emphasis should be placed on obtaining a comprehensive medical history and conducting a thorough clinical examination. Patients often describe neuropathic pain as a burning or shock-like sensation, leading them to seek care in the ED after ineffective relief from common analgesics such as paracetamol and NSAIDs. Collaboration between emergency medicine specialists, neurologists, and pain management experts can contribute to the development of evidence-based guidelines specifically tailored for the emergency department setting. This article provides a concise overview of the common clinical manifestations of neuropathic pain that may prompt patients to seek emergency care.
... Lhermitte's phenomenon is defined as "a transient, brief sensation related to flexion of the neck and felt in the back of the neck, lower back, or in other parts of the body" (2). Although not specific for MS, Lhermitte's phenomenon is frequently associated with MS (45). In many patients, this symptom is transient, and manifests only for some weeks, then resolves spontaneously (46). ...
Neuropathic pain and other pain syndromes occur in the vast majority of patients with multiple sclerosis at some time during their disease course. Pain can become chronic and paroxysmal. In this review, we will utilize clinical vignettes to describe various pain syndromes associated with multiple sclerosis and their pathophysiology. These syndromes vary from central neuropathic pain or Lhermitte's phenomenon associated with central nervous system lesions to trigeminal neuralgia and optic neuritis pain associated with nerve lesions. Muscular pain can also arise due to spasticity. In addition, we will discuss strategies utilized to help patients manage these symptoms.
... Lhermitte's sign is not specific to MS and manifests in other pathological conditions that include the compression or lesion of the cervical SC (57). In accordance with this idea, the MRI of individuals with MS shows demyelinated plaques in the dorsal columns at the cervical level (58). ...
Multiple sclerosis (MS) is a multifaceted, complex and chronic neurological disease that leads to motor, sensory and cognitive deficits. MS symptoms are unpredictable and exceedingly variable. Pain is a frequent symptom of MS and manifests as nociceptive or neuropathic pain, even at early disease stages. Neuropathic pain is one of the most debilitating symptoms that reduces quality of life and interferes with daily activities, particularly because conventional pharmacotherapies do not adequately alleviate neuropathic pain. Despite advances, the mechanisms underlying neuropathic pain in MS remain elusive. The majority of the studies investigating the pathophysiology of MS-associated neuropathic pain have been performed in animal models that replicate some of the clinical and neuropathological features of MS. Experimental autoimmune encephalomyelitis (EAE) is one of the best-characterized and most commonly used animal models of MS. As in the case of individuals with MS, rodents affected by EAE manifest increased sensitivity to pain which can be assessed by well-established assays. Investigations on EAE provided valuable insights into the pathophysiology of neuropathic pain. Nevertheless, additional investigations are warranted to better understand the events that lead to the onset and maintenance of neuropathic pain in order to identify targets that can facilitate the development of more effective therapeutic interventions. The goal of the present review is to provide an overview of several mechanisms implicated in neuropathic pain in EAE by summarizing published reports. We discuss current knowledge gaps and future research directions, especially based on information obtained by use of other animal models of neuropathic pain such as nerve injury.
... MS-related pain can cause both acute and chronic symptoms, is reported as one of the most severe symptoms in 8-32% of patients with MS [38] and often coexists as a combination of acute, paroxysmal and chronic pain in the same or different parts of the body [39] . According to the underlying pathophysiological mechanisms, pain is divided into five categories: (1) Neuropathic pain, defined as pain arising directly from an injury or condition affecting the somatosensory system [40] , which may present as persistent limb pain and numbness, as trigeminal neuralgia, and as the Lhermitte phenomenon (defined as the transient sensation associated with movements of the neck, back, lower back, and other parts of the body) [41] , (2) Nociceptive pain, whether inflammatory or non-inflammatory, which includes musculoskeletal and back pain that may be related to posture, optic neuritis [42] , headaches and pain caused by treatment, (3) Psychogenic pain, which is difficult to identify and refers to somatoform pain associated with psychiatric conditions such as depression and anxiety or pain behaviors developed in patients with chronic, persistent pain, (4) Idiopathic pain, which includes diseases that are not fully understood, such as fibromyalgia, interstitial cystitis and atypical facial pain, and (5) Mixed pain, which includes a heterogeneous group of pain with different pathophysiological mechanisms, which are caused by MS, such as muscle spasms and spasticity pain. ...
Aim: A review of the literature on the effect of hydrotherapy on the symptoms of fatigue, pain, spasticity as well as on the balance and gait of people with Multiple Sclerosis (MS). Method: Search databases such as MEDLINE, Cochrane Library, Science Direct and PEDro were used to search the literature. The inclusion criteria were studies that included physiotherapy and mainly hydrotherapy as a means of rehabilitation in MS. Results: Hydrotherapy programs significantly reduced the symptoms of fatigue, pain, spasticity as well as significantly improved balance and gait in patients with MS, as reflected in the evaluation tests. Conclusions: Hydrotherapy is proposed as a safe, effective and enjoyable method of rehabilitation in patients with MS to reduce symptoms and improve balance and gait.
... ПМ при НОМ характеризуется продольным распространением (не менее чем на 3 сегмента спинного мозга) с симметричным двусторонним поражением моторных и сенсорных проводящих путей [8], в то время как очаги поражения спинного мозга при РС менее распространены в продольном направлении (2 или меньше сегментов), односторонние с тенденцией к периферийной локализации, что обусловливает асимметричные и менее выраженные клинические проявления [23]. ПМ при НОМ обычно проявляется глубокими пара-или тетрапарезами, дисфункцией мочеиспускания и нарушениями чувствительности ниже уровня очага поражения спинного мозга [22]; также типичными проявлениями, возникающими в 35% случаев ПМ при НОМ, являются симптом Лермитта и тонические судороги мышц [24]; в 33% случаев ПМ при НОМ сопровождается болевым синдромом с иррадиацией по корешковому типу, что также не характерно для РС [25]. Однако открытие АП4-IgG, дальнейшее расширение диагностических критериев НОМ и введение термина «спектр оптикомиелит-ассоциированных расстройств» (СОАР) также расширило представление о разнообразии клинической картины НОМ. ...
Neuromyelitis Optica: New Data about Pathogenesis, Methods of Diagnostic and Treatment, Current Views about the Place of this Pathology in Structure of Neurological Diseases and Criteria of Diagnosis ______________________ Резюме __________________________________________________________________________ В статье рассмотрены основные сведения о редкой аутоиммунной патологии нервной системы-нейрооптикомиелите, или болезни Девика. Приведены краткие исторические све-дения об этом заболевании, а также эпидемиологические и демографические данные о нем. Рассмотрены современные взгляды на основные звенья патогенеза и, в частности, роль по-ражения гематоэнцефалического барьера в возникновении клинической картины. Подробно рассмотрены клинические проявления болезни, критерии диагностики, рассмотрены измене-ния этих критериев и изменения взглядов на сущность заболевания ввиду открытия ключевых патогенетических механизмов. В статье приведена информация о современных методах диа-гностики нейрооптикомиелита и о характерных признаках этого заболевания, которые выяв-ляются при использовании этих методов. Рассмотрены вопросы подхода к лечению болезни Девика. Ключевые слова: нейрооптикомиелит, аквапорин-4, антитела, поперечный миелит, неврит зрительного нерва, ритуксимаб. ______________________ Abstract __________________________________________________________________________ The article describes the basic information about a rare autoimmune pathology of the nervous system-neuromyelitis optica, or Devic disease. Brief historical information about the disease, as well as epidemiological and demographic data about it are given. The modern views on the main stages of pathogenesis and, in particular, the role of the blood-brain barrier in the emergence of the clinical picture are considered. The clinical manifestations of the disease, the diagnostic criteria are
... Lhermitte's phenomenon is a short-lasting, electricshock-like sensation, evoked by neck movements and felt in the back of the neck, lower back, or in other parts of the body. This phenomenon is related to demyelinated lesions affecting dorsal columns at the cervical level, as demonstrated by neuroimaging and neurophysiological studies [6][7][8]. The demyelination of large, non-nociceptive, Aβ fibers reasonably produces ectopic generation of high-frequency discharges. ...
Pain is a major matter for patients with multiple sclerosis; treatment response is frequently inadequate, with a significant impact on quality of life. The estimated prevalence of pain in multiple sclerosis ranges widely (26–86%), and different subtypes of pain, mediated by specific pathophysiological mechanisms, are described. The aim of this narrative review, performed using a systematic search methodology, was to provide current, evidence-based, knowledge about the pharmacological treatment of the different kinds of pain in multiple sclerosis. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov), considering publications up to November 2019. Two authors independently selected studies for inclusion, data extraction, and bias assessment. A total of 27 randomized controlled trials were identified, but in only a few cases, patients with different pain qualities were stratified. Following a mechanism-based approach, treatment of paroxysmal pain and painful tonic spasms should be based on sodium-channel blockers, whereas treatment of ongoing extremity pain should be based on gabapentinoids and antidepressants.
... It is caused due to the lesions in the cervical cord. It is a painful short-lasting electric shock-like sensation related to the neck and moves from the back of the neck to the limbs traveling throughout the body (Solaro et al. 2013;O'connor et al. 2008;Al-Araji and Oger 2005). 3. Musculoskeletal Pain: Lesions affect motor neurons and cause damage to muscles, tendons, ligaments, or soft tissue that result in the painful muscle contraction (O'connor et al. 2008). ...
An “individual with a disability” has a physical impairment or record of such an impairment that substantially limits a “major life activity.” Today, “person with a disability” is a more widely used term than “handicapped” as this phrasing reflects a positive approach by putting people first, not the disability. The disability term is used to refer an individual functioning including motor, sensory, cognitive, intellectual impairment, mental illness, and various types of chronic diseases (Oliver 1995; Crow 2008).
... Dysaesthetic extremity pain, has a prevalence of 12-28%, usually presents with tingling or burning, affects the legs predominantly, and worsens at night. Lhermitte's phenomenon, a paroxysmal electric shock-like pain usually evoked by neck flexion, begins in the back of the neck and spreads to the lower limbs and has been reported to have a prevalence of 41% in MS [48]. Trigeminal neuralgia (Tic Douloureux, TN) is characterized by a lancinating, sudden, usually unilateral, severe, stabbing pain in the distribution of one or more branches of the trigeminal nerve. ...
Botulinum neurotoxins (BoNTs) are now among the most widely used therapeutic agents in clinical medicine with indications applied to the fields of movement disorders, pain disorders, and autonomic dysfunction. In this literature review, the efficacy and utility of BoNTs in the field of movement disorders are assessed using the criteria of the Guideline Development Subcommittee of the American Academy of Neurology. The literature supports a level A efficacy (established) for BoNT therapy in cervical dystonia and a level B efficacy (probably effective) for blepharospasm, hemifacial spasm, laryngeal dystonia (spasmodic dysphonia), task-specific dystonias, essential tremor, and Parkinson rest tremor. It is the view of movement disorder experts, however, that despite the level B efficacy, BoNTs should be considered treatment of first choice for blepharospasm, hemifacial spasm, laryngeal, and task-specific dystonias. The emerging data on motor and vocal tics of Tourette syndrome and oromandibular dystonias are encouraging but the current level of efficacy is U (undetermined) due to lack of published high-quality studies.
... Interestingly, MS patients with primary progressive or progressive-relapsing MS are more likely to suffer from dysaesthetic pain than patients with the relapsing-remitting disease form (45). L'hermitte' s phenomenon is described as a transient, short-lasting paroxysmal electrical sensation that originates in the neck and spreads down to the lower limbs and is usually related to neck movement. Although this phenomenon is not exclusive to MS, it is frequently reported by patients with MS (45), with a prevalence ranging from 9 to 41% depending on the parameters of the study (47,48). In most patients, the symptoms resolve within 4 to 6 weeks; however, they may recur occasionally, especially during MS exacerbations (48). ...
ABSTRACT Chronic pain is defined as any consistent pain lasting more than 12 weeks; chronic pain afflicts 25% of the world’s population. The most common form of chronic pain is chronic neuropathic pain, which affects around 8% of the general population and is defined as pain that is initiated or caused by a primary lesion or dysfunction of the nervous system. Neuropathic pain is commonly associated with a variety of neurodegenerative, metabolic, and autoimmune diseases. In multiple sclerosis (MS), chronic neuropathic pain is one of the most frequent symptoms that dramatically reduces the quality of life of MS patients. Current treatment strategies include antidepressants, anticonvulsants, and cannabinoid drugs. However, the efficacy of these drugs varies between patients. Besides providing only insufficient relief of pain, these drugs also lead to severe side effects. Therefore, there is an unmet medical need to identify novel drug targets, which may lead to the development of novel therapeutics with enhanced tolerability profiles and efficacy for the management of MS-associated chronic neuropathic pain.
... Lhermitte's sign: According to the Multiple sclerosis Foundation approximately 38 percent of multiple sclerosis patients will experience Lhermitte's sign at one time or another. In literature, the data on prevalence of this disorder vary from 2% to 41% [11,13,[29][30][31]. The possible explanation for differences in prevalence of Lhermitte´s sign may be the fact, that there is some multiple sclerosis patients for which an electric feeling passing down the back to the legs on flexing the neck (the common form of Lhermitte´s sign) could be painless. ...
Central pain (CP) is little recognized and diagnosed type of pain in multiple sclerosis. Objective: This second part of our work related to pain in multiple sclerosis is concentrated on occurrence of CP and defined its characteristics. Methods: Questionnaires on pain were sent to 307 patients with definitive multiple sclerosis diagnose. Patients admitting to CP were examined with aim to diagnose CP. The dates were statistically processed. Results: Out of 220 responders 92% reported pain during the course of their multiple sclerosis. CP was found in 57.72%, including 40.91% with central neuropathic extremity and trunk pain (CNEP), 5.91% with trigeminal neuralgia (TN), and 33.18% with Lhermitte‘s sign (LS). In 28.8% of all patients, CP was an initial multiple sclerosis symptom. The prevalence of CP does not increase with age, disease duration, or the Expanded Disability Status Scale (EDSS). Lower extremities were the commonest location of CNEP (74.5%) and burning was the commonest painful sensation. Three and more concurrent unpleasant painful sensations experienced 68.9% of patients, which were in 46.7% located in the lower extremities. Three and more concurrent CP locations (including TN and LS) were reported by 89% of patients. Number of locations in CP increases significantly with age and EDSS, in contrast to group with nociceptive and peripheral neuropathic pain (n=113), where does not increase with age, EDSS and multiple sclerosis duration. The group with nociceptive and peripheral neuropathic pain featured significantly less patients with only one pain location (p=0.0269) and only one pain quality. In contrast to the other group, In CP increases significantly the number of patients with increase the number of concurrent pain qualities (p<0.0001). Conclusion: CP is not only a frequent complaint among persons with multiple sclerosis, but is a distinctive type of pain requiring special attention and their identification remains still the major challenge.
... Dysaesthetic extremity pain, has a prevalence of 12-28%, usually presents with tingling or burning, affects the legs predominantly, and worsens at night. Lhermitte's phenomenon, a paroxysmal electric shock-like pain usually evoked by neck flexion, begins in the back of the neck and spreads to the lower limbs and has been reported to have a prevalence of 41% in MS [48]. Trigeminal neuralgia (Tic Douloureux, TN) is characterized by a lancinating, sudden, usually unilateral, severe, stabbing pain in the distribution of one or more branches of the trigeminal nerve. ...
Multiple sclerosis is a common disease in which the disease process involves multiple levels of the central nervous system leading to the emergence of a myriad of clinical symptoms. The symptomatic treatment of multiple sclerosis often does not meet patient’s satisfaction despite the availability of a variety of pharmacotherapeutic agents. This evidence-based review discusses the utility of botulinum neurotoxin therapy for treating the symptoms of multipe sclerosis. The available data from randomized, blinded clinical trials indicate that BoNT therapy is efficacious for the treatment of spasticity, bladder dysfunction, and certain types of focal pain in multiple sclerosis. Emerging literature from open-label observations suggests the utility of BoNT therapy in several other symptoms caused by MS: certain tremors, myokymia, tonic spasms, spastic dysphagia, and internuclear ophthalmoplegia. The data on MS-related sialorrhea are not available.
... Dysaesthetic extremity pain, has a prevalence of 12-28%, usually presents with tingling or burning, affects the legs predominantly, and worsens at night. Lhermitte's phenomenon, a paroxysmal electric shock-like pain usually evoked by neck flexion, begins in the back of the neck and spreads to the lower limbs and has been reported to have a prevalence of 41% in MS [48]. Trigeminal neuralgia (Tic Douloureux, TN) is characterized by a lancinating, sudden, usually unilateral, severe, stabbing pain in the distribution of one or more branches of the trigeminal nerve. ...
Purpose of review The purpose of this review is to provide updated information on the role of botulinum neurotoxin (BoNT) therapy in multiple sclerosis (MS). This review aims to answer which symptoms of multiple sclerosis may be amenable to BoNT therapy.
Recent findings We searched the literature on the efficacy of BoNTs for treatment of MS symptoms up to April 1st 2017 via the Yale University Library’s search engine including but not limited to Pub Med and Ovis SP. The level of efficacy was defined according to the assessment’s criteria set forth by the Subcommittee on Guideline Development of the American Academy of Neurology. Significant efficacy was found for two indications based on the available blinded studies (class I and II) and has been suggested for several others through open-label clinical trials.
Summary There is level A evidence (effective- two or more class I) that injection of BoNT-A into the bladder’s detrusor muscle improves MS-related neurogenic detrusor overactivity (NDO) and MS-related overactive (OA) bladder. There is level B evidence (probably effective- two class II studies) for utility of intramuscular BoNT-A injections for spasticity of multiple sclerosis. Emerging data based on retrospective class IV studies demonstrates that intramuscular injection of BoNTs may help other symptoms of MS such as focal tonic spasms, focal myokymia, spastic dysphagia, and double vision in internuclear ophthalmoplegia. There is no data on MS-related trigeminal neuralgia and sialorrhea, two conditions which have been shown to respond to BoNT therapy in non-MS population.
... Lhermitte's symptom and sign consists of an electric sensation in the back or limbs provoked by bending the neck, other movements such as coughing or laughing can evoke the same effect. It indicates involvement of the posterior columns (Al-Araji and Oger, 2005). ...
Abstract
- Background: Cognitive impairment (CI) is a common manifestations of multiple sclerosis (MS), can occur early or late in the disease course.
- Objective: To evaluate types and severity of CI in different MS subtypes.
- Subjects and Methods: This study was conducted on 40 MS patients and 20 healthy control subjects. Physical disability was assessed by the Expanded Disability Status Scale and cognitive functions were assessed using; the Montreal Cognitive Assessment Scale, the Wechsler Memory Scale-Revised, the Wisconsin Card Sorting Test and the Bender-Gestalt test. Event Related Potential p300, brain and/or spinal MRI and brain Magnetic Resonance Spectroscopy (MRS) were also done.
- Results: There is significant CI in MS patients when compared with control. The most commonly affected cognitive domains are information processing speed leading to impairment in memory, attention, visuo-spatial and executive functions. MRS showed decreased N-acetyl aspartate (NAA) / Creatine (Cr), NAA/ Choline (Cho) ratios and increased Cho/Cr ratio in MS patients. Secondary progressive MS patients seem to have more CI than other types.
- Conclusion: CI is a common MS manifestation occurring in early disease course and in all MS subtypes. The degree of CI is positively correlated with axonal loss in MRS evidenced by reduction in NAA/Cr ratio.
... Lhermitte's sign was present in 34.7% of our patients. In literature, data on the prevalence of this disorder vary considerably from 9 to 41% [5,14,41]. Our results showed trigeminal neuralgia to be present in 5.91% of MS patients, which is consistent with the published data reporting the prevalence frequencies ranging from 1.6 to 18% [4,5,6,38,42]. ...
... LS was first observed in patients with multiple sclerosis by Marie and Chatelin in 1917 but was not recognized by the neurology community until it was reported by Jean Lhermitte in 1924 [7]. Although LS is most commonly associated with multiple sclerosis, it can also occur in other demyelinating conditions such as neuromyelitis optica or as a side effect of RT to the cervical or thoracic spinal cord [8][9][10]. The latter condition, termed radiogenic LS, is caused by reversible demyelination of ascending sensory neurons at the dorsum columns due to inhibition of oligodendrocyte proliferation after irradiation of the cervical or thoracic spinal cord [11][12][13]. ...
Purpose:
To prospectively examine the risk of developing Lhermitte's sign (LS) in patients with lymphoma treated with modern-era chemotherapy followed by consolidation intensity-modulated radiation therapy.
Methods:
We prospectively interviewed all patients with lymphoma who received irradiation to the mediastinum from July 2011 through April 2014. We extracted patient, disease, and treatment-related variables from the medical records of those patients and dosimetric variables from treatment-planning systems and analyzed these factors to identify potential predictors of LS with Pearson chi-square tests.
Results:
During the study period 106 patients received mediastinal radiation for lymphoma, and 31 (29 %) developed LS. No correlations were found between LS and any of the variables examined, including total radiation dose, maximum point dose to the spinal cord, volume receiving 105 % of the dose, and volumes receiving 5 or 15 Gy.
Conclusion:
In this group of patients, treatment with chemotherapy followed by intensity-modulated radiation therapy led to 29 % developing LS; this symptom was independent of radiation dose and seemed to be an idiosyncratic reaction. This relatively high incidence could have resulted from prospective use of a structured interview.
... Lhermitte's phenomenon is a common feature of MS, but a study found that around 20% of sufferers had never informed their doctor about this symptom and none had requested specific treatment for it (AlAraji and Oger, 2005). The phenomenon is described as an electric shock-like sensation that is short-lasting (<2 s), related to neck movement (flexion) and felt in the back of the neck, lower back or other parts of the body. ...
Pain is a common and disabling symptom in multiple sclerosis (MS). Current understanding of pain is that it is a complex phenomenon involving cognitive, emotional and behavioural dimensions. A biopsychosocial framework is therefore best used to manage pain, particularly in the context of a chronic disease such as MS that has a significant impact on health-related quality of life. This article describes the epidemiology of MS pain and its common types, particularly neuropathic pain, as well as the evidence for MS pain management strategies. It also outlines a pragmatic approach to the pharmacological management of neuropathic pain and highlights the role of specialist pain services in the management of MS pain.
Introduction:
Multiple sclerosis (MS) is an inflammatory and degenerative autoimmune condition, resulting frequently in a disabling condition. Significant improvements of long-term prognosis have been recently achieved with an early and more aggressive use of disease modifying therapies (DMTs). Addressing the complexity of managing its progressive forms remains a significant challenge.
Areas covered:
This review provides an update on DMTs for relapsing-remitting MS (RRMS) and progressive MS and their efficacy, safety, and mechanism of action, emphasizing the critical role of biomarkers in optimizing treatment decisions. Moreover, some key information on drugs used to manage symptoms such as pain, fatigue, spasticity and urinary problems will be provided. The literature search was conducted using PubMed, Embase, and Cochrane Library databases covering the period from January 2000 to January 2024.
Expert opinion:
Major advances have been achieved in the treatment of RRMS. Treatment should start immediately as soon as the neurologist is confident with the diagnosis and its choice should be based on the prognostic profile and on the patient's propensity to accept drug-related risks. The therapeutic landscape for progressive MS is quite disappointing and necessitates further innovation. Personalized medicine, leveraging biomarker insights, holds promise for refining treatment efficacy and patient outcomes.
OBJECTIVE
This article provides an approach to the assessment, diagnosis, and treatment of central neuropathic pain.
LATEST DEVELOPMENTS
Recent studies of the pathophysiology of central neuropathic pain, including evidence of changes in the expression of voltage-gated sodium channels and N -methyl- d -aspartate (NMDA) receptors, may provide the basis for new therapies. Other areas of current research include the role of cannabinoid-receptor activity and microglial cell activation in various animal models of central neuropathic pain. New observations regarding changes in primary afferent neuronal activity in central neuropathic pain and the preliminary observation that peripheral nerve blocks may relieve pain due to central neuropathic etiologies provide new insights into both the mechanism and treatment of central neuropathic pain.
ESSENTIAL POINTS
In the patient populations treated by neurologists, central neuropathic pain develops most frequently following spinal cord injury, multiple sclerosis, or stroke. A multimodal, individualized approach to the management of central neuropathic pain is necessary to optimize pain relief and may require multiple treatment trials to achieve the best outcome.
Paroxysmal neurological symptoms in patients with multiple sclerosis (MS) have long been acknowledged. However, consideration of whether such symptoms are a clinical attack and sufficient for fulfillment of MS diagnostic criteria has varied as criteria have evolved over time. Previous studies and anecdotal reports indicate that some patients with MS first present with syndromes such as trigeminal neuralgia, Lhermitte’s phenomenon, tonic spasm, and seizure years before an attack typical of MS such as optic neuritis or myelitis. We discuss four patients with presumed MS who initially presented with these syndromes with evidence of a corresponding central nervous system (CNS) lesion who, were these symptoms considered an attack, could have been diagnosed with relapsing remitting MS or clinically isolated syndrome. This case series aims to highlight the unmet need for data for such patient presentations and for clinical guidance from future MS diagnostic criteria to optimize care.
Introduction
Fatigue is a complex and often debilitating symptom of multiple sclerosis (MS), affecting a large number of individuals with the condition. Research has shown that fatigue and impaired mobility are the two main causes of work loss in people with MS, with fatigue being one of the leading causes of unemployment.
Aim
The research aimed to study the impact of fatigue on individuals with MS, including its effects on physical functioning, daily life activities, work, family, and social life.
Material and method
The data was collected using the Fatigue Assessment Scale, a tool specifically designed for individuals with multiple sclerosis to assess the impact of fatigue on their work, home, and school life. The Fatigue Severity Scale measures fatigue levels, which distinguishes fatigue from clinical depression due to overlapping symptoms. Approximately 700 participants from all over the world participated in the study, with the majority coming from the USA, Canada, and Germany.
Results
The results indicate that fatigue presents a significant challenge for individuals with MS, impacting activities of daily life including leisure, work, and treatment (kinesitherapy). The results also show a connection between gender and fatigue, although the dependence or independence between the two was not determined. Our findings suggest that fatigue is one of the three symptoms that causes significant difficulties for people with MS, affecting all areas of their functionality.
Conclusions
In conclusion, this scientific paper highlights the importance of addressing fatigue in individuals with MS, as it can have a significant impact on their quality of life. Effective management strategies are essential to ensure the health, well-being, and recovery of affected SM patients. Further research is needed to understand the various causes of fatigue in MS and to develop effective interventions to address it.
Pain in neurological diseases or injuries can be the primary complaint or may present as a co-existing or comorbid process. The etiology of pain can be multiple and exhaustive, but this section is to illustrate how commonly pain may manifest in patients with neurological conditions and to provide insight in the mechanism of pathology of each disease. Most of the potential interaction is brief and intended to excite interest for further discussions as there is no single pathomechanism that is clear in any of this disease condition.
Neuropathic pain is a complex and challenging secondary pain condition. It is a sequela of central nervous or peripheral nervous system lesions and pathologies. It can be debilitating and affects approximately 7% of the general population. Many factors contribute to the development of this chronic neuropathic pain. It can originate from the central part of the nervous system as a result of brain or spinal cord injury, stroke, or multiple sclerosis. Peripheral neuropathic pain manifests in the peripheral nervous system, and includes large fiber and small fiber polyneuropathy, radiculopathy, and mononeuropathy. Pharmacological options include tricyclic antidepressants (TCA), serotonin and norepinephrine reuptake inhibitors (SNRI), and gabapentinoids. For more severe cases, interventional pain management techniques such as peripheral nerve blocks, spinal cord, or peripheral nerve stimulation may be reasonable options.
Among a multitude of pain syndromes (PS) of diverse locations and types of pathogenesis encountered in multiple sclerosis (MS) patients, most research attention is paid to neuropathic PS, which are not uncommonly present at the early stages of MS, significantly reduce quality of life by producing impairments to patients’ social adaptation, and lead to poor therapeutic responses. The most typical in MS patients are central neuropathic pains, whose pathogenesis is linked with the formation of plaques of demyelination in the CNS. The diagnosis of neuropathic PS in MS is based mainly on the features of the clinical picture; MRI brain scan data and neurophysiological investigations are adjunctive. This review addresses contemporary views of the three main types of neuropathic PS in MS: constant limb pain, trigeminal neuralgia, and Lhermitte’s phenomenon. The clinical manifestations of each of these syndromes are described, along with current views on pathogenesis and data on the informativeness of supplementary investigation methods, and existing approaches to conservative and surgical treatment based on randomized trial data are analyzed.
Central neuropathic pain is caused by a disease or lesion of the brain or spinal cord. It is difficult to predict which patients will develop central pain syndromes after a central nervous system injury, but depending on the etiology, lifetime prevalence may be greater than 50%. The resulting pain is often highly distressing and difficult to treat, with no specific treatment guidelines currently available. This narrative review discusses mechanisms contributing to central neuropathic pain, and focuses on pharmacological approaches for managing common central neuropathic pain conditions such as central post-stroke pain, spinal cord injury-related pain, and multiple sclerosis-related neuropathic pain. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids have some evidence for efficacy in central neuropathic pain. Medications from other pharmacologic classes may also provide pain relief, but current evidence is limited. Certain non-pharmacologic approaches, neuromodulation in particular, may be helpful in refractory cases. Emerging data suggest that modulating the primary afferent input may open new horizons for the treatment of central neuropathic pain. For most patients, effective treatment will likely require a multimodal therapy approach.
Among the numerous pain syndromes (PS) of various localizations and types, observed in patients with multiple sclerosis (MS), the greatest attention of researchers is attracted by neuropathic PS. Neuropathic PS are often present already in the early stage of MS, significantly reduce the quality of life, hinder the social adaptation of patients, poorly respond to therapy. Central neuropathic PS, which pathogenesis is closely related with plaques in the central nervous system, are most common in patients with MS. Diagnostics of neuropathic PS in MS is based mainly on typical clinical symptoms; MRI and neurophysiological methods data are of secondary importance. This review focuses on modern concepts of three main neuropathic PS in MS: ongoing extremity pain, trigeminal neuralgia and Lhermitte's sign. Clinical symptoms of neuropathic PS, current ideas about their pathogenetic mechanisms, MRI and neurophysiological techniques data and the existing approaches to conservative therapy and surgical treatment based on randomized trials data are presented.
Ağrının Multipl sklerozun (MS) bir semptomu olmadığı düşüncesi devam etse de, birçok çalışma MS hastalarının yarısından fazlasının ağrı şikayeti olduğunu doğrulamıştır. MS’te ağrının nedeni birçok farklı mekanizma ile ilişkilidir. Ağrıya neden olan durumların çoğu önlenebilir, ortadan kaldırılabilir veya iyileştirilebilir ve kronikleşen durumlarda hastaya uygun stratejiler seçilerek ağrısı yönetilebilir. Ağrı yönetimi multidisipliner bir ekip anlayışını gerektirir. Bu ekip içinde hemşireler önemli bir role sahiptir. Hemşireler, MS hastalarına özgü ağrı tipi ve tedavi seçeneklerinin farkında olmalı ve buna yönelik gerekli olan bakımı sağlamalıdır. Bu makalenin amacı MS hastalığında görülen ağrıların doğası, nedenleri, tedavisi ve hemşirelik bakımı ile ilgili kavramları güncel literatür doğrultusunda tartışmak ve ilgili literatüre katkı sağlamaktır.
Thoracic flexion, a rapid forward flexion at the waist, can elicit a circumferential electrical sensation in some patients with multiple sclerosis. The clinical and radiographic features of this phenomenon are described here. This symptom is typically a sensory band around the T6-T7 dermatomes and is usually associated with recent thoracic cord lesions. It is clinically independent of cervical pathology and Lhermitte’s sign. Similar to the vertical radiation of symptoms upon neck flexion due to cervical cord lesions, this sign may help localize MS plaques to the thoracic cord, even when thoracic MRI is negative.
Central nervous system pain is an unpleasant emotional experience due to abnormal processing of information due to a lesion or disease affecting the processing of somatosensory information. Sensation of pain is continuously modulated at the spinal cord level by descending influences and at the brain stem and cortical levels via interconnected pain networks. Neuroplasticity is central to pathological pain, may be initiated by pathology anywhere in the CNS, and occurs at molecular, neuronal, and network levels. Common causes of CPS include central poststroke pain (CPSP), spinal cord injury, and multiple sclerosis. Central pain syndromes are difficult to diagnose as they often coexist with other types of pain and may occur months or years after the initial injury, and there is lack of a clear, widely accepted diagnostic criteria. Diagnosis requires a history consistent with central nervous system pathology and neurologic signs of abnormal pain processing such as allodynia and hyperalgesia. Medications used for treatment of CPS aim to target different pathophysiological mechanisms and include antidepressants, anticonvulsants, cannabinoids, and other drugs. Management of CPS can be challenging as patients often require combinations of medications attained through slow titration and a process of trial and error. Despite this, most patients still experience incomplete pain relief. Neuromodulatory techniques such as transcranial magnetic stimulation, spinal cord stimulation, and deep brain stimulation are promising treatments in select patients. Ultimately, management of CPS requires a multidisciplinary approach with the aggressive treatment of other causes of pain, optimal management of depression and other psychosocial factors, and use of cognitive behavioral therapy, medications, and if needed, neuromodulatory techniques.
Introduction: The prevalence of pain in Multiple Sclerosis (MS) is estimated to be between 29-86% depending on various stages of the disease. According to a recent mechanism-based classification, MS pain syndromes include ongoing extremity pain, trigeminal neuralgia, and Lhermitte’s phenomenon, painful tonic spasms and spasticity pain, pain associated with optic neuritis, musculoskeletal pain, migraine, and treatment-induced pain.
Area covered: Pharmacological approaches for MS pain include anticonvulsants, antidepressants, botulinum toxin, cannabinoids, muscle relaxants, opioid analgesics, and intrathecally administered baclofen. It has been reported that pharmacological treatments have poor efficacy and alarming side effects. For these reasons, non-pharmacological interventions, either alone or in combination with pharmacological treatments are commonly used in clinical practice. Examples of these interventions include electrical or chemical neurostimulation therapy, exercise, and psychological approaches. This is discussed in more detail herein.
Expert opinion: The management of MS pain can be challenging due to the natural course of the disease and the lack of a definite cure. Recommendations based on rigorous scientific methods for MS pain treatment are unavailable. Thus, clinicians should consider available treatment regimens based on efficacy, safety, cost, and the clinical complexity of the patient. The use of therapeutic approaches combining pharmacological and non-pharmacological treatments may help to reduce the risk of overuse and mitigate the complaint of simultaneous and multiple therapies.
Neuromyelitis optica spectrum disorders (NMOSD) are a heterogeneous group of inflammatory, demyelinating and antibody-mediated diseases of the central nervous system (CNS). The anti-aquaporin-4-IgG (AQP4-IgG) seems to be the pathogenetic agent, being present in the large majority of patients, although seronegative forms can occur. Clinical manifestations include core features, such as myelitis, optic neuritis, and area postrema syndrome, possibly associated with collateral symptoms like pain, dystonic movements, and pruritus. Diagnosis is based on both clinical presentation and anti-AQP4-IgG testing. MRI features provide supportive elements in seronegative patients. The most effective therapy in acute attacks is plasma exchange, whereas multiple drugs are used for chronic maintenance (azathioprine, mycophenolate mofetil, rituximab and eculizumab).
Given its potential for diffuse dissemination throughout virtually every portion of the central nervous system (optic nerves, brain, and spinal cord), it is perhaps not surprising that a broad array of symptoms may be reported by patients with Multiple Sclerosis (MS). Nonetheless, the majority of patients with MS will at some point present with a stereotyped constellation of symptoms and signs constituting a first clinical “attack” of demyelination, often referred to as a Clinically Isolated Syndrome (CIS)
The symptoms of progressive MS are thought to be driven by neuronal loss within the CNS and the widespread distribution of the disease can manifest in a wide variety of symptoms. Typically, however, a stereotyped pattern emerges in progressive disease—an upper motor neuron syndrome with the character of a high spinal cord lesion and superimposed ataxia and cognitive impairment. This results in symptoms such as impaired mobility, spasticity, tremor and incoordination, bladder and bowel dysfunction and cognitive difficulties. In addition, fatigue, mood disturbance and paroxysmal symptoms such as trigeminal neuralgia may be troublesome. In the absence of a curative intervention for progressive disease, reducing the burden of symptoms will lead to improvement in quality of life for patients and carers, as well as reducing the significant socioeconomic impact of a chronic, disabling condition. Indeed, such a combined approach which prioritises the identification of disease modifying and improved symptom-relieving therapies is supported by the International Collaborative on Progressive MS Alliance [1].
Carpal tunnel syndrome is the most commonly diagnosed compressive neuropathy and the third most common procedure performed by orthopedic surgeons. The majority of carpal tunnel syndrome is idiopathic with classic symptoms of nocturnal paresthesias and activity-related symptoms with prolonged grip. Carpal tunnel syndrome can be idiopathic or caused by a variety of conditions such as space-occupying disorders or endocrinopathies. As with many disorders, other conditions can cause symptoms mimicking carpal tunnel syndrome, whose pathologies do not involve the median nerve at the carpal tunnel. These diagnoses include neurologic and non-neurologic conditions and should always be considered when evaluating patients with carpal tunnel symptoms, especially in those who present with atypical complaints and an abnormal physical examination. This chapter focuses on those conditions providing clinicians with a broad differential diagnosis for patients with paresthesias of the hand.
In this chapter, we address a frequent and debilitating symptom—pain of one of the most common causes of neurological disability in the young adult: multiple sclerosis. We introduce multiple sclerosis and define the role of neuroimaging in the diagnosis of the disease and beyond. Pain syndromes in multiple sclerosis are described, as well as other comorbidities that may interfere or be associated with pain. We discuss the published literature in neuroimaging and pain in multiple sclerosis, and emphasize the impact of chronic pain in an already non-resilient brain.
Background:
Chronic pain is common and significantly impacts on the lives of persons with multiple sclerosis (pwMS). Various types of non-pharmacological interventions are widely used, both in hospital and ambulatory/mobility settings to improve pain control in pwMS, but the effectiveness and safety of many non-pharmacological modalities is still unknown.
Objectives:
This review aimed to investigate the effectiveness and safety of non-pharmacological therapies for the management of chronic pain in pwMS. Specific questions to be addressed by this review include the following.Are non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) effective in reducing chronic pain in pwMS?What type of non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) are effective (least and most effective) and in what setting, in reducing chronic pain in pwMS?
Search methods:
A literature search was performed using the specialised register of the Cochrane MS and Rare Diseases of the Central Nervous System Review Group, using the Cochrane MS Group Trials Register which contains CENTRAL, MEDLINE, Embase, CINAHL, LILACUS, Clinical trials.gov and the World Health Organization International Clinical Trials Registry Platform on 10 December 2017. Handsearching of relevant journals and screening of reference lists of relevant studies was carried out.
Selection criteria:
All published randomised controlled trials (RCTs)and cross-over studies that compared non-pharmacological therapies with a control intervention for managing chronic pain in pwMS were included. Clinical controlled trials (CCTs) were eligible for inclusion.
Data collection and analysis:
All three review authors independently selected studies, extracted data and assessed the methodological quality of the studies using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) tool for best-evidence synthesis. Pooling data for meta-analysis was not possible due to methodological, clinical and statistically heterogeneity of the included studies.
Main results:
Overall, 10 RCTs with 565 participants which investigated different non-pharmacological interventions for the management of chronic pain in MS fulfilled the review inclusion criteria. The non-pharmacological interventions evaluated included: transcutaneous electrical nerve stimulation (TENS), psychotherapy (telephone self-management, hypnosis and electroencephalogram (EEG) biofeedback), transcranial random noise stimulation (tRNS), transcranial direct stimulation (tDCS), hydrotherapy (Ai Chi) and reflexology.There is very low-level evidence for the use of non-pharmacological interventions for chronic pain such as TENS, Ai Chi, tDCS, tRNS, telephone-delivered self-management program, EEG biofeedback and reflexology in pain intensity in pwMS. Although there were improved changes in pain scores and secondary outcomes (such as fatigue, psychological symptoms, spasm in some interventions), these were limited by methodological biases within the studies.
Authors' conclusions:
Despite the use of a wide range of non-pharmacological interventions for the treatment of chronic pain in pwMS, the evidence for these interventions is still limited or insufficient, or both. More studies with robust methodology and greater numbers of participants are needed to justify the effect of these interventions for the management of chronic pain in pwMS.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effectiveness and safety of non-pharmacological therapies for the management of chronic pain in pwMS. Specific effectiveness questions to be addressed by this review include the following: Are non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) effective in reducing chronic pain in pwMS? What type of non-pharmacological interventions (unidisciplinary and/or multidisciplinary rehabilitation) are effective (least and most effective) and in what setting, in reducing chronic pain in pwMS? © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Multiple sclerosis (MS) is an inflammatory, chronic, demyelinating disease of the central nervous system leading to motor, sensory and cognitive impairment. Among a variety of other symptoms, pain accounts for 30 per cent of all symptomatic treatment in MS. A mechanism-based classification of pain in MS has recently been adopted and will be followed in this chapter: pain is thus classified into neuropathic, nociceptive, psychogenic, idiopathic and unexplained. Treatment of neuropathic pain in MS includes tricyclic antidepressants, antiepileptic medications, intrathecally administered baclofen, opioid analgesics, anesthetic and antiarrhythmic agents, and cannabinoids. Forms of pain covered are trigeminal neuralgia, which is attributed to the MS plaque, musculoskeletal pain and secondary pain. Until now it has been hard to establish a clear correlation between pain and clinical variables. Issues around a proper diagnosis of pain in MS could be resolved with the optimisation of DN4 (Douleur Neuropathique en 4 Questions/Neuropathic Pain in 4 Questions) questionnaire, in clinical setting. Clinical experience is for the moment leading pain treatment in MS.
Chronic pain is common in patients with neurologic complications of a central nervous system insult such as stroke. The pain is most commonly musculoskeletal or related to obligatory overuse of neurologically unaffected limbs. However, neuropathic pain can result directly from the central nervous system injury. Impaired sensory discrimination can make it challenging to differentiate central neuropathic pain from other pain types or spasticity. Central neuropathic pain may also begin months to years after the injury, further obscuring recognition of its association with a past neurologic injury. This review focuses on unique clinical features that help distinguish central neuropathic pain. The most common clinical central pain syndromes—central poststroke pain, multiple sclerosis–related pain, and spinal cord injury–related pain—are reviewed in detail. Recent progress in understanding of the pathogenesis of central neuropathic pain is reviewed, and pharmacological, surgical, and neuromodulatory treatments of this notoriously difficult to treat pain syndrome are discussed.
Introduction:Neuropathic pain is defined by the IASP as pain initiated or caused by a primary lesion or dysfunction of the nervous system [1]. Although this definition has been useful to establish a difference between neuropathic pain and nociceptive pain, it lacks diagnostic specificity. Recently, a new precise definition of neuropathic pain has been proposed to meet these shortcomings and to be used for clinical and research purposes (Table 12.1) [2]. Neuropathic pain after spinal cord injury (SCI) is a type of central neuropathic pain and is a frequent complication of spinal injury which is often refractory. People with spinal cord injury consistently rate pain as one of the most difficult problems to manage, despite the other problems (bowel and bladder function, sexual functioning). Studies investigating the prevalence of neuropathic pain in patients with SCI estimate that chronic pain manifests in approximately two-thirds of patients while one-third of these patients experience severe pain. Spinal cord injury-related pain significantly interferes with daily functioning and ability to participate in life activities [3]. When pain is not treated sufficiently, it leads to physical and psychological disorders decreasing the quality of life and life satisfaction. The long-term prognosis for pain relief following SCI is often poor. Patients reporting neuropathic pain are likely to continue experiencing severe pain at 3-5 years following their injury [4]. Predictive factors for onset of (chronic) neuropathic pain following SCI are old age at the time of the injury, the early onset of pain in the weeks following the initial injury (initial intense pain, continuous pain), associated pathologies (ulcers, infection), and gunshot wound being the cause of the trauma. Level of injury, complete or incomplete SCI, and gender have no impact on the onset of neuropathic pain [5].
Introduction: Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system (CNS). Autoimmunity and degeneration are two intertwined processes that lead to the progressive demyelination and eventual death of CNS neurons [1]. The three most common forms of MS, based on clinical course, are relapsing-remitting (RRMS), secondary progressive (SPMS), and primary progressive (PPMS). Relapsing-remitting MS is the most common form, and is characterized by episodic relapses - the clinical manifestation of a symptomatic lesion in the CNS. Approximately 85% of RRMS evolve into SPMS, which is marked by an absence of relapses and a steady worsening of disability. Primary progressive MS is defined by the absence of relapses, with progressive disability accruing from the onset of disease. Regardless of disease type, the subsequent CNS dysfunction manifests in a multitude of clinical symptoms, including weakness, spasticity, numbness, paresthesias, vision impairment, ataxia, tremor, cognitive impairment, fatigue, mood disorders, bowel and bladder dysfunction, sexual dysfunction, and several types of pain. Of the multitude of symptoms that people with MS experience, roughly one third rank pain as the most serious [2-4]. Pain is associated with sleep disorders, mood disorders, and poor health-related quality of life scores [3,5-8]. Effective treatments to manage central pain in MS are also lacking and are currently limited to those known to work for peripheral pain syndromes. To date, there have been few randomized controlled trials to guide specific treatments for MS-associated pain.
Given that MS is a complex, multisystem disease which may cause difficult symptoms in many different systems, the approach to symptom control should be led and coordinated by a physician with a specialist interest in MS. Over the course of the disease, a variable degree of input is likely to be required from primary care physicians as well as specialists in a variety of medical specialities, including, although not limited to, neurology, neurorehabilitation, and palliative care. The role of health professionals in disciplines allied to medicine should not be underestimated and careful attention must be given to patient preference. The needs of caregivers should also be respected and facilitated. In the absence of an available cure for MS, research into improved symptom management should be supported and must include systematic, well-designed clinical trials to evaluate treatments as they emerge.
Radiation myelopathy is a rare, but extremely serious side-effect of radiotherapy. Recovery from radiation-induced motor sequelae is rare, whereas, the regeneration of sensory losses is relatively frequent. Among the sensory radiogenic injuries of the spinal cord, Lhermitte's sign (LS) is most frequent. This review describes the clinical picture and diagnostic imaging signs of radiogenic LS. There have been only a few studies on large patient groups with radiogenic LS, demonstrating a rate of occurrence of 3.6-13%, relating mainly to mantle irradiation or the radiotherapy of head and neck tumors. These cases typically manifest themselves 3 months following radiotherapy and gradually disappear within 6 months. Only 3 LS cases have been described in the English literature with extraordinarily severe symptoms lasting for more than 1 year. MRI, a sensitive tool in the detection of demyelination, failed to reveal any pathological sign accompanying radiogenic LS. However, positron emission tomography demonstrated increased [18F]fluorodeoxyglucose accumulation and [15O]butanol perfusion, but a negligible [11C]methionine uptake in the irradiated spinal cord segments in patients with long-standing LS. These imaging data are suggestive of a close direct relationship between the regional perfusion and metabolism of the spinal cord, very much like the situation in the brain. We postulate that an altered, energy-demanding conduction along the demyelinated axons of patients with chronic radiogenic LS may explain the increased metabolism and perfusion.
• The Lhermitte's sign was first described by Pierre Marie and Chatelin in 1917. Lhermitte reported on this symptom in 1920, and in 1924 he published the seminal article on the subject. In 1928, it was introduced to the American literature, and it was around that time that the symptom became well known. The historic development of this observation into an eponym is documented.
SYNOPSIS
A self-administered questionnaire based on the operational diagnostic criteria of the International Headache Society (IHS) was evaluated in a cross-sectional epidemiological survey of headache disorders. A clinical interview was used as index of validity. Seven hundred and thirteen subjects were included.Sensitivity, specificity, predictive value, and chance-corrected agreement rate for the diagnosis of migraine was 51%, 92%, 50% (PVpos), 93% (PVneg), and 0.43 respectively. Corresponding values for episodic tension-type headache were 43%, 96%, 95% (PVpos), 46% (PVneg), and 0.30; and for chronic tension-type headache 14%, 100%, 100% (PVpos), 97% (PVneg), and 0.24. It is concluded that a questionnaire is not a satisfactory tool in diagnosing headache disorders according to the IHS criteria.The methods of data collection seem to have significant influence on the results. Caution in handling data obtained by means of subjective statements is advocated.
The International Panel on MS Diagnosis presents revised diagnostic criteria for multiple sclerosis (MS). The focus remains on the objective demonstration of dissemination of lesions in both time and space. Magnetic resonance imaging is integrated with clinical and other paraclinical diagnostic methods. The revised criteria facilitate the diagnosis of MS in patients with a variety of presentations, including “monosymptomatic” disease suggestive of MS, disease with a typical relapsing-remitting course, and disease with insidious progression, without clear attacks and remissions. Previously used terms such as “clinically definite” and “probable MS” are no longer recommended. The outcome of a diagnostic evaluation is either MS, “possible MS” (for those at risk for MS, but for whom diagnostic evaluation is equivocal), or “not MS.”
The Lhermitte's sign was first described by Pierre Marie and Chatelin in 1917. Lhermitte reported on this symptom in 1920, and in 1924 he published the seminal article on the subject. In 1928, it was introduced to the American literature, and it was around that time that the symptom became well known. The historic development of this observation into an eponym is documented.
Tuberous sclerosis belongs to the diseases diagnosed usually at pre-school or school age. Pringle's naevus ist the basic sing indicating the diagnosis. Genetic determination of the disease makes possibly early diagnosis necessary for correct genetic counselling. In the light of long-term observations of children with tuberous sclerosis the authors discuss the problems connected with early diagnosis of this condition evaluating the diagnostic usefulness of various signs and symptoms of the disease, and the usefulness of radiological examination methods. The importance of computer tomography for early diagnosis, and of family examination in cases of tuberous sclerosis is emphasized.
Lhermitte's sign was experienced by 33.3% of 114 patients with multiple sclerosis, and in 16% it occurred in the first episode. Eleven patients with subacute combined degeneration of the cord due to pernicious anaemia also were reviewed, and one reported Lhermitte's sign. Review of the literature suggests that the symptom rarely occurs in other conditions except subacute combined degeneration of the cord, neck trauma, radiation myelitis and prolapsed cervical disc.
To test the presumption that Lhermitte's sign in multiple sclerosis is the result of a lesion in the cervical spinal cord.
The radiologic files of 887 patients with multiple sclerosis were reviewed. A detailed questionnaire regarding Lhermitte's sign was sent to 75 patients who had undergone magnetic resonance imaging of the brain and cervical spinal cord. Of the 64 patients who responded, 55 patients who had complete magnetic resonance imaging files were studied. The cases of two illustrative patients are presented.
A strong association between Lhermitte's sign and abnormalities of the cervical spinal cord seen on magnetic resonance imaging was noted. Most of the abnormalities were in the posterior part of the cervical spinal cord.
The findings confirm the presumption that a lesion in the posterior columns of the cervical spinal cord is the cause of Lhermitte's sign in multiple sclerosis.
To assess the frequency and quality of sensory symptoms in a population of patients with Multiple Sclerosis (MS) and compare them with controls.
Survey to target population and control group evaluating demographic data, data on disease course, presence of various symptoms of MS.
Neurological practices affiliated with a tertiary community hospital.
224 patients with MS, 93 controls of similar age and sex.
Sensory symptoms were more common in MS patients than in controls, and differed in severity and quality. Fifty per cent described brief (seconds to hours) episodes of neurological dysfunction, significantly more often than in controls (P = 0.001). Pain was present at some time in similar percentages in patients and controls, but active pain problems were present more often in MS patients (P = 0.001). The qualitative description of pain in MS patients was more often neuropathic, with burning, itching, electric and formicatory pain, as opposed to throbbing, sharp or muscular pain. Pain was localized to arms, legs, trunk, hands, feet and face more often in the MS group. Lhermitte's phenomenon was present in two-thirds of patients at some time in their disease course. Twenty per cent of the patients identified themselves as having respiratory problems (Controls 7.5%, P = 0.005). Fatigue limited activity in 78% of patients, but only in 17% of controls (P = 0.001). Dizziness, memory dysfunction, and restless legs symptoms were all more frequent in patients. The self-rated 'worst' symptoms of MS was pain in 12%, fatigue in 17% and dizziness in 5%, a total of 34% of 'worst' symptoms. Sensory symptoms were present in patients with early disease and without disability as often as in disabled patients and in those with longer disease duration. There was however a strong correlation between the total number of sensory symptoms reported and the presence of disability in the MS patients.
Sensory symptoms are common in MS patients. Pain syndromes, transient neurologic events, Lhermitte's phenomenon, fatigue, respiratory symptoms and vertigo were present significantly more frequently in patients with MS than in a control population and contributed to subjective morbidity. Future clinical trials assessing therapy in MS might include sensory symptoms as secondary endpoints to capture this 'hidden reservoir' of disease morbidity.
The pathophysiology of multiple sclerosis is reviewed, with emphasis on the axonal conduction properties underlying the production of symptoms, and the course of the disease. The major cause of the negative symptoms during relapses (e.g. paralysis, blindness and numbness) is conduction block, caused largely by demyelination and inflammation, and possibly by defects in synaptic transmission and putative circulating blocking factors. Recovery from symptoms during remissions is due mainly to the restoration of axonal function, either by remyelination, the resolution of inflammation, or the restoration of conduction to axons which persist in the demyelinated state. Conduction in the latter axons shows a number of deficits, particularly with regard to the conduction of trains of impulses and these contribute to weakness and sensory problems. The mechanisms underlying the sensitivity of symptoms to changes in body temperature (Uhthoff's phenomenon) are discussed. The origin of 'positive' symptoms, such as tingling sensations, are described, including the generation of ectopic trains and bursts of impulses, ephaptic interactions between axons and/or neurons, the triggering of additional, spurious impulses by the transmission of normal impulses, the mechanosensitivity of axons underlying movement-induced sensations (e.g. Lhermitte's phenomenon) and pain. The clinical course of the disease is discussed, together with its relationship to the evolution of lesions as revealed by magnetic resonance imaging and spectroscopy. The earliest detectable event in the development of most new lesions is a breakdown of the blood-brain barrier in association with inflammation. Inflammation resolves after approximately one month, at which time there is an improvement in the symptoms. Demyelination occurs during the inflammatory phase of the lesion. An important mechanism determining persistent neurological deficit is axonal degeneration, although persistent conduction block arising from the failure of repair mechanisms probably also contributes.
To evaluate the clinical course of MS in individuals with onset of MS before age 16.
Patients with onset of MS before age 16 (n = 116) with complete clinical information on the clinical course from the MS Clinic at The University of British Columbia (UBC) Site Hospital computerized database (MS-COSTAR) were included in this study. The data were compared to those from the Canadian natural history study for MS clinic attendees, regardless of age at onset.
The mean duration of observation was 19.76 +/- 0.90 years; the mean age at MS onset was 12.73 +/- 0.25 years. Only three cases (2.6%) had a primary progressive (PP) MS course. To date, 60 (53.1%) of 113 subjects have developed secondary progressive (SP) MS. The 50% probability for SPMS was reached 23 years after onset. For patients with relapsing remitting (RR) or SPMS the mean disease duration from onset to the time of confirmed Expanded Disability Status Scale (EDSS) 3.0 was 16.03 +/- 1.17 years (at mean age 28.47 +/- 1.14); mean duration from onset to the time of EDSS 6.0 was 19.39 +/- 1.43 years (at mean age 32.32 +/- 1.44). Annual relapse rate was 0.54 +/- 0.05 per year. The correlation between the number of relapses during the first year of disease and the course of the disease was also significant.
The prevalence of early onset MS (3.6%) in our study confirms the previous findings on early onset MS. A RR course was seen in the majority of cases of early onset MS. A high frequency of relapses, early age at permanent disability, and the presence of malignant cases raise the question of possible early use of disease-modifying therapy in patients with early onset MS.
In most epidemiological studies on carpal tunnel syndrome (CTS), the case definition is based on questionnaire data with or without neurophysiological testing. The aim of this study was to test if the use of questionnaire data results in misclassification of cases.
In two studies, involving 940 and 311 participants, respectively, the people indicating CTS symptoms (tingling) in a questionnaire were clinically interviewed. In a subpopulation (n = 404), all went through an interview regardless of their questionnaire answers.
Only 35-45% of the participants reporting tingling once a week or more in the questionnaire actually had symptoms consistent with CTS when interviewed. The remaining 55-65% had no or infrequent symptoms or symptoms because of other disorders. Few potential CTS cases were missed. The positive predictive values were 0.48 (95% CI = 0.30-0.66) and 0.52 (95% CI = 0.38-0.67) on the right and left hands, respectively. The sensitivities, specificities and negative predictive values ranged from 0.87 to 1.00.
Questionnaire information overestimates the prevalence of CTS symptoms. However, asking about tingling in a questionnaire is a simple and sensitive first step to detect potential CTS cases, but symptoms should be confirmed by interview.
To compare history of 22 different diseases reported during an in-person interview with that reported on a mailed self-administered questionnaire.
7841 participants of the European Prospective Investigation into Cancer (EPIC)-Potsdam study. The interview at baseline and the questionnaire at follow-up approximately 2 years later included identical questions about whether the participant had ever had a physician diagnosis of each disease. Incident diagnoses occurring in the interval between the interview and questionnaire were excluded from the analysis.
Agreement between self-report from the interview and from the questionnaire was highest (kappa = 0.83-0.88) for myocardial infarction, cancer and diabetes mellitus; it was lower (kappa = 0.68-0.77) for gout, hypertension, hay fever, asthma, osteoporosis, ulcer of the duodenum, thyroid disease, stroke, and kidney stones, and was lowest (kappa = 0.39-0.59) for chronic gastritis, ulcer of the stomach, cerebral ischemia, benign tumor, inflammatory bowel disease, angina pectoris, hyperlipidemia, rheumatism, colon polyps and skin disease. The poor agreement for less severe or more transient diseases was primarily a result of disease frequently being reported at the interview but not on the questionnaire.
Self-administered questionnaires do not generate same information particularly for less severe or transient diseases as personal interviews. For these diseases, self-administered questionnaires are not recommended. Pilot studies that test validity will be necessary.
Interview data versus questionnaire data in the diagnosis of carpal tunnel syndrome in epidemio-logical studies Early onset multiple sclerosis. A longitudinal study The pathophysiology of multiple sclerosis: the mechanisms underlying the production of symptoms and the natural history of the disease
- Thomsen Jf
- Mikkelsen
- G Vorobeychik
- D Paty
- V Devonshire
- Ubc D Sadovnick
- Ms
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Multiple sclerosis with Lhermitte's sign
- Cf Read
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Sensory symptoms of multiple sclerosis: a hidden reservoir of morbidity Agreement of self-reported medical history: comparison of an in-person interview with a self-administered questionnaire
- Rae-Grant Ad
- Nj Eckert
- Reed S Bartz
- Jf
- Bergmann Mm
- Ej
- K Hofmann
- Boeing
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