Symptomatic treatment in multiple sclerosis

Interhemispheric Asymmetries in Intracortical Facilitation Correlate With Fatigue Severity in Individuals With Poststroke Fatigue

PURPOSE

Poststroke fatigue (PSF) contributes to increased mortality and reduces participation in rehabilitative therapy. Although PSF's negative influences are well known, there are currently no effective evidence-based treatments for PSF. The lack of treatments is in part because of a dearth of PSF pathophysiological knowledge. Increasing our understanding of PSF's causes may facilitate and aid the development of effective therapies.

METHODS

Twenty individuals, >6 months post stroke, participated in this cross-sectional study. Fourteen participants had clinically relevant pathological PSF, based on fatigue severity scale (FSS) scores (total score ≥36). Single-pulse and paired-pulse transcranial magnetic stimulation were used to measure hemispheric asymmetries in resting motor threshold, motor evoked potential amplitude, and intracortical facilitation (ICF). Asymmetry scores were calculated as the ratios between lesioned and nonlesioned hemispheres. The asymmetries were then correlated (Spearman rho) to FSS scores.

RESULTS

In individuals with pathological PSF ( N = 14, range of total FSS scores 39-63), a strong positive correlation ( rs = 0.77, P = 0.001) between FSS scores and ICF asymmetries was calculated.

CONCLUSIONS

As the ratio of ICF between the lesioned and nonlesioned hemispheres increased so did self-reported fatigue severity in individuals with clinically relevant pathological PSF. This finding may implicate adaptive/maladaptive plasticity of the glutamatergic system/tone as a contributor to PSF. This finding also suggests that future PSF studies should incorporate measuring facilitatory activity and behavior in addition to the more commonly studied inhibitory mechanisms. Further investigations are required to replicate this finding and identify the causes of ICF asymmetries.

Cortical neurodynamics changes mediate the efficacy of a personalized neuromodulation against multiple sclerosis fatigue

The people with multiple sclerosis (MS) often report that fatigue restricts their life. Nowadays, pharmacological treatments are poorly effective accompanied by relevant side effects. A 5-day transcranial direct current stimulation (tDCS) targeting the somatosensory representation of the whole body (S1) delivered through an electrode personalized based on the brain MRI was efficacious against MS fatigue (FaReMuS treatment). This proof of principle study tested whether possible changes of the functional organization of the primary sensorimotor network induced by FaReMuS partly explained the effected fatigue amelioration. We measured the brain activity at rest through electroencephalography equipped with a Functional Source Separation algorithm and we assessed the neurodynamics state of the primary somatosensory (S1) and motor (M1) cortices via the Fractal Dimension and their functional connectivity via the Mutual Information. The dynamics of the neuronal electric activity, more distorted in S1 than M1 before treatment, as well as the network connectivity, altered maximally between left and right M1 homologs, reverted to normal after FaReMuS. The intervention-related changes explained 48% of variance of fatigue reduction in the regression model. A personalized neuromodulation tuned in on specific anatomo-functional features of the impaired regions can be effective against fatigue.

Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association

At least half of all stroke survivors experience fatigue; thus, it is a common cause of concern for patients, caregivers, and clinicians after stroke. This scientific statement provides an international perspective on the emerging evidence surrounding the incidence, prevalence, quality of life, and complex pathogenesis of poststroke fatigue. Evidence for pharmacological and nonpharmacological interventions for management are reviewed, as well as the effects of poststroke fatigue on both stroke survivors and caregivers.

Management of fatigue in persons with multiple sclerosis

Fatigue is one of the most common symptoms of multiple sclerosis. Despite advances in pharmacological and non-pharmacological treatment, fatigue continues to be the disabling symptom in persons with MS (pwMS), affecting almost 80% of pwMS. In current practice, both pharmacological and non-pharmacological interventions are used in combination, encompassing a multi-disciplinary approach. The body of research investigating the effect of these interventions is growing. This review systematically evaluated the existing evidence on the effectiveness and safety of different interventions currently applied for the management of fatigue in person with multiple sclerosis in improving patient outcomes, to guide treating clinicians.

Pharmacological treatment of pain in multiple sclerosis

Pain is a common symptom in multiple sclerosis (MS) and was recently estimated to be experienced by up to 75% of patients. Nociceptive and neuropathic pain in MS may be present concurrently and at different stages of the disease and may be associated with other symptoms. Evidence for treating pain in MS is limited. Many clinical features of pain are often unrecognized by clinicians and are difficult for patients to describe. Treatment is often based on anecdotal reports and clinical experience. We present a review of treatment options for pain in MS that should serve to update current knowledge, highlight shortcomings in clinical research and provide indications towards achieving evidence-based treatment of pain in MS.

Further evaluation of the Motivational Model of Pain Self-Management: coping with chronic pain in multiple sclerosis

BACKGROUND

Growing evidence suggests that motivation to engage in pain-coping strategies is a key predictor of how well a person adjusts to pain. According to the Motivational Model of Pain Self-Management, readiness to engage in pain self-management behaviors is influenced by beliefs about the importance of the behavior (importance) and the ability to carry out the behavior (self-efficacy).

PURPOSE

The purpose of this study was to test the Motivational Model of Pain Self-Management for exercise and task persistence pain-coping behaviors in a sample of 114 individuals with multiple sclerosis and chronic pain.

METHODS

Measures included the Multidimensional Pain Readiness to Change Questionnaire-2 and measures of importance, self-efficacy, and coping behavior duration. Tests of mediation were conducted with two path analyses, one for each coping behavior.

RESULTS

The effects of importance and self-efficacy beliefs on coping behaviors were mediated or partially mediated by readiness to engage in those behaviors.

CONCLUSIONS

These findings provide support for the Motivational Model of Pain Self-Management and have important implications for the development of treatments for chronic pain.

Pharmacological management of pain in patients with multiple sclerosis

Multiple sclerosis (MS) is an inflammatory, demyelinating, autoimmune disease of the CNS. There are currently a number of disease-modifying medications for MS that modulate or suppress the immune system; however, these medications do not directly relieve MS symptoms, which include visual deficits, gait problems, sensory deficits, weakness, tremor, spasticity and pain, among others. Pain is a common symptom in MS which has recently been estimated to be experienced by more than 40% of patients. Nociceptive pain occurs as an appropriate physiological response transmitted to a conscious level when nociceptors in bone, muscle or any body tissue are activated, warning the organism of tissue damage. Neuropathic pain is initiated as a direct consequence of a lesion or disease affecting the somatosensory system, with no physiological advantage. Nociceptive and neuropathic pain in MS may be present concurrently and at different stages of the disease, and may be associated with other symptoms. Central neuropathic pain has been reported to be among the most common pain syndromes in MS. It is described as constant, often spontaneous, burning occurring more frequently in the lower limbs. Treatment typically includes tricyclic antidepressants and antiepileptic medications, although studies have been conducted in relatively small samples and optimal dosing has not been confirmed. Cannabinoids have been among the few treatments studied in well designed, randomized, placebo-controlled trials for central neuropathic pain. In the largest of these trials, which included 630 subjects, a 15-week comparison between Delta9-tetrahydrocannabinol and placebo was performed. More patients receiving active treatment perceived an improvement in pain than those receiving placebo, although approximately 20% of subjects reported worsening of pain while on active treatment. Trigeminal neuralgia, while affecting less than 5% of patients with MS, is the most studied pain syndrome. The pain can be extreme and is typically treated with carbamazepine, although adverse effects can mimic an MS exacerbation. Painful topic spasms occur in approximately 11% of the MS population and are treated with antispasticity medications such as baclofen and benzodiazepines. Gabapentin has also demonstrated efficacy, but all studies have included small sample sizes. In general, evidence for treating pain in MS is limited. Many clinical features of pain are often unrecognized by clinicians and are difficult for patients to describe. Treatment is often based on anecdotal reports and clinical experience. We present a review of treatment options for pain in MS, which should serve to update current knowledge, highlight shortcomings in clinical research and provide indications towards achieving evidence-based treatment of pain in MS.

Validation and Reliability of the Neuropathic Pain Scale (NPS) in Multiple Sclerosis

OBJECTIVE

Central neuropathic pain occurs in around 28% of patients with multiple sclerosis (MS). The Neuropathic Pain Scale (NPS) has received preliminary validation in peripheral neuropathic pain conditions. The aim of this study was to validate its use in MS central pain syndromes.

METHODS

We administered the NPS to 141 patients with MS, together with the Short Form McGill Pain Questionnaire (SFMPQ), the Hospital Anxiety and Depression Scale (HADS), and Short Form 36 Health Survey (SF-36).

RESULTS

Cronbach's alpha was 0.78 (95% CI 0.69; 0.83), implying a high degree of internal consistency. Three factors, "Familiar," "Superficial," and "Alien Perception," were extracted, accounting for 64% of the variance. The NPS 10-item total correlates with: the SFMPQ 15-item total score, rho=0.63 (95% CI 0.49; 0.74), its Visual Analog Scale, rho=0.49 (95% CI 0.33; 0.64), the transformed Pain domain of the SF-36 rho=-0.49 (95% CI -0.63; -0.32), but not with its remaining seven health domains, or with either the HADS anxiety or the depression scores. Limits of agreement for short-term test or re-test reliability of the 100 point NPS total (median 2 days, range 1 to 7) were -12 to 14 and when administered to 78 patients who rated their neuropathic pain the "Same" [median interval 33 days (range 19 to 126), the long-term test or re-test correlation coefficient was 0.71 (95% CI 0.6; 0.79)].

DISCUSSION

The NPS appears a useful tool in the assessment of neuropathic pain in MS patients and possibly in measuring outcomes of therapeutic interventions.

Impact of Pain on Outcomes in Long-Term Care Residents with and without Multiple Sclerosis

OBJECTIVES

To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission.

DESIGN

Retrospective analysis of a large data set.

SETTING

LTC facilities in Missouri.

PARTICIPANTS

Residents admitted to non-hospital-based LTC facilities.

MEASUREMENTS

Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale.

RESULTS

Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P<.001) and a greater prevalence of pressure ulcers (P=.004) and depression (P<.001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P<.001), pressure ulcers (P<.001), depression (P<.001), and cognitive performance (P<.001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P<.001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02).

CONCLUSION

Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.

Comfort care in severely disabled multiple sclerosis patients

Comfort may be considered as the material aspect of well-being, and its limitation, defined as discomfort, exacerbates both the patient's and caregivers' difficulties. Discomfort results from the interaction of a patient's environment, treatment, and from the nature and severity of elementary deficits, such as spasticity, ranges of motion, pain, postural disorders, motor deficit and fatigue, bladder problems, insufficient ventilatory control, and also psychological difficulties. Although discomfort reduction may represent a major challenge in disabled persons, discomfort is usually underestimated in the assessment of deficiencies, disabilities, handicap, and even in quality of life (QOL) estimations. In this paper, we explain why discomfort may be a crucial problem in severe multiple sclerosis (MS) and argue for a systematic assessment of discomfort in the follow-up of the disease, especially in the following domains: dressing, washing, maintaining posture in a wheelchair and bed, food intake, mastication and swallowing, bowel control, urinary and feces emission, and also sexual life. The way to enhance comfort in MS patients is then analyzed.

Treatment of multiple sclerosis with lofepramine, L-phenylalanine and vitamin B(12): mechanism of action and clinical importance: roles of the locus coeruleus and central noradrenergic systems

In a randomized, placebo-controlled double-blind trial a combination of lofepramine, phenylalanine and vitamin B(12) was found to be effective in relieving the symptoms of multiple sclerosis (MS). The effect occurred within 2-4 weeks, and improved all types of symptoms in all types of MS. The combination was also effective in relieving symptoms in patients with chronic pain and chronic fatigue. We hypothesize that the action of this combined therapy may relate to activation of the noradrenergic locus coeruleus/lateral tegmentum (LC/LT) system which has the potential to influence the functioning of large areas of the brain and spinal cord.

Is there a differential impact of fatigue and physical disability on quality of life in multiple sclerosis?

To investigate the quantitative impact of fatigue on health-related quality of life (HRQoL) in multiple sclerosis (MS) and to determine whether fatigue was related to HRQoL independently from bodily disability, data on HRQoL were ascertained for 87 patients with definite MS by using the SF-36. HRQoL scores and subscores were related to the basic MS disability score (EDSS) and further MS parameters, and to fatigue, which was assessed by using different fatigue scales. Factors related to predominantly physical but not mental HRQoL aspects were identified as related to EDSS, duration of disease, and age. Different fatigue scores did impact significantly on both physical and especially mental HRQoL. The influence of fatigue on physical HRQoL was independent from EDSS. Fatigue experience reduces HRQoL markedly and independently from EDSS. Therefore, fatigue assessment provides additional information to disability-derived scales such as the EDSS with relevant implications for therapeutic decisions.

Cardiovascular autonomic dysregulation and fatigue in multiple sclerosis

Both cardiovascular disturbances and fatigue are frequent in multiple sclerosis (MS). We investigated their relationship in 84 MS patients (mean age 39.9 +/- 8.9 years) using five established autonomic tests and three different fatigue questionnaires. 64.2% of the patients were categorised as being fatigued Fatigue perception was weakly related to EDSS. Moderate cardiovascular disturbances were found in 16.6% of the patients, and 10.7% had severe cardiovascular autonomic abnormalities. Cardiovascular dysfunction was slightly related to age and to EDSS. In 19.4% of all patients signs of autonomic failure and fatigue were co-existent Using correlation analysis, we found only weakly significant correlation coefficients between some single autonomic test parameters and fatigue scores, which were confounded by age effects. The analysis of dichotomised data revealed slightly significant differences in fatigue experience between patients with and without abnormalities regarding the handgrip test and the Valsalva reaction. Thus, autonomic disturbances might contribute to fatigue symptoms in a MS subgroup, but the overall influence of the autonomic cardiovascular regulation towards fatigue experience seems to be of minor relevance.