Kurtzke's Disability Status Scale Research Articles

Self-management, self-esteem and their associations with psychological well-being in people with multiple sclerosis

BackgroundOptimal self-management seem to be protective factor of health-related quality of life and psychological well-being in many chronic conditions. However, the results in people with multiple sclerosis (MS) are still inconclusive. Thus, the aim of this study is to assess the associations between self-management, self-esteem and psychological well-being in people with MS when controlled for sociodemographic and clinical variables. MethodsA total of 165 people with MS filled in The Multiple Sclerosis Self-Management Scale, Rosenberg Self-Esteem scale, and General Health Questionnaire-28, to assess main variables under study. Functional status was measured by Kurtzke disability Status Scale. ResultsWe found significant associations between self-esteem and somatic symptoms, anxiety/insomnia, social dysfunction and severe depression. Explained variance of the models ranged from 16% to 38% for somatic symptoms and severe depression, respectively. Self-management significantly contributed to the explained variance in all models sans GHQ social dysfunction. Self-esteem was significant contributor to overall variance in all models. DiscussionAccording to our results, self-management and self-esteem were found to be associated with multiple domains of psychological well-being. These findings may be used in neurological practice, to help people with MS who report psychological distress in one or more domains.

The Gulf War era multiple sclerosis cohort: 3. Early clinical features.

To present clinical features at diagnosis for a large nationwide incident cohort of multiple sclerosis (MS) among those serving in the US military during the Gulf War era (GWE). Medical records and databases from the Department of Veterans Affairs (VA) for cases of MS with onset in or after 1990, active duty between 1990 and 2007 and service connection by the VA, were reviewed for diagnosis and demographic variables. Neurological involvement was summarized by the Kurtzke Disability Status Scale (DSS) and the Multiple Sclerosis Severity Score (MSSS). Among 1919 cases of clinically definite MS, 94% had a relapsing-remitting course and 6% were primary progressive at diagnosis. More males of all races and blacks of both sexes were progressive. At diagnosis, functional system involvement was pyramidal 69%, cerebellar 58%, sensory 55%, brainstem 45%, bowel/bladder 23%, cerebral 23%, visual 18%, and other 5%. Mean DSS scores were: white males, females 2.9, 2.7; black males, females 3.3, 2.8; and other-race males, females 3.2, 2.6. Mean and median MSSS were marginally greater in black males and other males compared to the other sex-race groups. In this incident cohort, males and blacks had significantly higher proportions of primary progressive MS. DSS at diagnosis was significantly more severe in blacks and significantly less so in whites and in women vs men, but MSSS was only marginally greater in black males and other-race males. This morbidity assessment early in the course of MS provides population-based data for diagnosis, management, and prognosis.

Rehabilitation with Neuromuscular Electrical Stimulation Leads to Functional Gains in Ambulation in Patients with Secondary Progressive and Primary Progressive Multiple Sclerosis: A Case Series Report

Gait disability in patients with secondary progressive multiple sclerosis (SPMS) or primary progressive multiple sclerosis (PPMS) rarely improves. This article reports on a case series of patients with SPMS and PPMS who were treated using neuromuscular electrical stimulation (NMES), a well-tolerated physical therapy (PT) treatment modality used to aid musculoskeletal recovery, coupled with a home-exercise program (HEP) to treat MS-related gait disability. The setting for this trial was a PT private practice. This trial was conducted with patients who had SPMS or PPMS with MS-related gait disability. CASE SERIES DESCRIPTION/INTERVENTION: Between June 2007 and June 2009, a licensed physical therapist (R.D.) used NMES coupled with a HEP to work with patients who had SPMS/PPMS and multiple sclerosis (MS)-related gait disability. All of the cases in which an NMES test session of NMES was conducted were included in the case series. Data regarding MS symptoms, treatment, gait, and function were abstracted from the PT clinic notes. Results of assessment with the expanded Kurtzke Disability Status Scale (EDSS) at presentation and at most recent visit were abstracted from the clinical record by the treating physical therapist (R.D.). CLINICAL OUTCOME/RESULTS: Nine (9) patients (7 with SPMS and 2 with PPMS) met inclusion criteria for review. Mean of years of diagnosis was 10.4 (range, 4-15), and mean EDSS score at presentation was 5.9 (range, 4.5-6.5). Mean of days of NMES was 140 (range, 22-495). Mean EDSS scores improved by 0.78 (range, 0-2.0). NMES, an approved Food and Drug Administration treatment modality for muscle spasm, muscle pain, and disuse atrophy-all of which are commonly present in patients with gait disability associated with SPMS and PPMS-was associated with measurable gains in ambulatory function. Additional studies are warranted.

Methisoprinol in the treatment of multiple sclerosis.

Twenty-five patients affected by remittent form of multiple sclerosis (MS) were treated with methisoprinol for a period of 2 years. The clinical parameters, recorded during a 2-year observation period preceding onset of therapy, were compared with the analogous measures recorded during treatment. Treatment was associated with significant favourable changes. In fact, there were observed: a reduction in mean annual relapse rate for 22 of 25 patients; an improvement in the clinical status as demonstrated by the reduction of the Kurtzke Disability Status Scale values obtained in 14 of 25 patients; a reduction in the mean period of standard corticosteroid therapy.

Natural History of Multiple Sclerosis with Childhood Onset

The course and prognosis of childhood-onset multiple sclerosis have not been well described. We used data from 13 adult neurology departments affiliated with the European Database for Multiple Sclerosis (EDMUS) network to identify a cohort of 394 patients who had multiple sclerosis with an onset at 16 years of age or younger and a comparison group of 1775 patients who had multiple sclerosis with an onset after 16 years of age. We determined the initial clinical features, the dates of disease onset, and the occurrence of outcomes, including relapse, conversion to secondary progression, and irreversible disability as measured by scores of 4 (limited walking ability but ability to walk more than 500 m without aid or rest), 6 (ability to walk with unilateral support no more than 100 m without rest), and 7 (ability to walk no more than 10 m without rest while using a wall or furniture for support) on the Kurtzke Disability Status Scale (range, 0 to 10; higher scores indicate more severe disability). For patients with childhood-onset multiple sclerosis, the estimated median time from onset to secondary progression was 28 years, and the median age at conversion to secondary progression was 41 years. The median times from onset to disability scores of 4, 6, and 7 were 20.0, 28.9, and 37.0 years, respectively, and the corresponding median ages were 34.6, 42.2, and 50.5 years. In comparison with patients with adult-onset disease, those with childhood-onset disease were more likely to be female than male (female:male ratio, 2.8 vs. 1.8), were more likely to have an exacerbating-remitting initial course (98% vs. 84%), took approximately 10 years longer to reach secondary progression and irreversible disability, and reached these landmarks at an age approximately 10 years younger (P<0.001 for all comparisons). Patients with childhood-onset multiple sclerosis take longer to reach states of irreversible disability but do so at a younger age than patients with adult-onset multiple sclerosis.

Natural History of Human T-Lymphotropic Virus 1–Associated Myelopathy

The progression of neurological disability in human T-lymphotropic virus 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) remains undefined. To determine the time course of disability scores and to identify predictors of outcome among patients with HAM/TSP. Clinical 14-year follow-up study. University hospital. Patients One hundred twenty-three patients with HAM/TSP. We determined time from onset to the following 4 Kurtzke Disability Status Scale (DSS) end points: scores of 6 (unilateral aid required), 6.5 (bilateral aid required), 8 (wheelchair confinement), and 10 (death related to the disease). Times to reach selected DSS scores were estimated using the Kaplan-Meier method. Univariate and multivariate analyses identified variables related to the rate of progression to DSS 8. The HTLV-1 proviral loads were also assessed. The disability of the cohort progressed throughout the follow-up period. The median times from onset to DSS 6, 6.5, and 8 were 6, 13, and 21 years, respectively. The median time from DSS 6 to DSS 8 was 8 years; DSS 10 was reached by one fourth of the patients within 20 years. Age at onset of 50 years or older and high HTLV-1 proviral load were associated with a shorter time to DSS 8 (P = .01 and P = .02, respectively). A shorter time to DSS 6 significantly adversely affected the time to progression from DSS 6 to DSS 8. Human T-lymphotropic virus 1-associated myelopathy/tropical spastic paraparesis is a rapidly disabling disease. Monitoring for HTLV-1 proviral load is recommended in future therapeutic trials.

Age at disability milestones in multiple sclerosis

Many efforts have been devoted to the description of the prognosis of multiple sclerosis and its possible influential factors in terms of time to reach disability milestones. By contrast, the age at which patients with multiple sclerosis reach these milestones has not yet stirred much interest. We have tested the hypothesis whether the prognosis of multiple sclerosis depends on the current age of patients and the initial course of the disease. We have assessed disease onset and course, and assignment of scores of irreversible disability in 1844 patients with multiple sclerosis. We have used three scores on the Kurtzke Disability Status Scale as benchmarks of disability accumulation: DSS 4 (limited walking but without aid), DSS 6 (walking with unilateral aid) and DSS 7 (wheelchair-bound). We used Kaplan-Meier analyses to estimate the age of the patients at assignment of disability milestones. The possible influence of the initial course of multiple sclerosis and of other clinical variables early assessable in the disease on these outcome measures was also studied, using the Kaplan-Meier curves for univariate analyses and Cox models for multivariate analyses. For the 1844 patients, median ages at time of assignment of irreversible disability were 44.3 years (95% CI 43.3-45.2) for a score of DSS 4, 54.7 years (95% CI 53.5-55.8) for DSS 6 and 63.1 years (95% CI 61.0-65.1) for DSS 7. These results were essentially similar whether the initial course of multiple sclerosis was exacerbating-remitting or progressive, and whatever the initial symptomatology. Females reached disability milestones at an older age than males. The most influential clinical factor was age at clinical onset of multiple sclerosis: the younger the onset, the younger the age at assignment of disability milestones. Therefore, prognosis in multiple sclerosis appears, at least to some extent, as age-dependent and not substantially affected by the initial course, be it exacerbating-remitting or progressive. Aside acute focal recurrent inflammation and diffuse chronic neurodegeneration, accelerated ageing-related mechanisms may operate in the central nervous system of multiple sclerosis patients.

European validation of a standardized clinical description of multiple sclerosis

The EDMUS system is a clinical database specifically tailored to the description of multiple sclerosis (MS). The EVALUED (Evaluation of the EDMUS system) study is an European project with two objectives: 1) to assess the inter-examiner reliability of the whole EDMUS system; 2) to validate the EDMUS-Grading Scale (EGS),which is a simplified version of the Kurtzke Disability Status Scale (DSS). The protocol included 12 neurologists working in pairs within six European centres (Bari, Basel, Florence, London, Lyon, Würzburg). They assessed independently 30 MS patients in their centre, filling in the EDMUS forms. The reliability of the system was assessed on selected key items in the history of the MS onset, the clinical course and the disease course classification. The clinical examination of the patients permitted an assessment of the Kurtzke Expanded Disability Status Scale (EDSS) and the EGS. Level of agreement was measured in terms of kappa and weighted kappa indexes whenever appropriate. The study included 180 patients with definite or probable MS of whom 37% were males. Age was 35.8+/-9.6 years (mean +/- SD), disease duration 7.8+/-5.7 years, and mean EDSS score 4.1+/-2.2. The disease course was relapsing-remitting in 67%, secondary progressive in 22%, and progressive from disease onset in 11%. For key items of the history, the inter-examiner reliability level ranged from moderate to excellent. Concerning the disability scales, perfect agreement was reached in 59 % for EDSS and 78% for EGS. The close correlation and linear association (r=0.94, p<0.0001) between both scales demonstrated EGS's construct validity. The EDMUS system allows a consistent clinical description of MS using a common language. This standardized follow-up of MS patients is valuable especially in studies requiring a critical mass of informative patients.

Early clinical predictors and progression of irreversible disability in multiple sclerosis: an amnesic process.

Prognosis of multiple sclerosis is highly variable. Clinical variables have been identified that are assessable early in the disease and are predictors of the time from the disease onset to the onset of irreversible disability. Our objective was to determine if these clinical variables still have an effect after the first stages of disability have been reached. We determined the dates of disease onset and assignment of scores of irreversible disability in 1844 patients with multiple sclerosis. We used three scores on the Kurtzke Disability Status Scale as benchmarks of disability accumulation: 4 (limited walking but without aid); 6 (walking with unilateral aid); and 7 (wheelchair bound). We used Kaplan-Meier analyses and Cox regression models to determine the influence of the clinical variables on the time to disability onset. Median times from onset of multiple sclerosis to assignment of a score of 4, 6 and 7 were significantly influenced by gender, age, symptoms and course (relapsing-remitting or progressive) at onset of the disease, degree of recovery from the first relapse, time to a second neurological episode, and the number of relapses in the first 5 years of the disease. Similarly, times from onset of multiple sclerosis to a score of 6 and 7 were influenced by time to a score of 4. In contrast, none of the variables substantially affected the time from a score of 4 to a score of 6 or 7, or from a score of 6 to a score of 7. Early assessable clinical variables significantly influence the time from the onset of multiple sclerosis to the assignment of a disability score of 4, but not the subsequent progression of irreversible disability.

Prognostic factors for progression of disability in the secondary progressive phase of multiple sclerosis

Predicting clinical outcome is one of the major and most interesting issues in MS patients. If the global evolution of disability (usually chosen levels on the Kurtzke's Disability Status Scale) has been widely studied, much less is known about the progression of disability during the secondary progressive phase of the disease. It is usually said that there is a poorer prognosis once patients enter a progressive phase, whether from onset (like in primary progressive MS) or after an initial relapsing–remitting phase. The secondary progressive phase of multiple sclerosis (MS) is the one most often associated with the development of severe and irreversible disability. Despite this fact, there is a lot of information about the initial relapsing–remitting phase in the literature, but much less about the secondary progressive one. We review here information available from the literature and from the Lyon MS database about this secondary progressive phase.

Relapses and Progression of Disability in Multiple Sclerosis

The influence of the patterns of onset of multiple sclerosis and relapses of the disease on the time course of irreversible disability is controversial. In 1844 patients with multiple sclerosis who were followed for a mean (+/- SD) of 11 +/- 10 years, we determined the time of the clinical onset of the disease, the initial course (relapsing-remitting or progressive) and the subsequent course (relapsing-remitting, secondary progressive, or primary progressive), the times of relapses, the time to the onset of irreversible disability, and the time course of progressive, irreversible disability. We used three scores on the Kurtzke Disability Status Scale (range, 0 to 10, with higher scores indicating more severe disability) as measures of the severity and progression of disability: a score of 4 (limited walking ability but able to walk for more than 500 m without aid or rest), a score of 6 (ability to walk with unilateral support no more than 100 m without rest), and a score of 7 (ability to walk no more than 10 m without rest while leaning against a wall or holding onto furniture for support). We used Kaplan-Meier analyses to determine the influence of relapses on the time to the onset of irreversible disability. The median times from the onset of multiple sclerosis to the assignment of a score of 4, a score of 6, and a score of 7 on the disability scale were longer among the 1562 patients with a relapsing-remitting onset of disease (11.4, 23.1, and 33.1 years, respectively) than among the 282 patients who had progressive disease from the onset (0.0, 7.1, and 13.4 years, respectively; P<0.001 for all comparisons). In contrast, the times from the assignment of a score of 4 to a score of 6 were similar in the two groups (5.7 and 5.4 years, P=0.74). The time course of progressive, irreversible disease among patients with the primary progressive type of multiple sclerosis was not affected by the presence or absence of superimposed relapses. Among patients with multiple sclerosis, relapses do not significantly influence the progression of irreversible disability.

The natural history of multiple sclerosis: a geographically based study: 8: familial multiple sclerosis.

We have examined the demographics and long-term outcome of 1044 patients with sporadic and familial multiple sclerosis in a population-based cohort from London, Ontario. The mean follow-up was 25 years in duration, and by this time most patients had reached the unambiguous endpoint scores of the Kurtzke disability status scale (DSS), DSS 6, 8 or 10. An affected family member was identified in 19.8% of the total population, and this subgroup was further divided arbitrarily into the following three groups by the type and number of relatives affected: (i) first degree only; (ii) first degree plus others; (iii) second or third degree. The outcome in these groups was compared with that for those patients who, at a mean 25 year follow-up, had no relatives known to be affected. Familial cases closely resembled those remaining sporadic in both demographics and outcome, although onset in the most heavily loaded families was earlier and male/female ratio was greater. The times to DSS 6, 8 and 10 did not differ significantly when sporadic, familial and familial subgroups were compared. These results provide no clinical support for viewing familial multiple sclerosis as distinct from the sporadic form. The observed recurrence rate for siblings in a strictly defined epidemiological sample was 3.5%, much as projected. These results validate the recurrence risks which have previously been derived from age-corrected data for these first-degree relatives.

A follow-up study on spastic paraparesis in Japanese HAM/TSP

We followed 24 patients with HTLV-I-associated myelopathy (HAM) for 4–12 years (mean 7 years) and assessed longitudinal changes of their spastic paraparesis by Kurtzke's Disability Status Scale (DSS). The DSS score of spastic paraparesis was unchanged in 18 patients (75%), advanced (worsened) by two in 1 patient and by one in 3 patients, and declined (improved) by one in 2 patients during the follow-up period. The results demonstrated that HAM presents with a variety of clinical courses including spontaneous improvement.

The benefit of inpatient neurorehabilitation in multiple sclerosis

The role of an inpatient neurorehabilitation unit in the management of multiple sclerosis (MS) remains unclear. A necessary first step is the demonstration of benefit in those who are admitted. In order to address this question, 79 patients with MS admitted over a 16-month period for multidisciplinary rehabilitation were studied using assessment scales as measures of disability and handicap. Fourteen patients were recovering from a recent relapse and the remaining 65 were in the progressive phase of the disease. The patients were clinically assessed and rated on admission and discharge using Kurtzke's Disability Status Scale (DSS), the Barthel Index (BI) and the Environmental Status Scale (ESS). A statistically significant functional improvement was seen in 65% of patients as determined by the Barthel Index and 44% improved on the ESS. Improvement was most marked in those in whom a reduction in impairment had occurred during recovery from relapse but also occurred in 63% of those who had not changed neurologically. These results suggest a beneficial effect from admission to a neurorehabilitation unit for patients with MS, including those in the progressive phase of the disease, although its role in the long-term management of MS remains to be defined.

Progression of neurological disability in HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP)

HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is apparently a disease with a chronic evolution without spontaneous remissions. The real profile of its natural history and of the progression of the neurological disability, however, awaits confirmation. We devised the present study to evaluate the progression profile of the neurological disability of HAM/TSP in a series of 43 patients who have never received any kind of previous immune therapy. Patients were divided into different groups according to the duration of their disease. Age, gender and the Kurtzke's disability status scale (DSS) at the time of the first examination were compared. There were no statistically significant differences among groups with different disease duration. The present study suggests that the evolution of the neurological disability in HAM/TSP occurs mainly during the first year of the disease and becomes relatively stable after that. Therefore we speculate that the variable therapeutic success rates observed in many series of the literature could be due to the timing in the beginning of the pharmacological immunessupression. Probably the therapeutic window in HAM/TSP lies within the first year of the disease. Thus it might be of utmost importance that future therapeutical trials take into consideration the duration of the disease since this factor can play an important role in the results of the trial.

Meta-analysis of clinical studies of the efficacy of plasma exchange in the treatment of chronic progressive multiple sclerosis.

To examine the hypothesis that addition of therapeutic plasma exchange (TPEX) to an immunosuppressive drug regimen increases that regimen's efficacy to halt the progression of chronic progressive multiple sclerosis (CPMS). The literature was searched for prospective controlled clinical trials evaluating the efficacy of TPEX in CPMS. Six studies were eligible for meta-analysis. Their results were combined, using Cochran's and Peto's methods. Three outcome measures were studied: 1) the change in Kurtzke's disability status scale (DSS) scores, 2) the relative odds of neurologic decline by 1 or more DSS grades, and 3) the relative odds of neurologic improvement by 1 or more DSS grades, in the treatment versus the comparison group of patients. Reported results of neurologic evaluations at 6, 12, 24, and 36 months of follow-up were analyzed separately. TPEX significantly (P < .05) reduced the proportion of patients who experienced neurologic decline (by 1 or more DSS grades) at 12 months of follow-up (relative odds of decline = 0.441, 95% confidence interval = 0.210-0.929). There is a need for further clinical research into the possibility of a beneficial effect of TPEX in patients with CPMS likely to experience neurologic decline over the ensuring 12 months. Targeting treatment to a particular subgroup of CPMS patients may be necessary for TPEX to prove effective.

Multiple sclerosis: correlation of anxiety, physical impairment and cognitive dysfunction.

The aim of the study was to examine the correlation between anxiety and physical impairment and to discover whether anxiety correlated with specific forms of cognitive dysfunction. Ninety-four patients (42 females, 52 males) with definite MS entered the study. Anxiety was measured using the State-Trait Anxiety Inventory, physical impairment by means of the Kurtzke Disability Status scale, and cognitive impairment by using the Trail Making, Symbol Digit Modalities, Auditory Verbal Learning, Story Recall and the Recurring Figures tests. Moderately handicapped patients (DSS 4-5) showed signs of anxiety, and physical impairment correlated with anxiety (p < 0.05; d.f. 1.92). Trail Making also correlated with anxiety (p < 0.01; d.f. 1.86). On the basis of the results of this and previous studies, it is concluded that anxiety can be a sign of cognitive dysfunction, physical impairment or social strain.

Interferon inhibitor factor predicting success of plasmapheresis in patients with multiple sclerosis

Interferons (IFN) are biological molecules with antiviral, antiproliferative, and immunomodulatory actions. Plasmapheresis (PP) combined with IFN therapy in 24 multiple sclerosis (MS) patients was associated with a rapid increase in detectable IFN levels. We describe the presence of a detectable factor in the serum of MS patients which decreases the efficacy of IFN therapy in these patients. We call this factor "interferon inhibitor factor" (IIF). Standard IFN assay indicates inhibition of WISH cell protection by IFN owing to the presence of IIF in patient's serum. Similar results were also obtained with human fibroblast and human leukocyte IFNs. The best results were obtained with an IFN mixture; results with 1:20 diluted patient's sera showed elevation of 120% greater than 1:10 dilution. With 1:40 dilution, an elevation of 1,041% was noticed. The IIF from patient sera collected during PP was purified and characterized. Native gel electrophoresis of IIF indicates a single protein band; further analysis on SDS gels indicates two bands at the 200 and 21-kD range. ELISA failed to reveal the presence of any anti-IFN antibodies. This study demonstrates the presence of IIF in MS patients' sera which are removed from the circulation by PP. Removal of IIF from circulation was associated with increased IFN levels and clinical improvement as measured by Kurtzke's disability status scale (KDSS).

The natural history of multiple sclerosis: a regional study with some longitudinal data.

A regional survey of multiple sclerosis (MS) patients in Wellington, New Zealand in 1983 identified 245 patients, giving a prevalence (all categories included) of 72 per 100,000. Retrospective review of the history and medical records identified a poorer prognosis for disability where there was progressive onset of symptoms, secondary progression after a remitting phase, older age of onset (40 years or more), or a motor syndrome involving the limbs at presentation. In 1983 follow up data were obtained on 96 patients who were seen during a previous survey in 1968. For those with definite or probable MS, progression to severe disability (Kurtzke disability status scale (DSS) 6-9) or death (DSS 10) was seen in 26/34 with moderate disability (DSS 3-5) in 1968 and in only 5/29 with mild disability (DSS 0-2). When the analysis is confined to those with symptoms for at least five years in 1968, severe disability or death from MS occurred in 22/30 with moderate and 4/19 with mild disability (chi 2 = 10.8, p = 0.001). It is concluded that the patient's established disability level after five years of illness is a useful, but not infallible, prognostic indicator. From the follow up of the 1968 patients, the probability of MS-related mortality for a given disease duration was calculated. Using this survival distribution to adjust the disability ratings in the 1983 population, it was found that the proportion with mild disability decreased steadily with increasing disease duration, reaching 14% when the disease duration was more than 25 years.

Acute radicular pain as a presenting symptom in multiple sclerosis.

From December 1973 through November 1988, we cared for 11 patients who presented with acute radicular pain and in whom radicular compression was ruled out by imaging techniques. Eventually, multiple sclerosis was diagnosed and judged to be responsible for the acute radiculopathy. The patients (seven women, aged 18 to 40 years; median, 32 years) and four men (aged 23 to 34 years; median, 29 years) were followed up from 6 months to 15 years (mean, 4 years 11 months). They represent 3.9% of 282 newly diagnosed cases of multiple sclerosis during the same 15 years. A retrospective analysis of the characteristics of their illness and its evolution was conducted. Six had lumbosacral radiculopathies; three, cervical and two, thoracic. In six of the 11 patients, symptoms occurred in close relationship to trauma; seven had recurrent radicular pain; four had other pain syndromes; and three others, paroxysmal symptoms. One patient died of complications from multiple sclerosis 3 years after diagnosis. Three others were rated five or greater in the extended Kurtzke disability status scale during follow-up.