Evaluation of major salivary glands with ultrasonography in multiple sclerosis patients.

BACKGROUND: This study aimed to investigate the homogeneity of the major salivary glands in multiple sclerosis (MS) patients using ultrasonography (USG), assess DMFT indices, measure resting salivary flow rates, and compare these values with healthy individuals. METHODS: In this study, 20 individuals diagnosed with Relapsing-Remitting Multiple Sclerosis (RRMS) (mean age 36.15 ± 8.51) and 20 systemically healthy individuals (mean age 35.7 ± 9.22) were included. Oral and radiologic examinations were performed in all individuals. The parotid and submandibular salivary glands were examined using USG, and their homogeneity was assessed based on the scoring system recommended by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) study group. Resting salivary flow rates and DMFT indices were measured, and the obtained data were subjected to statistical analysis. RESULTS: The parotid glands exhibited more heterogeneity on USG within the MS patient group than the control group, with a statistically significant difference between the two groups (p = 0.015). A statistically significant correlation was observed in total homogeneity values between the patient and control groups (p = 0.021). Furthermore, the MS patient group exhibited higher DMFT indices and lower salivary flow rates than the control group. The difference between the DMFT indices and salivary flow rate between the patient groups was statistically significant (p = 0.004 and p = 0.002 respectively). CONCLUSIONS: The parenchyma of the major salivary glands in MS patients exhibited decreased homogeneity than the healthy controls. Additionally, the MS group showed a decrease in salivary flow rate and an increase in the DMFT index. Autonomic dysfunction and medications used for MS are thought to cause salivary gland hypofunction and dry mouth. It can be interpreted that hyposalivation and motor skill losses in MS patients lead to an increase in DMFT index.

A Systematic Literature Review on Inflammatory Markers in the Saliva of Patients with Multiple Sclerosis: A Cause or a Consequence of Periodontal Diseases.

Background and Objectives: Multiple sclerosis (MS) is a chronic neurodegenerative disease often linked with systemic conditions such as periodontal diseases (PDs). This systematic review aims to explore the association between inflammatory markers in saliva and PDs in MS patients, assessing the use of saliva as a non-invasive tool to monitor disease progression. Materials and Methods: 82 publications were examined after a thorough search of scholarly databases to determine whether inflammatory markers were present in MS patients and whether they were associated with periodontal disease (PD). Quality and bias were assessed using the Newcastle-Ottawa Scale, resulting in eight articles that were thoroughly analyzed. Results: The results point to a strong correlation between MS and periodontal disorders, which may point to the same pathophysiological mechanism. It does, however, underscore the necessity of additional study to determine a definitive causal association. Conclusions: The findings indicate a strong association between MS and PDs, likely mediated by systemic inflammatory responses detectable in saliva. The review highlights the importance of oral health in managing MS and supports the utility of saliva as a practical, non-invasive medium for monitoring systemic inflammation. Further research is necessary to confirm the causal relationships and to consider integrating salivary diagnostics into routine clinical management for MS patients.

Change in upper limb function in people with multiple sclerosis treated with nabiximols: a quantitative kinematic pilot study.

OBJECTIVES: Nabiximols represents an increasingly employed add-on treatment option for spasticity in people with multiple sclerosis (PwMS) who either were unresponsive or reported excessive adverse reactions to other therapies. While several studies performed in the last decade demonstrated its effectiveness, safety, and tolerability, few quantitative data are available on the impact on motor dysfunctions. In this open-label, not concurrently controlled study, we aimed to assess the impact of a 4-week treatment with nabiximols on upper limb functionality. METHODS: Thirteen PwMS (9 female, 4 male) with moderate-severe spasticity underwent a combination of clinical tests (i.e., Box and Block, BBT and Nine-Hole Peg test, 9HPT) and instrumental kinematic analysis of the "hand to mouth" (HTM) movement by means of optical motion capture system. RESULTS: After the treatment, improvements in gross and fine dexterity were found (BBT + 3 blocks/min, 9HPT - 2.9 s, p < 0.05 for both cases). The kinematic analysis indicated that HTM movement was faster (1.69 vs. 1.83 s, p = 0.05), smoother, and more stable. A significant reduction of the severity of spasticity, as indicated by the 0-10 numerical rating scale (4.2 vs. 6.3, p < 0.001), was also observed. CONCLUSION: The findings from the present pilot study suggest that a 4-week treatment with nabiximols ameliorates the spasticity symptoms and the overall motor function of upper limb in PwMS with moderate-severe spasticity. The use of quantitative techniques for human movement analysis may provide valuable information about changes originated by the treatment in realistic upper limb motor tasks involved in activities of daily living.

Oral health-related quality of life is more strongly correlated with mental health than with oral health in relapsing-remitting multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a leading cause of neurological disability in young and middle-aged populations, associated with substantial burden of illness. Because a growing literature now shows that this burden extends to poorer oral health, oral health-related quality of life (OHRQoL) may be reduced as well. OBJECTIVES: To test whether people with relapsing-remitting MS (RRMS) have poorer OHRQoL than demographically matched controls, and to establish which variables are associated with worse OHRQoL. MATERIALS AND METHODS: In total, 64 people with RRMS and 69 demographically matched controls participated. Both groups completed the Oral Health Impact Profile (OHIP-14), a validated measure of OHRQoL, as well as an objective oral health examination performed by a qualified dentist, a measure of dental-related functionality and a measure of mental health. RESULTS: OHRQoL was significantly poorer in the RRMS relative to the control group. However, although poorer OHRQoL in the RRMS group was moderately associated with objectively assessed oral health (r = .30), it was more strongly associated with mental health (r = .61). For the control group, the reverse pattern of association was evident, with OHRQoL more strongly associated with oral health (r = .48) relative to mental health (r = .20). CONCLUSION: People with RRMS report poorer OHRQoL than demographically matched controls, but these appraisals are more strongly linked to mental health than to objective oral health indicators.

THE CONCENTRATION OF INTERLEUKIN 6 AND TUMOR NECROSIS FACTOR ALPHA IN SALIVA AND BLOOD OF PATIENTS WITH INACTIVE MULTIPLE SCLEROSIS AND COEXISTING HASHIMOTO'S THYROIDITIS.

The concentration of interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) in the blood is higher in patients with active multiple sclerosis (MS) compared to those with inactive disease. The concentration of IL-6 and TNF-α in the blood is higher in patients with Hashimoto's thyroiditis (HT) compared to those with a healthy thyroid. The aim of the study was to assess whether serum IL-6 and TNF-α levels correlated with saliva in patients with inactive MS and whether there was a difference in these groups of patients depending of thyroid status. We also examined the correlation of thyroid stimulating hormone (TSH) levels with thyroid status. The study included 54 patients in the inactive phase of MS. The level of cytokines in the blood was determined by chemiluminescence, and in saliva by ELISA. Blood and saliva IL-6 levels showed positive correlation, while blood and saliva TNF-α levels were not correlated. There was a significantly higher TSH level in patients with inactive MS with positive thyroid antibodies, without therapy, compared with those with negative antibodies.

Evaluation of the response to electric pulp testing in multiple sclerosis patients without a history of trigeminal neuralgia: a case-control study.

BACKGROUND: The importance of evaluating the pulpal threshold to electrical stimulation, as a side effect of probable neuropathy in Multiple Sclerosis (MS) patients is a novel issue. This study aimed to investigate electrical pulp test thresholds in MS patients without a history of trigeminal neuralgia compared to healthy individuals. METHODS: Sixty-nine maxillary central incisors, belonging to 34 relapsing-remitting MS patients, and 35 healthy individuals were included in this survey. The MS patients matched for intended variables, were 22-50 years old, had a more than 1-year history of MS, no history of trigeminal neuralgia and/or other neuropathy. The electric pulp sensibility test was performed on all samples. Electric pulp testing (EPT) results were recorded based on the pulp tester's grade that evoked a response. Data were analyzed with paired T-test, Mann-Whitney test, and Spearman correlation (P < 0.05). RESULTS: According to the results of this study, the mean values of response to EPT were 1.2 ± 0.5 and 1.8 ± 0.5 in MS patients and healthy individuals, respectively. The pulpal response to EPT between the two groups was significantly different (P < 0.0001). CONCLUSIONS: MS patients showed a significantly reduced response to the electric pulp test in their maxillary central incisors in comparison to matched healthy persons.

Is there an association between multiple sclerosis and oral health?

Data sources PubMed, Scopus, Web of Science, MEDLINE and CINAHL.Study selection Randomised controlled trials, cross-sectional studies and cohort studies.Data extraction and synthesis Two reviewers independently extracted data using piloted forms and contacted authors if relevant data were missing. Assessment of quality was done using the Newcastle-Ottawa scale (NOS) for both cohort and cross-sectional studies. The score of NOS ranged from 1-9, where 6-7 is considered moderate quality while 8-9 is high quality.Results Seventeen studies were included in the review (13 cross-sectional and four cohort). Seven out of 13 cross-sectional studies scored ≤5 which indicates poor quality. The four case-control studies were of moderate quality. Overall, there is limited evidence that patients with multiple sclerosis (MS) have more dental caries or gingival disease. However, evidence suggests that patients with MS have more risk of periodontal disease and poor oral hygiene. The evidence also suggests a moderate association between MS and temporomandibular disorders (TMD).Conclusions With the exception of TMD, current evidence does not establish an association between MS and most oral health conditions. More high-quality evidence is needed to further explore and establish an association.

Oral Colonization by Candida Species in Patients with Multiple Sclerosis.

INTRODUCTION: Multiple sclerosis (MS) is a chronic inflammatory demyelinating autoimmune disease that affects the central nervous system. Since immune system plays a key role in this disease, patients with MS can present higher risk of infections. PURPOSE: This study aimed to investigate the prevalence of Candida spp. in the oral cavity of MS patients in relation to a control group METHODS: In total, 100 individuals were selected: 55 diagnosed with MS and 45 healthy individuals (control group). Saliva samples were collected and seeded in culture media selecting for Candida. Following an incubation period of 48 h, colony-forming units (CFU mL-1) were counted and colonies were isolated for Candida species identification by multiplex PCR. The results were analysed by chi-squared and Mann-Whitney U statistical tests considering a significance level of 5%. RESULTS: Candida spp. were confirmed in the oral cavity of 50.09% patients in the MS group and 35.55% individuals in the control group. In individuals positive for the growth of Candida spp., the median values of Candida colonies were 220 CFU mL-1 for the MS group and 120 CFU mL-1 for the control group. However, no statistically significant differences were observed between groups for both prevalence and CFU mL-1 count. Of the Candida species identified, 73.91% were C. albicans, 21.73% C. glabrata, 2.17% C. tropicalis, and 2.17% C. krusei. CONCLUSIONS: The colonization of Candida spp. in the oral cavity of individuals with multiple sclerosis was higher than in the control group; however these findings were not proven to be statistically significant.

Invited Review: From nose to gut - the role of the microbiome in neurological disease.

Inflammation and neurodegeneration are key features of many chronic neurological diseases, yet the causative mechanisms underlying these processes are poorly understood. There has been mounting interest in the role of the human microbiome in modulating the inflammatory milieu of the central nervous system (CNS) in health and disease. To date, most research has focussed on a gut-brain axis, with other mucosal surfaces being relatively neglected. We herein take the novel approach of comprehensively reviewing the roles of the microbiome across several key mucosal interfaces - the nose, mouth, lung and gut - in health and in Parkinson's disease (PD), Alzheimer's disease (AD) and multiple sclerosis (MS). This review systematically appraises the anatomical and microbiological landscape of each mucosal surface in health and disease before considering relevant mechanisms that may influence the initiation and progression of PD, AD and MS. The cumulative effects of dysbiosis from the nose to the gut may contribute significantly to neurological disease through a wide variety of mechanisms, including direct translocation of bacteria and their products, and modulation of systemic or CNS-specific immunity. This remains an understudied and exciting area for future research and may lead to the development of therapeutic targets for chronic neurological disease.

Safety and efficacy of ADS-5102 (amantadine) extended release capsules to improve walking in multiple sclerosis: A randomized, placebo-controlled, phase 2 trial.

BACKGROUND: Walking impairment causes disability and reduced quality of life in patients with multiple sclerosis (MS). OBJECTIVE: Characterize the safety and efficacy of ADS-5102 (amantadine) extended release capsules, 274 mg administered once daily at bedtime in patients with MS with walking impairment. METHODS: This randomized, double-blind, placebo-controlled, 4-week study was conducted at 14 trial sites in the United States. Study objectives included safety and tolerability of ADS-5102, and efficacy assessments (Timed 25-Foot Walk (T25FW), Timed Up and Go (TUG), 2-Minute Walk Test, and Multiple Sclerosis Walking Scale-12). Fatigue, depression, and cognition also were assessed. RESULTS: A total of 60 patients were randomized (30 to ADS-5102 and 30 to placebo); 59 of whom were treated. The most frequent adverse events (AEs) were dry mouth, constipation, and insomnia. Five ADS-5102 patients and no placebo patients discontinued treatment due to AEs. One patient in the ADS-5102 group experienced a serious AE-suspected serotonin syndrome. A 16.6% placebo-adjusted improvement was seen in the T25FW test ( p < 0.05). A 10% placebo-adjusted improvement in TUG was also observed. No changes in fatigue, depression, or cognition were observed. CONCLUSION: ADS-5102 was generally well tolerated. These data demonstrate an effect of ADS-5102 on walking speed. Further studies are warranted to confirm these observations.

[Prospective evaluation of mouth and eye dryness induced by antimuscarinic drugs used for neurogenic overactive bladder in 35 patients with multiple sclerosis]. / Évaluation prospective de l'impact des anticholinergiques sur la sécheresse buccale et oculaire chez 35 patients atteints de sclérose en plaque avec hyperactivité vésicale neurogène.

INTRODUCTION: Mouth and eye dryness are frequently reported by patients with multiple sclerosis (MS) as side effects of antimuscarinic drugs used for neurogenic overactive bladder. We evaluated the impact of antimuscarinic drugs prescription on these symptoms. METHODS: MS patients consulting for overactive bladder were included. Xerostomia were evaluated at baseline and thirty days after treatment by self-reporting questionnaires (Xerostomia Quality of Life [X-Qol] and Xerostomia Questionnaire [XQ]), by salivary flow rate and sugar test. Xerophtalmia were evaluated by a self-reporting questionnaire (Ocular Surface Disease Index [OSDI]) and Schirmer test. Iatrogenic anticholinergic impregnation was evaluated by the Anticholinergic Drug Scale. RESULTS: From January to December 2014, 35 patients were included. Mean age was 50.1±10.2 years, mean EDSS=4.9. Mean anticholinergic impregnation was 0.6±1.0. Before treatment, none correlation was found between anticholinergic impregnation and other parameters. Twenty-two patients were evaluated after treatment. At baseline and thirty days after treatment, mean scores were respectively: 0.78±0.51 and 0.73±0.43 (P=0.67) for X-Qol, 9.22±11.8 and 7.03±11.4 (P=0.32) for XQ, 18.8±14.9 and 13.9±11.6 (P=0.06) for OSDI. Mean salivary flow rates were respectively 1.54±1.11 and 1.22±1.3 (P=0.53), positive sugar tests concerned respectively 68% and 55% of patients (P=0.53), and positive Schirmer test concerned 50% before and after treatment. CONCLUSION: Eye and mouth dryness exist in our MS population, even before prescription of antimuscarinic treatment, and is not getting worse after prescription. Those symptoms should not be the reason to stop an efficient treatment, but should be the reason to find and treat their aetiology. LEVEL OF EVIDENCE: 4.

Expanded Disability Status Scale-Based Disability and Dental-Periodontal Conditions in Patients with Multiple Sclerosis.

OBJECTIVE: The aim of this study was to evaluate the association between different disability states in patients with multiple sclerosis (MS) as determined by the expanded disability status scale (EDSS) and dental-periodontal measures. SUBJECTS AND METHODS: Eighty patients with MS (64 females and 16 males) were included in this study. Data on MS types, attack frequency, disease duration, EDSS scores and orofacial complaints prior to an MS attack were obtained from medical records. The plaque index (PI), probing depth (PD), clinical attachment level (CAL), gingival index (GI), decayed-missing-filled teeth (DMFT) index and number of present teeth were measured during one dental examination for each subject. The MS patients were divided into the following 2 groups based on their EDSS scores: low physical disability (L-DS) and high physical disability (H-DS). Differences in dental parameters between groups of low and high disability were investigated. p < 0.05 was considered statistically significant. RESULTS: The mean age of the participants was 38.06 ± 10.11 years. Age and disease duration were higher in the H-DS MS group than in the L-DS MS group (p < 0.05). The PI, PD and GI were higher and the number of filled teeth was lower in the H-DS MS group than in the L-DS MS group (p < 0.05). The EDSS scores of the H-DS MS group presented a significant correlation with the number of decayed teeth (r = -0.548, p = 0.005). Orofacial complaints prior to an MS attack were reported by 18 (22.5%) patients. CONCLUSION: Oral measurements revealed various differences between groups of low and high disability in MS patients. In addition, some maxillofacial-oral complaints prior to an MS attack were observed.

Clinical experiences with cannabinoids in spasticity management in multiple sclerosis.

INTRODUCTION: Spasticity is a common symptom among patients with multiple sclerosis (MS). This study aims to assess the effectiveness and safety of the combination of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in clinical practice for the treatment of spasticity in MS. METHODS: Retrospective observational study with patients treated with inhaled THC/CBD between April 2008 and March 2012. Descriptive patient and treatment variables were collected. Therapeutic response was evaluated based on the doctor's analysis and overall impression. RESULTS: Of the 56 patients who started treatment with THC/CBD, 6 were excluded because of missing data. We evaluated 50 patients (42% male) with a median age 47.8 years (25.6-76.8); 38% were diagnosed with primary progressive MS, 44% with secondary progressive MS, and 18% with relapsing-remitting MS. The reason for prescribing the drug was spasticity (44%), pain (10%), or both (46%). Treatment was discontinued in 16 patients because of ineffectiveness (7 patients), withdrawal (4), and adverse effects (5). The median exposure time in patients whose treatment was discontinued was 30 days vs 174 days in those whose treatment continued at the end of the study. THC/CBD was effective in 80% of patients at a median dose of 5 (2-10) inhalations/day. The adverse event profile consisted of dizziness (11 patients), somnolence (6), muscle weakness (7), oral discomfort (2), diarrhoea (3), dry mouth (2), blurred vision (2), agitation (1), nausea (1), and paranoid ideation (1). CONCLUSIONS: THC/CBD appears to be a good alternative to standard treatment as it improves refractory spasticity in MS and has an acceptable toxicity profile.

Multiple sclerosis and oral health: an update.

Multiple sclerosis is a chronic, neurodegenerative disease seen in 69.1 per 100,000 person-years in the world. As multiple sclerosis and periodontal disease both have an inflammatory origin, dental professionals should be aware of the link between these two diseases. In patients unable to carry out effective oral hygiene, dental treatment should be done by dental hygienists and/or dentists to prevent dental caries and periodontal disease. It is hoped that by identifying multiple sclerosis patients in dental clinics, the required support and treatment could be provided to these patients to improve their quality of life and that dental professionals would feel comfortable treating patients with multiple sclerosis.

Association of chronic periodontitis with multiple sclerosis: A systematic review and meta-analysis.

BACKGROUND: Chronic periodontitis (CP) is a multifactorial, chronic inflammatory disease of microbial etiology that manifests as a result of the dysfunction of the immune mechanism, culminating in the destruction of the alveolar bone of the jaws. Multiple sclerosis (MS) is an autoimmune disorder that affects the central nervous system (CNS), leads to demyelination and degeneration of nerve axons and often causes severe physical and/or cognitive impairment. As CP and MS involve inflammatory mechanisms and immune dysfunction, researchers have attempted to study the association between them. AIM: To systematically review the literature on the epidemiological association between CP and MS in adults. METHODS: PRISMA 2020 statement was used in the study protocol. The design was done according to the Cochrane methodology. A comprehensive literature search was performed in PubMed, Scopus and Cochrane databases; a manual search and evaluation of the gray literature was also performed. The meta-analysis was performed by Review Manager (RevMan) 5.4. Odds ratio (OR) with 95% confidence interval (CI) was defined as the effect size of the outcome. Heterogeneity was assessed by Chi-square and I2. The articles evaluated were written in English, without a time limit, concern observational studies (patient-controls) and report the diagnostic criteria of the diseases. Duplicate entries were excluded. To evaluate the reliability of the results of each study, Newcastle-Ottawa Scale (NOS) and GRADE tools were used. Two independent reviewers did all evaluations with a resolution of discrepancies by a third. RESULTS: Meta-analysis included three observation studies examined 3376 people. MS patients are significantly more likely to be diagnosed with CP than healthy controls (OR 1.93, 95% CI 1.54-2.42, p<0.0001). CONCLUSION: A high prevalence of CP was found among MS patients compared with healthy controls. Healthcare professionals should be aware of the association between these pathological entities to provide patients with high-quality care through an effective and holistic diagnostic and therapeutic approach.

Case report: an orofacial pain patient with spots on the brain-multiple sclerosis versus central systemic lupus erythematosus.

Orofacial pain bridges an important gap between medicine and dentistry. This article presents the case of a man who reported preauricular pain, tinnitus, and vertigo that began after extraction of an impacted third molar and who was sent for evaluation of a possible temporomandibular joint disorder. However, he was subsequently found to have markers and imaging results consistent with recurrent and more centralized lupus and/or multiple sclerosis.

Oral health status of a population with multiple sclerosis.

OBJECTIVE: To determine the oral treatment needs of a sample of patients diagnosed with multiple sclerosis in the Community of Madrid (Spain). PATIENTS AND METHODS: A cross-sectional epidemiological study was carried out with a sample of 64 patients who were aged 25 to 77 years. They were distributed into homogeneous age groups: < 46 years, 46-54 years and > 54 years. In order to evaluate the oral health status and treatment requirements, the parameters and guidelines of the WHO were used. RESULTS: The prevalence of caries was 100%, or very close in all three groups. As age increased, the morbidity rate decreased, but the mortality rate increased considerably. On analyzing gingival health, 65% of patients had calculus, 5% bleeding and 30% were healthy. CONCLUSIONS: The DMFT index found provided data that was, in general, very similar to that of the general population in Spain. However, the gingival health status found demonstrated that the population of multiple sclerosis patients requires specific assistance.

Effectiveness of intravenous sedation for oral surgery in a patient with multiple sclerosis and a past history of posterior reversible encephalopathy syndrome: A case report.

INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) is a relatively new syndrome comprising headache, altered mentation, and seizures, associated with neuroimaging findings characteristic of subcortical edema in the posterior regions. As previous studies have reported perioperative development and recurrence of PRES, a cautious anesthetic management of the syndrome is required. CASE REPORT: We describe the anesthetic management for oral surgery in a patient with multiple sclerosis and a history of PRES, both of which are risk factors of recurrent PRES. Although we faced a dilemma regarding the management method of anesthesia, we finally performed intravenous sedation for the surgery without any complications. CONCLUSION: Appropriate preoperative evaluation and anesthetic management are important to maintain hemodynamics and avoid recurrence of PRES.

Bruxism and temporal bone hypermobility in patients with multiple sclerosis.

In this study, the authors investigated the link between jaw clenching/bruxism and temporal bone movement associated with multiple sclerosis (MS). Twenty-one subjects participated in this study (10 patients with MS and 11 controls). To quantify the change in intracranial dimension between the endocranial surfaces of the temporal bones during jaw clenching, an ultrasonic pulsed phase locked loop (PPLL) device was used. A sustained jaw clenching force of 100 lbs was used to measure the mean change in acoustic pathlength (delta L) as the measure of intracranial distance. In the control subjects the mean delta L was 0.27 mm +/- 0.24. In subjects with MS the mean delta L was 1.71 mm +/- 1.18 (p<0.001). The increase in magnitude of bi-temporal bone intracranial expansion was approximately six times greater in subjects with MS compared to controls. Therefore, jaw clenching/bruxism is associated with more marked displacement of the temporal bones and expansion of the cranial cavity in patients with MS than in control subjects.

Acupuncture in Post-Stroke Shoulder Pain Syndrome with Multiple Sclerosis: A Case Study.

The present case study illustrates the case of a 47-year-old female (Ms X) with primary progressive Multiple Sclerosis (MS) who presented with central post-stroke pain (CPSP) over her left shoulder and underwent acupuncture treatment (AT) since she appeared irresponsive to conventional treatment. The aim of this case study is to explore the effectiveness of acupuncture as a complimentary treatment in improving central neurogenic pain in MS patients affected by CPSP. AT lasted six weeks, some modification of the conventional AT points was required to ensure continuity and safety of the treatment plan. In fact, Ms X suffered from gingivitis that led to hypersensitivity of her left upper limb (UL) to acupuncture needling; moreover, she experienced sensation loss in her legs as a result of post-stroke complications. The outcome showed that the subject's shoulder range of motion (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) score and pain improved remarkably, enabling Ms X to resume post-stroke rehabilitation and reduce her analgesic intake.