Cross-Sectional Examination of the Associations Between Symptoms, Community Integration, and Mental Health in Multiple Sclerosis.

OBJECTIVE: To determine the frequency and severity of 8 symptoms in persons with multiple sclerosis (MS) and to examine the association between these symptoms and community integration and mental health. DESIGN: Cross-sectional survey that assessed 8 symptoms (pain, fatigue, imbalance, numbness, weakness, shortness of breath, vision loss, and memory loss), disease progression (self-report version of the Expanded Disability Status Scale), community integration, and mental health. SETTING: Community. PARTICIPANTS: Adults with self-reported MS who responded to a mailed survey (N=180). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The presence and intensity of symptoms were measured with a symptoms checklist. Community integration was assessed with the Community Integration Questionnaire, and mental health was measured by the Mental Health Index of the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: The average number of symptoms reported was 5.07±2.18. The most common symptoms (fatigue, weakness, and imbalance) were also rated as the most severe. Not all symptoms were associated with level of disease progression or with MS subtype. Symptoms related to mobility were more likely to be associated with these variables. The 8 symptoms as a whole accounted for significant amounts of variance (range, 13%-21%) in measures of community integration and mental health, with specific symptoms making differential independent contributions to these measures. CONCLUSIONS: This study demonstrates that most individuals with MS report a number of bothersome symptoms. Type of MS or level of progression does not tell the whole story regarding the impact of symptoms.

At-grade stabilization structure impact on surface water quality of an agricultural watershed.

Decades of farming and fertilization of farm land in the unglaciated/Driftless Area (DA) of southwestern Wisconsin have resulted in the build-up of P and to some extent, N, in soils. This build-up, combined with steep topography and upper and lower elevation farming (tiered farming), exacerbates problems associated with runoff and nutrient transport in these landscapes. Use of an at-grade stabilization structure (AGSS) as an additional conservation practice to contour strip cropping and no-tillage, proved to be successful in reducing organic and sediment bound N and P within an agricultural watershed located in the DA. The research site was designed as a paired watershed study, in which monitoring stations were installed on the perennial streams draining both control and treatment watersheds. Linear mixed effects statistics were used to determine significant changes in nutrient concentrations before and after installation of an AGSS. Results indicate a significant reduction in storm event total P (TP) concentrations (P = 0.01) within the agricultural watershed after installation of the AGSS, but not total dissolved P (P = 0.23). This indicates that the reduction in P concentration is that of the particulate form. Storm event organic N concentrations were also significantly reduced (P = 0.03) after the AGSS was installed. We conclude that AGSS was successful in reducing the organic and sediment bound N and P concentrations in runoff waters thus reducing their delivery to nearby surface waters.

Improved physical fitness correlates with improved cognition in multiple sclerosis.

OBJECTIVE: To determine whether there is an association between improvements in objective measures of physical fitness and performance on cognitive tests in people with multiple sclerosis (MS). DESIGN: Post hoc correlational analysis in which people demonstrating physical improvement were compared with those not demonstrating physical improvement. SETTING: Individuals with MS residing in the community. PARTICIPANTS: Adults with clinically confirmed MS (N=88) who participated in a controlled trial of a telephone-based health promotion intervention, chose to work on exercise, and completed the pre- and postintervention assessments. INTERVENTIONS: Participants were measured for strength (isokinetic dynamometer), aerobic fitness (bicycle ergometer), and cognition (Paced Auditory Serial Addition Test [PASAT], Trail Making Test [TMT]) at baseline and 12 weeks later. Change in fitness was calculated by subtracting each participant's baseline score from the outcome score, and then transforming the difference to a z score. Individuals with a z score ≥1 on any fitness measure were placed in the physically improved group (n=25). All others were in the physically not improved group (n=57). MAIN OUTCOME MEASURES TMT, PASAT RESULTS: After controlling for covariates (age, sex, ethnicity, education, disease activity, MS type), there was a significant group-by-time interaction, suggesting that cognitive functioning changed over time based on level of fitness. Participants in the physically improved group demonstrated improved performance on measures of executive functioning after 12 weeks of exercise. CONCLUSIONS: The results of this study lend support to the hypothesis that change in fitness is associated with improved executive functioning in people with MS.

A PROMIS fatigue short form for use by individuals who have multiple sclerosis.

PURPOSE: To derive from the Patient Reported Outcomes Measurement Information System (PROMIS) fatigue item bank, a short form for individuals with multiple sclerosis (MS), the PROMIS-Fatigue(MS). METHODS: A panel of 37 clinicians and 46 individuals with MS ranked the relevance of PROMIS fatigue items to persons with MS. Eight items were selected for the PROMIS-Fatigue(MS) that maximized relevance rankings, content coverage, and item discrimination. The PROMIS-Fatigue(MS) and an existing, 7-item PROMIS fatigue short form (PROMIS-Fatigue(SFv1.0)) were administered to a new sample of 231 individuals with MS. Known groups and content validity were assessed. RESULTS: Scores from the short forms were highly correlated (r = 0.92). Discriminant validity of the PROMIS-Fatigue(MS) scores was supported in known groups comparisons. Scores of neither short form exhibited an advantage in quantitative analyses. The PROMIS-Fatigue(MS) targeted more of the content included in participants' responses to open-ended questions than did the PROMIS-Fatigue(SFv1.0). CONCLUSIONS: The PROMIS-Fatigue(MS) was derived to have content validity in MS samples. The validity of the measure was further supported by the ability of PROMIS-Fatigue(MS) items to discriminate among groups expected to differ in levels of fatigue. We recommend its use in measuring the fatigue of individuals with MS.

Exercise training and cognition in multiple sclerosis: The GET Smart trial protocol.

BACKGROUND AND OBJECTIVES: Multiple sclerosis (MS) causes cognitive impairment in approximately 50% of cases. Disease modifying medications and cognitive rehabilitation produce only small positive effects on cognition in MS. Converging animal and human research suggests that aerobic exercise may improve cognition in people with MS, but definitive trials are lacking. We describe the design of the GET Smart study, a randomized controlled trial comparing the effects of aerobic exercise versus stretching and toning on cognition in MS. METHODS: The study is a single-blind, parallel group randomized (1:1) controlled trial that compares aerobic exercise training with an active control group consisting of stretching and toning exercises for improving cognition. Participants are nondepressed, ambulatory, non-exercising adults with MS aged 18-54 years who have below average cognitive processing speed. Both treatments were designed to generate equivalent outcome expectancies and entailed supervised, progressive exercise programs, 3 times per week for up to 40 min over a 6 month period. PROJECTED PATIENT OUTCOMES: The primary hypothesis is that the aerobic training group will demonstrate significantly greater cognitive processing speed compared with the control group at the end of the treatment phase (6 months) as measured by a composite of the Paced Auditory Serial Additon Test and the oral Symbol-Digit Modalities Test using intent-to treat analyses. Secondary outcomes are neuropsychological functioning and cardiorespiratory fitness as well as participant reported outcomes such as depression, sleep, and fatigue. Study findings will inform future research, patient education, clinical care and policymaking. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02106052.

Hematopoietic stem cell transplantation for multiple sclerosis: collaboration of the CIBMTR and EBMT to facilitate international clinical studies.

Clinical investigation of autologous hematopoietic stem cell transplantation (HSCT) as therapy for multiple sclerosis (MS) has been ongoing for over a decade. While several phase II studies have been finalized or are in progress, no definitive prospective randomized studies comparing HSCT versus alternative therapies for MS have been completed. In this conference report of North American and European experts who are involved in the care of MS patients, including neurologists and HSCT physicians, and representatives of the Center for International Blood and Marrow Transplant Research (CIBMTR) and European Group for Blood and Marrow Transplantation (EBMT), we (1) critically review progress to date in HSCT for MS; (2) describe current registry based projects including long-term follow-up studies in HSCT for MS and harmonization of the MS disease-specific research forms that will be used in future by both databases; (3) discuss challenges in study design for a prospective randomized clinical trial of HSCT versus alternative therapy for MS such as feasibility, and the importance of multidisciplinary clinical teams, need for a large sample size and duration of observation required for outcomes assessment; and (4) address future directions in HSCT therapy for MS. To undertake a definitive multicenter clinical trial in autologous HSCT for MS, it will be important to begin well in advance to assemble the team, evaluate proposals for study design, and consider options for the infrastructure and logistical support that will be needed. International collaboration, including partnership with the CIBMTR and EBMT, may be desirable and may in fact be critical for successful completion of a definitive comparative study.

Reliability in interpretation of median somatosensory evoked potentials in the setting of coma: factors and implications.

BACKGROUND: Median nerve short-latency somatosensory evoked potentials (SSEPs) are useful in determining prognosis for awakening after coma following hypoxic ischemic encephalopathy, but reliability of interpretation is unclear. OBJECTIVE: To measure inter- and intra-observer reliability of determining presence or absence of SSEPs in comatose patients following hypoxic ischemic encephalopathy and to identify factors that enhance reliability. DESIGN: Retrospective review by four readers (experience ranging from 2-27 years) of SSEP recordings in 95 comatose patients. Twenty waveforms were presented twice and five waveforms were presented pre- and post-neuromuscular junction (NMJ) blockade. SETTING: Academic teaching hospital and level 1 trauma center. PATIENTS: Inpatients in coma due to hypoxic ischemic encephalopathy. MEASUREMENTS AND MAIN RESULTS: Kappa values among the four readers, reflecting inter-observer reliability, ranged from 0.39 to 0.79 (mean 0.60, SD 0.16), a level of agreement interpreted as "moderate." Better inter-observer reliability was seen when: cortical amplitudes were ≥ 0.7 µV, baseline noise was smaller, and when experience level between reviewers was most similar. In cases examined both pre- and post-NMJ blockade, average kappa values of inter-observer reliability increased significantly from 0.03 pre-NMJ blockade to 0.41 post-NMJ blockade. Intra-observer reliability was higher than that for inter-observer, with a "substantial" average kappa of 0.84 (range 0.79-0.89, SD .06). CONCLUSIONS: Inter- and intra-observer reliability of SSEP interpretation in comatose patients varies from moderate to substantial, respectively. In order to reliably interpret the presence of small cortical responses, NMJ blockade should be used when baseline noise is excessive.

Efficacy of paroxetine in treating major depressive disorder in persons with multiple sclerosis.

OBJECTIVE: The objective of this study was to evaluate the efficacy of paroxetine in treating major depressive disorder (MDD) in persons with multiple sclerosis (MS). METHOD: In this double-blind trial, 42 participants with MS and MDD were randomly assigned to one of two parallel 12-week treatment arms: paroxetine or placebo. The participants started at an initial dose of 10 mg/day paroxetine or placebo, titrated up to 40 mg daily based on symptoms response and side effects. The primary outcome measure was the Hamilton Rating Scale for Depression (HAM-D). Secondary outcomes included fatigue, anxiety and self-reported quality of life. RESULTS: Intent-to-treat analyses revealed that both groups improved from pretreatment to posttreatment. Although the treatment group improved more than the control group on most measures, few differences were statistically significant. For the primary outcome, 57.1% of participants in the treatment arm had at least a 50% reduction in HAM-D score, compared with 40% in the control group (nonsignificant). Treatment effects were greater among the participants who completed the study; 78.6% of completers had a treatment response compared with 42.1% of controls (P=.073). CONCLUSION: Although paroxetine may not be efficacious for all persons with MS and MDD, it appears to benefit some individuals.

The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial.

OBJECTIVE: To determine if motivational interviewing-based telephone counseling increases health promotion activities and improves other health outcomes in people with multiple sclerosis (MS). DESIGN: Randomized controlled trial with wait-list controls and single-blinded outcome assessments conducted at baseline and at 12 weeks. SETTING: MS research and training center in the Pacific Northwest. PARTICIPANTS: Community-residing persons (N=130) with physician confirmed MS aged 18 or older who were able to walk unassisted at least 90 m (300 ft). INTERVENTION: A single in-person motivational interview followed by 5 scheduled telephone counseling sessions to facilitate improvement in 1 of 6 health promotion areas: exercise, fatigue management, communication and/or social support, anxiety and/or stress management, and reducing alcohol or other drug use. MAIN OUTCOME MEASURES: Health Promotion Lifestyle Profile II plus fatigue impact, subjective health, and objective measures of strength, fitness, and cognition. Intent-to-treat analyses of change scores were analyzed using nonparametric tests. RESULTS: Seventy persons were randomized to treatment and 60 to the control condition. The treatment group reported significantly greater improvement in health promotion activities, including physical activity, spiritual growth, and stress management as well as in fatigue impact and mental health compared with controls. In addition, the exerciser subgroup showed greater improvement than controls in self-selected walking speed. CONCLUSIONS: A less intensive, more accessible approach to health promotion based on telephone counseling and motivational interviewing shows promise and merits further study.

Collateral geochemical impacts of agricultural nitrogen enrichment from 1963 to 1985: a southern Wisconsin ground water depth profile.

In this study, we used chlorofluorocarbon (CFC) age-dating to investigate the geochemistry of N enrichment within a bedrock aquifer depth profile beneath a south central Wisconsin agricultural landscape. Measurement of N(2)O and excess N(2) allowed us to reconstruct the total NO(3)(-) and total nitrogen (TN) leached to ground water and was essential for tracing the separate influences of soil nitrification and ground water denitrification in the collateral geochemical chronology. We identify four geochemical impacts due to a steady ground water N enrichment trajectory (39 +/- 2.2 micromol L(-1) yr(-1), r(2) = 0.96) over two decades (1963-1985) of rapidly escalating N use. First, as a by-product of soil nitrification, N(2)O entered ground water at a stable (r(2) = 0.99) mole ratio of 0.24 +/- 0.007 mole% (N(2)O-N/NO(3)-N). The gathering of excess N(2)O in ground water is a potential concern relative to greenhouse gas emissions and stratospheric ozone depletion after it discharges to surface water. Second, excess N(2) measurements revealed that NO(3)(-) was a prominent, mobile, labile electron acceptor comparable in importance to O(2.) Denitrification transformed 36 +/- 15 mole% (mol mol(-1) x 100) of the total N within the profile to N(2) gas, delaying exceedance of the NO(3)(-) drinking water standard by approximately 6 yr. Third, soil acids produced from nitrification substantially increased the concentrations of major, dolomitic ions (Ca, Mg, HCO(3)(-)) in ground water relative to pre-enrichment conditions. By 1985, concentrations approximately doubled; by 2006, CFC age-date projections suggest concentrations may have tripled. Finally, the nitrification induced mobilization of Ca may have caused a co-release of P from Ca-rich soil surfaces. Dissolved P increased from an approximate background value of 0.02 mg L(-1) in 1963 to 0.07 mg L(-1) in 1985. The CFC age-date projections suggest the concentration could have reached 0.11 mg L(-1) in ground water recharge by 2006. These results highlight an intersection of the N and P cycles potentially important for managing the quality of ground water discharged to surface water.

Coping with chronic pain among younger, middle-aged, and older adults living with neurological injury and disease.

Objective. This article compares use of pain coping strategies among older, middle-aged, and younger adults living with chronic pain and seeks to determine whether the relationship between pain severity and coping is moderated by age. Method. Participants were 464 adults reporting chronic pain secondary to multiple sclerosis, spinal cord injury, or neuromuscular disease. Participants completed a survey including measures of pain severity and the Chronic Pain Coping Inventory. Results. After controlling for clinical and demographic variables, older adults (older than 60) reported a wider range of frequently used strategies and significantly more frequent engagement in activity pacing, seeking social support, and use of coping self-statements than did younger or middle-aged adults. Moderation analyses suggest that, for younger adults, efforts at coping generally increased with greater pain severity, whereas this relationship did not exist for older adults. Discussion. These data suggest differences in the quantity and quality of pain coping among age groups.

The electromyographer's guide to the motor unit.

This article's purpose is to explain the anatomicophysiologic basis for observations and measurements made by the electromyographer. An electromyographer may be trained in the techniques of electromyography without understanding the anatomicophysiology, and valuable interpretive subtleties may be missed. This article is an attempt to provide that background (ie, the link among anatomy, physiology, and electrodiagnostic findings). It is hoped that with a fuller understanding of the anatomicophysiologic basis of clinical electromyography, subtle observations can be made which will allow a more sophisticated level of interpretation of electromyography results. Such interpretations should improve the electromyographer's capacity to provide useful information to a referring physician and hence, improve the management of a patient.

Effect of Cognitive Demand on Functional Mobility in Ambulatory Individuals with Multiple Sclerosis.

BACKGROUND: As disease progresses, cognitive demands may affect functional mobility in individuals with multiple sclerosis (MS). The Timed Up and Go (TUG) test assesses functional mobilityin populationssuch as MS. A cognitive-demanding task can be added to the TUG test to assess its effect on functional mobility. METHODS: People with MS (n = 52) and controls (n = 57) performed three versions of the TUG test: TUG alone (TUG-alone), TUG plus reciting the alphabet (TUG-alpha), and TUG plus subtracting numbers by 3s (TUG-3s). Times to complete the TUG tests were compared among controls and three groups of participants with MS created using Expanded Disability Status Scale (EDSS) scores 0 to 3.5, 4.0 to 5.5, and 6. Differences among groups were analyzed using split-plot analysis of variance. RESULTS: Group and TUG type were significant (P < .001 for both), with no interaction effect of group × TUG type (P = .21). Mean times were 8.7, 9.4, and 11.1 seconds to perform the TUG-alone, TUG-alpha, and TUG-3s, respectively. Mean times for groups were 8.0, 8.2, 11.1, and 11.6 seconds for controls and individuals with MS and EDSS 0 to 3.5, 4.0 to 5.5, and 6, respectively. CONCLUSIONS: People with MS with an EDSS score greater than 3.5 had a statistically significant reduction in performance of the TUG test even with the addition of a simple cognitive task, which might have implications for a person's more complex everyday activities.

Brain pathology of a patient 7years after autologous hematopoietic stem cell transplantation for multiple sclerosis.

Aggressive immunosuppression followed by autologous hematopoietic stem cell transplantation (aHSCT) can be an effective treatment for severe multiple sclerosis (MS), but not all stages of disease may benefit equally. The case of a 49-year-old woman with advanced secondary-progressive MS whose clinical course was not improved by aHSCT and who seven years after transplantation succumbed to complications of severe MS disease-related disability is presented. Autopsy findings of ongoing neurodegeneration despite only rare infiltrating T-lymphocytes illustrate that late MS disease may not represent a suitable disease stage for aHSCT.

Project Extension for Community Healthcare Outcomes (ECHO) in Multiple Sclerosis: Increasing Clinician Capacity.

BACKGROUND: A pilot program using the Project Extension for Community Healthcare Outcomes (ECHO) model was conducted for multiple sclerosis (MS) clinicians in the Pacific Northwest. The pilot was a collaboration between the National Multiple Sclerosis Society and faculty at the University of Washington. The goal was to determine the feasibility of using this telehealth model to increase the capacity and capability of clinicians in rural areas to treat people with MS. METHODS: Thirteen practice sites with 24 clinicians were recruited to participate. Videoconferencing was used to conduct weekly sessions consisting of brief didactics followed by case consultations. RESULTS: Most participants completing the outcome survey (10 of 15) indicated that they were more confident in treating patients with MS. They were satisfied with the training, felt better able to care for their patients, and had made changes in their treatment based on the case consultations and didactic content. They valued the case studies and case-based didactics and learned from each other as well as from the team. CONCLUSIONS: The pilot MS Project ECHO warrants further investigation regarding its potential effect on access to MS care delivery for underserved populations.

High-dose immunosuppressive therapy and autologous HCT for relapsing-remitting MS.

OBJECTIVE: To evaluate the safety, efficacy, and durability of multiple sclerosis (MS) disease stabilization after high-dose immunosuppressive therapy (HDIT) and autologous hematopoietic cell transplantation (HCT). METHODS: High-Dose Immunosuppression and Autologous Transplantation for Multiple Sclerosis (HALT-MS) is a phase II clinical trial of HDIT/HCT for patients with relapsing-remitting (RR) MS who experienced relapses with disability progression (Expanded Disability Status Scale [EDSS] 3.0-5.5) while on MS disease-modifying therapy. The primary endpoint was event-free survival (EFS), defined as survival without death or disease activity from any one of: disability progression, relapse, or new lesions on MRI. Participants were evaluated through 5 years posttransplant. Toxicities were reported using the National Cancer Institute Common Terminology Criteria for Adverse Events (AE). RESULTS: Twenty-five participants were evaluated for transplant and 24 participants underwent HDIT/HCT. Median follow-up was 62 months (range 12-72). EFS was 69.2% (90% confidence interval [CI] 50.2-82.1). Progression-free survival, clinical relapse-free survival, and MRI activity-free survival were 91.3% (90% CI 74.7%-97.2%), 86.9% (90% CI 69.5%-94.7%), and 86.3% (90% CI 68.1%-94.5%), respectively. AE due to HDIT/HCT were consistent with expected toxicities and there were no significant late neurologic adverse effects noted. Improvements were noted in neurologic disability with a median change in EDSS of -0.5 (interquartile range -1.5 to 0.0; p = 0.001) among participants who survived and completed the study. CONCLUSION: HDIT/HCT without maintenance therapy was effective for inducing long-term sustained remissions of active RRMS at 5 years. CLINICALTRIALSGOV IDENTIFIER: NCT00288626. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that participants with RRMS experienced sustained remissions with toxicities as expected from HDIT/HCT.

Double trouble in hereditary neuropathy: concomitant mutations in the PMP-22 gene and another gene produce novel phenotypes.

BACKGROUND: Mutations in the peripheral myelin protein 22 (PMP-22) gene are the most common cause of Charcot-Marie-Tooth neuropathy and may rarely occur in combination with other neurogenetic diseases. OBJECTIVE: To characterize 3 families having a mutation in PMP-22 in addition to another neurogenetic disease mutation. DESIGN: Clinical, electrophysiologic, and genetic evaluations were made of 3 families with more than 1 genetic neuromuscular disease. SETTING AND PATIENTS: Family members were evaluated in neurogenetic and muscular dystrophy clinics in a university medical center setting. RESULTS: Three unusual families were found: (1) 2 young brothers each having a PMP-22 duplication and a missense mutation in the GJB1 (Connexin-32) gene; (2) a 32-year-old woman having a PMP-22 duplication and a 1000-fold CTG repeat expansion in the DMPK gene (DM1 myotonic dystrophy); and (3) a 39-year-old man with a PMP-22 deletion and a missense mutation in the ABCD1 gene (adrenomyeloneuropathy). The mutations were "additive," causing a more severe phenotype than expected with each individual disease and coinciding with the important impact of each gene on peripheral nerve function. CONCLUSIONS: Individuals having 2 separate mutations in neuromuscular disease-related genes may develop unusually severe phenotypes. Neurologists should be alert to this possibility.

The reliability and validity of pain interference measures in persons with multiple sclerosis.

Valid measures of pain-related interference with functioning could serve as useful outcome measures in much needed clinical trials of pain treatments for persons with multiple sclerosis (MS). The purpose of this study was to examine the psychometric properties of two pain interference measures in persons with MS and chronic pain. Modified versions of the Interference scale of the Brief Pain Inventory (BPI) and the Disability scale of the Graded Chronic Pain Scale were administered via a mailed survey to 187 community-dwelling persons with MS. Data from the 125 participants who reported pain were analyzed. Although both measures demonstrated excellent internal consistency, in the current sample, evidence regarding the construct and concurrent validity was stronger for the modified versions of the BPI Interference scale. These results provide preliminary support for the reliability and validity of modified versions of the BPI Interference scale in persons with MS and chronic pain.

Satisfaction with, and the beneficial side effects of, hypnotic analgesia.

Case study research suggests that hypnosis treatment may provide benefits that are not necessarily the target of specific suggestions. To better understand satisfaction with and the beneficial "side effects" of hypnosis treatment, questions inquiring about treatment satisfaction and treatment benefits were administered to a group of 30 patients with chronic pain who had participated in a case series of hypnotic analgesia treatment. The results confirmed the authors' clinical experience and showed that most participants reported satisfaction with hypnosis treatment even when the targeted symptom (in this case, pain intensity) did not decrease substantially. Study participants also reported a variety of both symptom-related and nonsymptom-related benefits from hypnosis treatment, including decreased pain, increased perceived control over pain, increased sense of relaxation and well-being, and decreased perceived stress, although no single benefit was noted by a majority of participants.

Use of Neurofeedback to Enhance Response to Hypnotic Analgesia in Individuals With Multiple Sclerosis.

This proof of principle study examined the potential benefits of EEG neurofeedback for increasing responsiveness to self-hypnosis training for chronic pain management. The study comprised 20 individuals with multiple sclerosis (MS) who received 5 sessions of self-hypnosis training--1 face-to-face session and 4 prerecorded sessions. Participants were randomly assigned to have the prerecorded sessions preceded by either (a) EEG biofeedback (neurofeedback) training to increase left anterior theta power (NF-HYP) or (b) a relaxation control condition (RLX-HYP). Eighteen participants completed all treatment sessions and assessments. NF-HYP participants reported greater reductions in pain than RLX-HYP participants. The findings provide support for the potential treatment-enhancing effects of neurofeedback on hypnotic analgesia and also suggest that effective hypnosis treatment can be provided very efficiently.