The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
RESEARCH ARTICLE

Functional Evaluation of Multiple Sclerosis Patients in Khoy (IRAN)



Shahriar Sakhaei, Hossein Motaarefi, Soryya Zinalpoor, Hassan Ebrahimpour Sadagheyani*
Department of Medical-surgical Nursing Khoy, University of Medical Sciences Khoy, Iran

Abstract

Introduction and Purpose:

Multiple Sclerosis (MS) is a common, hidden, degenerative, and progressive chronic disease that is more prevalent in women than in men. It is caused by damage to the myelin of central nervous system and results in neuropathy. The clinical pattern of the disease is 70 percent relapsing - remitting, and depending on the severity and type of nervous involvement, results in a variety of physical, psychological and social disabilities. The present study was designed to determine the functional level of MS patients.

Methods:

In this cross-sectional study, 70 MS female patients referred to the Health Center for Special Diseases at the Madani Hospital of Khoy in 2016 were selected total samples via Census. Two questionnaires were used: the demographic information form and the 29-question MSISS questionnaire that consists of both physical and psychological dimensions. Data analyses were carried out using SPSS v.16 software for an independent sample T-test, and ANOVA.

Results:

The 69% of the sample was comprised of married women, 74% were housewives, 83% were found to be disabled, 77% had a relapsing-remitting form of illness and 89% had no communication problems. The average age was 35 years and the average duration of illness was 4 years. Severe physical disability was found in 11.4% and 17.1% suffered from severe psychological disability. The general disease-related disability was considered mild in 65.7%. Disability was related to age, lifestyle, the presence or absence of a caregiver, the type of illness and communication problems. Physical and psychological dimensions of disability were unrelated (p<0.001).

Conclusion:

According to the high rate of psychological disability compared to physical dimension and effects of physical disorders on the soul, it is necessary to minimize the severity of disability by directing and controlling tensions, changes in lifestyle, the use of complementary therapies, rehabilitation Interventions, psychosocial support, and receiving services from the Association for the supportive of MS patients.

Because psychological disability was greater than physical disability, therapy needs to address psychological stressors. Changes in lifestyle, use of complementary therapies, rehabilitation interventions and psychosocial support are recommended. Support associations for MS patients can also be helpful.

Keywords: Function, Physical disability, Psychological disability, Multiple sclerosis, Chronic disease, Neuropathy.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 11
First Page: 37
Last Page: 43
Publisher Id: TOPHJ-11-37
DOI: 10.2174/1874944501811010037

Article History:

Received Date: 24/09/2017
Revision Received Date: 24/12/2017
Acceptance Date: 29/12/2017
Electronic publication date: 14/02/2018
Collection year: 2018

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© 2018 Sakhaei et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Medical-surgical Nursing, Khoy University of Medical Sciences, Khoy, Iran; Tel: 98-914-1607298; Fax: 9804436255777; E-mail: sadageyani@yahoo.com




1. INTRODUCTION

Multiple Sclerosis (MS) is a common, hidden, degenerative, and progressive chronic disease that is more prevalent in women than in men [1Dennison L, Moss-Morris R, Chalder T. A review of psychological correlates of adjustment in patients with multiple sclerosis. Clin Psychol Rev 2009; 29(2): 141-53.[http://dx.doi.org/10.1016/j.cpr.2008.12.001] [PMID: 19167801] -3Payamani F, Nazari A, Miri M, Ghadirian Baharabchi F, Taghipour M. The study of MS patients’ life style referred to MS Association. Inter J Med Res Health Sci 2016; 5(1): 230-4.]. MS is one of the most common neurological diseases and the most debilitating disease in young ages. The disease is twice as common in women as in men and it is associated with inflammation, scarring, and gradual demyelination of the nerves of the brain and the spinal cord [1Dennison L, Moss-Morris R, Chalder T. A review of psychological correlates of adjustment in patients with multiple sclerosis. Clin Psychol Rev 2009; 29(2): 141-53.[http://dx.doi.org/10.1016/j.cpr.2008.12.001] [PMID: 19167801] -3Payamani F, Nazari A, Miri M, Ghadirian Baharabchi F, Taghipour M. The study of MS patients’ life style referred to MS Association. Inter J Med Res Health Sci 2016; 5(1): 230-4.]. MS was first described in 1868 by Jean-Martin Charcot who was a French nerve specialist. There is no cure for multiple sclerosis, but it was proven that many treatments could be useful. In Iran, there are more than 50 thousand MS patients. Iran is one of the countries with a high prevalence rate of MS (15-30 per 100,000 people) [4Etemadifar M, Janghorbani M, Shaygannejad V, Ashtari F. Prevalence of multiple sclerosis in Isfahan, Iran. Neuroepidemiology 2006; 27(1): 39-44.[http://dx.doi.org/10.1159/000094235] [PMID: 16804333] , 5Taghizadeh M, Asemi Z, Mahlooji M. Assessment of multiple sclerosis patient’s nutritional situation. Abstract proceeding of 3rd International Congress on Multiple Sclerosis, 2006.]. The disease affects more than 2.5 million people in the world and adds 200 people per week. MS is the third cause of disability in the US and 80% of people have some degree of disability [6Schulz K-H, Gold SM, Witte J, et al. Impact of aerobic training on immune-endocrine parameters, neurotrophic factors, quality of life and coordinative function in multiple sclerosis. J Neurol Sci 2004; 225(1-2): 11-8.[http://dx.doi.org/10.1016/j.jns.2004.06.009] [PMID: 15465080] , 7Mandysova P. Knowing the course of multiple sclerosis. J Neurosci Nurs 1998; 28(10): 12-6.]. While the cause is not clear, studies point to viral infection and immune system disorders [8Zadeh MN. Comparison of extent of psychological hardiness and moral intelligence among individuals quitted addiction and individuals with addiction relapse and examination of effect of gender roles on these variables. Inter J Psych Behav Sci 2017; 7(1): 19-26.]. It seems that the activation of immune mechanisms against myelin tissue is involved in the development of the disease [9Saeedi H, Nasab S-H, Zadeh AM, Ebrahimi HA. The effectiveness of positive psychology interventions with Islamic approach on quality of life in females with multiple sclerosis. Biomed Pharmacol J 2015; 8(2): 965-70.[http://dx.doi.org/10.13005/bpj/848] ]. The incidence of the disease-related disability depends on the location of the nerves. The visual nerves, cerebellum, brain stem, cerebellum, and spinal cord are more likely to be affected than other parts of the central nervous system [10McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: Guidelines from the international panel on the diagnosis of multiple sclerosis. Ann Neurol 2001; 50(1): 121-7.[http://dx.doi.org/10.1002/ana.1032] [PMID: 11456302] ]. This chronic and progressive disorder causes sensory impairment, weakness, muscle cramps, visual impairment, cognitive impairment, fatigue, limb tremor, urinary tract disorder, feces, sexual function, balance, forgetfulness, hearing loss, numbness, and speech impairment. The range of symptoms varies from mild to severe and from transient to chronic [11Marrie RA, Cutter G, Tyry T, Vollmer T, Campagnolo D. Disparities in the management of multiple sclerosis-related bladder symptoms. Neurology 2007; 68(23): 1971-8.[http://dx.doi.org/10.1212/01.wnl.0000264416.53077.8b] [PMID: 17548546] , 12Marrie R, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. Comorbidity, socioeconomic status and multiple sclerosis. Mult Scler 2008; 14(8): 1091-8.[http://dx.doi.org/10.1177/1352458508092263] [PMID: 18728060] ]. The clinical course of MS is different and unpredictable to different people, and its most common form is associated with a period of relapsing - remitting. Patients have different symptoms at different times, and each person may have certain symptoms, although some symptoms are more common. Physical symptoms associated with psychological problems such as anxiety, depression and cognitive impairment lead to significant disability [13Brunner LS, Suddarth DS. Textbook of medical-surgical nursing 3rd ed. 3rd ed.2012., 14Werring DJ, Thompson AJ. Improving the quality of life of patients with multiple sclerosis: Diagnosis. Drugs Today (Barc) 1998; 34(2): 145-56.[http://dx.doi.org/10.1358/dot.1998.34.2.485188] [PMID: 15094871] ] and physical, psychological and social impairment in individuals [15Rousseaux M, Pérennou D. Comfort care in severely disabled multiple sclerosis patients. J Neurol Sci 2004; 222(1-2): 39-48.[http://dx.doi.org/10.1016/j.jns.2004.04.002] [PMID: 15240194] ]. People suffer from a variety of physical and psychological disorders during their lifetime and these disorders affect Daily performance, family life, and social and functional autonomy [16Solari A, Mattarozzi K, Vignatelli L, et al. Development and validation of a patient self-assessed questionnaire on satisfaction with communication of the multiple sclerosis diagnosis. Mult Scler 2010; 16(10): 1237-47.[http://dx.doi.org/10.1177/1352458510376178] [PMID: 20813775] ]. The disease often affects people who are at the stage of their productive life and are concerned about their family responsibilities and role [17Amcconell E. Myths & facts, nursing education 1999.]. This disease threatens the individual's independence and ability to participate effectively in the family and community, and affects all aspects of life and gradually leads to disability [2Halper J, Holland NJ. Multiple sclerosis: A self-care guide to wellness: Demos medical publishing 2005., 13Brunner LS, Suddarth DS. Textbook of medical-surgical nursing 3rd ed. 3rd ed.2012.]. Patients experience a higher level of psychiatric disorders such as depression, stress, and anxiety, which may occur due to direct effects of inflammation and demyelination of the nerves or resulting from the psychological effects of multiple sclerosis [18Liu XJ, Ye HX, Li WP, Dai R, Chen D, Jin M. Relationship between psychosocial factors and onset of multiple sclerosis. Eur Neurol 2009; 62(3): 130-6.[http://dx.doi.org/10.1159/000226428] [PMID: 19571540] ]. In the Grossman study, 17.9% of patients with MS had severe physical problems and 38.8% had severe social problems, and severe depression and anxiety were 11.2% and 14.9% respectively [19Grossman P, Kappos L, Gensicke H, et al. MS quality of life, depression, and fatigue improve after mindfulness training: A randomized trial. Neurology 2010; 75(13): 1141-9.[http://dx.doi.org/10.1212/WNL.0b013e3181f4d80d] [PMID: 20876468] ]. The psychological problems compared to physical changes make severe problems to the patient [20Pugliatti M, Rosati G, Carton H, et al. The epidemiology of multiple sclerosis in Europe. Eur J Neurol 2006; 13(7): 700-22.[http://dx.doi.org/10.1111/j.1468-1331.2006.01342.x] [PMID: 16834700] , 21Ajilchi B, Oskoei AS, Kargar FR. Marital satisfaction and mental health in multiple sclerosis patients’ and healthy individuals’ accordance to sex. Psychology (Irvine) 2013; 4(11): 845.[http://dx.doi.org/10.4236/psych.2013.411121] ]. Due to the complex nature of the disease, various mental and physical disabilities can arise, and family, occupational, and social causes, care and rehabilitation of patients are necessary to consider [22Giordano A, Granella F, Lugaresi A, et al. Anxiety and depression in multiple sclerosis patients around diagnosis. J Neurol Sci 2011; 307(1-2): 86-91.[http://dx.doi.org/10.1016/j.jns.2011.05.008] [PMID: 21621796] ]. In order to achieve the highest level of health and have a positive belief in abilities, it is important to have multi-supportive programs [23Zouhmand M. Association between social support and quality of life in persons with multiple sclerosis 2007; 11.]. Training about the disease, the importance of follow-up therapy and self-efficacy can improve physical, mental, and limit performance [24Benedict RH, Wahlig E, Bakshi R, et al. Predicting quality of life in multiple sclerosis: Accounting for physical disability, fatigue, cognition, mood disorder, personality, and behavior change. J Neurol Sci 2005; 231(1-2): 29-34.[http://dx.doi.org/10.1016/j.jns.2004.12.009] [PMID: 15792817] ]. Based on the increasing population of patients, the mortality rate, increased costs of treatment and multiple problems, the reduction of the patient's problems should be considered as a priority of health and research [4Etemadifar M, Janghorbani M, Shaygannejad V, Ashtari F. Prevalence of multiple sclerosis in Isfahan, Iran. Neuroepidemiology 2006; 27(1): 39-44.[http://dx.doi.org/10.1159/000094235] [PMID: 16804333] ]. Regarding the nature of the disease and the importance of the issue, by conducting numerous studies, it is possible to identify and determine the frequency of symptoms and to take positive steps towards proper management and reduction of patients' disability. The present study is aimed to determine the capability level of MS patient referred to the health center for Special Diseases in Madani Hospital of Khoy in 2016.

2. MATERIALS AND METHODS

This cross-sectional study was carried out after coordination and obtaining the consent of 70 MS female patients, who referred to the health center for Special Diseases in Madani Hospital of Khoy in 2016. The researcher explained the research goals and the inclusion criteria such as confirmation of MS disease by a physician, age range of 20-50 years, cooperation, and ability to answer questions, lack of samples in the acute phase of the disease, and exclusion criteria such as the incidence of other acute or chronic physical, mental, or psychiatric disorders. For the emotional and mental status of sample to answer the questions and referral patients, only female patients were considered due to research limitations. Total samples were selected via censuses in 2016. The measurement tools included 15-questions Patients characteristic of form (indicates the individual characteristics and its information about the disease) and 29-questions MSISS questionnaires (to measure the capability of patients) in two physical (20 questions) and psychological (9 questions) dimensions (about their concerns and ability restrictions over the past two weeks). To measure the level of ability, the 5-option Likert scale was used (from never to very much with the range of points 29-145), which a high score indicated an aggravation of disability. The validity of questionnaires was approved by the perspective of 12 experts and the reliability of the questionnaire was verified by retesting on 20 patients with an internal correlation of Cronbach’s alpha (α=0.85). Data analyses were carried out using SPSS v.16 software with independent sample T-test, and ANOVA (P≤ 0.05).

3. RESEARCH FINDINGS

According to the present study, the majority of studied units included married women (69%), housewives (74%) with 83% disability, relapsing - remitting (77%), without communication problems (89%) (Table 1). In physical dimension, the most frequent disability was related to the mild disability (74% and with a score less than 45) and in psychological dimension (21-32), it was 45.7% (Table 2). Generally, in the present research, the severity of disease-related disability was mild (65.7%) (Table 3). In the evaluation of statistical relationship, there were significant differences between limitation of disease-related disability and age, disablement, lifestyle, having a caregiver, type of illness and communication problems in the level lower than (α=0.05). Besides, based on the results, there was a connection between physical and psychological dimension (P<0/001) (Table 4).

Table 1
Patients characteristics.


Table 2
Distribution of relative and absolute frequency of physical and mental dimensions in multiple sclerosis patients.


Table 3
Distribution of relative and absolute frequency of overall disability in multiple sclerosis patients.


Table 4
Relationship between disability and Underlying variables in samples under study.


4. DISCUSSION

Occurrences of some symptoms as well as disabilities in patients with MS result in dependency and social solitary. Although the main goal of nursing is to maintain the activity and independence of patients through rehabilitation programs by the recognition of needs and mental health support, mentioned issues prevent the realization of therapeutic goals. According to the aims of the present study, the most frequent disability was mild. In the study of Sanglaji and colleagues, based on Expanded Disability Status Scale (EDSS), mild, average, and severe disability were 33.7%, 51.1%, and 15.2% respectively, which is partly consistent with the present study. Considering the similar results of various studies, the necessity of establishing rehabilitation centers with educational and counseling programs to increase the capacity and improve the health of these patients at the community level is necessary [25Ghabaee DNZ, Nesami MB, Shafaroudi MM. Evaluation of the relationship between spiritual well-being and quality of life in patients with multiple sclerosis, parameters 2010; 11]. Comparing the two physical and mental dimensions showed that the frequency of severity of disability in psychological problems was more than physical. This result indicated that patients suffered from more mental and physiological problems, which could be related to the patient's concern about the disease, the effects of the illness and the outcome of the therapeutic intervention. In the study of Mitchell and colleagues, about 48% of patients experienced anxiety, stress, and depression in the first year after diagnosis [26Mitchell AJ, Benito-León J, González JM, Rivera-Navarro J. Quality of life and its assessment in multiple sclerosis: Integrating physical and psychological components of wellbeing. Lancet Neurol 2005; 4(9): 556-66.[http://dx.doi.org/10.1016/S1474-4422(05)70166-6] [PMID: 16109362] ]. The results of Sicily and Johnson's study also showed a significant and direct relation between the anxiety and stress of MS patients with severity of illness, so that the severity of disability increased the stress and anxiety of patients [27Janssens AC, van Doorn PA, de Boer JB, et al. Anxiety and depression influence the relation between disability status and quality of life in multiple sclerosis. Mult Scler 2003; 9(4): 397-403.[http://dx.doi.org/10.1191/1352458503ms930oa] [PMID: 12926846] ]. Those of Etemadi Far and colleagues showed that with the increasing severity of disease, mental health of patients was more affected than their physical health [28Etemadi Far M, Zare M, Sehat M. Relationship between the quality of life of patients with multiple sclerosis demographic characteristics of patients who participated in the city of Isfahan MS Association in 2003 [Thesis]. Isfahan, Iran: School of Medicine, Isfahan University of Medical Sciences. 2004.]. Concerns of patients with MS include two parts such as the effect of the disease on physical activity and concern about the impact of the severity of the disease on social interactions, family relationships, and daily activities [29Thornton EW, Tedman S, Rigby S, Bashforth H, Young C. Worries and concerns of patients with multiple sclerosis: Development of an assessment scale. Mult Scler 2006; 12(2): 196-203.[http://dx.doi.org/10.1191/135248506ms1273oa] [PMID: 16629423] ]. Therefore, in order to cope with the psychological effects of the disease, maintaining mental and psychological support is essential. In the physical dimension, the highest incidence of severe inability was the lack of ability to perform for a long time and in the mental-psychological dimension, irritability, irregularity, and anxiety. In the study of Dehghi and colleagues, among physical problems, motion constraints limited the daily routine task and social activities more than other symptoms of illness [30Qaderi K, Merghati Khoei E. Female sexual problems in multiple sclerosis and its association with quality of life. J Urmia Nurs Midwife Facult 2013; 11(7)]. In the study of Ravanmehr and colleagues, the frequency of movement disorders, visual acuity, and balance problems were 40%, 30%, and 40%, respectively and they showed the highest frequency. Besides, speech and digestive problems had the lowest frequency [31Jahanbakhsh E, Haghighatian M, Ravanmehr F, Hossein PK. Association between the social support and quality of life of patients with multiple sclerosis in Isfahan 2013. 9(4): 403-11.]. Therefore, it is necessary to identify the type of physical or psychological disabling symptoms and to act appropriately to control the problems of the treatment team [32Janardhan V, Bakshi R. Quality of life in patients with multiple sclerosis: The impact of fatigue and depression. J Neurol Sci 2002; 205(1): 51-8.[http://dx.doi.org/10.1016/S0022-510X(02)00312-X] [PMID: 12409184] ]. As a result, the disabilities could be treated by providing the necessary training along with self-management and stimulating the forgotten abilities of the patients. Since nurses spend the most time with patients, they can play an important role in identifying the unobservable symptoms, the effect of these symptoms on daily functioning, and how to reduce the adverse effects of these disabilities [33Hopman WM, Coo H, Edgar CM, McBride EV, Day AG, Brunet DG. Factors associated with health-related quality of life in multiple sclerosis. Can J Neurol Sci 2007; 34(2): 160-6.[http://dx.doi.org/10.1017/S0317167100005989] [PMID: 17598592] ]. Sutherland and colleagues concluded that the relaxation program would generate more energy and would result in less limitation of MS patients in performing physical and psychomotor roles [34Sutherland G, Andersen MB, Morris T. Relaxation and health-related quality of life in multiple sclerosis: The example of autogenic training. J Behav Med 2005; 28(3): 249-56.[http://dx.doi.org/10.1007/s10865-005-4661-2] [PMID: 16015459] ]. The results of the present study indicated that there was a statistically significant relationship between Limitations of disease-related disability with age, disablement, lifestyle, having caregiver, type of illness and communication problems. Moreover, there was a correlation between physical and mental disability, while, according to those of Etemadi Far and his colleagues, there was no significant relationship between quality of life and with demographic characteristics of age, gender, occupation, and education level, severity, and type of disease. The results of the mentioned study were different with background variables of the present study. It seems that the geographical difference, the severity of the disability and the type of instrument affected this difference. Besides, in the study of Etemedi Far, there was a significant relationship between physical health and mental health, which was in agreement with our findings [28Etemadi Far M, Zare M, Sehat M. Relationship between the quality of life of patients with multiple sclerosis demographic characteristics of patients who participated in the city of Isfahan MS Association in 2003 [Thesis]. Isfahan, Iran: School of Medicine, Isfahan University of Medical Sciences. 2004.]. Therefore, resolving the problems of MS patients, empowerment in identifying the nature of the disease, relieving symptoms, increasing self-care awareness and self-confidence, will be possible by facilitating the adaptive methods and support.

CONCLUSION

Regarding the results of the study and the frequency of severity of disability in MS patients in the psychological dimension compared to the physical dimension and the effect of physical and mental disorders, it is necessary to minimize the severity of the disabilities by teaching how to control the stress, changing lifestyle, and by creating conditions for the use of complementary therapies such as relaxation, guided visualization, thought diversion, music therapy, massage therapy and rehabilitation measures (physiotherapy, occupational therapy, use of assistive devices), counseling, psychotherapy and community support services for MS patients. Since the MS affects all aspects of physical, psychological, family and community, and only medical treatment and control of period of disease are not enough to treat patients, therefore, the medical community, especially nurses, should provide comprehensive rehabilitation plans to increase the performance of patients.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was granted ethical clearances for the entire program of research by the ethical committee of Vice-Chancellor for Research and Technology University.

HUMAN AND ANIMAL RIGHTS

70 MS Female patients were referred to the health center for Special Diseases in Madani Hospital of Khoy in 2016.

CONSENT FOR PUBLICATION

Informed and written consent was obtained from all the subjects.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We would like to show our gratitude to all the patients and those who cooperated in this study.

REFERENCES

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[4] Etemadifar M, Janghorbani M, Shaygannejad V, Ashtari F. Prevalence of multiple sclerosis in Isfahan, Iran. Neuroepidemiology 2006; 27(1): 39-44.[http://dx.doi.org/10.1159/000094235] [PMID: 16804333]
[5] Taghizadeh M, Asemi Z, Mahlooji M. Assessment of multiple sclerosis patient’s nutritional situation. Abstract proceeding of 3rd International Congress on Multiple Sclerosis, 2006.
[6] Schulz K-H, Gold SM, Witte J, et al. Impact of aerobic training on immune-endocrine parameters, neurotrophic factors, quality of life and coordinative function in multiple sclerosis. J Neurol Sci 2004; 225(1-2): 11-8.[http://dx.doi.org/10.1016/j.jns.2004.06.009] [PMID: 15465080]
[7] Mandysova P. Knowing the course of multiple sclerosis. J Neurosci Nurs 1998; 28(10): 12-6.
[8] Zadeh MN. Comparison of extent of psychological hardiness and moral intelligence among individuals quitted addiction and individuals with addiction relapse and examination of effect of gender roles on these variables. Inter J Psych Behav Sci 2017; 7(1): 19-26.
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[10] McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: Guidelines from the international panel on the diagnosis of multiple sclerosis. Ann Neurol 2001; 50(1): 121-7.[http://dx.doi.org/10.1002/ana.1032] [PMID: 11456302]
[11] Marrie RA, Cutter G, Tyry T, Vollmer T, Campagnolo D. Disparities in the management of multiple sclerosis-related bladder symptoms. Neurology 2007; 68(23): 1971-8.[http://dx.doi.org/10.1212/01.wnl.0000264416.53077.8b] [PMID: 17548546]
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[13] Brunner LS, Suddarth DS. Textbook of medical-surgical nursing 3rd ed. 3rd ed.2012.
[14] Werring DJ, Thompson AJ. Improving the quality of life of patients with multiple sclerosis: Diagnosis. Drugs Today (Barc) 1998; 34(2): 145-56.[http://dx.doi.org/10.1358/dot.1998.34.2.485188] [PMID: 15094871]
[15] Rousseaux M, Pérennou D. Comfort care in severely disabled multiple sclerosis patients. J Neurol Sci 2004; 222(1-2): 39-48.[http://dx.doi.org/10.1016/j.jns.2004.04.002] [PMID: 15240194]
[16] Solari A, Mattarozzi K, Vignatelli L, et al. Development and validation of a patient self-assessed questionnaire on satisfaction with communication of the multiple sclerosis diagnosis. Mult Scler 2010; 16(10): 1237-47.[http://dx.doi.org/10.1177/1352458510376178] [PMID: 20813775]
[17] Amcconell E. Myths & facts, nursing education 1999.
[18] Liu XJ, Ye HX, Li WP, Dai R, Chen D, Jin M. Relationship between psychosocial factors and onset of multiple sclerosis. Eur Neurol 2009; 62(3): 130-6.[http://dx.doi.org/10.1159/000226428] [PMID: 19571540]
[19] Grossman P, Kappos L, Gensicke H, et al. MS quality of life, depression, and fatigue improve after mindfulness training: A randomized trial. Neurology 2010; 75(13): 1141-9.[http://dx.doi.org/10.1212/WNL.0b013e3181f4d80d] [PMID: 20876468]
[20] Pugliatti M, Rosati G, Carton H, et al. The epidemiology of multiple sclerosis in Europe. Eur J Neurol 2006; 13(7): 700-22.[http://dx.doi.org/10.1111/j.1468-1331.2006.01342.x] [PMID: 16834700]
[21] Ajilchi B, Oskoei AS, Kargar FR. Marital satisfaction and mental health in multiple sclerosis patients’ and healthy individuals’ accordance to sex. Psychology (Irvine) 2013; 4(11): 845.[http://dx.doi.org/10.4236/psych.2013.411121]
[22] Giordano A, Granella F, Lugaresi A, et al. Anxiety and depression in multiple sclerosis patients around diagnosis. J Neurol Sci 2011; 307(1-2): 86-91.[http://dx.doi.org/10.1016/j.jns.2011.05.008] [PMID: 21621796]
[23] Zouhmand M. Association between social support and quality of life in persons with multiple sclerosis 2007; 11.
[24] Benedict RH, Wahlig E, Bakshi R, et al. Predicting quality of life in multiple sclerosis: Accounting for physical disability, fatigue, cognition, mood disorder, personality, and behavior change. J Neurol Sci 2005; 231(1-2): 29-34.[http://dx.doi.org/10.1016/j.jns.2004.12.009] [PMID: 15792817]
[25] Ghabaee DNZ, Nesami MB, Shafaroudi MM. Evaluation of the relationship between spiritual well-being and quality of life in patients with multiple sclerosis, parameters 2010; 11
[26] Mitchell AJ, Benito-León J, González JM, Rivera-Navarro J. Quality of life and its assessment in multiple sclerosis: Integrating physical and psychological components of wellbeing. Lancet Neurol 2005; 4(9): 556-66.[http://dx.doi.org/10.1016/S1474-4422(05)70166-6] [PMID: 16109362]
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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