What Is The Lhermitte's Sign and What Does It Mean?
Testing for Lhermitte's sign
What is Lhermitte's?
Written in May 2012
I can't give you one definition of Lhermitte's Sign because each person who experiences it, describes it differently. If you were to eavesdrop on a conversation among patients in a doctor's waiting room, you might hear the following:
Patient #1: Lhermitte's sign is a tingly but shocking feeling.
Patient #2: No, no, it is a shooting jolt of electricity, starting at the top of my neck then continuing down my back.
Patient #3: It is a sharp burning sensation.
Patient #4: Sometimes it feels like a giant numb spot that buzzes only if I rub it. (All the other participants answer in unison - "then don't rub it!" )
Actually all of the definitions would be correct because Lhermitte's sign is all these things and more.
It usually starts at the back of your neck and continues downward. Fast. It can stop just as quickly too - on the way to your arms, to your spine or your legs.
Some people say that their experience starts at their feet and works its way upward, causing a weakness in the legs and possibly some hesitation for a few seconds upon starting to walk, before taking a step or two.
Usually, the intenseness of the electric shock sensation does not last long. It is the suddenness of that jolt of electricity - that can make you jerk a little. It doesn't last long either and usually it is over before you know it.
Many patients rarely mention this symptom to their doctor because in comparison to their other symptoms, it doesn't last for hours and hours unless a patient is in a stationary position or does not move around for long periods of time. Also, a sudden change in position can cause the sensation.
Some patients say that sometimes it feels like a buzzing or tingling and sometimes it feels like a sharp stabbing pain.
For me, sometimes I will have long periods of numbness that can last for weeks. During that time, I can still feel pain and those jolting electric shocks. The numbness is just another layer on top of the pain.
Your Doctor May Go Out Of His Way To Cause Your L'hermitte's Sign To Happen
Usually when you go to a new doctor, during his examination, he will put you through the paces trying to see what your limitations are and how much pain you feel on a scale of one to ten. Saving it for last part of his exam, usually he will say "touch your chin to your chest" and then he will push hard on the back of your neck (while your head is lowered) which makes the L'hermitte's sensation happen instantly. A newer patient won't expect the push - or the jolting pain right after.
In my early years of being newly diagnosed with Multiple Sclerosis, I could expect the L'hermitte's sensation to hang around for days and sometimes weeks. So I always dreaded whenever a new or consult doctor would cause the sensation to happen.
The only reason he does it is to see if the sensation is present, followed by asking you to rate your pain on a scale of one to ten.
Once your doctor has it documented with your symptoms in your chart, there really is no reason to keep doing this each visit.
What If You Don't Feel Any Of These Symptoms?
If you do not have a neurological condition, an autoimmune disease or disc impingement, you probably will not exhibit the Lhermitte's sign or feel much pain when the doctor does this test. The notes in your chart will say: "negative for Lhermitte's."
It doesn't hurt too bad ... until he pushes on it!
Have you ever felt Lhermitte's in your neck or shoulders?
They chat a bit on this video, but some of the info is helpful
- Lhermitte's Sign is named after Jacques Jean Lhermitte, French neurologist and neuropsychiatrist, (1877-1959).
- Lhermitte's Sign is not only found in Multiple Sclerosis.
- Some people have a hard time describing it to their doctors.
- Some people don't even bother telling their doctors because they either they feel it is not important to the reason for their visit, or they forget they have it because they are not feeling it at that very moment.
- An injury to the neck, back or shoulders can set off this sensation.
- Sometimes Lhermitte's Sign can last for months if left untreated or if staying in the same position (example: patient in coma, on vent, in wheelchair with no changes in position).
- Although treatment usually consists of pain medications, there are other alternatives for those who do not want pain meds.
I am my own worse enemy
If I get it too often, it is usually due to my own fault.
You can cause it yourself in everyday actions that you take for granted, like:
- Putting the phone between your ear and your shoulder so you can write something down
- Signing your name on a store receipt when you turn your head a certain way
- Sleeping with double pillows which can put your head and neck at an awkward angle
- Sitting in the hairdresser’s chair where a sudden movement or head tilt can set it off
In fact, Lhermitte’s sign is often referred to as Barber Chair syndrome. When the hairdresser wants to cut hair at the back of your neck to get it even, you will be told to bend your head forward or tilt your head down to your chest.
In people who have underlying neurological conditions, this causes an instant Lhermitte's sign.
I have even experienced it when the dentist drilled a tooth and hit a nerve. It sent a jolt from my jaw over to my ear and down the side and back of my neck. I don't know what was worse - the jolt or the unexpectedness of the jolt.
Lhermitte's Sign - the "red" signifies the route of pain
So if the doctor knows you have it, why is the doctor messing with your neck?
Actually, he is building a symptom list to help him make the correct diagnosis. Don't be afraid to tell him to quit testing for the Lhermitte's sign, especially if he asks to do it on each visit. Just say no. Tell him he already has information in your chart and you still have the same sensations.
Sometimes repeated testing over a short period of time will aggravate this and cause it to stick around for a while. Patients have been known to hit NSAIDS and even harder medications when NSAIDS didn't kick the pain.
At one point, I had Lhermitte's symptoms for nearly seven years because of the way I had to sit in my wheelchair while at work and at home. It also didn't help that I was sitting in front of a computer for many hours a day. Like I said, I'm my own worse enemy and I know it. I often said I'd only be an hour or so on the computer and the next thing I know, four hours or more had gone by. It is only when I went to change positions, wheel from one room to another, or transfer from the wheelchair that I got the "jolt."
Sedentary positions where you have to hold your head straight or when you don't take frequent breaks will often aggravate Lhermitte's so that it feels like it will never go away. If you have it for long periods, now you know how to deal with it.
If your doctor pinpoints the cause after building his symptom list, he may offer to treat your Lhermitte's symptoms. If you want him to, that is.
Sometimes it is better to live with something like this than it is to take medication for it, because one medication leads to another (because of side effects, etc.) and before you know it, you are taking five medications to treat one thing.
If confronted with taking a prescription medication for symptoms of Lhermitte's which comes and goes, I would skip it and concentrate on getting to the bottom of what is causing Lhermitte's and treat that.
Prescription pain medications will decrease your sensitivity to pain and if you are still in diagnosis stage, these meds can mask your symptoms, making it harder for your doctor to figure out the main diagnosis. So that is why I would advise anyone to skip taking prescription pain meds (hard drugs) for Lhermitte's until you get a name for your overall diagnosis. Use over the counter remedies like NSAIDS or Ibuprofen which won't mask as badly as prescription drugs.
When your doctor documents the Lhermitte’s symptom in your chart and adds it to other symptoms, he then will start looking for a cause by ordering imaging tests and other laboratory studies.
Lhermitte's sign is almost always associated with Multiple Sclerosis, but it can be because of disc damage and some neurological disorders.So it is not disease specific only to Multiple Sclerosis.
If you are still in the diagnosis stages, when you exhibit Lhermitte's sensation, don't assume right off the bat that you have MS. Wait until you are formally diagnosed with MS.
I developed a very stubborn case of Lhermitte's when I was in a car accident at around age 13 which resulted in several bulging discs and two herniated discs. No matter what I did, the Lhermitte's symptom would not calm down. Because of the disc damage, I developed painful Arnold-Chiari malformation which caused my neck to crack often (and I thought loudly!). Even though Lhermitte's was present, I did not yet have MS. I was diagnosed with Multiple Sclerosis ten years later.
Because I had Lhermitte's a full ten years before my MS diagnosis, it made diagnosing MS a little harder. This was also in the days before they had MRI's. In fact, CT scans were brand new -- one CT machine was the size of a 12 x 18 foot room. Now they are more than half that size.
So if you have herniated discs, Arnold-Chiari malformation, any cervical spinal cord injuries or inflammations that could indicate disc problems, chances are you already know what Lhermitte's sign feels like. Now it has a name.
When the doctor is compiling his list of symptoms, he will look for Lhermitte’s sign in patients where he suspects any of the following:
- Arnold-Chiari malformation
- disc subluxation
- transverse myelitis
- tuberculosis of the cervical spine
- tumors of cervical spinal cord
- Behcet’s disease - when joint pain is present
- radiation myelitis - spinal cord injury after having radiation treatments
- tethered cord syndrome (TCS)
- lipomas of the spinal cord
- lesions on the spinal cord related to other diseases
Lhermitte's can be seen in patients who are undergoing high dose chemotherapy and those who have a significant Vitamin B-12 deficiency.
Lhermitte's is not the defining symptom. It is not a pivotal piece needed to make a diagnosis - it is a contributing symptom, added to the list, to be taken into consideration when the patient can be confirmed as having something else.
. It is not a definitive symptom for diagnosis of any one disease. Even though it is usually associated with MS, as you can see it is a symptom used to diagnose other disorders too.
Treatments for Lhermitte's symptoms
Treatment of Lhermitte's
You would do well to avoid fatigue and getting overheated (for example: frequent hot baths) because these aggravate it and can cause this sensation to flare up. The more overheated you get, the longer it will take for the sensation to calm down. That includes vigorous exercise, hot baths and heating pads.
If you are fatigued, have taken to your bed or nap for four or more hours, it has been known to alleviate or slow down the recurence of the symptoms.
Sometimes you can move just the wrong way and feel that jolt of electricity shooting from your neck down your arm and you'll think you are having symptoms of a heart attack. Rest assured, you are not having a heart attack, that is a neurological symptom.
In some cases, the drugs that are used to treat Lhermitte's Sign are actually designed for something else entirely. When prescribed for a condition not listed in the literature, this is called using the drug "off label."
Anticonvulsants treat epileptic seizures but have proven effective in treating Lhermitte's. Examples are: Neurontin (Gabapentin) or Lyrica. These drugs block abnormal electrical signals in the brain to cut down on that jolt of electricity you feel.
Some physicians order a rigid neck collar or brace that will limit your range of motion so that you can't change your position very quickly thus triggering Lhermitte's symptoms. Just make sure your doctor keeps up with your physical therapy consults so that your neck doesn't get weak or lose what range of motion you already have.
TENS unit - This didn't work very well with me, but some people report good results. A TENS unit is a trans-cutaneous electric nerve stimulation machine with a battery pack about the size of a transistor radio (if you are old enough to remember what they are!). It has electrodes attached to sticky pads that you stick onto the painful area and it sends a small electrical throbbing charge to the nerves which is supposed to block pain receptors and, in turn, cut down on the pain of Lhermitte's symptoms.
For me, all it did was stir up the jolting and jerking sensations, so I soon abandoned it as a form of therapy. It may work for you, I'm just saying it didn't work for me.
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