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Multiple Sclerosis Relapses

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Updated March 19, 2009

MS relapses are one of the most frustrating areas of multiple sclerosis for patients, their doctors and loved ones to deal with and understand. The first year after my MS diagnosis, I was constantly wondering if the disappearing-reappearing-disappearing tingling in my feet was an exacerbation, because some days it would seem to be almost gone, then other days it would almost keep me from walking normally. Then I would have the girdle-band pain that was there for a couple of hours, then gone for three days, only to come back temporarily.

A Personal Note:

I have since learned that it is important to react and see the neurologist if the symptoms are interfering with daily activities or causing discomfort. I have come to accept the “tingles” as just a quirky unwelcome visitor, without an impending sense of dread that they signal an impending relapse. This approach has helped to keep me calm and enjoy life, without giving more power to my MS.

What a Relapse Is:

A relapse is a clinically significant event (meaning that it has outward signs and/or symptoms) caused by an MS lesion on your brain or spinal cord. It is either a worsening of symptoms that you already have, or the appearance of new symptoms. Relapses are also referred to as "exacerbations," "attacks" or "flares."

Causes of Relapse:

Relapses are caused by the inflammation that occurs when your immune system attacks the myelin surrounding nerves in your brain or spinal cord. Myelin is the protective coating that covers nerves and helps them conduct signals. When the myelin is attacked by immune cells, a “lesion” or an area of inflammation and eventual damage (demyelination) occurs, making the nerves less efficient in conducting signals. Your symptoms depend on the location of this lesion. For instance, inflammation in the cerebellum can cause loss of balance and coordination, while inflammation of the optic nerves can cause decreased vision.

Signs of a Relapse:

Some relapses are very obvious, for instance, losing your sight in one eye due to an attack of optic neuritis. However, other relapses may not be as sudden or dramatic and you may just feel extra “wobbly” or tired. The way to really know if you are having a relapse is to have an MRI with gadolinium (contrast material that is injected during the MRI scan). Gadolinium is drawn to areas of inflammation and “lights up” when a lesion is “active.” In this case, demylenation is currently occurring, and you are having a true relapse, rather than feeling symptoms caused by older lesions.

Days, Weeks or Months:

In order to be a true relapse, the episode has to last at least 24 hours. There are such things as “mini-relapses,” meaning a quirky symptom which lasts for a couple of minutes up to several hours and then goes away, but these are not true relapses. True relapses usually last several weeks, although they can be as short as a couple of days or as long as several months.

A relapse must be separated from a previous relapse by at least a month. This is to distinguish it from symptoms that may be from a previously active lesion (which can change as inflammation subsides, remyelination occurs and/or scar tissue forms).

Preventing Relapses:

The first and most important thing that you can do to prevent relapses is to begin using, and adhere to, one of the disease-modifying therapies. These are shown to reduce relapses by one-third on average over a two-year period, and data is showing that over a longer term (10 years and longer), the average reduction in relapses is much greater.

Treating Relapses:

Many relapse symptoms can be treated with high-dose corticosteroids, usually Solu-Medrol. The decision is made to treat a relapse based on how much disability the symptoms are causing and how much they interfere with daily activities. The steroid treatment usually significantly shortens the duration of the most severe symptoms, allowing a faster return to normal activities. However, some symptoms may take a longer time to go away and may never quite clear up entirely.

Pseudoexacerbation:

A pseudoexacerbation is a temporary increase in symptoms that is brought on by an external factor. Most often they are caused by heat from hot weather, exertion or fever. This can be caused by an increase in core temperature of as little as half of a degree. Once the body temperature returns to normal, the symptoms subside.

Remission:

The NMSS says: “A remission does not mean that all the symptoms of MS disappear, but rather that a person with MS returns to the baseline that existed before the last exacerbation began.” However, some relapses leave damage in their wake in the form of plaques or scar tissue, so that even though the inflammation is gone and the lesion is no longer active, you will never return to that “baseline.” For example, a person may walk again after a relapse during which they were unable to walk, but they might have a limp. One large study showed that 42% of exacerbations leave some degree of “residual impairment.”

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