An exacerbation of MS (also known as a relapse, attack or flare-up) causes new symptoms or the worsening of old symptoms. It can be very mild, or severe enough to interfere with a person’s ability to function at home and at work. No two exacerbations are alike, and symptoms vary from person to person and from one exacerbation to another. For example, the exacerbation might be an episode of optic neuritis (caused by inflammation of the optic nerve that impairs vision), or problems with balance or severe fatigue. Some relapses produce only one symptom (related to inflammation in a single area of the central nervous system) while other relapses causes two or symptoms at the same time (related to inflammation in more than one area of the central nervous system).
To be a true exacerbation, the attack must last at least 24 hours and be separated from the previous attack by at least 30 days. Most exacerbations last from a few days to several weeks or even months.
What causes exacerbations?
Exacerbations (relapses) are caused by inflammation in the central nervous system (CNS). The inflammation damages the myelin which slows or disrupts the transmission of nerve impulses and causes the symptoms of MS.
In the most common disease course in MS — called relapsing-remitting MS — clearly defined acute exacerbations are followed by remissions as the inflammatory process gradually comes to an end. Going into remission doesn’t necessarily mean that the symptoms disappear totally — some people will return to feeling exactly as they did before the exacerbation began, while others may find themselves left with some ongoing symptoms.
The good news is that not all exacerbations require treatment. Mild sensory changes (numbness, pins-and-needle sensations) or bursts of fatigue that don’t significantly impact a person’s activities can generally be left to get better on their own.
For severe exacerbations (involving loss of vision, severe weakness or poor balance, for example) which interfere with a person’s mobility, safety or overall ability to function, most neurologists recommend a short course of high-dose corticosteroids to reduce the inflammation and bring the relapse to an end more quickly. The most common treatment regimen is a three-to-five-day course of intravenous Solu-Medrol® (methylprednisolone). High-dose oral Deltasone® (prednisone) may also be used. Corticosteroids are not believed to have any long-term benefit on the disease.
Other treatment options:
H.P. Acthar Gel (ACTH) is an option for those who are unable to cope with the side effects of high-dose corticosteroids, have been treated unsuccesfully with corticosteroids, do not have access to intravenous therapy, or have trouble receiving medication intravenously because of difficulty accessing the veins.
Plasmapheresis (plasma exchange) may be considered for the 10 percent of very severe exacerbations that do not respond adequately to the standard steroid treatment.
The goal of a rehabilitation program is to restore or maintain functions essential to daily living. Restorative rehabilitation can be especially useful immediately after an exacerbation to help people get back on track.
The members of the rehab team — including physical therapists, occupational therapists, speech/language pathologists and cognitive remediation specialists — address problems with mobility, dressing and personal care, role performance at home and work, and overall fitness. They also provide evaluation and treatment of speech and swallowing difficulties and problems with thinking and memory that may have appeared or worsened during the exacerbation.