Taking control of multiple sclerosis exacerbations

Wellness

Over 1 million people are living with multiple sclerosis in the United States, with 12,000 new diagnoses each year. It is a disease usually diagnosed when people are in the prime of their lives between 20 and 40 years of age. Living with multiple sclerosis often creates feelings of insecurity about the future and lack of control in one’s life. Exacerbations, also described as attacks or flare-ups, are a powerful reminder of the unpredictability of the disease. 

Medical management of multiple sclerosis is broken up into disease modifying therapies, symptom management and relapse management. In this blog, I will focus on relapse management. Understanding what a relapse or exacerbation is and what has been shown to be beneficial following an exacerbation can help gain back a sense of control and improve one’s overall function.   

What is an exacerbation?

It is important to know the difference between what constitutes a true exacerbation and what is something called a pseudo-exacerbation. An exacerbation is a change in neurologic symptoms that lasts at least 24 hours. It may also present as a neurologic symptom that had previously been stable for the past 30 days and worsens. An exacerbation can lead to complete or incomplete recovery.

A pseudo-exacerbation is a brief flare-up of old symptoms unrelated to new damage in the brain or spinal cord. Often pseudo-exacerbations result from an elevation in core body temperature, heat or humidity or an infection in the body such as a urinary tract infection, upper respiratory infection or a viral infection that can cause a transient change in symptoms. It is important to figure out what is causing the change in symptoms, so it can be addressed appropriately and decrease the impact on your immune system.

Managing MS exacerbations

Typically, exacerbations are treated with IV corticosteroids, followed by a tapering dose of oral steroids. The goal of corticosteroid therapy is to reduce inflammation and end relapses quicker.  It is important to note that there are no long-term benefits of steroid use and in fact chronic steroid use is linked to hypertension, diabetes, osteoporosis, cataracts and ulcers.   

Medication, combined with inpatient rehabilitation, has been linked to successful outcomes following an exacerbation. Research has shown that inpatient rehabilitation can help decrease the long-term effects of an exacerbation. Inpatient rehabilitation focuses on short-stay, goal-oriented, patient-centered multi-disciplinary rehabilitation. A multi-disciplinary team is usually made up of doctors, nurses, physical therapists, occupational therapists and speech therapists. It can also include dieticians, urologists, mental health professionals and case managers, depending on a person’s individual needs.

How can inpatient rehabilitation help?

Rehabilitation plays a significant role in the management of multiple sclerosis. Education, prevention and symptom management are important to improve function, help adapt to limitations and manage relapses. Studies have shown that inpatient rehabilitation led by a multi-disciplinary team can be beneficial for up to six months after returning to the community, and that even limited periods of rehabilitation helped in reducing short-term disability.

Combining IV steroids with rehabilitation has been shown to be superior to just IV steroids alone for treating multiple sclerosis exacerbations and can improve overall quality of life. Despite this evidence, many patients do not receive adequate rehabilitation or education after receiving IV steroids.

Can exercise during rehabilitation trigger a relapse?

There are some misconceptions that exercise during rehabilitation may trigger a relapse.  A 2014 study by Pilutti, et al. actually showed that there was a 27% lower risk of relapse with exercise training. This study determined that exercise is generally safe, and patients should not be deterred from participating in exercise out of concern for experiencing a relapse.

If you believe you are experiencing an exacerbation or pseudo-exacerbation, please contact your neurologist so you can begin the best course of action for your individual needs. A combination of medical management and individualized inpatient rehabilitation can help decrease the effects of an exacerbation and minimize long-term impairments. 

Maria Rundell, PT, DPT, NCS, MSCS, is a physical therapist at Encompass Health Rehabilitation Hospital of Colorado Springs.

References:

Cheung AL, Pilutti LA, Hicks AL, Martin Ginis KA, et al. Effects of Exercise Training on Fitness, Mobility, Fatigue, and Health-Related Quality of Life Among Adults with Multiple Sclerosis: A Systematic Review to Inform Guideline Development. Archives of Physical Medicine and Rehabilitation. 2013; 94: 1800-28.

Craig J, Young A, et al. A randomized controlled trial comparing rehabilitation against standard therapy in multiple sclerosis patients receiving intravenous steroid treatment. J Neurosurg Psychiatry 2003; 74: 1225-1230.

Liu et al. Does neurorehabilitation have a role in relapsing-remitting multiple sclerosis. J Neurol 2003;250: 1214-1218.

Nedeljkiovic et al. Multidisciplinarty rehabilitation and steroids in the management of multiple sclerosis relapses: a randomized controlled trial. Arch Med Sci 2016; 12, 2: 380-389.

Pilutti et al. The safety of exercise training in multiple sclerosis: A systematic review. Journal of the Neurological Sciences. 2014; 343: 3-7.

Repovic, Pavle et al. Treatment of Multiple Sclerosis Exacerbations. Neurol Clin 2011; 29: 389-400.

Thrower, Ben. Relapse Management in Multiple Sclerosis. The Neurologist 2009;15: 1-5. Wallin et al. The prevalence of MS in the United States. A population-based estimate using health claims data. Neurology 2019; 92 (10).