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Exacerbations
From day to day, those with multiple sclerosis (MS) will have their good days and then have some bad days. This type of fluxuation is common and it's always a bit random because you never really know what the next day is going to be like. The next day might be more painful or maybe will be shaking with more tremors, you just never know. These minor issues come and go but they are there because of damage that has already occured. This is the state of your new normal.

When you experience a MS exacerbation, also known as a relapse or flare-up, it's an attack or worsening of symptoms that are new and happening at the present moment. The symptoms appear because of new damage in the brain or spinal cord that disrupts nerve signals. You might notice new symptoms or the return of old symptoms. Relapses are different with every person and they vary in length, severity, and symptoms but should improve over time.

When an exacerbation ends it would then be in a period of remission. At the early stages of this disease, it's typical in most cases for that time of remission to last a while. With the current available treatments, that time of remission can be extended significantly in many cases. Since there is no cure as of yet, delaying what is to come and its severity is the best option that's currently available. An extra year of running or walking on your own may not seem like much to many people, but to someone with MS, it means so much.

An exacerbation of MS is caused by inflammation in the central nervous system (CNS) that causes damage to the myelin and slows or blocks the transmission of nerve impulses. To be a true exacerbation, the attack must last at least 24 hours and be separated from a previous exacerbation by at least 30 days. However, most exacerbations last from a few days to several weeks or even months. Exacerbations can range from mild to severe enough to interfere with a person's ability to function at home and at work.

In relapsing-remitting MS (RRMS), the most common course of MS, clearly defined acute exacerbations or relapses 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 that don't seem to go away.

Now when you experience a return or relapse of symptoms, it usually means that there is a chance that new lesions are forming in the CNS, and they are disrupting neural transmission. This can literally mean that there is new disease activity and damage happening at that moment.

Not all exacerbations require treatment from your doctor. Mild symptoms or sensory changes like numbness, pins-and-needle sensations, or increased fatigue that don’t significantly impact a person's activities can generally be left to get better on their own. Over time you can usually distinguish the good from the bad and know when to see your doctor.

Treating An Exacerbation

Your symptoms might go away on their own if they're mild, but it's important to let your doctor know what's going on. Treating symptoms can shorten an exacerbation and help you recover faster. The goal is to bring down the inflammation that is causing your symptoms. For severe exacerbations, 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 3 to 5 day course of intravenous Solu-Medrol (methylprednisolone) or the use of high-dose oral Deltasone (prednisone). Corticosteroids, however, are believed to only have a short-term benefit on the disease since they only target the inflammation and not its cause.

Some people can't take steroids and some are bothered by steroid side effects, including weight gain, mood changes, trouble sleeping, and upset stomach. Another option is ACTH gel (Acthar gel). It's injected into your muscle or under the skin. ACTH triggers your adrenal gland to release natural hormones that bring down inflammation.

For a very severe or acute attack that doesn't get better with steroids, a plasma exchange may be performed. Plasma exchange, formally known as plasmapheresis, is the process of taking blood out of the body, removing constituents in the plasma that's thought to be harmful, and then transfusing the rest of the blood (mainly red blood cells) mixed with replacement plasma back into the body. The American Academy of Neurology recommends using plasma exchange as a secondary treatment for severe flares in relapsing forms of MS and related diseases. The treatment was not found to be effective for secondary and chronic-progressive forms of MS.

During a relapse you might feel more tired than usual. It's important that you try to get enough rest and to also avoid heat, which can make your symptoms worse.

After An Exacerbation

What you do after an exacerbation depends on how bad it was and if any new or additional damage has remained. If it was stopped fast enough, you might be able to return to a 'business as usual' state. If it has left its mark on you with new or worsening of old symptoms, then you probably have some work to do.

You can recover fully after a relapse, but it might take some time (weeks or months) to get over all your symptoms. If you had a lot of nerve damage, some symptoms might not fully go away. If this is the case, then you might need extra help getting back to your normal life. Depending on what is affected, a rehab program might be your best option.

Some of the things you might need to focus on are:
Exercise
Speech
Dressing and personal care
Movement
Home chores
Problems with thinking and memory
Pseudoexacerbations
There may be times in which you might think what seems like an exacerbation turns out not to be one. An infection or fever can cause temporary problems with nerve conduction in previously damaged areas of the brain. Therefore, if you are sick and have the flu, you might experience symptoms that seem like or mimic an exacerbation. These symptoms most likely are not an actually sign of new lesions, but rather a temporary disruption to an area of old damage where nerve impulses were conducting normally. Once the fever or the infection is treated, then you should see a complete return to where you where before.

A pseudoexacerbation is a brief flare-up of old symptoms that is unrelated to damage in the CNS and can be caused by anything that temporarily raises the core body temperature enough to slow nerve transmissions, such as a urinary tract infection, a cold or other virus, exertion during exercise, or high heat and humidity. Pseudoexacerbations will get better without treatment once the body temperature returns to normal.

Though the term pseudoexacerbation may sound as if it means "fake" or "all in your head," that's hardly the case. The symptoms are very real and can include muscle weakness, tingling, blurred or double vision, spasms, and more.

Reducing the number of relapses typically help delay permanent future disability. This is one of the reasons why it's so important to find the most effective MS medication and remain on it. Certain things can start a flare-up and everyone's triggers are different.

To reduce the chance of any type of flare-up from returning:
Take your medications
Keep up your health
Don't smoke
Try to relax
Rest when you can
Quick Fixes
There isn't a quick fix for MS, but rather for some of the symptoms. If you find yourself working in the heat or become overheated, you'll probably notice that some of your symptoms might worsen. Heat is a bad four letter word to anyone with MS. It might make your tremors more noticeable, your strength may decrease, and your pain could increase, and so on.

Several good ways to cool down fast would be to take a cold shower, get in a swimming pool, stand in front of an air conditioner or fan, drink some cold water. By simply doing one or all of these, you should find that as your body temperature drops and then your symptoms should decrease. As time goes on, you'll be able to recognize in advance when you need to slow down, take a break, or stop.

If you know that you might be up late at night, it's important to get plenty of rest or even a nap before hand. You probably feel tired all of the time as it is, but with a longer day comes a price that you will have to somehow pay for. Do what you can to minimize the effects on yourself and try to conserve or spread out your energy. As we've mentioned before, think of daily energy as a battery and you can't recharge it again until you get plenty of sleep or at least some rest. Down time is very important, take a mid-day nap or just sit down some place that is quiet for a short time. If you are stuck some place that a moment of peace and quiet isn't available, as is common for most people, you might try some calming music to help drown out the chaos around you.

Proper nutrition also comes into play in that if you eat or drink a lot of junk, your energy levels are most likely going to fluctuate more and crash harder. If you try to eat healthier, your energy levels just might be good enough to get you through the day. Vitamins are also a very good source to help supplement your nutritional needs; however, it's extremely important that you discuss the vitamins that you plan on taking with your neurologist before hand.

Remember that there may be nothing wrong or harmful with what you plan on taking, but there could be a small chance that a reaction with one or more of the prescribed medications may occur. Alcohol is also something that must be discussed with your neurologist for the same reasons as vitamins, and all of the other reasons that should be obvious. Proper nutrition is important with or without MS being factored in.