Overview:

The diagnosis and treatment of MS relapses in clinical practice can be quite difficult due to the manifestations of relapses, such as optic neuritis, paroxysms (a fit, attack, or sudden increase or recurrence of symptoms).

Symptoms of relapse can vary significantly thus adding complication in how to treat the symptoms.  A common misconception among many patients that disease remission is a symptom-free period of time. Most MS patients will always be symptomatic in some ways.  Fluctuations in symptoms, such as fatigue, can be caused by factors such as stress, poor sleep, overexertion and mistaken as a relapse.

Pseudo-relapses are not actually relapses but instead present symptoms that appear as though a relapse may be under way. Pseudo-relapses can make diagnosing of an actual relapse event more difficult. Worsening of symptoms due to overexposure to heat or overexertion are not representative of actual relapses of MS, but are most likely attributable to conduction blocks within demyelinated axons.  Electrical signals within the patient’s damaged central nervous system (CNS) are unable to reach their destinations resulting in symptoms.

Infections such as viral upper respiratory infections and simple urinary tract infections are often associated with pseudo-relapses in patients with MS, however, systemic infections may provoke actual relapses by introducing a inflammatory bias in immune response that is capable of triggering disease activity and exacerbations (attacks).

Am I Having a Relapse?

If a true clinical relapse is suspected in a patient with MS, the clinician must decide if the relapse is to be treated at all and how. Researchers have studied the effects of corticosteroids on both short-term and long-term recovery from optic neuritis in patients with MS, the results have demonstrated significant improvements in short-term outcomes; however, no long-term benefits in terms of attaining pre-relapse functioning have been shown.

When considering a  decision to treat a relapse it often depends on the functional impact of the relapse on a patient’s daily life. Typically, the standard of care and first-line treatment option for relapses in MS is 3 to 5 days of intravenous methylprednisolone, with or without an oral taper, or a high-dose oral steroid.

Because high-dose oral and intravenous steroid regimens have shown similar efficacy in treating MS relapses the decision of which agent to use is normally determined by patient and clinician preferences. Other treatments for relapses of MS include adrenocorticotrophic hormone, intravenous immunoglobulin, and plasma exchange. These treatments are usually reserved for those who are unresponsive to steroids.

It is important to note that combining rehabilitation with standard, intravenous methylprednisolone therapy may result in improved performance on measures of disability and quality of life following a relapse.

A new MS relapse is clinically often considered to be:

  • Symptoms must last at least 24 hours – Relapses tend to last days, weeks or even months.
  • Symptoms must occur at least 30 days after a previous relapse.
  • Old symptoms must have become worsened or new symptoms having appeared.
  • Stress, heat, infections, overexertion and other factors need be ruled out.

If you are experiencing worsening symptoms and suspect you may be having a relapse you should contact your care provider.  You may wish to wait a few days to see if the symptoms appear to get better.  Typically an actual relapse will result in new symptoms and/or a significant worsening of existing symptoms beyond your baseline for a given symptom.

It is important to document and relay accurate information to your care provider to help assess if you are having an actual relapse .vs. a pseudo-relapse.

Am I Having a Pseudo-Relapse?

If you have been recently diagnosed or have had few relapses it can but difficult to tell if you are having an actual relapse or pseudo-relapse. Multiple sclerosis is different for each and every person and it may take some time to learn and better assess your symptoms, severity and pseudo-relapse triggers.  It can be quite difficult to assess at times so do not hesitate to contact your health care provider accordingly.

These are a few things you can look out for which may explain why your symptoms are worse:

  • Temperature and changes in symptoms:  When you get too hot when being outside, have been exercising, sauna, hottub, or even a hot shower or bath you find your symptoms get worse it is a sign of a psuedo-relapse.  Usually in a matter of hours, once you have cooled down, the symptoms lessen or go away and may be followed by a feeling of considerable fatigue.  Some patients find that symptoms seem flare up when they are too cold as well and yet others experience both.
  • Infections such as a bladder infection (UTI), stomach flu or even a simple cold or allergies can make their symptoms worsen.  Once the condition is treated the symptoms tend also revert back to the original levels.  It is important however to know that severe infections in some patients have resulted in actual relapses.  Thus it is again important should you have any sort of medical condition rear-up to get in contact with your health care provider.  The sooner problems are addressed the better in living with MS.
  • Stress is something that really needs to be avoided with multiple sclerosis.  Not only does it make life more difficult to live with but it can cause pseudo-activity and among the patient community it has also been considered a significant trigger towards actual relapses.
  • Daily changes or fluctuations in symptoms are somewhat common with MS.  Sometimes there appear to be no particular reasons for symptoms to rear-up.  Often quite resting helps alleviate the problems but should they persist or worsen your health care provider should be contacted.

If you have a partner they too should be monitoring you.  For example you may be experiencing a cognitive fog or memory issues that result in your being unaware that this in itself is a new symptom.

There are certainly hosts of other triggers that can result in worsening of symptoms but these do not necessarily mean that you are having a MS relapse.  In fact, with most people who live with Relapsing Remitting MS the up’s and down’s of symptoms are pseudo-relapses.  It is important however if you are unsure to contact your health care provide and get things looked at.  If a real relapses is believed to be happening getting the inflammation addresses is important.

Summary:

Pseudo-relapse occurs due to conduction block in nerves and many factors can contribute to conduction block.

It is recommended that MS patients document their disease progression, effects and symptoms daily.  We recommend using a simple paper daily planner.  This gives you and your medical care provider(s) an opportunity to see what is happening day to day, week to week to help assess your treatment needs and disease activity.

Since it can be particularly difficult to self-assess a relapse .vs. pseudo-relapse should the symptoms not wane in 24-48 hours of time it is important to get in touch and set up an appointment soonest possible with your health care team.  If a relapse is indeed occurring getting treatment to reduce the inflamation caused by the excarbation (attack) is very very important.

Distinguishing a pseudo-event and a true MS attack can be quite frustrating for both the patient and clinician.  It is EVER so important to document so when you do visit your care provider because symptoms are appearing that they have a record to look at and that record is complete.  Thus they can see perhaps that a new level of spasticity is presenting itself or headaches where few existed previously.  Significant levels of fatigue where before they were managed, cognitive fog where none had presented before.

When in doubt, do not hesitate. Contact your health care provider.  Faster treatment may save more central nervous system cells.