| Management Of MS Exacerbations: An Interdisciplinary Approach |
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A common characteristic of Multiple Sclerosis is the unpredictable appearance of
increased disease activity or exacerbations. The increase in symptoms can often disrupt
daily activities including work, family life and recreation, and may be very frustrating
and confusing for people with MS and their families.
An acute relapse or exacerbation is defined as an increase and maintenance of a
change in symptoms for at least 24-48 hours. This could be a recurrence of past
symptoms, worsening of existing symptoms or the appearance of new symptoms.
Relapses may be triggered by external factors, such as infections, or fevers.
Relapses tend to be associated with the appearance of inflammatory changes seen
on MRI and tend to be more frequent in the first 5-10 years of the disease.
Prevention or reduction in exacerbations is the first management technique.
With disease modifying agents (DMA), including interferons and COPAXONE®
(glatiramer acetate injection), the frequency of exacerbations is reduced,
as are the number of new inflammatory lesions seen on MRI. These agents
have been approved by the FDA for relapsing-remitting MS and should be
strongly considered.
Despite the use of DMAs, exacerbations do occur. Appropriate medical management
of acute relapses can decrease the duration of the exacerbation. In addition,
an interdisciplinary approach can provide the necessary rehabilitation, counseling
and emotional support to maintain and/or improve function lost as the result of
the relapse.
Medical management of an acute relapse includes reduction of inflammation secondary
to the exacerbation as well as symptom management medications. Steroids are commonly
used to decrease the inflammation which is thought to occur around existing or new
lesions. Steroids are generally used to shorten the duration and severity of an
acute attack, although there is no evidence that they impact the long term course
of the disease.
Traditionally, steroids are administered intravenously or orally.
Intravenous (IV) steroids are more commonly used for more severe exacerbations,
and may be given at home or in an out patient setting. The usual course
is 3-5 days of IV sometimes followed by a 1-2 week oral taper. Oral steroids
alone are usually given in a tapering fashion over 1-2 weeks. Tapering the
medication includes gradually reducing the amount of medication over time.
Common side effects of steroids include stomach irritation, irritability or
mood changes, insomnia, acne or weight gain.Steroid treatments should be
closely monitored by a physician and/or nurse who is part of the MS team.
Symptom management may include medications to treat increases in spasticity,
bowel/bladder dysfunction, depression, fatigue or pain. Many symptoms are also
managed through intervention from the interdisciplinary rehabilitation team.
Physical therapy and occupational therapy will concentrate on restoration of
functional mobility. Interventions will include a careful assessment of bed
mobility, transfers, gait and activities of daily living. The therapists will
take into consideration range of motion, strength (or weakness), balance,
spasticity, fatigue and many other symptoms common with exacerbations.
Early rehabilitation intervention is essential in the restoration of functional mobility.
Interventions may include exercise recommendations, functional mobility
training, and education in compensatory techniques to improve overall function.
Compensatory techniques may include the use of assistive devices or teaching
methods of modifying an activity to improve safety and efficiency of movement.
Other members of the rehabilitation team commonly utilized during acute relapses
include speech/language pathologist, vocational rehabilitation specialist and psychologist.
Speech/language pathologists are valuable members of the rehabilitation team.
The speech/language pathologist provides assessment and treatment for speech and
swallowing disorders sometimes experienced as a part of an acute relapse.
A speech/language pathologist, neuropsychologist or occupational therapist
may be utilized for cognitive assessment and rehabilitation also.
Vocational rehabilitation specialists can be helpful with improvements in the work
environments by suggesting appropriate accommodations necessary for maximizing
function and quality of life.
Other symptoms that may worsen during exacerbations include bowel and bladder
dysfunction, spasticity or pain. These can be managed with appropriate medications,
and/or rehabilitative strategies.
Common psychological symptoms of acute relapses include depression, anxiety,
frustration and uncertainty about future functioning. These changes in a person’s
emotional state affect the person with MS as well as family and friends.
Depression, sadness and even a grief process may be triggered by an acute relapse.
A relapse is an emotional, as well as physical, intrusion that is unexpected and
unwanted. The unpredictability of symptoms may cause feelings of being
“out of control”. How long will this last? How life-changing will this relapse be?
Regaining a sense of control, even in small ways, is an important proactive
response to a relapse. For instance, utilizing all supports, from friends
who ask what they can do (tell them and be specific, e.g., a ride to the
doctor on Tuesday at 9:00 am) to assistive devices, decreases isolation
and increases energy conservation. Calling on the expertise of members of
an established interdisciplinary medical team (e.g., physician, nurse,
physical therapist, occupational therapist, psychologist, etc.) can provide
new options and a sense of taking control of what is within one’s control.
Anxiety, frustration and fear are also common responses to acute relapse.
Uncertainty about the future is always anxiety-provoking and the need to
accommodate variable and even annoying symptoms will impact both the
individual with MS and his/her family. Creating opportunities for
discussion of feelings or the development of alternative plans for
adapting to symptoms, can change worrying alone and helplessness to
identifying effective coping strategies.
Seeking information from competent resources, taking control of factors
within one’s control and seeking connection with others are primary ways
to minimize the emotional impacts of an acute relapse.
Acute relapses can be frustrating and frightening to families living with MS.
However, timely recognition and management can reduce the effects on overall quality of life.
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| - reprinted with permision from- The Heuga Center . |
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