Worse after the hot shower — Uhthoff’s and the INO

The temperature direction is the clinical hinge this week: heat-linked, transient worsening in MS is Uhthoff’s phenomenon — conduction failing through demyelinated fibres and recovering with cooling — a pseudo-exacerbation that is paced, not steroided, and Frohman’s reviews characterise both it and the internuclear ophthalmoplegia that explains her diplopia. The physiotherapy follows: cool sessions, pacing and fatigue management, compensatory eye-movement strategies while the INO settles, and graded exercise per the MS recommendations rather than a heroic week or a frightened fortnight. What you do with it: teach her the pseudo-exacerbation by name, schedule around the heat, protect the environment while the diplopia lasts, keep the exercise dose graded and honest, and send persistent deficits — days, not hours — back to neurology as the true relapse they would be.

• Symptoms that persist for days after cooling, or new deficits outside the old pattern — that is a true relapse and neurology hears about it
• Fever or infective symptoms — infection is the commonest pseudo-exacerbation driver and is treated, not paced

• The wide-based gait — cerebellar ataxia, honestlyTier 3
• The grocery-store dizziness — PPPDTier 2

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