What Is Relapsing-Remitting Multiple Sclerosis?

It is not a completely strange concept that the immune system can mistakenly attack a healthy part of the body, leading to autoimmune diseases. An unregulated immune system can attack any part of the body, such as the skin, kidneys, lungs, liver and heart. When the immune system mistakenly attacks the nervous system, including the brain, it causes a condition called multiple sclerosis (MS). 

Our nervous system comprises the brain, spinal cord, and a complex network of nerves. Our organs and body systems constantly communicate with the brain through this network of nerves by transmitting messages to facilitate bodily functions. The nerves are protected by a layer of fat and protein called the myelin sheath. When this myelin sheath becomes damaged, the transmission of messages along the underlying nerves is affected, causing a wide range of symptoms.

Overview

Multiple sclerosis is an autoimmune condition in which the immune system attacks the nervous system, causing a wide range of symptoms, including issues with movement, vision, sensation and balance.¹ MS can be classified into one of three main types — primary progressive MS (PPMS) secondary progressive MS (SPMS), and relapsing-remitting MS (RRMS). Of these, relapsing-remitting MS is the most common, characterised by new or worsening symptoms (relapse) followed by partial or complete recovery (remission). Between 80 and 90 per cent of people with MS are diagnosed with RRMS, of which about two-thirds will go on to develop secondary progressive MS later in life.¹ 

While MS is one of the most common causes of disability in young adults, its diagnosis is challenging, with no prevention or cure for RRMS. This article delves into RRMS, the most common type of MS, which can lead to other forms of the condition. 

Relapse

Relapsing-remitting MS showcases two characteristics: relapse and remission. A relapse is defined as the appearance of new or worsening symptoms for a period of 24 hours or more with no infection or fever.² Relapses are sometimes also referred to as an attack, flare-up, exacerbation, acute episode, or clinical event. During a relapse, symptoms usually come on over a short period, ranging from hours to days, and often persist for a few weeks to within a month. Some symptoms may disappear after a relapse whilst others may persist and get worse over time. Repeated relapses over several years can lead to accumulating neurological damage and increased disability. 

Remission

A remission is defined as the period between relapses. People with relapsing-remitting MS may be in remission for several years at a time. During remission, all symptoms may disappear or some symptoms may continue and become permanent.

Signs and symptoms

The symptoms of relapsing-remitting MS vary from person to person and range from mild to severe disability and can also affect any part of the body. It is common to have a combination of symptoms which may come and go or worsen over time. The main symptoms are listed below: 

• Fatigue
• Difficulty walking
• Problems with vision
• Numbness or tingling 
• Muscle stiffness and spasms
• Problem with balancing 
• Depression
• Tremor
• Heat sensitivity
• Problem with controlling bladder 

Causes

Although the exact cause of relapses in RRMS is unclear, several factors are thought to be involved as outlined below.^2,3

Genetic factors

Genetic factors are associated with the activation of the immune system.⁴

Environmental factors

Stress

Although the evidence is yet unclear, many experts believe that stress may be one of many factors which could increase the risk of a relapse.

Infections

Not all, but some bacterial or viral infections may cause a relapse.^5,6

Smoking

There is evidence that smoking cigarettes whilst on some DMTs increases the risk of a relapse.

Vitamin D deficiency

Some studies have shown that being low in vitamin D may be linked to having more relapses.⁷

Diagnosis

Diagnosing relapsing-remitting MS is challenging as there is not a single test or procedure that can confirm the condition. Your GP may ask about your medical history and refer you to a specialist for further diagnostic tests, which are briefly described below:^8.9

• MRI scan to look for damage to the brain and spinal cord¹
• Cerebrospinal fluid analysis also known as a lumbar puncture or spinal tap, can be used to find characteristics of MS such as oligoclonal bands which represent evidence of inflammation involving the brain and/or spinal cord
• Blood tests can be used to look for signs of RRMS including level of vitamin B12 and thyroid-stimulating hormone¹⁰ 
• Optical Coherence Tomography (OCT) is a painless test that scans the nerves in the back of the eye (retina) to detect damage

Treatment 

There is currently no known cure for relapsing-remitting MS but there are treatments that may help to control the disease and manage symptoms. These treatments can reduce the number of relapses and slow down disease progression.^9,11

Disease-modifying therapies (DMT) are drugs that alter the course of relapsing-remitting MS, reduce relapses and delay the progression of disabilities. These treatments work by targeting the immune system to reduce inflammation and prevent damage to the nervous system. There are around 20 DMTs for MS available on the NHS, including immunomodulatory drugs, immunosuppressive drugs, anti-inflammatory drugs, and high doses of steroids. Pain management drugs can also be offered depending on the symptoms. Studies have shown that receiving DMTs reduces the risk of permanent damage to your body and works better the sooner after diagnosis you start them.^3,10. Drugs can be offered in different forms as outlined below:⁴

• Injection: Drugs like interferons and glatiramer acetate can be delivered by injection
• Oral medication: Drugs like fingolimod, teriflunomide, dimethyl fumarate, siponimod, and cladribine can be offered as oral medication
• Infusion: Drugs like natalizumab, ocrelizumab, alemtuzumab, and rituximab can be delivered by infusion

Life with relapsing-remitting MS

Many people with RRMS can lead long, active, and healthy lives with the right care and support. 

Recognising the triggers of relapse and understanding their effects are useful as symptoms differ from person to person. It is also important that your healthcare team is aware of your symptoms or signs, as the more they know, the better they can help you. 

Looking after your well-being and reducing your risk factors is the key to staying well with MS. The NHS recommends healthy and balanced eating, regular exercise, getting vaccinated and stopping. Physical therapy and rehabilitation can be considered for muscle spasms. 

Managing a long-term condition like RRMS can be challenging for you and your loved ones. Be honest about how you feel, and let your family, friends, and healthcare providers know what they can do to help. Your healthcare providers can provide you with information about available support such as counselling and mental health support. Some people find it helpful to talk to other people who have MS at an online or in-person support group.

Secondary progressive MS

People with relapsing-remitting MS may later go on to develop secondary progressive MS (SPMS), which is another type of MS. SPMS is characterised by an initial relapse followed by gradual neurologic deterioration. The cause of SPMS is unclear. Therefore, it is important that people with RRMS  receive early and aggressive treatment which may reduce or prevent the onset of SPMS.³

FAQs

Where can I get support about multiple sclerosis??

If you or someone you know is diagnosed with RRMS and needs support, there are two main MS charities in the UK – The MS Society and The MS Trust. These organisations provide support, advice, and information about RRMS and fund ongoing research. Shift.ms is another online community and social network for people with MS. 

What is the life expectancy of people with RRMS?

MS itself is rarely fatal. The average life expectancy for people with MS is approximately 5 to 10 years lower than average but this gap is getting smaller over time due to the availability of disease-modifying treatments. 

What is primary progressive MS?

Unlike relapsing-remitting, the symptoms of primary progressive MS gradually worsen and accumulate over time without periods of remission. Primary progressive MS is much less common than relapsing-remitting MS, affecting 10-15% of people diagnosed with MS.

How common is relapsing-remitting MS?

Approximately 1.3 million people worldwide are living with relapsing-remitting MS. In the UK, about 130,000 people live with MS, 85 % of whom are diagnosed with the relapsing-remitting type.

Summary

Relapsing-remitting MS is the most common type of MS, characterised by periods of relapses (worsening in symptoms) and remissions (improvement in symptoms). Like all types of MS, relapsing-remitting MS is autoimmune in nature where the immune system mistakenly attacks the nervous system, leading to a range of neurological symptoms. The symptoms of relapsing-remitting MS are diverse and vary from person to person, but often affect vision, movement, and sensation. 

Although there is currently no known cure for RRMS, its symptoms can be managed with disease-modifying drugs, physical therapy and lifestyle changes. with a significant improvement in the quality of life of people with the condition over the past two decades. Early treatment with disease-modifying drugs can reduce the number of relapses and slow down the progression of the disease.

Living with relapsing-remitting multiple sclerosis RRMS can be challenging. Although MS itself is not life-threatening, it can lead to a wide range of complications such as swallowing difficulties or severe infections.