Relapsing Multiple Sclerosis

Relapsing multiple sclerosis is the most common form of a chronic disease affecting the central nervous system, where symptoms flare up during attacks followed by periods of partial or complete recovery. Understanding this condition and how to manage it can help you maintain quality of life and slow disease progression.

What is relapsing multiple sclerosis?
Forms of relapsing multiple sclerosis
How common is this condition?
Signs and symptoms
What causes this condition?
What can trigger relapses?
How is it diagnosed?
Treatment options
Managing relapses
Lifestyle changes to help manage the condition
What to expect

What is relapsing multiple sclerosis?

Relapsing multiple sclerosis is a type of multiple sclerosis (MS), which is a chronic disease where the immune system mistakenly attacks the body’s own central nervous system. The central nervous system includes the brain, spinal cord, and optic nerves^[1]^[3].

In this condition, your immune system attacks myelin, which is a protective layer that surrounds and insulates nerve fibers called axons. Myelin helps neurons send electrical signals to and from the brain, telling the body what to do. When myelin or the nerves themselves become damaged, nerves cannot correctly pass along their signals. This damaging process forms scar tissue called sclerosis (also known as plaques or lesions), which gives the disease its name^[4]^[5].

The term “relapsing” describes what to expect over the course of the disease. People with relapsing MS experience flare-ups (also called relapses, attacks, or exacerbations) of symptoms followed by periods of partial or complete recovery, known as remission. During a relapse, you may experience new symptoms or worsening of existing symptoms. These episodes can last from a couple of days up to several weeks or even months^[1]^[3].

Between relapses, symptoms may disappear completely, but permanent problems can remain, especially as the disease advances. During remissions, there is no obvious progression of the disease, although symptoms may continue at a stable background level^[5]^[15].

Forms of relapsing multiple sclerosis

The various ways symptoms may develop has been used to describe different forms of relapsing MS^[5]^[13]:

Clinically isolated syndrome (CIS): This is the first episode of neurologic symptoms caused by inflammation and damage to the myelin in the central nervous system. The episode must last for at least 24 hours to be considered CIS. People who experience CIS may or may not go on to develop relapsing MS.
Relapsing-remitting MS (RRMS): This is the most common form of relapsing MS. People with RRMS experience defined attacks of new or increasing neurologic symptoms. These attacks are followed by periods of recovery called remission. While in remission, symptoms may continue and become permanent, or disappear.
Active secondary-progressive relapsing MS (SPMS): Relapsing MS can transition to SPMS, a condition in which the disease tends to progress more steadily. With active SPMS, you may still experience relapses.

How common is this condition?

Approximately 1 million people are living with multiple sclerosis in the United States. An estimated 80% to 85% of people diagnosed with MS have relapsing forms of the disease, making it the most common form of MS^[1]^[3]^[7].

MS most often develops in people in their 20s and 30s. Women are two to three times more likely to have MS than men^[4]^[5].

Based on health claims data, estimates suggest that the prevalence of MS in the US ranges from 851,749 to 913,925 people. Worldwide, approximately 2.3 million people were affected in 2015^[2]^[5].

Signs and symptoms

The symptoms of relapsing multiple sclerosis vary from person to person and are unpredictable. They depend on the location and extent of damage in the central nervous system. Common symptoms include^[1]^[4]^[6]:

Vision changes: Blurry vision, impaired color vision, painful eye movement, double vision, or temporary vision loss
Numbness and tingling: Tingling or numbness in various parts of your body, especially in the arms or legs
Muscle problems: Weakness, stiffness, or spasms
Balance and coordination difficulties: Trouble walking or maintaining balance
Fatigue: Severe tiredness
Electrical sensations: A squeezing sensation around your chest or abdomen (sensory level), or electrical tingling down your back when you bend your neck forward
Bladder and bowel problems: Difficulty or hesitation when trying to urinate, feeling of urgency, or constipation
Cognitive difficulties: Brain fog, memory problems, and difficulty concentrating
Vertigo: Dizziness or spinning sensations
Depression

It’s common to have a combination of symptoms during a relapse. For some people who have complete recovery, they won’t have any symptoms between relapses. For others, incomplete recovery means they’ll have persistent symptoms, which healthcare providers can usually manage^[1].

The two most common early symptoms are trouble seeing (often starting with pain in the eye, headache on one side, or blurred vision) and spinal cord inflammation, which can appear as limb weakness, bowel and bladder issues, tingling, and numbness^[3].

What causes this condition?

The exact cause of multiple sclerosis is unknown. MS occurs when your body’s immune system attacks the central nervous system, damaging the myelin that protects nerve fibers^[1]^[4].

Research suggests it relates to a genetic predisposition (changes in your DNA) that makes you more likely to have an autoimmune condition like MS. However, genetics play only a small part in MS, so the risk of passing the condition to your children is relatively low^[1]^[7].

Environmental factors can also cause MS. Scientists think MS may be caused by an infection that lies dormant in the body, such as Epstein-Barr virus (the virus that causes infectious mononucleosis). Evidence suggests that MS relapse is influenced by interactions between genetic and environmental factors, as well as infectious diseases^[2]^[4].

When you have relapsing MS, immune cells cross the blood-brain barrier, cause inflammation within the central nervous system, and attack the myelin sheath. This interferes with the ability of neurons to send signals between the brain and the body, causing various symptoms^[5].

What can trigger relapses?

MS relapse occurs when inflammation of the nerves and myelin causes a temporary recurrence of existing symptoms or entirely new symptoms. Several factors can trigger or worsen symptoms^[1]^[3]:

Heat or certain temperatures: Increased body temperature from hot weather, hot showers, or intense exercise
Infections: Even mild infections such as a sinus infection or urinary tract infection can cause old MS symptoms to reappear
Stress: Emotional stress and difficulty managing stress
Smoking tobacco products
Vitamin D deficiency
Lack of sleep
Mood changes: Depression or exhaustion

It’s important to distinguish between a true relapse and a pseudo-exacerbation. A pseudo-exacerbation is a temporary worsening of MS symptoms without actual myelin inflammation or damage, brought on by other influences like infection, fever, exercise, or stress. When these factors are resolved, symptoms should improve^[3]^[8].

Evidence suggests that MS relapse is also influenced by age, sex, pregnancy, and serum levels of vitamin D^[2].

Triggers for one person diagnosed with relapsing MS may not affect another person with the same condition^[1].

How is it diagnosed?

Diagnosing relapsing multiple sclerosis can be difficult because symptoms aren’t always present, and there isn’t a single test that can confirm or rule out the condition. Healthcare providers use many tests and information to diagnose the disease^[4]^[7].

A person diagnosed with MS has damage in at least two separate areas of the central nervous system which occurred at different points in time, and all other possible diagnoses have been ruled out^[3].

The diagnostic process typically includes^[4]^[7]:

Medical history: Your healthcare provider will ask questions about your symptoms and when they occur
Physical examination: Checking how well your vision, sense of balance, and other functions are working
MRI (Magnetic Resonance Imaging): Scans of your brain and spine that may find areas of damage (lesions) in your brain or spinal cord
Blood tests: To rule out other conditions that can cause similar symptoms
Spinal tap (lumbar puncture): To look for signs of damage to your nervous system
Eye scans (OCT): To look for damage in the back of the eye

Some relapses are silent, especially early in the course of the disease. These relapses may damage the myelin and cause new lesions without perceived symptoms or disability. Silent relapses can be detected by MRI, which may be recommended periodically for patients who have recently been diagnosed^[6].

To be considered a new MS relapse^[15]:

Old MS symptoms must have become worse or new symptoms appeared
Symptoms must last for at least 24 hours
Symptoms must occur at least 30 days from the start of the last relapse
There must be no other explanation for the symptoms

Treatment options

Unfortunately, there is no cure for multiple sclerosis. However, treatment has improved dramatically over the past decade. Treatment for relapsing MS focuses on reducing the severity and frequency of flare-ups to prevent further damage to your nervous system^[2]^[7].

Disease-modifying therapies

Disease-modifying therapies (DMTs) are medications used regularly to decrease the risk of relapses, slow the progression of the disease, and prevent new MS lesions from forming. More than a dozen medicines are available that can help prevent relapses and slow MS^[6]^[19].

These newer treatments can prevent new lesions in 99% of MS patients and are very effective, especially when used early in the course of the disease. The sooner you get on the right medicine routine and the longer you stick with it, the better you’ll control your disease^[6]^[18].

Newer MS treatments, particularly medicines that deplete circulating B cells (a type of immune cell), such as ocrelizumab and ofatumumab, can prevent relapses and are thought to slow the progression of the disease. These medications are incredibly effective if used early in the course of the disease^[6].

Depending on the course of treatment your doctors deem best, you may receive medication as a pill, a shot (injection), or an infusion (released into your bloodstream through an IV)^[7].

Other treatments

In addition to disease-modifying therapies, there are many effective treatments to manage symptoms of the disease, including^[19]:

High-dose corticosteroids: To treat acute flare-ups and reduce inflammation
Muscle relaxants: To alleviate spasticity and stiffness
Physical and occupational therapy: To maintain mobility and manage daily activities

Managing relapses

When treatment is necessary, relapses are usually treated with a high-dose course of powerful corticosteroids (a type of steroid) over a period of three to five days. These medications help reduce inflammation in the central nervous system^[8]^[9].

Corticosteroids are approved by the United States Food and Drug Administration (FDA) for the treatment of MS relapses. They are given by intravenous (IV) infusion, providing the drug directly into the bloodstream for a quicker response. As an alternative to IV steroids, treatment for a moderate to severe relapse also includes an equivalent, high-dose, oral regimen of steroids^[8]^[14].

Administration may be performed in a hospital, infusion center, or sometimes at home. Less-severe relapses are usually not treated with steroids, so their use may be reserved for more severe flare-ups^[8].

While corticosteroids usually lessen the severity and duration of a relapse, they do not appear to affect the long-term progression of the disease. They help reduce inflammation and shorten the duration of exacerbations, but they do not have a long-term benefit for treating the disease itself^[6]^[8].

For individuals who are not able to tolerate the side effects of steroids, who have found that previous treatments were not effective, or who may have difficulty getting timely medical support for IV infusions, other options are available. These include highly purified forms of adrenocorticotropin (ACTH) and therapeutic apheresis (a procedure that removes harmful substances from the blood)^[8]^[14].

If you’re not sure whether you’re having a relapse, you could wait a day or two to see if your symptoms improve before contacting a health professional. With time, you will become an expert on your own MS and will develop a better feel for whether you’re having a relapse^[15].

Lifestyle changes to help manage the condition

Managing stress and following healthy lifestyle habits can have a very positive impact on overall MS management, including your mood and quality of life. On the other hand, difficulty managing stress can further complicate MS and even bring about new symptoms^[16].

Exercise regularly

Exercise strengthens the muscles that help you walk. It also eases fatigue, boosts mood, and improves quality of life. There’s even evidence that strength training might help slow MS damage in the brain^[18]^[20].

An exercise program for MS includes 150 minutes of aerobic activities each week, such as walking, swimming, yoga, Pilates, or cycling. Also stretch for at least 10 minutes each day to release tight muscles. Use weights or resistance bands twice a week to strengthen your muscles. A physical therapist can show you how to do each exercise correctly to prevent injury^[18]^[20].

Eat a healthy diet

A balanced diet is important, especially when you have a long-term disease like MS. Research shows that people with MS who eat a lot of fruits, vegetables, and whole grains have less disability and fewer symptoms like depression and fatigue^[18]^[20].

Limit processed foods and animal fats like red meat and butter. Get your fats from healthier sources such as fish, nuts, avocados, and olive oil. Too much salt can make MS inflammation worse, so steer clear of salty foods and aim for a heart-healthy diet^[17]^[20].

Include biotin-rich foods in your diet, such as eggs, fish, seeds, nuts, and sweet potatoes. Biotin is a vitamin that protects the health of nerves in your brain. Also include foods high in soluble fiber (like oats, beans, and fruits) to promote healthy gut bacteria and insoluble fiber (like bran cereal, whole grains, and vegetables) to prevent constipation^[20].

Manage vitamin D levels

People who have higher levels of vitamin D in their blood are at lower risk of getting MS, and higher levels help protect your nerves. You can get your daily vitamin D from foods like fatty fish and fortified milk. Your body also makes its own stores of this vitamin when your skin is exposed to sunlight. Ask your doctor what dose of vitamin D supplement is right for you^[17]^[18].

Get enough rest

Aim for seven to eight hours of sleep each night. Many patients with MS have a hard time getting a good night’s sleep, yet adequate sleep is vital for staying healthy. If you struggle with sleep problems, talk with your healthcare provider so they can determine the underlying cause and offer solutions^[17]^[20].

Don’t smoke

Smoking isn’t healthy for anyone, and it can make MS worse. MS progresses at a faster rate in people who smoke. On top of that, some MS medications may not work as well in smokers^[17]^[18]^[20].

Stay cool

When your body temperature increases, it affects the ability of MS-damaged nerves to work. Avoid activities such as sunbathing, very hot showers or baths, and intense exercise^[20].

Build a support system

No one should go through a chronic illness alone. Families and caregivers play a large role throughout the entire MS journey. It’s important to feel like you have people with whom you can be yourself, share your challenges, and feel supported along the way^[16].

Support groups may be a key element of your support system. They introduce you to other people who are living with multiple sclerosis. It can be truly life-changing to connect with other people who have the same diagnosis as you and are going through similar things. Just branching out and trying to stay active is really vital^[16]^[17].

Seek help when needed

MS can change your ability to keep up with everyday life. Attend occupational therapy to learn how to improve your ability to perform daily tasks like eating, cooking, cleaning, and bathing. Embrace mobility aids like braces, a cane, or a wheelchair to help you maintain your energy. Ask for accommodations at work, and accept help from loved ones^[16].

What to expect

While there is no cure, multiple sclerosis is not considered a fatal disease. A couple of decades ago, the gap in life expectancy between people with and without MS was much bigger. Fortunately, therapies today are much better, and MS can be diagnosed earlier, when treatment is more effective^[19].

Significant physical disability occurs within 20 to 25 years of the first appearance of symptoms in roughly one-third of people with untreated MS. Research has shown that several MS treatments can slow this progression^[3].

At first, 12 to 18 months may pass between MS relapses. However, as time goes on, many patients have relapses that occur more often and last longer, until they become a persistent condition called secondary progressive MS. However, people with MS are being diagnosed and treated earlier than ever before, which improves outcomes^[7]^[19].

When you prioritize self-care and follow a healthy lifestyle, you’re better prepared to manage the everyday stressors of life. Managing stress, following your treatment plan, and making healthy lifestyle choices can have a very positive impact on your symptoms, mood, and quality of life^[16]^[19].