What are the other Names for this Condition? (Also known as/Synonyms)

• RRMS (Relapsing-Remitting Multiple Sclerosis)

What is Relapsing-Remitting Multiple Sclerosis? (Definition/Background Information)

• Multiple sclerosis (MS) is a common and chronic autoimmune disorder affecting the central nervous system (brain and spinal cord). In this disorder, the myelin sheath, a protective layer surrounding the nerve cells is progressively destroyed (called demyelination), resulting in associated neurological signs and symptoms
• The following four main courses of multiple sclerosis is reported, but not all courses may be observed in each individual:
  • Clinically isolated syndrome (CIS)
  • Relapsing-Remitting Multiple Sclerosis (RRMS)
  • Secondary-progressive multiple sclerosis (SPMS)
  • Primary-progressive multiple sclerosis (PPMS)
• Relapsing-Remitting Multiple Sclerosis is the most common form of multiple sclerosis that is generally seen in younger adults. It is reported that 80-85% of the individuals are present with RRMS at the time of initial diagnosis
• The common signs and symptoms associated with Relapsing-Remitting Multiple Sclerosis include learning and memory problems, short periods of fatigue, muscle stiffness, and vision problems
• As the name indicates, in Relapsing-Remitting Multiple Sclerosis, the neurological symptoms flare up or exacerbate, called relapses, which are then followed by periods of recovery and relative calm, termed remissions
  • The relapses may be characterized by the presentation of new symptoms or worsening of existing symptoms and last a duration of 24-48 hours or more
  • The remissions may last weeks and months during which time the symptoms get milder, recede, and the individual recovers either partially or fully from the symptoms
• This cycle or relapses and remissions may last for several years/decades following which Relapsing-Remitting Multiple Sclerosis may progress and change its course to develop into the secondary-progressive form of multiple sclerosis. This transition may take a decade or more to take place

Who gets Relapsing-Remitting Multiple Sclerosis? (Age and Sex Distribution)

• Relapsing-Remitting Multiple Sclerosis is most commonly observed in young adults between 20-30 years of age, or slightly older
• Both males and females are affected, though the condition affects more females than males (2:1 to 3:1 female-male ratio)
• The condition is observed worldwide, and individuals of all racial and ethnic groups may be affected. However, individuals of Northern European descent are at an increased risk for MS compared to other races
• Studies have shown that people living in certain regions having temperate climates, such as parts of Australia and New Zealand, Europe, Canada and United States, seem to have a higher risk

What are the Risk Factors for Relapsing-Remitting Multiple Sclerosis? (Predisposing Factors)

The risk factors associated with Relapsing-Remitting Multiple Sclerosis include:

• Young adult women are known to have a higher risk
• Family history of multiple sclerosis
• People of Northern European descent
• Environmental triggers: People living in certain countries with temperate climate, such as Southern Canada, Northern United States, New Zealand, and Europe, report a greater number of MS cases; hence, certain environmental factors may be involved
• Presence of autoimmune diseases such as type 1 diabetes mellitus and thyroid disease
• Smoking
• Studies have also shown that a lack of vitamin D may lead to MS
• Epstein-Barr virus (EBV) infection
• Individuals with certain HLA gene types have an increased risk for MS

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Relapsing-Remitting Multiple Sclerosis? (Etiology)

The exact cause of multiple sclerosis is unknown, but it is considered an autoimmune disorder. In MS, the body’s own immune system attacks the myelin sheath, resulting in its damage.

• The myelin sheath is a protective layer/membrane surrounding the nerve cells. Inflammation of the myelin sheath ultimately affects the nerve signals. The damage to nerves is characterized by plaque formation in the brain and spinal cord
• In Relapsing-Remitting Multiple Sclerosis, there are regular inflammatory attacks on the nerve fiber sheath that cause local nerve damage and signal disruption. This results in a set of neurological symptoms depending on the location of the nerve damage
• Studies have shown that a genetic defect or a virus could be the reason for the damage to the myelin sheath, causing a series of events that lead to the condition. It is believed that childhood infections and environmental factors could also play a role in individuals developing MS

What are the Signs and Symptoms of Relapsing-Remitting Multiple Sclerosis?

Relapsing-Remitting Multiple Sclerosis is characterized by cycles of relapses and remissions - where flare ups/relapses are noted that last for a period of 1-2 days or more (even a week), followed by lessening of the symptoms and a recovery phase/remission lasting weeks and months. Sometimes, the individual remains asymptomatic during periods of remission and no disease progression is noted.

During neurological attacks or relapses, the severity of the existing symptoms may increase, or an onset of new symptoms may be seen. These may be noted on MRI scans as “new or increased activity” (new brain lesions) by the healthcare provider. A worsening of the symptoms indicates the progressiveness of multiple sclerosis which is expressed as increased disability in the individual over time.

The signs and symptoms of RRMS vary; it depends on the location of the affected region. Also, these may significantly differ from one individual to another. The commonly observed signs and symptoms include:

Movement-related signs and symptoms that include:

• Muscle stiffness or spasticity; muscle spasms
• Exaggerated reflexes or hyperreflexia
• Loss of balance
• Coordination difficulties
• Numbness or abnormal sensations
• Difficulties while walking, moving one’s arm or leg; weakness in the arm or leg
• Tremors

Bowel and bladder associated signs and symptoms that include:

• Constipation
• Difficulty beginning to urinate
• Increased urinary frequency; urgency due to defect in bladder muscle (detrusor muscle)

Visual-related signs and symptoms that include:

• Double vision
• Eye discomfort
• Loss of vision, one eye at a time may be affected
• Episodes of optic neuritis: Pain and temporary loss of vision, also known as Uhthoff’s phenomena, which could be triggered by hot bath, fever, exposure to sun, stress, and other factors

Other signs and symptoms may include:

• Decreased attention span
• Depression
• Dizziness
• Hearing loss
• Sexual-related problems
• Fatigue 

How is Relapsing-Remitting Multiple Sclerosis Diagnosed?

A diagnosis of Relapsing-Remitting Multiple Sclerosis may involve the following tests and exams:

• Complete evaluation of medical history and family history, along with a thorough physical exam
• Evaluation of the presenting signs and symptoms
• Neurological examination that involves the central nervous system (brain and spinal cord)
• Magnetic resonance imaging (MRI) scan of the affected region of the brain and spinal cord
• Spinal tap: Cerebrospinal fluid is examined for the presence of oligoclonal bands (these are antibodies present in the spinal fluid of individuals with multiple sclerosis)
• Visual evoked potential (VEP) test: The test measures the electrical activity in the scalp region in response to a light stimulus. Individuals with MS may have an abnormal VEP test
• Nerve function test
• Specialized blood tests to look for specific antibodies, as well as blood tests to rule out other disorders or conditions with signs and symptoms similar to multiple sclerosis
• A diagnosis generally involves ruling out other conditions of the central nervous system that may cause similar neurological symptoms

The criteria for the diagnosis of Relapsing-Remitting Multiple Sclerosis comprises of two or more episodes of neurological symptoms affecting two or more different regions of the central nervous system taking place at distinctly different times. A continuous pattern or sequence of relapses and remissions along-with correlating lesions on MRI scans at multiple locations are indicative of RRMS to a neurologist.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Relapsing-Remitting Multiple Sclerosis?

The complications associated with Relapsing-Remitting Multiple Sclerosis may include:

• Emotional distress and depression
• Difficulty swallowing
• Difficulty concentrating
• Osteoporosis
• Urinary tract infections
• Side effects from the long-term use of medication

How is Relapsing-Remitting Multiple Sclerosis Treated?

Following a diagnosis of multiple sclerosis, the healthcare provider in consultation with the patient decides on the treatment plan and the use of prescription medications. However, since medications that help control and manage multiple sclerosis tend to change the course of the condition, such therapies are termed disease-modifying therapies (immunotherapies).

Certain FDA-approved medications are available in treating Relapsing-Remitting Multiple Sclerosis with the goals of:

• Reducing flare-ups
• Mitigating progression of the condition
• Slowing or limiting further involvement of the central nervous system (as identified by MRI scans)

The medications help control flare-ups and the neurological symptoms to enable the patients lead a better quality of life.

The following medications may be administered towards delaying multiple sclerosis onset after careful consideration by the healthcare expert:

• Beta interferons
• Immunosuppressive agents
• Glatiramar acetate (immunomodulator drugs)
• Monoclonal antibodies
• Oral sphingosine 1-phosphate (S1P) receptor modulator medication

Apart from the above, certain other treatment measures may be needed, depending on the severity and duration of the condition. These include:

• Acute attacks of the disorder are treated with corticosteroids and plasma exchange therapy (plasmapheresis)
• Use of other drugs such as baclofen (to reduce muscle spasm) or benzodiazepine
• Physical therapy is also helpful in treating the symptoms of the disorder
• Cholinergic drugs can be used to decrease urinary-related signs and symptoms
• Anti-depressants may be used for mood or behavior associated conditions
• Physical therapy including occupational therapy and rehabilitation
• Healthy living including a well-balanced diet and exercising, including adequate sleep

How can Relapsing-Remitting Multiple Sclerosis be Prevented?

Currently, there are no effective preventative methods available for Relapsing-Remitting Multiple Sclerosis.

What is the Prognosis of Relapsing-Remitting Multiple Sclerosis? (Outcomes/Resolutions)

Presently, multiple sclerosis is an incurable condition and its prognosis is difficult to predict. Nevertheless, in many, the life expectancy can be normal or near-normal. Most individuals with MS are able to continue with their life and work with minimal disabilities.

• With Relapsing-Remitting Multiple Sclerosis, the prognosis depends on its severity and long-term disease course
• Regular medical evaluation is essential to assess how the disease is progressing and if any changes are necessary to be brought into the treatment plans
• In a significant number of individuals, RRMS advances to develop into secondary-progressive multiple sclerosis, which show an increased disability burden

Additional and Relevant Useful Information for Relapsing-Remitting Multiple Sclerosis:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/health-topics/neurological-institute/