Secondary Progressive Multiple Sclerosis (SPMS) Disease Course:

Secondary Progressive multiple sclerosis (SPMS) follows an initial relapsing-remitting course.  Most people who endure life with relapsing-remitting MS will in time transition towards secondary progressive MS.  Statistically the length of time to transition from relapsing-remitting MS (RRMS) to secondary progressive MS has been 10-20 years average.

New treatments for RRMS may well and probably have changed this statistic but tangible data currently does not exist since the majority of these treatments have only been available to patients for less than 10 years.

The secondary-progressive course of the disease signifies a more progressive worsening of neurological function and more accrual of disability as time progresses.  Disability increases over time with or without any evidence of disease activity such as is shown in a magnetic resonance imaging scan (MRI).  Relapsing-remitting types of relapses may or may not occur as well as periods of stability.  SPMS is characterized by a worsening of disability, rather than by relapses followed by recovery. Some people may experience relapses (relapsing secondary progressive MS), but people with secondary progressive MS don’t tend to recover completely from a relapse.

Since secondary progressive MS also may have relapses occur a disease course called “Progressive Relapsing MS” or PRMS use to be defined.  You may see “PRMS” around the internet.  It added confusion to the disease and was not exactly characteristic of certain facets of SPMS.  The term PRMS has since been deprecated in modern MS management.

SPMS can be further characterized at different points in time as either active or inactive, as well as with progression or without progression.  This makes SPMS difficult to diagnose and each person’s experience with SPMS is different.

MSProgressionBefore the newer treatments came forward, the US National MS Society estimated 50% of patients who start out with RRMS will develop SPMS within 10 years, with the number rising to 90 percent within 25 years.  In 2006 the first highly effective disease-modifying treatment (DMT) came to market, several more medications have since become available to patients.  Statistics towards transition times to secondary progressive MS for patients engaging these new treatments remains unknown.  It is thought that treating relapsing-remitting multiple sclerosis as early as possible to try and inhibit disease progression may stave off or delay transition to secondary progressive multiple sclerosis.

Current relapsing-remitting treatments are not 100% effective in stopping the disease and thus professional consensus is while they may delay the onset of SPMS they will not stave off the progression of RRMS into the secondary progressive phase.

Some people find that the increase or progression of disability is very gradual in SPMS, whilst for others, it can occur more quickly.  A small percentile of patients are diagnosed with SPMS from onset of diagnosis.  It is thought that they may have experienced RRMS in the past but in a very mild form or the significance of symptoms were dismissed.  Alternatively, disease activity may have been taking place but areas of damage in the brain or spinal cord did not result in any symptoms.

The term “secondary-progressive” comes from the fact that secondary–progressive MS (SPMS) can only be diagnosed in a person who has previously experienced RRMS.

Diagnosing Secondary Progressive Multiple Sclerosis (SPMS) 

Relapsing-remitting MS is characterized by exacerbations (attacks) resulting in inflammation called relapses.  In SPMS the patient experiences fewer of these relapses but instead a gradual worsening in symptoms over time.  The time span may be somewhat short or longer term as the disease progresses.

Diagnosing SPMS can be clear to the clinician or fairly difficult.  If a patient’s symptoms appear to be progressing and getting worse the physician needs to try and assess a variety of criteria.

For example:

  • Are the worsening symptoms due to the last relapse such as permanent but stable damage that remains after the inflammatory attack ended and thus experiencing the RRMS disease course.
  • Have symptoms worsened yet no new activity is appearing on the MRI scan.
  • The disease is continuing to worsen even though the person is no longer experiencing inflammatory relapses which would mean that the person has transitioned to a SPMS disease course.

A variety of strategies, including a careful history of the changes in a person’s symptoms, the neurologic examination, and repeat magnetic resonance imaging (MRI) scans, help determine whether the transition to SPMS has occurred.

Most neurologists will look for at least six months of clear progression before they use the term secondary progressive MS.

It is important to document multiple sclerosis from onset of diagnosis as this can be very valuable information in managing a patients RRMS and thus being able to better monitor disease progression.  Data is showing that early interventions in the course of the disease may be extremely important in staving off significant disability accrual and damage to the central nervous system (CNS).

Monitoring of Secondary Progressive Multiple Sclerosis (SPMS):

RRMS_SPMSDisease activity and progression should be evaluated at least yearly by neurologic examination and MRI. Being able to characterize the course of your disease at different points in time helps you and your MS care provider discuss your treatment options and expected outcomes.

For example:

  • If you have SPMS that is active, you and your MS care provider will want to talk about treatment with a disease-modifying therapy to reduce the risk of a relapse.
  • If you have SPMS that is active and progressing in spite of the medication you are taking, the conversation with your MS care provider might be about the potential benefits and risks associated with switching to a more aggressive treatment strategy.
  • If your SPMS is not active but there is evidence of progression and accumulation of disability, you and your MS care provider will want to focus on rehabilitation strategies to help improve your function and mobility, and promote safety and independence.
  • If your SPMS is stable without activity or progression, the conversation with your MS care could focus on rehabilitation and other symptom management strategies to help you maintain function.

Just as is the case with relapsing-remitting MS it is important to document any progression of secondary progressive MS.  Documenting the course of the disease daily can help the patients care team understand the progression of the disease and try to best manage its progression.

Treatment of Secondary Progressive MS: 

Treatment for secondary progressive multiple sclerosis may vary in your country and as such it is a wise idea to discuss SPMS and prospect treatments for it if your RRMS symptoms appear to be worsening.

There is no cure for secondary-progressive multiple sclerosis. If a patient has SPMS with relapse episodes, corticosteroids can be given to shorten and lessen the severity of the relapse. Symptoms of SPMS can affect a patient’s daily life and physical and occupational therapy may be used to manage symptoms and adjust patients to living and working situations.

In most countries, SPMS is considered a progression stage of relapsing-remitting MS.  If disease activity continues to appear on magnetic resonance imaging scan’s (MRI) then RRMS treatments may be continued or be applied towards managing disease progression.

If a patient has been on an RRMS treatment and it has been effective towards managing the disease it is likely that the medication will continue to be used unless his or her physician feels that it is no longer doing an adequate job of controlling disease activity. At that time, the physician will likely recommend changing to another one of these medications or perhaps to Novantrone® (mitoxantrone), a chemotherapeutic agent that has been approved by the United States Food and Drug Administration (FDA) specifically for SPMS, as well as worsening relapsing MS.

Physical therapy, exercise, and diet can be important factors in managing MS and this stands true for SPMS.

How does Secondary Progressive Multiple Sclerosis Differ from Primary Progressive Multiple Sclerosis?

RRMS Image

In order for a person to be diagnosed with SPMS they almost always have been diagnosed or did not realize they had relapsing-remitting multiple sclerosis (RRMS).

Secondary progressive MS tends to occur between 10-20 years after RRMS where-as primary progressive MS (PPMS) is diagnosed at onset, there is no relapsing-remitting disease course in PPMS.

Primary progressive MS are much more likely to experience mobility issues and accruement of disability. PPMS patient may not experience the vision impairments and many symptoms associated with RRMS and its progression to SPMS.

PPMS tends to be diagnosed later in life though this is not always the case.

Summary:

Secondary progressive MS marks a transition point from the inflammatory exacerbations (attacks) to a steadily worsening of the disease which is characterized by greater nerve damage and/or loss.  Relapses become less frequent or may stop completely.  Periods of stability may or may not occur and the speed by which the disease progresses varies widely within the patient population.  Symptoms worsening or apparent new symptoms may appear with less or no recovery from them resulting in more disability accrual.

Statistically, more than two-thirds of people remain able to walk though they may need a cane or walker to do so while others may need a wheelchair all of the time.

Research into stopping progression from RRMS to SPMS is well underway as are medications for secondary progressive MS.