Primary Progressive MS (PPMS): Symptoms, vs. RRMS, and More

The outlook for people with PPMS is different for everyone and unpredictable.

When compared with people who have other forms of MS, people with PPMS may experience more problems with walking and are likely to leave the workforce early. They’re more likely to require additional assistance with daily life and activities, too.

Symptoms may become more noticeable over time, especially as you get older and begin to lose certain functions in organs like your bladder, bowels, and genitals due to age and PPMS.

Four modifiers are used to characterize PPMS over time:

• Active with progression is PPMS with worsening symptoms and relapses, or with new MRI activity. Increasing disability will also occur.
• Active without progression is PPMS with relapses or MRI activity, but no increasing disability.
• Not active with progression is PPMS with no relapses or MRI activity, but with increasing disability.
• Not active without progression is PPMS with no relapses, MRI activity, or increasing disability.

A key characteristic of PPMS is the lack of remissions.

Even if a person with PPMS sees their symptoms stall — meaning they don’t experience worsening disease activity or an increase in disability — their symptoms don’t actually improve. With PPMS, people don’t regain functions they may have lost.

Here are the main differences between PPMS and SPMS:

• SPMS often begins as a diagnosis of RRMS that eventually becomes more severe over time without any remissions or improvement of symptoms.
• SPMS is always the second stage of an MS diagnosis, while RRMS is an initial diagnosis on its own.

Here are the main differences between PPMS and RRMS:

• RRMS is the most common type of MS (accounting for about 85 percent of diagnoses), while PPMS is one of the rarest.
• RRMS is twice to three times as common in women than men. PPMS is equally common in women and men.
• Episodes of new symptoms are more common in RRMS than in PPMS.
• During a remission in RRMS, you may not notice any symptoms at all, or may just have a few symptoms that aren’t as severe.
• Typically, more brain lesions appear on brain MRIs with RRMS than with PPMS, if untreated.
• RRMS tends to be diagnosed much earlier in life than PPMS, in around the 20s and 30s, as opposed to the 40s and 50s with PPMS.

PPMS affects everyone differently.

Common early symptoms of PPMS include weakness in your legs and having trouble walking. These symptoms typically become more noticeable over a period of 2 years.

Other symptoms typical of the condition include:

• stiffness in the legs
• problems with balance
• pain
• weakness and tiredness
• trouble with vision
• bladder or bowel dysfunction
• depression
• fatigue
• numbness, tingling, or both in different parts of the body

It can be difficult to differentiate between RRMS and PPMS because many of the symptoms are the same. Symptoms that become worse consistently over 1 year may be a sign that a person has PPMS.

A person with PPMS may have:

• brain lesions that are visible on an MRI scan
• two or more spinal cord lesions
• elevated levels of immune proteins or antibodies in their spinal fluid

The exact cause of PPMS, and MS in general, isn’t yet known.

The most common theory is that MS begins when the immune system starts attacking the central nervous system. This results in a loss of myelin, the protective covering around nerves in the central nervous system.

While doctors don’t believe that PPMS can be inherited, it may have a genetic component. Some believe that MS may be triggered by a virus or a toxin in the environment when combined with a genetic predisposition for the condition.

To get an accurate diagnosis of MS, work closely with your doctor to identify which of the four types of MS you may have.

Each type of MS has a different outlook and treatment needs.

There’s no specific test that provides a PPMS diagnosis.

Doctors often have difficulty diagnosing PPMS than other types of MS and other progressive conditions.

This is because a neurological issue needs to have progressed for 1 or 2 years for doctors to confirm a PPMS diagnosis.

Other conditions with symptoms similar to PPMS include:

• an inherited condition that causes stiff, weak legs
• a vitamin B12 deficiency that causes similar symptoms
• Lyme disease
• viral infections, such as human T-cell leukemia virus type 1 (HTLV-1)
• forms of arthritis, such as spinal arthritis
• a tumor near the spinal cord

To diagnose PPMS, your doctor may:

• evaluate your symptoms
• review your neurological history
• conduct a physical examination focusing on your muscles and nerves
• conduct an MRI scan of your brain and spinal cord
• perform a lumbar puncture to check for signs of MS in the spinal fluid
• conduct evoked potential (EP) tests to identify the specific type of MS (EP tests stimulate sensory nerve pathways to determine electrical activity of the brain)

Ocrelizumab (Ocrevus) is the only drug approved by the Food and Drug Administration (FDA) to treat PPMS. It helps limit nerve degeneration.

Some medications treat specific symptoms of PPMS, such as:

• muscle tightness
• pain
• fatigue
• bladder and bowel problems

There are many disease-modifying therapies (DMTs) and steroids approved by the FDA for relapsing forms of MS.

These DMTs don’t specifically treat PPMS.

Several new treatments are being developed for PPMS to help reduce inflammation that specifically attacks your nerves.

Some of these also help address damage and repair processes that affect your nerves. These treatments may be able to help restore myelin around your nerves damaged by PPMS.

One treatment, ibudilast, has been used in Japan for more than 20 years to treat asthma. It may have some ability to treat inflammation in PPMS.

A 2021 study found that ibudilast decreased brain atrophy in participants with progressive MS, but it didn’t reduce the number of new lesions. Trials are ongoing.

Another treatment called masitinib has been used for allergies by targeting mast cells involved in allergic reactions. It shows promise as a treatment for PPMS, too.

It’s important to note that these two treatments are still very early in development and research.

People with PPMS can relieve symptoms with exercise and stretching to:

• stay as mobile as possible
• manage weight
• increase energy levels

Here are some other actions you can take to manage your PPMS symptoms and maintain your quality of life:

• Eat a balanced and nutritious diet.
• Stay on a regular sleep schedule as much as possible.
• Go to physical or occupational therapy, which can teach you strategies for increasing mobility and managing symptoms.

If you’re living with PPMS, it’s important to find sources of support. There are options to seek support on an individual basis or in the wider MS community.

Living with a chronic illness can take an emotional toll. If you’re experiencing ongoing feelings of sadness, anger, grief, or other difficult emotions, let your doctor know. They may refer you to a mental health professional who can help.

You can also look for a mental health professional on your own. For example, the American Psychological Association offers a search tool to find psychologists throughout the United States. MentalHealth.gov also offers a treatment referral helpline.

You may find it helpful talking with other people who are living with MS. Consider looking into support groups, either online or in person.

The National Multiple Sclerosis Society offers a service to help you find local support groups in your area. The organization also has a peer-to-peer connection program run by trained volunteers who live with MS.

Check in with your doctor regularly if you have PPMS, even if you haven’t had any symptoms for a while, and especially when you have more noticeable disruptions in your life by an episode of symptoms.

It’s possible to have a high quality of life with PPMS when you work with your doctor to figure out the best treatments as well as lifestyle and dietary changes for you.

There’s no current cure for PPMS, but treatment makes a difference. Although the condition is progressive, people can experience periods of time when symptoms don’t actively worsen.

If you’re living with PPMS, your doctor will recommend a treatment plan based on your symptoms and general health.

Developing healthy lifestyle habits and staying connected to sources of support can also help you maintain your quality of life and overall well-being.