Treatment of cognitive impairment in multiple sclerosis: position paper

A cluster-randomised controlled feasibility trial evaluating the Cognitive Occupation-Based programme for people with Multiple Sclerosis (COB-MS)

INTRODUCTION

There is a high prevalence of cognitive difficulties in MS, but despite this, there are few programmes targeting cognition that focus on the ability to function well in everyday life. The Cognitive Occupation-Based programme for people with Multiple Sclerosis (COB-MS), an occupation-focused cognitive intervention, was developed to address this. It addresses both the functional difficulties and the wide-ranging symptoms that present in MS.

OBJECTIVE

Here we report on the results of a cluster-randomised controlled feasibility trial (ISRCTN11462710; registered 4th September 2019) evaluating the COB-MS in terms of feasibility and initial efficacy as a cognitive intervention for people with MS.

METHOD

The eight-session COB-MS intervention was delivered remotely by occupational therapists to participants with MS in the intervention group. Following the end of the trial the COB-MS was delivered to the wait-list control group. Data was collected from people with MS experiencing cognitive difficulties at baseline, post-intervention, 12-weeks, and 6-month follow-up. The primary outcome measure was the Goal Attainment Scaling at 12 weeks. Data was also collected in the domains of cognition, quality of life, and mood.

RESULTS

One hundred and eighteen people with MS and cognitive difficulties were randomised to either usual care (n = 60) or COB-MS intervention (n = 58). Ninety-four participants were retained at 6-month follow-up. The COB-MS was found to be feasible, including trial procedures and protocol. Data indicates that the COB-MS is accepted by participants and had positive impacts on daily life. Those allocated to the COB-MS group had a significant improvement in the primary outcome compared to the control condition. Progression criteria set for the feasibility trial have been met therefore further testing of the COB-MS at a definitive trial is supported by the results.

CONCLUSION

The results provide a strong basis for a pathway to a future definitive trial of COB-MS, with respect to both feasibility and preliminary, clinical efficacy.

TRIAL REGISTRATION

ISRCTN11462710 Date of registration: 4th September 2019.

Impact of physical activity, physical fitness and exercises on cognitive impairment in patients with multiple sclerosis: A review of evidence and underlying mechanisms

Cognitive impairment in persons with MS (pwMS) occurs commonly, early and independently of other clinical features of the disease. MS-related cognitive impairment is mainly characterized by weakening of information processing speed, working memory and episodic memory. Much evidence, based on both neuropsychological and neuroimaging outcomes, highlights successful cognitive rehabilitation interventions. In this context, promotion of physical activity and exercise training could be a dual, motor and cognitive, rehabilitation method. The aim of this article is, firstly, to review existing evidence regarding the effects of exercise on cognition among pwMS, and secondly, to explore the possible mechanisms of action of the cognitive-motor coupling.

Effect of Aerobic Exercise versus Non-Invasive Brain Stimulation on Cognitive Function in Multiple Sclerosis: A Systematic Review and Meta-Analysis

OBJECTIVE

In this study, we investigated the effects of noninvasive brain stimulation (NIBS) and exercise on cognition in patients with multiple sclerosis (pwMS).

METHODS

A literature search was performed using the Cochrane Library, Scopus, PubMed and Web of Science. The time interval used for database construction was up to February 2024; the collected trials were subsequently screened, and the data were extracted.

RESULTS

We identified 12 studies with 208 pwMS treated with noninvasive brain stimulation. Seven of the twelve studies concluded that NIBS was effective in improving reaction time, attention and processing speed. Additionally, 26 articles investigated the effect of various types of exercise on cognition among 708 pwMS. Twelve studies used aerobic exercise only, three studies used resistance only, one used yoga, and ten studies used mixed forms of exercise, such as Pilates, resistance and Frenkel coordination. Aerobic exercise was effective in improving at least one cognitive domain in ten studies. Resistance exercise was found to improve cognition in three studies. Yoga failed to show any improvement in one study.

CONCLUSIONS

NIBS might be an effective intervention for cognition improvement among pwMS. Aerobic exercise and combined forms of exercise are the most frequently investigated and applied and found to be effective. Further studies are needed, especially for resistance, balance and stretching exercises.

Advanced neuroimaging techniques to explore the effects of motor and cognitive rehabilitation in multiple sclerosis

INTRODUCTION

Progress in magnetic resonance imaging (MRI) technology and analyses is improving our comprehension of multiple sclerosis (MS) pathophysiology. These advancements, which enable the evaluation of atrophy, microstructural tissue abnormalities, and functional plasticity, are broadening our insights into the effectiveness and working mechanisms of motor and cognitive rehabilitative treatments.

AREAS COVERED

This narrative review with selected studies discusses findings derived from the application of advanced MRI techniques to evaluate structural and functional neuroplasticity modifications underlying the effects of motor and cognitive rehabilitative treatments in people with MS (PwMS). Current applications as outcome measure in longitudinal trials and observational studies, their interpretation and possible pitfalls and limitations in their use are covered. Finally, we examine how the use of these techniques could evolve in the future to improve monitoring of motor and cognitive rehabilitative treatments.

EXPERT COMMENTARY

Despite substantial variability in study design and participant characteristics in rehabilitative studies for PwMS, improvements in motor and cognitive functions accompanied by structural and functional brain modifications induced by rehabilitation can be observed. However, significant enhancements to refine rehabilitation strategies are needed. Future studies in this field should strive to implement standardized methodologies regarding MRI acquisition and processing, possibly integrating multimodal measures. This will help identifying relevant markers of treatment response in PwMS, thus improving the use of rehabilitative interventions at individual level. The combination of motor and cognitive strategies, longer periods of treatment, as well as adequate follow-up assessments will contribute to enhance the quality of evidence in support of their routine use.

A Cognitive Occupation-Based programme for people with MS: acceptability, feasibility, and experiences of people with multiple sclerosis

PURPOSE

COB-MS is an eight-session, Cognitive Occupation-Based programme for people with both MS and cognitive difficulty - designed to enhance cognition and daily functioning, through a combination of goal-setting, cognitive strategy engagement, group activities, home-practice activities and one-on-one sessions. This research aims to investigate the acceptability of COB-MS from the perspective of people living with MS, as well as the occupational therapists who facilitated the programme.

MATERIALS AND METHODS

Two content analyses were conducted on interview data from (n = 11) COB-MS participants and (n = 8) COB-MS facilitators. Thematic analysis was also conducted on the participant interview data.

RESULTS

Through a, primary, content analysis, participants reported that the COB-MS provided both a positive experience and quality resources. Qualitative improvement and utilisation of their learning beyond completion of the intervention were also identified. Four themes were identified via, secondary, thematic analysis: (1) Group interaction within COB-MS was vital; (2) Online COB-MS had positive and negative effects on participation; (3) COB-MS as a provider of clarity; and (4) Using learned strategies after the completion of COB-MS. Recommendations for future administration are provided.

CONCLUSIONS

Findings suggest COB-MS acceptability, as well as appropriateness and feasibility, indicative of progression to a definitive trial in future research.

TRIAL REGISTRATION

ISRCTN: ISRCTN11462710. Registered on 9 September 2019.

Free-living ambulatory physical activity and cognitive function in multiple sclerosis: the significance of step rate vs. step volume

BACKGROUND

Physical activity (PA) represents a promising behavioral approach for managing cognitive dysfunction in multiple sclerosis (MS). However, there is a lack of information on the pattern of free-living PA intensity (e.g., step rate) and its unique association with cognition. Such information is essential for informing clinical trials in MS.

OBJECTIVE

We examined associations among PA volume and intensity with cognitive function in persons with MS, and intensity was derived from steps-based metrics (peak 30-min cadence [Peak-30CAD], and time spent in incremental cadence bands).

METHODS

We included data from 147 persons with MS who underwent assessments of cognitive function (via Brief International Cognitive Assessment in MS) and wore an ActiGraph GT3X + accelerometer for 7 days. We performed bivariate and partial correlations and regression analyses examining associations among PA metrics and cognitive outcomes.

RESULTS

Higher Peak-30CAD was significantly associated with better performance in cognitive processing speed and verbal learning and memory (rs = 0.19-0.38), and the associations remained significant when controlling for daily steps, age, sex, and years of education (p < 0.05). By comparison, daily steps was only correlated with cognitive processing speed (rs = 0.26), and the association was non-significant when controlling for Peak-30CAD and covariates. There were stronger correlations among time spent in higher intensity cadence bands with cognitive performance (rs = 0.18-0.38).

CONCLUSION

Our results highlight the important role of PA intensity for cognition in MS, and may inform future development of focal PA interventions that focusing on step rate patterns for improving cognition in persons with MS.

A Review on the Feasibility and Efficacy of Home-Based Cognitive Remediation in People with Multiple Sclerosis

Cognitive impairment affects 34-65% of People with Multiple Sclerosis (PwMS), significantly impacting their quality of life. Clinicians routinely address cognitive deficits with in-clinic neuro-behavioural interventions, but accessibility issues exist. Given these challenges, coupled with the lifelong need for continuous assistance in PwMS, researchers have underscored the advantageous role of telerehabilitation in addressing these requirements. Nonetheless, the feasibility and efficacy of home-based cognitive remediation remain to be firmly established. In this narrative review, we aimed to investigate the feasibility and efficacy of digital telerehabilitation for cognition in PwMS. Thirteen relevant studies were identified and carefully assessed. Regarding the feasibility of cognitive telerehabilitation, evidence shows adherence rates are generally good, although, surprisingly, not all studies reported measures of compliance with the cognitive training explored. Considering the efficacy of rehabilitative techniques on cognitive performance in PwMS, findings are generally inconsistent, with only one study reporting uniformly positive results. A range of methodological limitations are reported as potential factors contributing to the variable results. Future research must address these challenges, as more rigorous studies are required to draw definitive conclusions regarding the efficacy of home-based cognitive remediation in PwMS. Researchers must prioritise identifying optimal intervention approaches and exploring the long-term effects of telerehabilitation.

Internet-delivered lifestyle physical activity intervention for cognitive processing speed in multiple sclerosis

BACKGROUND

We propose a randomized controlled trial(RCT) of a Social Cognitive Theory-based(SCT), Internet-delivered behavioral intervention targeting lifestyle physical activity(LPA) for yielding improvements in cognitive processing speed(CPS), learning and memory(L/M), symptoms, and quality of life(QOL) among persons with mild multiple sclerosis(MS)-related ambulatory impairment who have impaired CPS.

METHODS/DESIGN

The study involves a Phase-II, parallel group, RCT design. Participants with MS(N = 300) will be randomly assigned on an equal basis(1:1) into behavioral intervention(n = 150) or attention and social contact control(n = 150) conditions. The conditions will be administered over 6-months by trained behavior coaches who will be uninvolved in screening, recruitment, random assignment, and outcome assessment. We will collect outcome data remotely every 6-months over the 12-month period(baseline, immediate follow-up, and 6-month follow-up) using a treatment blinded assessor. The primary outcome is the raw, oral Symbol Digit Modalities Test as a neuropsychological measure of CPS. The secondary outcomes include the California Verbal Learning Test-II as an objective measure of L/M, and patient-reported outcomes of fatigue, depressive symptoms, anxiety, pain, and QOL. The tertiary outcome is accelerometry as an objective, device-based measure of steps/day for generating a minimal clinically important difference(MCID) value that guides the prescription of LPA for improving CPS in clinical practice. The primary data analyses will involve intent-to-treat principles, and mixed-effects models and logistic regression.

DISCUSSION

If successful, the proposed study will provide Class I evidence for the efficacy of a theory-based, Internet-delivered behavioral intervention focusing on LPA for improving CPS and mitigating its negative impact on other outcomes in persons with MS.

CLINICALTRIALS

gov: NCT04518657.

Improving cognition in people with multiple sclerosis: study protocol for a multiarm, randomised, blinded trial of multidomain cognitive rehabilitation using a video-serious game (E-SEP cognition)

Introduction

Multiple sclerosis (MS) is a prevalent neurological disease characterised by disseminated areas of demyelination and atrophy within the central nervous system, inducing cognitive disorders in 45%-65% of persons with MS (PwMS). Neuropsychology and neuroimaging studies provide evidence of the effectiveness of cognitive rehabilitation interventions, including memory and attention. Recently, serious game therapy (SGT) has been used in rehabilitation to improve cognitive processing speed. The aim of this study is to describe the protocol of a randomised controlled trial (RCT) to test the efficacy of a tablet-based cognitive home intervention among ambulatory PwMS, in comparison to a standardised neuropsychological rehabilitation.

Methods and analysis

This will be a parallel-assignment, double-blinded, RCT. One hundred and fifty (75 per arm) PwMS will be randomly assigned to receive cognitive rehabilitation session over 4 months (four 20-min sessions/week) of either: (1) tablet-based SGT or (2) conventional cognitive exercises. The same assessor will evaluate outcome measures at three points: at baseline (T0), after the 16 therapy sessions weeks (T1), and 6 months after the end of treatment (T2). The primary outcomes were the scores from the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Data analysis will be performed to compare the efficacy of the two treatments. We expect superior efficiency of tablet-based SGT in contrast to conventional cognitive exercises, based on BICAMS measures of speed processing information and episodic memory.

Ethics and dissemination

The trial protocol is registered on ClinicalTrials.Gov (NCT04694534) and benefits from a favourable opinion from an ethics committee (RC-P0066-2018-A00411-54).

Managing cognitive impairment and its impact in multiple sclerosis: An Australian multidisciplinary perspective

Cognitive impairment in multiple sclerosis (MS) affects approximately 40-70% of patients and can have varying degrees of severity. Even mild cognitive impairment can impact on quality of life and productivity. Despite this, patients are not routinely screened or monitored for cognitive impairment in Australia due to a range of issues, with time and space being the main limiting factors. This Australian multidisciplinary perspective provides recommendations on cognition management in Australia. It gives a broad overview of cognition in MS, advice on the screening and monitoring tools available to clinicians, and strategies that can be implemented in clinics to help monitor for cognitive impairment in patients with MS. We suggest a routine baseline assessment and multidomain cognitive battery in regular intervals; a change should trigger a thorough investigation of the cause.

Efficacy of ultraviolet B radiation versus vitamin D3 on postural control and cognitive functions in relapsing-remitting multiple sclerosis: A randomized controlled study

BACKGROUND

The relapsing-remitting multiple sclerosis (RRMS) is the most common type of MS with prevalence rate 20-60 patients/100.000 individuals in Egypt. Poor postural control and cognitive dysfunctions are well-established complications of RRMS without potent remedy yet. The latest evidence highlighted the potential and independent immune-modulating effects of vitamin D3 and ultraviolet radiation in the management of RRMS.

OBJECTIVE

To investigate the efficacy of broadband ultraviolet B radiation (UVBR) versus moderate loading dose of vitamin D3 supplementation in improving postural control and cognitive functions.

DESIGN

Pretest-posttest randomized controlled study.

SETTING

Multiple sclerosis outpatient unit of Kasr Al-Ainy Hospital.

PARTICIPANTS

Forty-seven patients with RRMS were recruited from both genders, yet only 40 completed the study.

INTERVENTIONS

Patients were randomized into two groups: UVBR group involved 24 patients, received sessions for 4 weeks and vitamin D3 group involved 23 patients, took vitamin D3 supplementation (50 000 IU/week) for 12 weeks.

MAIN OUTCOME MEASURES

Overall balance system index (OSI) and symbol digit modalities test (SDMT).

RESULTS

Highly significant decrease (P < 0.001) of the OSI in both groups post-treatment, indicating improved postural control. Moreover, highly significant improvement in the SDMT scores was noted, indicating information processing speed enhancement. Nonetheless, no statistically significant (P ≥ 0.05) differences were evident between the two groups post-treatment in all tested measures.

CONCLUSION

Both therapeutic programs were statistically equal in improving postural control and cognitive functions. However, clinically, UVBR therapy was more convenient owing to its shorter treatment time and higher percentage of change for all tested measures.

Visual oscillation effects on dynamic balance control in people with multiple sclerosis

Background

People with multiple sclerosis (PwMS) have balance deficits while ambulating through environments that contain moving objects or visual manipulations to perceived self-motion. However, their ability to parse object from self-movement has not been explored. The purpose of this research was to examine the effect of medial–lateral oscillations of the visual field and of objects within the scene on gait in PwMS and healthy age-matched controls using virtual reality (VR).

Methods

Fourteen PwMS (mean age 49 ± 11 years, functional gait assessment score of 27.8 ± 1.8, and Berg Balance scale score 54.7 ± 1.5) and eleven healthy controls (mean age: 53 ± 12 years) participated in this study. Dynamic balance control was assessed while participants walked on a treadmill at a self-selected speed while wearing a VR headset that projected an immersive forest scene. Visual conditions consisted of (1) no visual manipulations (speed-matched anterior/posterior optical flow), (2) 0.175 m mediolateral translational oscillations of the scene that consisted of low pairing (0.1 and 0.31 Hz) or (3) high pairing (0.15 and 0.465 Hz) frequencies, (4) 5 degree medial–lateral rotational oscillations of virtual trees at a low frequency pairing (0.1 and 0.31 Hz), and (5) a combination of the tree and scene movements in (3) and (4).

Results

We found that both PwMS and controls exhibited greater instability and visuomotor entrainment to simulated mediolateral translation of the visual field (scene) during treadmill walking. This was demonstrated by significant (p < 0.05) increases in mean step width and variability and center of mass sway. Visuomotor entrainment was demonstrated by high coherence between center of mass sway and visual motion (magnitude square coherence = ~ 0.5 to 0.8). Only PwMS exhibited significantly greater instability (higher step width variability and center of mass sway) when objects moved within the scene (i.e., swaying trees).

Conclusion

Results suggest the presence of visual motion processing errors in PwMS that reduced dynamic stability. Specifically, object motion (via tree sway) was not effectively parsed from the observer’s self-motion. Identifying this distinction between visual object motion and self-motion detection in MS provides insight regarding stability control in environments with excessive external movement, such as those encountered in daily life.

Glatiramer Acetate Immunomodulation: Evidence of Neuroprotection and Cognitive Preservation

Novel, neuroprotective uses of Copaxone (generic name: glatiramer acetate-GA) are being examined, primarily in neurological conditions involving cognitive decline. GA is a well-studied synthetic copolymer that is FDA-approved for immune-based treatment of relapsing remitting multiple sclerosis (RRMS). Clinical studies have explored the potential mechanism of action (MOA) and outcomes of GA immunization in patients. Furthermore, results from these and animal studies suggest that GA has a direct immunomodulatory effect on adaptive and innate immune cell phenotypes and responses. These MOAs have been postulated to have a common neuroprotective impact in several neuroinflammatory and neurodegenerative diseases. Notably, several clinical studies report that the use of GA mitigated MS-associated cognitive decline. Its propensity to ameliorate neuro-proinflammatory and degenerative processes ignites increased interest in potential alternate uses such as in age-related macular degeneration (AMD), amyotrophic lateral sclerosis (ALS), and Alzheimer's disease (AD). Preclinical studies are exploring less frequent subcutaneous administration of GA, such as once weekly or monthly or a single dosing regimen. Indeed, cognitive functions were found to be either preserved, reversed, or improved after the less frequent treatment regimens with GA in animal models of AD. In this systematic review, we examine the potential novel uses of GA across clinical and pre-clinical studies, with evidence for its beneficial impact on cognition. Future investigation in large-size, double-blind clinical trials is warranted to establish the impact of GA immunomodulation on neuroprotection and cognitive preservation in various neurological conditions.

Validation of the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) in the Russian Population

OBJECTIVE

Cognitive dysfunction is common in multiple sclerosis (MS). The Brief International Cognitive Assessment for MS (BICAMS) battery of tests has been suggested as a measure for the evaluation of the cognitive status of MS patients. This study aims to validate the BICAMS battery in the Russian population of MS patients.

METHODS

Age- and sex-matched MS patients (n = 98) and healthy individuals (n = 86) were included in the study. Symbol Digit Modalities Test (SDMT), California Verbal Learning Test, 2nd edition (CVLT-II) and the Brief Visuospatial Memory Test - Revised (BVMT-R) were administered to all participants. The battery was readministered 1 month later to 44 MS patients to investigate the test-retest reliability.

RESULTS

MS patients exhibited a significantly lower performance in testing with BICAMS than the control group in all three neuropsychological tests. Test-retest reliability was good for SDMT and CVLT-II (r = .82 and r = .85, respectively) and adequate for BVMT-R (r = .70). Based on the proposed criterion for impairment as z score below 1.5 SD the mean of the control group, we found that 34/98 (35%) of MS patients were found impaired at least in one cognitive domain. Patients with Expanded Disability Status Scale score ≥3.5 performed significantly worse than controls (SDMT, p < .0001; CVLT-II, p = .03; BVMT-R, p = .0004), while those with ≤3.0 scores did not.

CONCLUSION

This study demonstrates that the BICAMS battery is a valid instrument to identify cognitive impairment in MS patients and it can be recommended for routine use in the Russian Federation.

Cognitive Rehabilitation in Multiple Sclerosis in the Period from 2013 and 2021: A Narrative Review

Background: In recent years, several blinded randomized controlled trials (RCT) have been conducted on cognitive rehabilitation (CR) in adults with multiple sclerosis (MS). Objective: To review all blinded RCTs on CR in MS published since 2013. Methods: The National Library of Medicine database (Medline) and PSYCINFO were searched using the keywords MS and CR or cognitive training or NP rehabilitation or memory rehabilitation or attention rehabilitation. Results: After the exclusion of some papers not specifically focused on CR, a final list of 26 studies was established. The papers belong to three main categories: individual specific rehabilitation (8studies), group rehabilitation (4 studies), and computerized training (CT) (14 studies), while one study combined group rehabilitation and CT. Among the individual rehabilitation studies, 5 were devoted to memory, and most of the 19 other selected studies were about several cognitive domains. Most of the studies mainly concerned RRMS patients, except for 2 studies that were carried out exclusively in progressive forms. Despite the methodological limitations of some studies and the great heterogeneity of the protocols, the results are generally in favor of the efficacy of CR in neuropsychological tests. Conclusion: Recent blinded RCTs about CR in MS show promising results.

Onge J, Robinson J, Eguakun O, Feinstein A, Dorsch K, Kakar RS, Abdulhakim R, Rehman Z, Shawush M, Pillay V. Effectiveness of Three-Dimensional Multiple-Object Tracking in Patients with Multiple Sclerosis: A Pilot Trial

BACKGROUND

Computerized cognitive training remains an attractive supplemental modality to enhance rehabilitation in multiple sclerosis (MS). The objective of the present study was to assess the usability of three-dimensional multiple-object tracking (3D-MOT) in patients with MS.

METHODS

In this pilot study, 16 patients with relapsing-remitting MS and nine age-matched controls participated in four 30-minute training sessions of 3D-MOT. Computerized neuropsychological tests, including driving readiness (ie, Useful Field of View) and cognitive function (ie, Stroop Color and Word Test, Paced Visual Serial Addition Test, Symbol Digit Modalities Test) were conducted at baseline and at the conclusion of training.

RESULTS

Although scoring lower in 3D-MOT, the MS group improved their 3D-MOT scores in similar magnitude as the control group. The 3D-MOT training led to significant improvements in driving readiness in the MS group. Taken together, 3D-MOT training showed similar effectiveness in patients with MS as in age-matched controls.

CONCLUSIONS

Training with 3D-MOT may be an accessible and remotely administrable supplement to cognitive rehabilitation protocols for patients with MS.

Impact of Cognitive Impairment and Dysarthria on Spoken Language in Multiple Sclerosis

OBJECTIVE

To investigate the impact of cognitive impairment on spoken language produced by speakers with multiple sclerosis (MS) with and without dysarthria.

METHOD

Sixty speakers comprised operationally defined groups. Speakers produced a spontaneous speech sample to obtain speech timing measures of speech rate, articulation rate, and silent pause frequency and duration. Twenty listeners judged the overall perceptual severity of the samples using a visual analog scale that ranged from no impairment to severe impairment (speech severity). A 2 × 2 factorial design examined main and interaction effects of dysarthria and cognitive impairment on speech timing measures and speech severity in individuals with MS. Each speaker group with MS was further compared to a healthy control group. Exploratory regression analyses examined relationships between cognitive and biopsychosocial variables and speech timing measures and perceptual judgments of speech severity, for speakers with MS.

RESULTS

Speech timing was significantly slower for speakers with dysarthria compared to speakers with MS without dysarthria. Silent pause durations also significantly differed for speakers with both dysarthria and cognitive impairment compared to MS speakers without either impairment. Significant interactions between dysarthria and cognitive factors revealed comorbid dysarthria and cognitive impairment contributed to slowed speech rates in MS, whereas dysarthria alone impacted perceptual judgments of speech severity. Speech severity was strongly related to pause duration.

CONCLUSIONS

The findings suggest the nature in which dysarthria and cognitive symptoms manifest in objective, acoustic measures of speech timing and perceptual judgments of severity is complex.

Group cognitive rehabilitation to reduce the psychological impact of multiple sclerosis on quality of life: the CRAMMS RCT

BACKGROUND

People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis.

DESIGN

This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation.

SETTING

The trial was set in hospital neurology clinics and community services.

PARTICIPANTS

Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent.

INTERVENTION

The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant.

RESULTS

Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported.

LIMITATIONS

The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation.

CONCLUSIONS

This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis.

FUTURE WORK

Future research should evaluate the selection of those who may benefit from cognitive rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN09697576.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.

Comparison of the Effect of Cognitive Rehabilitation and Neurofeedback on Sustained Attention Among Elementary School Students With Specific Learning Disorder: A Preliminary Randomized Controlled Clinical Trial

Introduction:

Sustained Attention (SA) failure is one of the main characteristics of Specific Learning Disorders (SLD). Recent studies have reported a positive effect of Cognitive Rehabilitation (CR) and Neurofeedback (NFB) on SA in SLD. Thus, the effectiveness of CR and NFB is well understood. This preliminary study aimed to compare the effects of CR and NFB on SA among the elementary school students with SLD, using a randomized controlled clinical trial.

Methods:

In this preliminary randomized controlled clinical trial, 53 eligible students with SLD (based on DSM-5) within the age range of 7 to 10 years were randomly assigned in the NFB (n=18), CR (n=18), and control group (n=17). All the participants were evaluated for SA using the Continuous Performance Test (CPT), at the time of entry to the study, and one month later. The intervention groups participated in 20 sessions of CR and 20 sessions of NFB, while the control group was evaluated without any intervention.

Results:

A total number of 24 boys and 36 girls in four groups (n=15) completed the study. The Mean±SD age of the participants in the CR, NFB, and control groups were 8.66±1.48 years, 8.40±1.73 years, and 8.53±1.63 years, respectively. Results showed a significant difference in the variables of the CPT between the study groups (P<0.05). Also, the CPT scores of the CR group were higher than that of the NFB group (P<0.001).

Conclusion:

This study supports that CR is more effective than NFB on SA in students with SLD.

Application of an Adaptive, Digital, Game-Based Approach for Cognitive Assessment in Multiple Sclerosis: Observational Study

Background

Cognitive impairment is one of the most debilitating manifestations of multiple sclerosis. Currently, the assessment of cognition relies on a time-consuming and extensive neuropsychological examination, which is only available in some centers.

Objective

To enable simpler, more accessible cognitive screening, we sought to determine the feasibility and potential assessment sensitivity of an unsupervised, adaptive, video game–based digital therapeutic to assess cognition in multiple sclerosis.

Methods

A total of 100 people with multiple sclerosis (33 with cognitive impairment and 67 without cognitive impairment) and 24 adults without multiple sclerosis were tested with the tablet game (EVO Monitor) and standard measures, including the Brief International Cognitive Assessment for Multiple Sclerosis (which included the Symbol Digit Modalities Test [SDMT]) and Multiple Sclerosis Functional Composite 4 (which included the Timed 25-Foot Walk test). Patients with multiple sclerosis also underwent neurological evaluations and contributed recent structural magnetic resonance imaging scans. Group differences in EVO Monitor performance and the association between EVO Monitor performance and standard measures were investigated.

Results

Participants with multiple sclerosis and cognitive impairment showed worse performance in EVO Monitor compared with participants without multiple sclerosis (P=.01) and participants with multiple sclerosis without cognitive impairment (all P<.002). Regression analyses indicated that participants with a lower SDMT score showed lower performance in EVO Monitor (r=0.52, P<.001). Further exploratory analyses revealed associations between performance in EVO Monitor and walking speed (r=–0.45, P<.001) as well as brain volumetric data (left thalamic volume: r=0.47, P<.001; right thalamic volume: r=0.39, P=.002; left rostral middle frontal volume: r=0.28, P=.03; right rostral middle frontal volume: r=0.27, P=.03).

Conclusions

These findings suggest that EVO Monitor, an unsupervised, video game–based digital program integrated with adaptive mechanics, is a clinically valuable approach to measuring cognitive performance in patients with multiple sclerosis.

Trial Registration

ClinicalTrials.gov NCT03569618; https://clinicaltrials.gov/ct2/show/NCT03569618

The Importance of the Cognitive Aspects of Vocational Rehabilitation for Individuals With Multiple Sclerosis

Background:

Individuals with multiple sclerosis (MS) face symptoms that affect them physically and cognitively; 80% of individuals diagnosed with MS are out of work within 10 years, and 58% are unemployed. It appears that a diagnosis of MS creates a barrier to individuals obtaining and maintaining work. To combat this, vocational rehabilitation (VR) has been utilized by individuals with MS but with limited success. This may be due to the lack of interventions that address cognitive symptoms that occur.

Purpose:

The purpose of this perspective is to review the interaction between individuals with MS and the components of VR and discuss implications that could potentially increase the success of individuals with MS obtaining work.

Implications:

Approximately 48.1% of clients with MS receiving services from state VR agencies obtain or retain employment compared to 60% of clients with other diagnoses. This disparity highlights a disconnect in VR services. It has been seen that individuals with MS who were employed at application were more likely to receive services that include cognitive retraining-type services. Including more opportunities for cognitive retraining-type services may decrease this disparity and help more individuals with MS maintain or obtain work.

Factors influencing daily treatment choices in multiple sclerosis: practice guidelines, biomarkers and burden of disease

At two meetings of a Central European board of multiple sclerosis (MS) experts in 2018 and 2019 factors influencing daily treatment choices in MS, especially practice guidelines, biomarkers and burden of disease, were discussed. The heterogeneity of MS and the complexity of the available treatment options call for informed treatment choices. However, evidence from clinical trials is generally lacking, particularly regarding sequencing, switches and escalation of drugs. Also, there is a need to identify patients who require highly efficacious treatment from the onset of their disease to prevent deterioration. The recently published European Committee for the Treatment and Research in Multiple Sclerosis/European Academy of Neurology clinical practice guidelines on pharmacological management of MS cover aspects such as treatment efficacy, response criteria, strategies to address suboptimal response and safety concerns and are based on expert consensus statements. However, the recommendations constitute an excellent framework that should be adapted to local regulations, MS center capacities and infrastructure. Further, available and emerging biomarkers for treatment guidance were discussed. Magnetic resonance imaging parameters are deemed most reliable at present, even though complex assessment including clinical evaluation and laboratory parameters besides imaging is necessary in clinical routine. Neurofilament-light chain levels appear to represent the current most promising non-imaging biomarker. Other immunological data, including issues of immunosenescence, will play an increasingly important role for future treatment algorithms. Cognitive impairment has been recognized as a major contribution to MS disease burden. Regular evaluation of cognitive function is recommended in MS patients, although no specific disease-modifying treatment has been defined to date. Finally, systematic documentation of real-life data is recognized as a great opportunity to tackle unresolved daily routine challenges, such as use of sequential therapies, but requires joint efforts across clinics, governments and pharmaceutical companies.

Introduction of the Watzmann Severity Scale: A sensorimotor approach to estimate the course of inpatient rehabilitation in multiple sclerosis

Multiple sclerosis is an autoimmune disease with a plethora of potentially arising impairments and a coarse standard clinical estimation of severity, the expanded disability status scale (EDSS). In this study, we introduced the Watzmann Severity Scale (WSS), a sensorimotor function based statistical model of the EDSS of 113 patients. Using the WSS, we examined the rehabilitation course of 87 patients. The WSS revealed to be a reliable estimate of the EDSS with an R²_adjusted of 0.81, although lower EDSS grades were systematically overestimated. Further, patients slightly improved during their inpatient stay of in average 17d by 0.21 on the WSS, with changes in gait performance being the driving factor (|β|-weight of 0.84). We were not able to reliably predict changes in the WSS and found no association with the duration of hospitalization. We conclude and advise that rehabilitation should start earlier, if lower EDSS grades were not overestimated, to emphasize gait less in rehabilitation, and to change from a perspective of impairment and disability to performance in order to maximize patient rehabilitation.

CD8+ T Cell-Mediated Mechanisms Contribute to the Progression of Neurocognitive Impairment in Both Multiple Sclerosis and Alzheimer's Disease?

Neurocognitive impairment (NCI) is one of the most relevant clinical manifestations of multiple sclerosis (MS). The profile of NCI and the structural and functional changes in the brain structures relevant for cognition in MS share some similarities to those in Alzheimer's disease (AD), the most common cause of neurocognitive disorders. Additionally, despite clear etiopathological differences between MS and AD, an accumulation of effector/memory CD8+ T cells and CD8+ tissue-resident memory T (Trm) cells in cognitively relevant brain structures of MS/AD patients, and higher frequency of effector/memory CD8+ T cells re-expressing CD45RA (TEMRA) with high capacity to secrete cytotoxic molecules and proinflammatory cytokines in their blood, were found. Thus, an active pathogenetic role of CD8+ T cells in the progression of MS and AD may be assumed. In this mini-review, findings supporting the putative role of CD8+ T cells in the pathogenesis of MS and AD are displayed, and putative mechanisms underlying their pathogenetic action are discussed. A special effort was made to identify the gaps in the current knowledge about the role of CD8+ T cells in the development of NCI to "catalyze" translational research leading to new feasible therapeutic interventions.

On the Reliability of Examining Dual-Tasking Abilities Using a Novel E-Health Device—A Proof of Concept Study in Multiple Sclerosis

The assessment of neuropsychological functions and especially dual-tasking abilities is considered to be increasingly relevant in the assessment of neurological disease, and Multiple Sclerosis (MS) in particular. However, the assessment of dual-tasking abilities is hindered by specific software requirements and extensive testing times. We designed a novel e-health (progressive web application-based) device for the assessment of dual-tasking abilities usable in “bedside” and outpatient clinic settings and examined its reliability in a sample of N = 184 MS patients in an outpatient setting. Moreover, we examined the relevance of dual-tasking assessment using this device with respect to clinically relevant parameters in MS. We show that a meaningful assessment of dual-tasking is possible within 6 min and that the behavioral readouts overall show good reliability depending on dual-tasking difficulty. We show that dual-tasking readouts were correlated with clinically relevant parameters (e.g., EDSS, disease duration, processing speed) and were not affected by fatigue levels. We consider the tested dual-tasking assessment device suitable for routine clinical neuropsychological assessments of dual-tasking abilities. Future studies may further evaluate this test regarding its suitability in the long-term follow up assessments and to assess dual-tasking abilities in other neurological and psychiatric disorders.

Delivering Transcranial Direct Current Stimulation Away From Clinic: Remotely Supervised tDCS

INTRODUCTION

To demonstrate the broad utility of the remotely supervised transcranial direct current stimulation (RS-tDCS) protocol developed to deliver at-home rehabilitation for individuals with multiple sclerosis (MS).

METHODS

Stimulation delivered with the RS-tDCS protocol and paired with adaptive cognitive training was delivered to three different study groups of MS patients to determine the feasibility and tolerability of the protocol. The three studies each used consecutively increasing amounts of stimulation amperage (1.5, 2.0, and 2.5 mA, respectively) and session numbers (10, 20, and 40 sessions, respectively).

RESULTS

High feasibility and tolerability of the stimulation were observed for n = 99 participants across three tDCS pilot studies.

CONCLUSIONS

RS-tDCS is feasible and tolerable for MS participants. The RS-tDCS protocol can be used to reach those in locations without clinic access and be paired with training or rehabilitation in locations away from the clinic. This protocol could be used to deliver tDCS paired with training or rehabilitation activities remotely to service members and veterans.

Evolving relationship between respiratory functions & impairment in sleep and cognition in patients with multiple sclerosis

BACKGROUND

The most apparent source of disability in patients with multiple sclerosis (MS) is the physical and mental impact. The pathophysiological mechanisms of cognitive dysfunction are multifactorial although hypoventilation secondary to respiratory dysfunction may contribute to cognitive decline.

METHODS

This study was conducted on 146 MS patients with baseline clinical assessments including the Epworth sleepiness scale (ESS) and physical disability was assessed using the Expanded Disability Status Scale (EDSS). Cognitive testing was performed utilizing the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) and the Perceived Deficits Questionnaire (PDQ). Respiratory functions were assessed by spirometry and the respiratory muscle functional assessment was done by maximal mouth pressure measurement.

RESULTS

The respiratory muscle function test had a significant negative correlation with the score of ESS and PDQ scale and a significant positive correlation with the BICAMS scale score (p < 0.001). The ESS and PDQ scores were significantly negatively correlated with forced expiratory volume in the first second (FEV1)/ forced vital capacity (FVC) (p = 0.03, 0.02), FVC supine (p = 0.03, 0.01), FVC upright- FVC supine (ΔFVC) (p < 0.001, <0.001) FEV1 (p < 0.001) and FVC (L) (p < 0.001), respectively. While the BICAMS showed a significant positive correlation with spirometry results except FVC upright. ESS scores were significantly correlated with the BICAMS and PDQ scale score (p < 0.001).

CONCLUSION

Among MS patients, impaired respiratory functions are significantly associated with sleep disturbance and cognitive impairment. Thus the spirometry and respiratory muscle strength assessment are necessary from the early phase of MS.

Pharmacotherapy in multiple sclerosis-induced cognitive impairment: A systematic review and meta-analysis

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) commonly complicated by cognitive impairment. Unfortunately, no medical therapy has been proved to improve cognitive problems in these patients. This meta-analysis investigated the effectiveness of different categories of drugs on the minimal assessment of cognitive function in MS (MACFIMS)-related tasks outcome in MS patients. To this end, a systematic evaluation was conducted using PubMed, Google Scholar, and Scopus databases. Among a total of 128 publications, 31 studies met our inclusion criteria, and 22 included in the meta-analysis. We found that symbol digit modalities test (SDMT), paced auditory serial addition test (PASAT), controlled oral word association test (COWAT), and California verbal learning test (CVLT) were the most frequently reported tasks in included studies. The frequently reported drugs were classified into five main groups of acetylcholine esterase inhibitors, CNS stimulants, fampridine, herbal remedies, and miscellaneous. Overall heterogeneity of the studies was modest. The treatments did not affect cognitive function in any of the tasks (p>0.05). However, in subgroup analysis, we found significant improvement in SDMT task outecomes after treatment by fampridine (0.283 SMD, 95%CI, 0.015 to 0.550, p = 0.039, I2=11.7%). Our meta-analysis highlighted that the currently proposed therapeutic agents had no beneficial effects on the alleviation of MS-induced cognitive impairment.

Effect of cognitive rehabilitation on neuropsychological and semiecological testing and on daily cognitive functioning in multiple sclerosis: The REACTIV randomized controlled study

BACKGROUND

Specific cognitive rehabilitation (SCR) has been suggested for multiple sclerosis (MS). A randomized controlled trial (RCT) evaluating the therapeutic effects of SCR is necessary.

OBJECTIVE

To demonstrate the superiority of a SCR program (REACTIV) over nonspecific intervention (NSI) for neuropsychological (NP) assessment, virtual reality (VR) cognitive testing and daily cognitive functioning.

METHODS

A single-blind RCT compared SCR and NSI in patients with MS with cognitive complaint. Both programs included 50 individual sessions, 3 times a week for 17 weeks in a real-world setting. The primary end-point was NP assessment. Secondary end-points included semiecological VR tasks (Urban Daily Cog®) and daily cognitive functioning assessment. Maintenance of the effects at 8 months was studied.

RESULTS

Of the 35 patients, 18 completed the SCR, and 17 completed the NSI. Several NP and semiecological scores improved significantly more after SCR than after NSI. More NP scores improved significantly after SCR than after NSI. SCR improved daily cognitive functioning. Most improvements were maintained at 8 months.

CONCLUSION

SCR performed in a real-world setting is superior to NSI for improving performance in specific cognitive domains and information processing speed, and for improving cognitive functioning, as evaluated by ecological tools close to daily life and a daily cognitive functioning questionnaire.

Long-term assessment of the cognitive effects of nabiximols in patients with multiple sclerosis: A pilot study

OBJECTIVE

Moderate to severe spasticity is commonly reported in Multiple Sclerosis (MS) and its management is still a challenge. Cannabinoids were recently suggested as add-on therapy for the treatment of spasticity and chronic pain in MS but there is no conclusive scientific evidence on their safety, especially on cognition and over long periods. The aim of this prospective pilot study was to assess the long-term effects of a tetrahydrocannabinol-cannabidiol (THC/CBD) oromucosal spray (Sativex®) on cognition, mood and anxiety.

PATIENTS AND METHODS

An extensive and specific battery of neuropsychological tests (Symbol Digit Modalities Test-SDMT, California Verbal Learning Test-CVLT, Brief Visuospatial Memory Test-BVMT; PASAT-3 and 2; Free and Cued Selective Remind Test-FCSRT, Index of Sensitivity of Cueing-ISC) was applied to longitudinally investigate different domains of cognition in 20 consecutive MS patients receiving Sativex for spasticity. The primary endpoint was to assess any variation in cognitive performance. Secondary outcomes regarding mood and anxiety were investigated by means of Beck Depression Inventory (BDI) and Hamilton Anxiety Rating Scale (HAM-A). Any change in patients' spasticity was evaluated using the 0-10 Numerical Rating Scale (NRS).

RESULTS

Twenty per protocol patients were followed up and evaluated at baseline, 6 and 12 months. Domains involving processing speed and auditory verbal memory significantly improved within the first 6 months of therapy (SDMT: p < 0.001; CVLT: p = 0.0001). Mood and anxiety did not show any significant variation. Additionally, the NRS score significantly improved since the beginning (p < 0.0001).

CONCLUSIONS

These results are encouraging in supporting possible long-term benefits of Sativex on cognition and a wider role than symptom alleviator. Further studies on larger groups of patients would be necessary in order to test this intriguing possibility.

Serum vitamin D level is associated with speed of processing in multiple sclerosis patients

Multiple Sclerosis (MS) is often associated with low serum 25(OH)D levels, as well as cognitive dysfunctions. The relationship between 25(OH)D and the most commonly affected cognitive domain in MS; processing speed, is poorly explored. The purpose of this study is to: (1) assess the effect of serum 25(OH)D change on processing speed in MS, and (2) explore the relationship between serum 25(OH)D and brain volume changes in MS. A retrospective chart review was conducted, data from 299 patients were extracted (baseline), of whom 163 had follow-up measurements (after at least a 9-month interval). The Symbol Digits Modalities Test (SDMT) was used as a measure of processing speed. MRI data was available from 78 individuals at baseline, and 70 at follow-up. SDMT scores and brain volumes (Cerebellum (total, grey, and white), intracranial, Grey Matter (GM), and White Matter (WM)) were compared based on 25(OH)D levels and their changes towards follow-up. Results indicated that patients with deficient 25(OH)D levels had lower SDMT scores when compared to those with sufficient levels, and SDMT scores improved as a function of 25(OH)D. For MRI measures, only patients with sufficient 25(OH)D levels during both assessment periods had significant changes in intracranial and total cerebellum volumes. We conclude that 25(OH)D levels seem to have an effect on processing speed in MS, thus the importance of clinical monitoring and supplementation in this regard is reinforced.

Treatment and management of cognitive dysfunction in patients with multiple sclerosis

Cognitive impairment is a common and devastating manifestation of multiple sclerosis (MS). Although disease-modifying therapies have been efficacious for reducing relapse rates in MS, such treatments are ineffective for treating cognitive dysfunction. Alternative treatment approaches for mitigating cognitive problems are greatly needed in this population. To date, cognitive rehabilitation and exercise training have been identified as possible candidates for treating MS-related cognitive impairment; however, cognitive dysfunction is still often considered to be poorly managed in patients with MS. This Review provides a comprehensive overview of recent developments in the treatment and management of cognitive impairment in people with MS. We describe the theoretical rationales, current states of the science, field-wide challenges and recent advances in cognitive rehabilitation and exercise training for treating MS-related cognitive impairment. We also discuss future directions for research into the treatment of cognitive impairment in MS that should set the stage for the inclusion of cognitive rehabilitation and exercise training into clinical practice within the next decade.

The immediate effect of stroboscopic visual training on information-processing time in people with multiple sclerosis: an exploratory study

Stroboscopic visual training (SVT) is a form of training aimed at improving visual and perceptual performance by having individuals perform activities under conditions of intermittent vision. The efficacy of SVT has never been examined in people with multiple sclerosis (PwMS), therefore, our aim was to examine the immediate effect of SVT on cognitive function, gait and static balance performance in PwMS. This assessor-blinded, randomized crossover study included 26 PwMS, 16 females, mean age 47.9 and median EDSS score 4.5. Participants attended two sessions: SVT and control training. Exercises for both the SVT and control sessions were based on ball-catching tasks. Training sessions were identical in length (40-50 min) and type of exercise drills. The difference between the two practice regimes was that the SVT session was performed wearing stroboscopic glasses and the control training was performed with similar glasses without lenses. Cognition was evaluated by a computerized software (Mindstreams^®, NeuroTrax Corp., NY). Gait and balance were evaluated via wearable accelerometers (APDM, Oregon, USA). Outcome measures were collected twice during a single session, prior to training and immediately afterward. Information processing speed (p = 0.003) increased at the post-evaluation compared with baseline, solely in the SVT session. No differences between pre-post evaluations were observed for other cognitive scores following the SVT session. No differences between pre-post measurements were noted for gait and balance following the SVT session. The present study's results justify performing future RCT studies to examine the effects of a longer SVT program on cognition in PwMS.

The notion of "invisibility" in people's experiences of the symptoms of multiple sclerosis: a systematic meta-synthesis

Purpose: Invisible symptoms have a negative impact on people living with Multiple Sclerosis (MS), related to the very notion that they are "unseen." It is important to understand the notion of "invisibility" in MS, as invisible symptoms are particularly distressing, and there is a paucity of research focussing on their invisible nature and its specific impact. We aimed to systematically identify, appraise and synthesise qualitative research regarding the notion of "invisibility" in relation to people's lived experience of symptoms of MS.Methods and materials: Articles meeting inclusion criteria were critically appraised and synthesised using a meta-ethnographic approach.Results: 17 articles were identified from six electronic databases. Three third-order themes were presented as a line of argument. "Invisibility" was conceptualised by people with MS as a discrepancy between the internal experience of symptoms and what is observed externally. "Invisibility" of MS symptoms was found to have numerous impacts, including not feeling understood or validated by others, issues around the perceived legitimacy of the illness, and living with needs which are hidden. We found that "invisibility" by its nature offers people a choice of strategies they use to navigate it. This choice introduces a dilemma: disclose the diagnosis to be "seen," or remain "invisible."Conclusions: This review revealed the manner in which people with MS are affected by the invisibility of their symptoms and the various adaptations used to navigate these lived experiences. We highlight the need to improve clinician and public understanding, and to better respond to these experiences. Future research focusing on the exploration of people's experiences of "invisibility" in MS, including the ways in which "invisibility" is managed on a day-to-day basis could raise clinical and public awareness of the impact of "invisibility" and how to provide support for this, thus easing the dilemmas faced by those with MS.IMPLICATIONS FOR REHABILITATIONPeople with Multiple Sclerosis (MS) experience symptoms that are not overtly visible to others, impacting their emotional and social wellbeing negatively.It is important for healthcare professionals to validate MS patients' experiences around "invisibility" and provide appropriate support.Healthcare professionals should address with MS patients any issues around disclosure of their diagnosis to those around them and support them to navigate these decisions.Raising awareness about the impact of "invisibility" for people with MS may help to lessen patient burden and promote understanding amongst healthcare professionals and the general public.

Cognitive Impairment and Brain Reorganization in MS: Underlying Mechanisms and the Role of Neurorehabilitation

Multiple sclerosis (MS) is a chronic, immune-mediated, inflammatory, and degenerative disease of the central nervous system (CNS) that affects both white and gray matter. Various mechanisms throughout its course, mainly regarding gray matter lesions and brain atrophy, result in cognitive network dysfunction and can cause clinically significant cognitive impairment in roughly half the persons living with MS. Altered cognition is responsible for many negative aspects of patients' lives, independently of physical disability, such as higher unemployment and divorce rates, reduced social activities, and an overall decrease in quality of life. Despite its devastating impact it is not included in clinical ratings and decision making in the way it should be. It is interesting that only half the persons with MS exhibit cognitive dysfunction, as this implies that the other half remain cognitively intact. It appears that a dynamic balance between brain destruction and brain reorganization is taking place. This balance acts in favor of keeping brain systems functioning effectively, but this is not so in all cases, and the effect does not last forever. When these systems collapse, functional brain reorganization is not effective anymore, and clinically apparent impairments are evident. It is therefore important to reveal which factors could make provision for the subpopulation of patients in whom cognitive impairment occurs. Even if we manage to detect this subpopulation earlier, effective pharmaceutical treatments will still be lacking. Nevertheless, recent evidence shows that cognitive rehabilitation and neuromodulation, using non-invasive techniques such as transcranial magnetic or direct current stimulation, could be effective in cognitively impaired patients with MS. In this Mini Review, we discuss the mechanisms underlying cognitive impairment in MS. We also focus on mechanisms of reorganization of cognitive networks, which occur throughout the disease course. Finally, we review theoretical and practical issues of neurorehabilitation and neuromodulation for cognition in MS as well as factors that influence them and prevent them from being widely applied in clinical settings.

iCAMS: Assessing the Reliability of a Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) Tablet Application

Background

This study aimed to develop a Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) tablet application, "iCAMS," and examine equivalency between the original paper-based and the tablet-based assessments.

Methods

This study enrolled 100 participants with physician-confirmed multiple sclerosis (MS). Interrater reliability, parallel forms reliability, and concurrent validity were evaluated by incorporating two test administrators in each session: one scoring participant responses with the original paper assessments and the other with iCAMS. Although the participant was exposed to the material only once, responses were recorded on both administration methods. In addition to the standard test procedures, each research assistant used a stopwatch to measure the amount of time required to administer and score each version of BICAMS.

Results

Pearson correlation coefficients (r) revealed strong and significant correlations for all three tests. Excellent agreement was observed between iCAMS and paper versions of the BICAMS tests, with all intraclass correlation coefficients exceeding 0.93. The scores from all the cognitive tests were not statistically significantly different, indicating no proportional bias. Including scoring, administration of the iCAMS application saved approximately 10 minutes over the paper version.

Conclusions

Preliminary findings suggest that the tablet application iCAMS is a reliable and fast method for administering BICAMS.

[Methodological issues of cognitive impairment studies in pediatric multiple sclerosis patients]

The article provides a review of the characteristics of cognitive impairment in multiple sclerosis (MS) and methods for its assessment in children. The features of the most frequently used neuropsychological batteries, with consideration of specifics of cognitive impairment in MS, and data on assessment of a state of cognitive functions obtained using neuropsychological tests are presented. The authors also discuss the issue of a long-term impact of the disease on a state of cognitive functions. Clinical factors, which can lead to cognitive impairment (type of multiple sclerosis, age at manifestation, number of relapses), are described.

Environmental enrichment improves cognitive symptoms and pathological features in a focal model of cortical damage of multiple sclerosis

Multiple Sclerosis (MS) is a neuroinflammatory disease affecting white and grey matter, it is characterized by demyelination, axonal degeneration along with loss of motor, sensitive and cognitive functions. MS is a heterogeneous disease that displays different clinical courses: relapsing/remitting MS (RRMS), and MS progressive forms: primary progressive (PPMS) and secondary progressive (SPMS). Cortical damage in the progressive MS forms has considerable clinical relevance due to its association with cognitive impairment and disability progression in patients. One treatment is available for the progressive forms of the disease, but none are specific for cognitive deficits. We developed an animal model that reflects most of the characteristics of the cortical damage, such as cortical neuroinflammation, demyelination, neurodegeneration and meningeal inflammation, which was associated with cognitive impairment. Cognitive rehabilitation, exercise and social support have begun to be evaluated in patients and animal models of neurodegenerative diseases. Environmental enrichment (EE) provides exercise as well as cognitive and social stimulation. EE has been demonstrated to exert positive effects on cognitive domains, such as learning and memory, and improving anxiety-like symptoms. We proposed to study the effect of EE on peripherally stimulated cortical lesion induced by the long term expression of interleukin IL-1β (IL-1β) in adult rats. Here, we demonstrated that EE: 1) reduces the peripheral inflammatory response to the stimulus, 2) ameliorates cognitive deficits and anxiety-like symptoms, 3) modulates neurodegeneration, demyelination and glial activation, 4) regulates neuroinflammation by reducing the expression of pro-inflammatory cytokines and enhancing the expression of anti-inflammatory ones. Our findings correlate with the fact that EE housing could be considered an effective non- pharmacological therapeutic agent that can synergistically aid in the rehabilitation of the disease.

Exercise and Multiple Sclerosis

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system (CNS) with an estimated prevalence approaching 1 million adults in the United States. The disease pathogenesis and resulting damage express as dysfunction (e.g., walking and cognitive impairment) and symptoms (e.g., fatigue and depression) that compromise quality of life (QOL) and full participation. There has been a steadily increasing body of research on the outcomes of exercise among persons with MS, and this has accelerated sharply over the past decade. The current chapter provides a review of exercise and its outcomes, safety, and prescription in MS. This chapter initially reviews the evidence for benefits of exercise based principally on meta-analyses and literature reviews. The chapter then reviews evidence on the safety of exercise in MS and lastly provides guidelines for exercise prescription in MS. Collectively, this chapter serves as an overview and reference for researchers and clinicians interested in the benefits, safety, and prescription of exercise in MS.

Protocol for a systematically-developed, phase I/II, single-blind randomized controlled trial of treadmill walking exercise training effects on cognition and brain function in persons with multiple sclerosis

Slowed cognitive processing speed (CPS) is a common and debilitating consequence of multiple sclerosis (MS) that is notoriously difficult to treat. As such, we undertook a systematic line of research that indicated that supervised, progressive treadmill walking exercise (TMWX) training might improve CPS and brain functioning among fully-ambulatory persons with MS. The current study will be the first adequately-powered, single-blind randomized controlled trial (RCT) that examines the efficacy of 12-weeks of TMWX training compared with an active control condition on CPS, thalamocortical brain connectivity (based on resting-state fMRI), and exploratory functional outcomes in 88 fully-ambulatory persons with MS who present with slowed CPS. The intervention condition involves supervised, progressive TMWX training 3 times/week over 12-weeks; this initially involves 15-min of light-to-moderate intensity TMWX that progresses up to 40-min of vigorous intensity TMWX. The active control condition involves supervised, minimal intensity, stretching-and-resistance exercise that will be delivered on the same frequency as the intervention condition. The primary study outcomes involve Symbol Digit Modalities Test performance (i.e., CPS) and fMRI-based measures of thalamocortical resting-state functional connectivity. Exploratory study outcomes involve measures of community participation, activities of daily living, quality of life, and functional mobility. All study outcomes will be administered before and after the 12-week study period by treatment-blinded assessors. If successful, the current study will provide the first Class I evidence for the effects of TMWX training as an approach for improving CPS and its neural correlate, and possibly mitigating the impact of slowed CPS on functional outcomes in MS.

Cognitive rehabilitation for attention and memory in people with multiple sclerosis: a randomized controlled trial (CRAMMS)

Objective:

To assess the clinical and cost-effectiveness of cognitive rehabilitation for attention and memory problems in people with multiple sclerosis.

Design:

Multicentre, pragmatic, randomized controlled trial.

Setting:

Community

Participants:

People with multiple sclerosis aged 18–69 years, who reported cognitive problems in daily life and had cognitive problems on standardized assessment.

Interventions:

A group cognitive rehabilitation programme delivered in 10 weekly sessions in comparison with usual care.

Main measures:

The primary outcome was the Multiple Sclerosis Impact Scale Psychological subscale at 12 months after randomization. Secondary outcomes included measures of everyday memory problems, mood, fatigue, cognitive abilities and employment at 6 and 12 months after randomization.

Results:

In all, 245 participants were allocated to cognitive rehabilitation and 204 to usual care. Mean Multiple Sclerosis Impact Scale Psychological at 12 months was 22.2 (SD = 6.1) for cognitive rehabilitation and 23.4 (SD = 6.0) for usual care group; adjusted difference −0.6, 95% confidence interval (CI) = −1.5 to 0.3, P = 0.20. No differences were observed in cognitive abilities, fatigue or employment. There were small differences in favour of cognitive rehabilitation for the Multiple Sclerosis Impact Scale Psychological at 6 months and everyday memory and mood at 6 and 12 months. There was no evidence of an effect on costs (−£808; 95% CI = −£2248 to £632) or on quality-adjusted life year gain (0.00; 95% CI = −0.01 to 0.02).

Conclusion:

This rehabilitation programme had no long-term benefits on the impact of multiple sclerosis on quality of life, but there was some evidence of an effect on everyday memory problems and mood.

Neuropsychological management of multiple sclerosis: evaluation of a supervised and customized cognitive rehabilitation program for self-used at home (SEPIA): protocol for a randomized controlled trial

Background

Cognitive and mood disorders negatively impact daily life in patients with multiple sclerosis (MS). Pharmacological treatments did not demonstrate any effect on cognition compared with cognitive rehabilitation (CR). However, if CR programs offer promising results on cognition, they are less consistent concerning mood and quality of life (QoL). In this context, we designed a randomized controlled trial to evaluate the efficacy of an innovative computerized CR program, conducted at home, on QoL. Secondary objectives will estimate the improvement, or the stabilization over time, of patients’ cognitive performances and their emotional affects.

Methods

Forty MS patients (relapsing-remitting or secondary progressive forms) who have cognitive impairment will be recruited for the trial (called SEPIA-NCT03471338) and randomly assigned to either the experimental group or the control group. Patients randomly assigned in the experimental group will perform a home-based CR program with psychological support during eight consecutive weeks. CR will be based on computerized cognitive exercises from the PRESCO® software developed by HAPPYneuron^©. Training sessions (three sessions of 45 min per week) will consist of short exercises evaluating a broad range of cognitive domains and will be personalized for each patient (tracking tool and supervised guidance). The control group, designed to control for non-specific elements of the intervention, will receive only psychological support consisting of various issues related to MS, such as everyday cognitive-related difficulties or management of emotions. QoL, assessed by the MUSIQOL (Multiple Sclerosis International Quality Of Life) questionnaire, will be evaluated three times (at baseline and after 1 week and 25 weeks after home-based intervention) as well as secondary outcomes measuring self-esteem, cognition, depression, anxiety, metacognition, fatigue, and sleep quality. Given the expected MUSIQOL variation, the inclusion of 20 patients per group (alpha risk 5% and power 80%) will be required.

Discussion

Evidence suggests that computerized programs may be a practice option for CR for people with MS, but there is a paucity of studies evaluating QoL. We hope that this innovative program will highlight such benefits over time in patients’ daily life. In the future, such programs will allow a wider range of available therapeutic options for MS patients with cognitive impairment and for practitioners in charge of their care.

Trial registration

ClinicalTrials.gov identifier: NCT03471338. Retrospectively registered on 25 April 2018. https://clinicaltrials.gov/ct2/show/NCT03471338?term=NCT03471338&cond=Multiple+Sclerosis&draw=2&rank=1.

Cognitive impairment in multiple sclerosis: An exploratory analysis of environmental and lifestyle risk factors

BACKGROUND

Many potentially modifiable risk factors for MS are investigated. It is not known, however, if these factors also apply to MS-related cognitive impairment (CI), a frequent consequence of MS.

OBJECTIVE

The aim of our study was to assess risk factors for CI in MS patients, focusing on environmental exposures, lifestyle and comorbidities.

METHODS

We included MS patients referring to MS Centers in Florence and Barletta between 2014 and 2017. Neuropsychological performance was assessed through the Rao's battery and Stroop test, cognitive reserve (premorbid intelligence quotient-IQ) was evaluated using the National Adult Reading Test (NART). Potential risk factors were investigated through a semi-structured questionnaire.

RESULTS

150 patients were included. CI was detected in 45 (30%) subjects and was associated with older age (p<0.005), older age at MS onset (p = 0.016), higher EDSS score (p<0.005), progressive disease course (p = 0.048) and lower premorbid IQ score (p<0.005). As for risk factors, CI was related with lower physical activity in childhood-adolescence (p<0.005). In women, hormonal therapy resulted to be protective against CI (p = 0.041). However, in the multivariable analysis, the only significant predictors of CI were older age (p<0.05; OR 1.06, 95% CI 1.02-1.10) and lower premorbid IQ (p<0.05; OR 0.93, 95% CI: 0.88-0.98). Removing IQ from the model, CI was associated with higher EDSS (p = 0.030; OR 1.25, 95% CI 1.02-1.53) and, marginally, previous physical activity (p = 0.066; OR 0.49, 95% CI: 0.23-1.05).

CONCLUSIONS

Our findings suggest that physical activity in childhood-adolescence could be a contributor to cognitive reserve building, thus representing a potential protective factors for MS-related CI susceptible to preventive strategies.

Comparison of the Effect of Cognitive Rehabilitation and Neurofeedback on Sustained Attention Among Elementary School Students with Specific Learning Disorder: A Preliminary Randomized Controlled Clinical Trial

Specific learning disorder (SLD) can occur along with the problems of attention performance and be complicated by them. Recent studies have reported the positive effects of cognitive rehabilitation (CR) and neurofeedback (NFB) on sustained attention (SA) in SLD. Nevertheless, it has not yet been determinedwhat kind of treatment may be the most appropriate option for this disorder in terms of the different functions of cognitive status, especially SA. This preliminary study aimed to compare CR and NFB effects on SA among elementary school students with SLD using a randomized controlled clinical trial (RCT). Fifty- three eligible students with a DSM-5 SLD diagnosis, aged 7-10, were randomly allocated in NFB (n = 18), CR (n = 18), and control groups (n = 17). All the participants were evaluated for SA by performing the continuous performance test (CPT) on the studied groups at the time of their inclusion in the study and 7 weeks after it. The intervention groups took part in 20 sessions of CR and 20 sessions of NFB. Conversely, the untreated group were evaluated without any intervention.15 boys and 30 girls in 3 groups completed the study (n = 15 per group). The mean and standard deviation of participants' age were (8.66 ± 1.48) years, (8.40 ± 1.73) years and (8.53 ± 1.63) years in CR, NFB and untreated groups, respectively. The results showed significant differences between the groups based on the variables of the CPT test (p < 0.05). Also, the significant effects of the variables represented the higher scores of the CR compared to the NFB group (p < 0.001). This study provides einitial evidence that CR is more effective than NFB on SA improvement among students with SLD.