Saturday, April 20, 2013

Cognitive Rehabilitation in MS

Cognitive Rehabilitation in MS
Author: Dr. Krishna N. Sharma. MPT (Neuro), PhD (VC)

Cognition refers to the ‘higher’ brain functions e.g. memory and reasoning. Sometimes the MS patients associate the cognitive dysfunction to severity of physical symptoms or to duration of the disease which is actually a misbelief.1,2 Cognitive problems are one of the most frequent symptoms of MS, which is evident in about 50% of the patients.3,4 Approximately 10% to 20% patients show significant cognitive dysfunction. Symptoms may be exaggerated by underlying depression.5 The most often affected cognitive functions are - memory, attention, speed of processing, abstract reasoning, verbal fluency, and executive functions.6,7,8 Widespread deterioration of intellectual function in MS is rare.9

Why do they occur?

The Cognitive problems in MS are actually the result of demyelination in the cerebral tracts that connect with primary sensory, motor, speech, and integration areas of the cerebrum. It may result in poor recognition of deficits as well as an inability to store and retrieve new information. The combination of these two issues becomes a major obstacle in the way to rehabilitation.10

Testing Cognitive Dysfunctions:

Neuropsychological testing can assist in determining the degree of cognitive impairment in patients with MS. Wallin et al (2006) et al. categorized the tests for cognitive dysfunctions associated with MS in three main schools of thought:11

  1.  Short screening with traditional measures in a neurologist’s office i.e. BRB-N (Brief Repeatable Battery of Neuropsychological Tests). It is composed of the Buschke Selective Reminding Test, the 7/24 Spatial Recall Test, the Paced Auditory Serial Addition Test (PASAT), and the Controlled Oral Word Association Test (COWAT).12
  2.  Testing by a neuropsychologist with a minimal (but comprehensive) neurocognitive battery i.e. MACFIMS (Minimal Assessment of Cognitive Function in Multiple Sclerosis). It is composed of PASAT, COWAT, SDMT etc.13
  3. Testing with automated, computerized measures in a neurologist’s office or as part of a clinical trial i.e. ANAM (Automated Neuropsychological Assessment Metrics). It is composed of Procedural Reaction Time, Code Substitution, Sternberg Memory Search etc.14

Such an evaluation could be helpful in the following ways:

  • It can identify impaired and intact functions.
  • It will help the MS patient and the family members understand the nature and extent of the illness.
  •  It may help the person develop realistic vocational and other life goals.
  • The results can suggest compensatory techniques.

Designing Interventions:

Designing intervention is the second step of the cognitive rehabilitation. It is intended to improve the patient's ability to function in all aspects - personal, family, social, and vocation life. Since the disease is unpredictable, progressive, and fluctuating in nature and there is a complex interaction of motor, sensory, cognitive, functional, and affective impairments, it requires periodic reassessment, monitoring, and rehabilitative interventions. The therapist recognizes the deficit and includes the functionally oriented therapeutic tasks accordingly.

There are two approaches - Restorative Strategies and Compensatory Strategies, which are believed to be helpful in the cognitive dysfunctions. Since the effectiveness of Restorative Strategies to cognitive rehabilitation is largely inconclusive15, Compensatory strategies (i.e. teaching to use intact skills with/without external aids) are widely used and are suggested by most authors.

Compensatory Strategies-
  • Cognitive Structuring- The therapist applies suitable learning theory and make the patient practice the cognitive task to turn it in a routine behaviors.
  • Substitution Strategies- The therapist teaches to use the intact cognitive abilities to circumvent the impaired abilities. For example- Using intact visual memory in place of impaired verbal memory function.
  •  Scheduling and Timelines- The patients are encouraged to use schedulers and alarms.
  • Using the recording devices- It helps the patients remember and store the important details.
  • Memory strategies- The patients are taught and encouraged to use mnemonics, lists, clustering, and visualization techniques etc. to remember things.
  • Assistive Technology- The patients are advised to use handheld computers, electronic calendars, and memory logs etc.
  • Creating structured environment- It helps the patients find their things on certain fixed places to avoid the hassle in forgetting and searching things.

Restorative Strategies-

Though so many verities of therapeutic tasks/ games/ activities are available for restoring or improving cognition, there is lack of evidence-based-practice of the restorative strategies for the cognitive deficits associated with MS. There are very less researches which confirm significant improvement by the cognitive games.16,17
There are many toy games for cognitive rehabilitation e.g.- Peg Board, Puzzle-cubes, Quoridor, Tenzi, Fiddlesticks etc. But in this age of computer and technology few application softwares e.g.- COGNIsoft-I, BrainTrain, MSTY Games etc; and online cognitive rehabilitation games available on multiplesclerosis.com18,, Peartrees.com20, Mind360.com21 etc. are proving to be effective and easily administrable.

An MS Patient using COGNIsoft-I for Cognitive Rehabilitation

  • The activities should be conducted in quiet places to avoid distractions.
  • The sessions should be well-designed and engaging.
  • The activity should be demonstrated first.
  • The instructions should be simple and short.
  • The activities should be carried out with the concept of Errorless Learning22 in mind. Application of the principles of Spaced Retrieval Learning,23 Story Memory Technique,24 etc. would enhance the outcome.
  • Instructions may be given in the forms of Audio/ video tape, printed material also. It would help them remembering the activities even when they are at home.
  • The exercises should be done for the shorter periods of time to avoid cognitive fatigue.
  • New skills should not be taught before the previous skill has been strongly established.

1.    Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch Neurol 37:577-579, 1980
2.  Beatty WW, Goodkin DE. (1990) Screening for cognitive impairment in multiple sclerosis: An evaluation of the Mini Mental State Examination. Arch Neurol, 47, 297–301.
3.  Aronson K, G. E.; Socio-demographic characteristics and health status of persons with multiple sclerosis and their care givers. MS Management 3(1), 5-15. 1996.
4.       Lublin F, Reingold S; Defining the course of multiple sclerosis. Neurology 46(4):907-911, 1996.
5.   Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 714. 1995
6.  Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 714. 1995
7.  Rao SM, Leo GL, Bernardin L, et al: Congnitive dysfunction in multiple sclerosis. I. Grequency, patterns, and prediction, Neurology 41(5):685-691, 1991
8.    Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch Neurol 37:577-579, 1980
9.       Lublin F, Reingold S: Defining the course of multiple sclerosis. Neurology 46(4) :907-911, 1996.
10. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 728. 1995
11.   Wallin et al. Cognitive dysfunction in multiple sclerosis. JRRD, Volume 43, Number 1, 63-71. 2006
12. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology. 1991;41(5):685–91.
13.   Benedict RH, Fischer JS, Archibald CJ, Arnett PA, Beatty WW, Bobholz J, Chelune GJ, Fisk JD, Langdon DW, Caruso L, Foley F, LaRocca NG, Vowels L, Weinstein A, DeLuca J, Rao SM, Munschauer F. Minimal neuropsychological assessment of MS patients: a consensus approach. Clin Neuropsychol. 2002;16(3):381–97.
14. Wilken JA, Kane R, Sullivan CL, Wallin M, Usiskin JB, Quig ME, Simsarian J, Saunders C, Crayton H, Mandler R, Kerr D, Reeves D, Fuchs K, Manning C, Keller M. The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis. Mult Scler. 2003;9(2):119–27.
15.    O’Brien AR, Chiaravalloti N, Goverover Y, Deluca J. Evidenced-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature. Arch Phys Med Rehabil 2008;89(4):761–9.
16. Chooi, Weng-Tink; Thompson, Lee A. (2012). "Working memory training does not improve intelligence in healthy young adults". Intelligence 40 (6): 531–42.
17.    Redick, T. S.; Shipstead, Z.; Harrison, T. L.; Hicks, K. L.; Fried, D. E.; Hambrick, D. Z.; Kane, M. J.; Engle, R. W. (2012). "No Evidence of Intelligence Improvement After Working Memory Training: A Randomized, Placebo-Controlled Study". General J Exp Psychol Gen. 2012 Jun 18.
22.   Wilson BA, Baddeley A, Evans J, et al. Errorless learning in the rehabilitation of memory impaired people. Neurospsychol Rehabil 1994; 4(3): 307–26.
23.  Heesen C, Kasper J, Segal J, et al. Decisional role preferences, risk knowledge and information interests in patients with multiple sclerosis. Mult Scler 2004; 10: 1–8.
24.   Camp CJ, Foss JW, O’Hanlon AM, et al. Memory interventions for persons with dementia. Appl Cog Psychol 1996; 10: 193–210.