Cognition

Introduction

Cognitive changes are common among individuals with multiple sclerosis (MS), affecting 40-60% of the MS population.1  Much like physical MS symptoms, cognitive changes vary widely from person to person. Whereas many individuals with MS experience slowed processing speed as their predominate cognitive difficulty, others may experiences problems across a number of cognitive areas including learning, memory, problem-solving, and word-finding. Given the wide range of cognitive difficulties, treatments for cognitive impairment in MS are not a one-size-fits-all approach.

What is Cognitive Rehabilitation? 

Cognitive rehabilitation is a systematic treatment program designed to help individuals with MS improve functioning in everyday activities, including but not limited to communicating more effectively with others, completing tasks more accurately or efficiently, and staying organized. Cognitive rehabilitation treatments can encourage restoration and improvements in cognitive function, as well as teach specific strategies to compensate for cognitive impairment. The balance between restorative and compensatory strategies will vary, making cognitive rehabilitation a highly specialized treatment. Such variability has made it difficult for researchers to study cognitive impairment and cognitive rehabilitation in MS. Fortunately, emerging research from experts in the field support new recommendations for cognitive rehabilitation in MS, as described below.

New Practice Standards and Guidelines for Cognitive Rehabilitation in MS

Over the past decade, numerous MS research groups have sought to develop effective treatments for cognitive impairment in MS. However, the quality of these treatments, as well as the research methods used to investigate their effectiveness, have varied widely. In a recent systematic review of the scientific evidence for cognitive rehabilitation over the past 10 years, only six (15%) exhibited high-quality (Class I) ratings in terms of their design and methods.2 Therefore, although cognitive rehabilitation is an exciting and growing field, patients should carefully evaluate programs or interventions that claim to improve cognitive function, especially commonly advertised “brain training” programs.

To date, one cognitive rehabilitation treatment has stood out from the rest in terms of its effectiveness for improving cognitive impairment – the modified Story Memory Technique (mSMT).3 The mSMT is a 10-session intervention that involves the use of specific mental strategies to improve verbal learning and memory. The mSMT has been shown to be effective in three separate studies, including a brain imaging study that showed increased activity in brain regions involved in learning and memory.4 According to the systematic review,2 the mSMT is the only cognitive rehabilitation intervention that is currently considered a Practice Standard – meaning that the evidence is strong enough to suggest the mSMT is among the highest in quality and efficacy, and is recommended for use in individuals with MS and cognitive impairment.           

Two additional cognitive rehabilitation treatments, Attention Processing Training (APT) and RehaCom,5,6 have also been shown significant promise for improving attention (APT) and general cognitive abilities (RehaCom) in MS. However, due to the limited number of studies on these treatments, APT and RehaCom are currently considered Practice Guidelines – meaning that although evidence for these interventions is encouraging, additional high-quality studies are needed before these interventions can be considered Practice Standards.

Where To Turn for Help        

Your MS treatment team is a first-line resource for addressing cognitive changes. Talking to your neurologist or your primary care doctor about your cognitive changes is an important first step. They can help direct you to a neuropsychologist – a clinical psychologist who specializes in the assessment and treatment of cognitive impairment. He or she will work with you to identify your areas of strength, determine additional factors in your life that may be exacerbating your cognitive difficulties, and importantly, make treatment recommendations to help improve or compensate for your cognitive difficulties. Your providers may also help you get connected to speech-language pathologists for evaluation and cognitive rehabilitation therapy. Referrals to occupational therapists for functional application of cognitive strategies to daily activities and to learn strategies such as energy conservation and fatigue management can also play a significant role in managing cognitive impairment.

Cognition as a Piece in the Wellness Puzzle

Finally, we would remiss without emphasizing that cognitive function, although of high importance, represents only one aspect of overall health and wellness. Maintaining regular physical activity, making healthy nutritional choices, getting adequate sleep, and enlisting support from friends, family, and others in your life are all key components to supporting health and wellness that also have important implications for your cognitive and emotional wellbeing.

References

1. Chiaravalloti ND, DeLuca J. Cognitive impairment in multiple sclerosis. Lancet Neurol. 2008;7(12):1139-1151.

2. Goverover Y, Chiaravalloti ND, O’Brien A, DeLuca J. Evidenced Based Cognitive Rehabilitation for Persons with Multiple Sclerosis: An Updated Review of the Literature from 2007-2016. Arch Phys Med Rehabil. 2017.

3. Chiaravalloti ND, Moore NB, Nikelshpur OM, DeLuca J. An RCT to treat learning impairment in multiple sclerosis: The MEMREHAB trial. Neurology. 2013;81(24):2066-2072.

4. Leavitt VM, Wylie GR, Girgis PA, DeLuca J, Chiaravalloti ND. Increased functional connectivity within memory networks following memory rehabilitation in multiple sclerosis. Brain imaging and behavior. 2014;8(3):394-402.

5. Amato MP, Goretti B, Viterbo RG, et al. Computer-assisted rehabilitation of attention in patients with multiple sclerosis: results of a randomized, double-blind trial. Mult Scler. 2014;20(1):91-98.

6. Cerasa A, Gioia MC, Valentino P, et al. Computer-assisted cognitive rehabilitation of attention deficits for multiple sclerosis: a randomized trial with fMRI correlates. Neurorehabil Neural Repair. 2013;27(4):284-295.