Does cognitive training improve attention/working memory in persons with MS? A pilot study using the Cogmed Working Memory Training program

Medication use is associated with cognitive deficits in people with multiple sclerosis

BACKGROUND

People with multiple sclerosis (pwMS) receive medications with anticholinergic and sedative effects that may contribute to cognitive decline. We studied the short-term effect of these medications and polypharmacy on cognitive deficit among pwMS.

METHODS

This retrospective cross-sectional study of an MS referral centre included pwMS who attended clinic between 1/10/2022 and 31/11/2023 (n = 486). The Drug Burden Index (DBI) and Anticholinergic Effect on Cognition (AEC) scales assessed the cognitive burden of their medications. Polypharmacy was defined as taking ≥5 medications. Objective cognitive performance, specifically processing speed, was assessed using the Symbol Substitution Task (SST), while subjective cognitive deficits were evaluated with the Perceived Deficit Questionnaire-5 (PDQ-5). The associations between medication burden (DBI and AEC) and polypharmacy with cognitive deficits (SST and PDQ-5) were assessed through multivariable regression analysis. Adjustments were made for age, sex, EDSS, years since diagnosis and psychological distress and wellbeing (Mental Health Inventory).

RESULTS

486 pwMS were included in analysis. Medication burden (DBI and AEC) was associated with objective cognitive deficit (SST) (unstandardised B= -1.6, 95 %CI (-2.6, -0.5) with p = 0.003 and B= -0.8, (-1.4, -0.3) with p = 0.003 respectively). Medication burden (DBI and AEC) was furthermore associated with subjective cognitive decline (PDQ-5) (B = 0.8 (0.4, 1.2 with p < 0.001) and B = 0.3 (0.1, 0.5 with p = 0.009)). These associations were also seen for polypharmacy (SST B = -2.3 (-4.4, -0.1 with p = 0.04)) and PDQ-5 (B = 1.1 (0.2, 1.9 with p = 0.016)).

CONCLUSIONS

Anticholinergic medications, sedative medications and polypharmacy are negatively associated with cognition in pwMS. Caution should be applied in their prescribing. Research is warranted to investigate how to appropriately approach deprescribing in pwMS.

Virtual reality for multiple sclerosis rehabilitation

BACKGROUND

Multiple sclerosis (MS) is the most common neurological disease in young adults. Virtual reality (VR) offers a promising rehabilitation tool by providing controllable, personalised environments for safe, adaptable and engaging training. Virtual reality can be tailored to patients' motor and cognitive skills, enhancing motivation through exciting scenarios and feedback.

OBJECTIVES

Primary objective To assess the effects of virtual reality interventions compared with an alternative or no intervention on lower limb and gait function, and balance and postural control in people with MS. Secondary objective To assess the effects of virtual reality interventions compared with an alternative or no intervention on upper limb function, cognitive function, fatigue, global motor function, activity limitation, participation restriction and quality of life, and adverse events in people with MS.

SEARCH METHODS

We identified relevant articles through electronic searches of CENTRAL, MEDLINE, Embase, PEDro, CINAHL and Scopus. We also searched trials registries (ClinicalTrials.gov and the WHO ICTRP search portal) and checked reference lists. We carried out all searches up until August 2022.

SELECTION CRITERIA

We included only (quasi-)randomised controlled trials (RCTs) that assessed virtual reality interventions, defined as "an artificial, computer-generated simulation or creation of a real-life environment or situation allowing the user to navigate through and interact with", in people with MS. The primary outcomes were lower limb and gait function, and balance and postural control. Secondary outcome measures were upper limb function, cognitive function, fatigue, global motor function, activity limitation, participation and quality of life, and adverse events. Eligible participants were people with MS who were 18 years or older.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies based on pre-specified criteria, extracted study data and assessed the risk of bias of the included studies. We used the risk of bias 2 tool (RoB 2). A third review author was consulted to resolve conflicts.

MAIN RESULTS

We included 33 RCTs with 1294 people with MS. The sample sizes of the included studies were relatively small and there was considerable heterogeneity between studies regarding the virtual reality devices and the outcome measures used. The control group either received no intervention, conventional therapy or an alternative intervention (an intervention that does not fit the description of conventional therapy for the rehabilitation of people with MS). We most frequently judged the risk of bias as 'some concerns' across domains, leading to an overall high risk of bias in the majority of included studies for all outcome measures. Primary outcomes When compared with no intervention, virtual reality interventions may result in no difference in lower limb and gait function (Timed Up and Go, mean difference (MD) -0.43 sec, 95% confidence interval (CI) -0.85 to 0.00; 6 studies, 264 participants; low-certainty evidence) or balance and postural control (Berg Balance Scale, MD 0.29 points, 95% CI -0.1 to 0.68; 4 studies, 137 participants; very low-certainty evidence). When virtual reality interventions are compared to conventional therapy, results for lower limb and gait function probably do not differ between interventions (Timed Up and Go, MD -0.2 sec, -1.65 to 1.25; 4 studies, 107 participants; moderate-certainty evidence). However, virtual reality interventions probably improve balance and postural control (Berg Balance Scale, MD 2.39 points, 95% CI 1.22 to 3.57; 7 studies, 201 participants; moderate-certainty evidence), almost reaching the clinically important difference (3 points). Secondary outcomes Compared to no intervention, the use of virtual reality may also improve upper limb function (9-Hole Peg Test, MD -4.19 sec, 95% CI -5.86 to -2.52; 2 studies, 84 participants; low-certainty evidence), almost reaching the clinically important difference (4.38 points) and participation and quality of life, but the evidence is very uncertain (MS International QoL, MD 9.24 points, 95% CI 5.76 to 12.73; 2 studies, 82 participants; very low-certainty evidence). Compared to conventional therapy, virtual reality interventions may improve participation and quality of life (Falls Efficacy Scale-1, MD -3.07 points, 95% CI -5.99 to -0.15; 3 studies, 101 participants; low-certainty evidence), but not upper limb function (9-Hole Peg Test, MD 0.10 sec, 95% CI -1.70 to 1.89; 3 studies, 93 participants; low-certainty evidence). For other key secondary outcome measures, i.e. global motor function and adverse events, there were no data available as these were not measured in the studies.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality may be more effective than no intervention in improving upper limb function and participation and quality of life. Training with virtual reality may be superior to conventional therapy for improving balance and postural control, and participation and quality of life. For the other outcomes, there was no clear difference between virtual reality and conventional therapy. There was insufficient evidence to reach conclusions about the effect of virtual reality on global motor function, activity limitations and adverse events. Additional high-quality, large-scale studies are needed to expand and confirm these findings.

Rehabilitation of working memory after acquired brain injury and multiple sclerosis: A systematic review

The objective is to study the effectiveness of working memory (WM) rehabilitation after Acquired brain injury (ABI) and multiple sclerosis (MS). A systematic database search of published studies, following PRISMA recommendations, with assessment of methodological quality and risk of bias, was conducted. The results were analysed according to the rehabilitation method used. 31 studies (including 14 class I) were included, and 11 different training programs were identified. Despite great variability in training methodology and outcome measures, the results were positive overall. However, only three rehabilitation programs showed a transfer effect to WM (near) and daily life with long-term maintenance. The results were more variable for protocols limited to the use of computerized n-back training tasks. Overall, the current evidence supports multi-task WM training rather than single-task-limited program. It also supports early and long duration training, with some therapist support. However, it is not possible, to date, to make strong recommendations regarding the rehabilitation program to be used preferentially. Although results are encouraging, level of evidence remains modest, particularly regarding the maintenance of the therapeutic effect after the end of training, and the transfer to everyday life skills. The influence of rehabilitation parameters (training duration, therapist involvement … ) remains difficult to assess.

Systematic review and meta-analysis of standalone digital interventions for cognitive symptoms in people without dementia

Cognitive symptoms are prevalent across neuropsychiatric disorders, increase distress and impair quality of life. Self-guided digital interventions offer accessibility, scalability, and may overcome the research-to-practice treatment gap. Seventy-six trials with 5214 participants were identified. A random-effects meta-analysis investigated the effects of all digital self-guided interventions, compared to controls, at post-treatment. We found a small-to-moderate positive pooled effect on cognition (k = 71; g = -0.51, 95%CI -0.64 to -0.37; p < 0.00001) and mental health (k = 30; g = -0.41, 95%CI -0.60 to -0.22; p < 0.0001). Positive treatment effects on fatigue (k = 8; g = -0.27, 95%CI -0.53 to -0.02; p = 0.03) and quality of life (k = 22; g = -0.17, 95%CI -0.34 to -0.00; p = 0.04) were only marginally significant. No significant benefit was found for performance on activities of daily living. Results were independent of control groups, treatment duration, risk of bias and delivery format. Self-guided digital transdiagnostic interventions may benefit at least a subset of patients in the short run, yet their impact on non-cognitive outcomes remains uncertain.

Cognitive impairment in multiple sclerosis: from phenomenology to neurobiological mechanisms

Multiple sclerosis (MS) is an autoimmune-mediated disease of the central nervous system characterized by inflammation, demyelination and chronic progressive neurodegeneration. Among its broad and unpredictable range of clinical symptoms, cognitive impairment (CI) is a common and disabling feature greatly affecting the patients' quality of life. Its prevalence is 20% up to 88% with a wide variety depending on the phenotype of MS, with highest frequency and severity in primary progressive MS. Involving different cognitive domains, CI is often associated with depression and other neuropsychiatric symptoms, but usually not correlated with motor and other deficits, suggesting different pathophysiological mechanisms. While no specific neuropathological data for CI in MS are available, modern research has provided evidence that it arises from the disease-specific brain alterations. Multimodal neuroimaging, besides structural changes of cortical and deep subcortical gray and white matter, exhibited dysfunction of fronto-parietal, thalamo-hippocampal, default mode and cognition-related networks, disruption of inter-network connections and involvement of the γ-aminobutyric acid (GABA) system. This provided a conceptual framework to explain how aberrant pathophysiological processes, including oxidative stress, mitochondrial dysfunction, autoimmune reactions and disruption of essential signaling pathways predict/cause specific disorders of cognition. CI in MS is related to multi-regional patterns of cerebral disturbances, although its complex pathogenic mechanisms await further elucidation. This article, based on systematic analysis of PubMed, Google Scholar and Cochrane Library, reviews current epidemiological, clinical, neuroimaging and pathogenetic evidence that could aid early identification of CI in MS and inform about new therapeutic targets and strategies.

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.

Computer-assisted cognitive rehabilitation in neurological patients: state-of-art and future perspectives

Background and aim

Advances in computing technology enabled researchers and clinicians to exploit technological devices for cognitive training and rehabilitation interventions. This expert review aims to describe the available software and device used for cognitive training or rehabilitation interventions of patients with neurological disorders.

Methods

A scoping review was carried out to analyze commercial devices/software for computerized cognitive training (CCT) in terms of feasibility and efficacy in both clinical and home settings. Several cognitive domains responding to the different patients' needs are covered.

Results

This review showed that cognitive training for patients with neurological diseases is largely covered by several devices that are widely used and validated in the hospital setting but with few translations to remote/home applications. It has been demonstrated that technology and software-based devices are potential and valuable tools to administer remotely cognitive rehabilitation with accessible costs.

Conclusion

According to our results, CCT entails the possibility to continue cognitive training also in different settings, such as home, which is a significant breakthrough for the improvement of community care. Other possible areas of use should be the increase in the amount of cognitive therapy in the free time during the hospital stay.

Pre-training working memory/information processing capabilities and brain atrophy limit the improving effects of cognitive training

Background

Computerized training in persons with multiple sclerosis (PwMS) seems to enhance working memory (WM)/information processing (IP), but factors associated with the efficacy of the treatment have not been sufficiently explored. Objective: To identify clinical and radiological characteristics associated with positive WM/IP training responses.

Methods

Radiological and neuropsychological assessments were carried out on a sample of 35 PwMs who were divided into "WM/IP-impaired" and "WM/IP-preserved." All participants underwent adaptive n-back training for 10 days and were assessed post-training. Between-group differences ("WM/IP-impaired" vs. "WM/IP-preserved") in training-induced cognitive improvement were assessed and exploratory correlational/ regression-based methods were employed to assess the relationship between cognitive improvement and clinical and radiological variables.

Results

All PwMS exhibited WM/IP benefits after training, but those with preserved WM/IP functions showed greater positive effects as well as transfer effects to other WM/IP tests when compared to the impaired group. Additional analyses revealed that positive response to treatment was associated with WM/IP baseline capabilities and greater gray matter volume (GMVOL) in relevant areas such as the thalamus.

Conclusions

Restorative cognitive training is suitable to improve cognition in PwMS but its effective outcome differs depending on the baseline WM/IP capabilities and GMVOL.

Possible evidence of near transfer effects after adaptive working memory training in persons with multiple sclerosis

BACKGROUND

Cognitive deficits, especially in working memory (WM) and information processing (IP) efficiency, are common in people with multiple sclerosis (PwMS). Few studies have examined the efficacy of n-back training in improving these two cognitive functions in PwMS. In the present study, we examined the effects of an intensive n-back training program by measuring the gains on the trained task (2- and 3-back tasks), but we also studied possible near transfer effects to other tests that assess WM and IP, as well as far transfer effects or improvements in other cognitive functions.

METHODS

A sample consisting of 35 PwMS with different cognitive statuses. All the participants underwent an adaptive n-back training for 10 days (60 min/day), and they were neuropsychologically assessed at baseline (D1) and after training (D10). The effectiveness of the training was tested: (1) by using mean-based comparisons and Cohen's d values; (2) by estimating and comparing the quartile values of the D1 and D10 distributions. Two indexes of improvement in individual performance were calculated, the net score improvement index (NSI) and the percent of maximum possible individualized improvement (PMPI).

RESULTS

Repeat practice improves 2- and 3-back performance, showing more correct responses (CR) and lower reaction times (RT) on D10 compared to D1. These results were corroborated by the NSI and PMPI scores, but the gains after training were more statistically significant for the 3-back (observing higher CR and lower RT after training) than for the 2-back (observing gains in CR, but not in RT). We also observed a possible transference of this improvement on the n-back task to other WM/IPS tests. Specifically, statistically significant pre-post training differences were found in the values in three quartiles of the Paced Auditory Serial Addition Test (PASAT; q25, p < 0.03; q50, p < 0.001; q75, p < 0.002) and of the Symbol Digit Modalities Test (SDMT; q25, p < 0.03; q50, p < 0.001; q75, p < 0.001) as well as in two quartiles of the Letter-Number Sequencing Task (LNST; q50, p < 0.004; q75 p < 0.001), and in one quartile of the Digit Backwards Span Test (DSBT; q75, p < 0.001). Reliable change analyses confirmed these performance improvements on the PASAT, SDMT, and LNST.

CONCLUSIONS

This study confirmed that the intensive and adaptive n-back training produced improvements in the trained task in PwMS with different cognitive statuses. Furthermore, these gains were not only observed on the trained task, but they seemed to be also transferred to other tests that measured WM and IP functions.

Non-Pharmacological Treatments of Cognitive Impairment in Multiple Sclerosis: A Review

Cognitive impairment (CI) represents a common symptom in patients suffering from multiple sclerosis (MS), which can affect every stage of the disease course. Recent studies seem to support cognitive rehabilitation (CR) for minimizing the CI consequences. We reviewed the currently available evidence on the non-pharmacological approaches to CI, with the aim of giving an overview of the treatments used worldwide, from the traditional methods to the most recent techniques. A search of the literature was conducted on PubMed (articles in English performed in the last five years on humans). A total of 37 articles met our eligibility criteria after screening titles, abstracts and full-text and were divided into three main groups: in-presence interventions; studies performed via tele-rehabilitation and miscellaneous. Despite the great heterogeneity of the intervention and assessment methods, the evidence suggests that a non-pharmacological approach can improve MS-related CI. Cognitive rehabilitation seems effective and well established, as well as the use of computerized CR having the benefit of being even more appealing. Limited conclusions can be drawn on group CR due to the small number of studies focused on this kind of intervention. Some of the innovative approaches (virtual reality, EEG-based neurofeedback, brain stimulation, exercise, diet modification) may play a role in future studies and should be deeply explored.

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.