Cognitive impairments in relapsing-remitting multiple sclerosis: a meta-analysis

Attention Deficit/Hyperactivity Disorder in Children with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological autoimmune disease; pediatric-onset multiple sclerosis (POMS) represents 5% to 10% of total MS population. Children with POMS may experience attention difficulties due to the disease's impact on the central nervous system. However, little is known regarding Attention Deficit Hyperactivity Disorder (ADHD) in POMS, and its relation to cognitive performance.

METHODS

A retrospective case review was conducted using medical records of 66 children and adolescent patients diagnosed with POMS between 2012 and 2021 in a MS center of a tertiary medical center. All patients had undergone routine clinical neurological examinations and had been assessed for a diagnosis of ADHD by a department pediatric neurologist. In addition, sociodemographic data, disease-related variables, and cognitive performance were collected.

RESULTS

Of the 66 patients, 31 (47%) had a diagnosis of ADHD; 29 (44%) had cognitive impairment. Moreover, we identified four different profiles of POMS: those with only ADHD (17, 26%); only cognitive impairment (15, 23%), ADHD and cognitive impairment (14, 21%), and only POMS (20, 30%). A significant difference in disease duration was found among the four profiles [F(3,65) = 8.17, p < .001, η² = 0.29], indicating that patients with ADHD and cognitive impairment were characterized by longer disease duration.

CONCLUSIONS

ADHD may be prominently involved in POMS, even during the early stages of the disease and early diagnosis is crucial in order to provide appropriate interventions and support.

The Prevalence of Cognitive Impairment in Relapsing-Remitting Multiple Sclerosis: A Systematic Review and Meta-analysis

It is increasingly recognized that cognitive symptoms are a common sequelae of relapsing-remitting multiple sclerosis and are associated with adverse functional consequences. However, estimates of cognitive impairment (CIm) prevalence vary widely. This study aimed to determine the pooled prevalence of CIm among adults with RRMS and investigate moderators of prevalence rates. Following prospective registration (PROSPERO; CRD42021281815), electronic databases (Embase, Scopus, Medline, and PsycINFO) were searched from inception until March 2023. Eligible studies reported the prevalence of CIm among adults with RRMS, as determined through standardized neuropsychological testing and defined as evidence of reduced performance across at least two cognitive domains (e.g., processing speed, attention) relative to normative samples, healthy controls, or premorbid estimates. The electronic database search yielded 8695 unique records, of which 50 met selection criteria. The pooled prevalence of cognitive impairment was 32.5% (95% confidence interval 29.3-36.0%) across 5859 participants. Mean disease duration and age were significant predictors of cognitive impairment prevalence, with samples with longer disease durations and older age reporting higher prevalence rates. Studies which administered more extensive test batteries also reported significantly higher cognitive impairment prevalence. Approximately one third of adults with RRMS experience clinical levels of CIm. This finding supports the use of routine cognitive testing to enable early detection of CIm, and to identify individuals who may benefit from additional cognitive and functional support during treatment planning.

CXCL10/IgG1 Axis in Multiple Sclerosis as a Potential Predictive Biomarker of Disease Activity

BACKGROUND AND OBJECTIVES

Multiple sclerosis (MS) is a heterogeneous disease, and its course is difficult to predict. Prediction models can be established by measuring intrathecally synthesized proteins involved in inflammation, glial activation, and CNS injury.

METHODS

To determine how these intrathecal proteins relate to the short-term, i.e., 12 months, disease activity in relapsing-remitting MS (RRMS), we measured the intrathecal synthesis of 46 inflammatory mediators and 14 CNS injury or glial activation markers in matched serum and CSF samples from 47 patients with MS (pwMS), i.e., 23 RRMS and 24 clinically isolated syndrome (CIS), undergoing diagnostic lumbar puncture. Subsequently, all pwMS were followed for ≥12 months in a retrospective follow-up study and ultimately classified into "active", i.e., developing clinical and/or radiologic disease activity, n = 18) or "nonactive", i.e., not having disease activity, n = 29. Disease activity in patients with CIS corresponded to conversion to RRMS. Thus, patients with CIS were subclassified as "converters" or "nonconverters" based on their conversion status at the end of a 12-month follow-up. Twenty-seven patients with noninflammatory neurologic diseases were included as negative controls. Data were subjected to differential expression analysis and modeling techniques to define the connectivity arrangement (network) between neuroinflammation and CNS injury relevant to short-term disease activity in RRMS.

RESULTS

Lower age and/or higher CXCL13 levels positively distinguished active/converting vs nonactive/nonconverting patients. Network analysis significantly improved the prediction of short-term disease activity because active/converting patients featured a stronger positive connection between IgG1 and CXCL10. Accordingly, analysis of disease activity-free survival demonstrated that pwMS, both RRMS and CIS, with a lower or negative IgG1-CXCL10 correlation, have a higher probability of activity-free survival than the patients with a significant correlation (p < 0.0001, HR ≥ 2.87).

DISCUSSION

Findings indicate that a significant IgG1-CXCL10 positive correlation predicts the risk of short-term disease activity in patients with RRMS and CIS. Thus, the present results can be used to develop a predictive model for MS activity and conversion to RRMS.

Domain-specific cognitive impairment in multiple sclerosis: A systematic review and meta-analysis

OBJECTIVE

Methods of cognitive measurements in multiple sclerosis (MS) are not standardized. We aimed to identify the prevalence of cognitive domain-specific impairment (DSI) in MS by using subtests of the Brief Repeatable Battery of Neuropsychological Tests (BRB-N) with analyzing different cutoff values.

METHODS

The systematic review and meta-analysis were registered on PROSPERO (ID: CRD42021287004). The systematic literature search was performed via PubMed, Embase, and CENTRAL on 24 October 2021. Inclusion criteria were adults of different MS subtypes (CIS, RRMS, PPMS, and SPMS) with the condition of distinct DSI measured by BRB-N. Pediatric MS, computerized versions of BRB-N, and patients receiving steroids were excluded. Primary outcome was pooled prevalence rates of impaired patients within each cutoff and MS subtype, with 95% confidence interval, I-squared statistics for heterogeneity, and chi-squared test for subgroup differences. Risk of bias was assessed using the "JBI Quality Assessment Tool for Prevalence Studies."

RESULTS

In 48 eligible observational studies (n = 3431 patients), the three most prevalent thresholds were the 2.0 SD and 1.5 SD below the mean of normative values, and the score below the fifth percentile of the normative values. A progressively increasing worsening of the overall DSI was observed from CIS, moving toward RRMS, PPMS, and SPMS.

INTERPRETATION

Cognitive impairment is observed in all MS phenotypes, with varying degrees. Due to several potential influencing factors, our comprehensive literature review has not revealed consistent findings, and we, therefore, recommend considering a more sophisticated, "individual referencing" approach, acknowledging the diverse clinical and sociodemographic characteristics among populations and disparities in cognitive testing.

Cognitive Impairment and Depression in Mastocytosis: A Synthesis of the Literature

PURPOSE OF REVIEW

Symptoms of depression and cognitive dysfunction are commonly reported in mastocytosis. The aims of this review paper are to summarize the current literature on cognitive dysfunction and depressive symptoms, elucidate some of the mechanistic pathways underlying depressive symptoms in mastocytosis, identify gaps in the literature, and offer guidance for future research in this area.

RECENT FINDINGS

The study of cognition and depression in mastocytosis is in its infancy and the methodological flaws of the current literature limit interpretability. There is preliminary evidence that some individuals with mastocytosis might experience mild deficits in memory. On average, depression symptom scores fell within the mild to moderate or sub-syndromal range. Regrettably, only one study utilized a standardized diagnostic instrument to assess major depressive disorder. The authors' tendency to inaccurately equate depressive symptoms with a diagnosis of major depressive disorder presents a notable issue. The prevalence of cognitive deficits and depression appears to be similar to other chronic illnesses. Future work needs to better characterize cognition and characterize "depression" in this population.

Relationship between emotion recognition and cognition in multiple sclerosis: a meta-analysis protocol

Introduction

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterised by a broad and unpredictable range of symptoms, including cognitive and socio-cognitive dysfunction. Alongside the well-known deficits in information processing speed (IPS), executive functioning and episodic memory, recent evidence also highlighted socio-cognitive impairments in MS, such as emotion-recognition deficits. Recently, several studies investigated the association between emotion-recognition and cognitive impairment to assess whether social cognition is parallel to (or even dependent on) general cognitive dysfunction. Yet, there have been inconsistent findings, raising the need for a meta-analysis of the literature.

Objectives

The aim of the present paper is to outline the protocol for an upcoming meta-analysis we designed to clarify these conclusions.

Methods and analysis

We plan to estimate combined effect sizes for the association between emotion-recognition and cognitive impairment in MS across three cognitive domains (IPS, executive functions and episodic memory) and 7 emotion scores of interests (total and by 6-basic emotions subscores). Further, we plan to investigate whether identified variables are the cause for heterogeneity in any combined association. To that end, we will conduct additional meta-regression analyses to explore whether overall correlations differ according to clinical characteristics of MS patients (ie, disease duration, MS-phenotype, severity of depression and disability). Ultimately, this study will provide support either for an association of these disorders (in which emotion-recognition deficits might result from more fundamental cognitive dysfunction), or for two distinct sets of symptoms which may occur independently, for targeted patient profiles.

Importance of Identifying Cognitive Impairment in Multiple Sclerosis

This article aims to highlight the impact of cognitive impairment on outcomes and quality of life for people with multiple sclerosis (MS) and to review current evidence for the efficacy of disease-modifying therapies (DMTs) and other interventions. In addition, we provide clinical practice insights regarding screening and management of cognitive impairment in people with MS. Evidence suggests that cognitive deterioration often accompanies magnetic resonance imaging changes. Neocortical volume and deep grey matter atrophy correlate with cognitive impairment. Similarly, cognitive decline is predictive of a higher lesion burden. Cognitive impairment is an important clinical measure of disability and negatively impacts quality of life. Phase 3 studies suggest that DMTs such as natalizumab, ozanimod and fingolimod may provide long-lasting, clinically meaningful effects on cognition in people with MS. Further data are needed to support the use of adjunct cognitive behavioural and exercise interventions for people with MS who have cognitive impairment. More data are needed to define appropriate management strategies for cognitive impairment in people with MS. Baseline and periodic screening for cognitive impairment and inclusion of cognitive impairment as a clinical trial endpoint will help to inform efforts to manage this important aspect of MS.

Examining electroencephalogram signatures of people with multiple sclerosis using a nonlinear dynamics approach: a systematic review and bibliographic analysis

Background

Considering that brain activity involves communication between millions of neurons in a complex network, nonlinear analysis is a viable tool for studying electroencephalography (EEG). The main objective of this review was to collate studies that utilized chaotic measures and nonlinear dynamical analysis in EEG of multiple sclerosis (MS) patients and to discuss the contributions of chaos theory techniques to understanding, diagnosing, and treating MS.

Methods

Using the preferred reporting items for systematic reviews and meta-analysis (PRISMA), the databases EbscoHost, IEEE, ProQuest, PubMed, Science Direct, Web of Science, and Google Scholar were searched for publications that applied chaos theory in EEG analysis of MS patients.

Results

A bibliographic analysis was performed using VOSviewer software keyword co-occurrence analysis indicated that MS was the focus of the research and that research on MS diagnosis has shifted from conventional methods, such as magnetic resonance imaging, to EEG techniques in recent years. A total of 17 studies were included in this review. Among the included articles, nine studies examined resting-state, and eight examined task-based conditions.

Conclusion

Although nonlinear EEG analysis of MS is a relatively novel area of research, the findings have been demonstrated to be informative and effective. The most frequently used nonlinear dynamics analyses were fractal dimension, recurrence quantification analysis, mutual information, and coherence. Each analysis selected provided a unique assessment to fulfill the objective of this review. While considering the limitations discussed, there is a promising path forward using nonlinear analyses with MS data.

Narrative recall in relapsing-remitting multiple sclerosis: A potentially useful speech task for detecting subtle cognitive changes

Our research studied relapsing-remitting multiple sclerosis (RRMS). In half of the RRMS cases, mild cognitive difficulties are present, but often remain undetected despite their adverse effects on individuals' daily life. Detecting subtle cognitive alterations using speech analysis have rarely been implemented in MS research. We applied automatic speech recognition technology to devise a speech task with potential diagnostic value. Therefore, we used two narrative tasks adjusted for the neural and cognitive characteristics of RRMS; namely narrative recall and personal narrative. In addition to speech analysis, we examined the information processing speed, working memory, verbal fluency, and naming skills. Twenty-one participants with RRMS and 21 gender-, age-, and education-matched healthy controls took part in the study. All the participants with RRMS achieved a normal performance on Addenbrooke's Cognitive Examination. The following parameters of speech were measured: articulation and speech rate, the proportion, duration, frequency, and average length of silent and filled pauses. We found significant differences in the temporal parameters between groups and speech tasks. ROC analysis produced high classification accuracy for the narrative recall task (0.877 and 0.866), but low accuracy for the personal narrative task (0.617 and 0.592). The information processing speed affected the speech of the RRMS group but not that of the control group. The higher cognitive load of the narrative recall task may be the cause of significant changes in the speech of the RRMS group relative to the controls. Results suggest that narrative recall task may be effective for detecting subtle cognitive changes in RRMS.

Calling on clinicians to get social and emotional

OBJECTIVE

Disorders of social cognition, such as difficulties with emotion perception, alexithymia, Theory of Mind (ToM), empathy and disorders of emotion regulation, are prevalent and pervasive problems across many neurological, neurodevelopmental and neuropsychiatric conditions. Clinicians are familiar with how these difficulties present but assessment and treatment has lagged behind other traditional cognitive domains, such as memory, language and executive functioning.

METHOD

In this paper, we review the prevalence and degree of impairment associated with disorders of social cognition and emotion regulation across a range of clinical conditions, with particular emphasis on their relationship to cognitive deficits and also real-world functioning. We reported effects sizes from published meta-analyses for a range of clinical disorders and also review test usage and available tests.

RESULTS

In general, many clinical conditions are associated with impairments in social cognition and emotion regulation. Effect sizes range from small to very large and are comparable to effect sizes for impairments in nonsocial cognition. Socio-emotional impairments are also associated with social and adaptive functioning. In reviewing prior research, it is apparent that the standardized assessment of social cognition, in particular, is not routine in clinical practice. This is despite the fact that there are a range of tools available and accruing evidence for the efficacy of interventions for social cognitive impairments.

CONCLUSION

We are using this information to urge and call for clinicians to factor social cognition into their clinical assessments and treatment planning, as to provide rigorous, holistic and comprehensive person-centred care.

Cognitive measures used in adults with multiple sclerosis: A systematic review

Cognitive problems are common in people with Multiple Sclerosis (MS), and researchers and clinicians have used a vast array of measures to assess cognition. Our aim was to systematically identify cognitive measures routinely used in MS research, and outline their different uses. Previous recommendations of cognitive measures to use in MS have relied on expert consensus approaches. We believe this systematic review is a starting point for an evidence-based approach to recommend cognitive tests for use with people with MS. We systematically searched electronic databases using relevant search terms for studies that assessed cognitive functioning in MS (last search in February 2020). From 11,854 abstracts retrieved, based on title and abstract review, 2563 remained. Data were extracted from 1526 studies. Studies used 5665 measures of cognition, with 316,053 people with MS. Substitutional style tests, serial addition tests, and word list learning tests were the most commonly used individual tests, and the Brief Repeatable Battery of Neuropsychological Tests was the most commonly used battery. Some of the most frequently used measures were potentially inappropriate due to measuring irrelevant domains of cognition, and issues with sensitivity. Further research is needed to ascertain the psychometric properties, and acceptability of measures for people with MS.

TRACking health behaviors in people with Multiple Sclerosis (TRAC-MS): Study protocol and description of the study sample

Introduction

People with multiple sclerosis (PwMS) experience a range of physical, cognitive, and affective symptoms. Behavioral interventions targeting increased physical activity show promising support as low-cost methods to improve working memory, episodic memory, and processing speed in PwMS. In this randomized controlled trial, we will examine the efficacy of a pedometer-tracking intervention, designed to increase low-to-moderate levels of physical activity, for improving working memory in PwMS.

Methods and Analysis

Eighty-seven PwMS, between the ages of 30-59, have been recruited for the study. Seventy-five of the eligible and interested individuals were randomized to six-month health behavior monitoring groups: a Step-track group or a Water-track group (serving as the active control). Neuropsychological measures, assessing the primary outcome of the study, were administered at pre, midpoint, and post-intervention. Exploratory factor analysis of neuropsychological measures resulted in three factors: a working memory/processing speed factor, a visual episodic memory factor, and a verbal episodic memory factor. Changes in this latent measure of working memory/processing speed is the primary outcome of the current study. Functional MRI data will be analyzed to examine changes in the functional connectivity of the neural network supporting working memory.

Ethics and dissemination

The institutional review board granted approval for the study and all participants provided written informed consent. The results of this study will provide support showing that step-tracking increases overall levels of physical activity, improves working memory and processing speed, and strengthens the neural circuitry that supports better cognition. Evidence from this study will thus offer promising support for the routine use of step-tracking devices to improve cognitive functioning in PwMS. Study results will be disseminated through peer-reviewed publications and presentations at scientific conferences.

Quantitative Meta-analyses of Cognitive Abilities in Children With Pediatric-onset Multiple Sclerosis

Pediatric-onset multiple sclerosis (POMS), is the manifestation of multiple sclerosis in individuals before 18 years of age. About a third of children with POMS show some form of lower cognitive performance. The purpose of this study is to examine using quantitative meta-analyses the effect size of altered performance between children with and without POMS on overall intelligence quotient (IQ), information processing speed, and language functions. We searched the literature for studies that reported scores on cognitive tests administered to children with and without POMS. Studies were systematically reviewed using PRISMA guidelines. We analyzed data from 14 studies that examined 1283 children with and without POMS when cognitive categories consisted of five or more studies. Effect sizes, publication bias and potential confounds were considered. Significant cognitive differences are revealed for all categories with the strongest effect observed for overall IQ. A moderate effect is observed for information processing speed, and small effects for verbal fluency and verbal memory. Cognitive abilities present differently in children with POMS and a better understanding of this manifestation will inform intervention and remediation tools that can improve clinical and educational practice for the benefit of children with POMS.

Predominant domains and associated demographic and clinical characteristics in multiple sclerosis-related cognitive impairment in mildly disabled patients

Background

Cognitive impairment (CI) is a common finding in multiple sclerosis (MS); however, there is a limited information about its prevalence in mildly disabled cases. We aimed to determine the most affected domains, and also the relation between the demographic factors and cognitive outcomes in mildly disabled relapsing–remitting MS (RRMS).

Results

Ninety-one mildly disabled RRMS patients with expanded disability status scale (EDSS) < 4 and literacy level above 9 years, were recruited. Based on Minimal Assessment of Cognitive Function in MS (MACFIMS) battery, CI was observed in 19.8% of the patients while 40.60% of the patients had at least one failure in cognitive tests. The most common impaired cognitive domain was information processing speed and working memory (27.5%). There was no significant difference between men and women in terms of CI in our sample (p-values > 0.05). Disease duration (p = 0.01), EDSS (p = 0.01), and education (p < 0.01) were significantly different between CI and non-CI patients, while age (p = 0.72), sex (p = 0.50), diagnostic gap (p = 0.89), and frequency of relapses (p = 0.22), did not differ considerably.

Conclusions

RRMS patients experience some degrees of CI that may present even before the onset of remarkable physical disability; nevertheless, a higher EDSS score and longer disease duration increases the risk of CI. These findings suggest routine cognitive assessment of MS patients.

In-Depth Characterization of Somatic and Orofacial Sensitive Dysfunctions and Interfering-Symptoms in a Relapsing-Remitting Experimental Autoimmune Encephalomyelitis Mouse Model

Among the many symptoms (motor, sensory, and cognitive) associated with multiple sclerosis (MS), chronic pain is a common disabling condition. In particular, neuropathic pain symptoms are very prevalent and debilitating, even in early stages of the disease. Unfortunately, chronic pain still lacks efficient therapeutic agents. Progress is needed (i) clinically by better characterizing pain symptoms in MS and understanding the underlying mechanisms, and (ii) preclinically by developing a more closely dedicated model to identify new therapeutic targets and evaluate new drugs. In this setting, new variants of experimental autoimmune encephalomyelitis (EAE) are currently developed in mice to exhibit less severe motor impairments, thereby avoiding confounding factors in assessing pain behaviors over the disease course. Among these, the optimized relapsing-remitting EAE (QuilA-EAE) mouse model, induced using myelin oligodendrocyte glycoprotein peptide fragment (35–55), pertussis toxin, and quillaja bark saponin, seems very promising. Our study sought (i) to better define sensitive dysfunctions and (ii) to extend behavioral characterization to interfering symptoms often associated with pain during MS, such as mood disturbances, fatigue, and cognitive impairment, in this optimized QuilA-EAE model. We made an in-depth characterization of this optimized QuilA-EAE model, describing for the first time somatic thermal hyperalgesia associated with mechanical and cold allodynia. Evaluation of orofacial pain sensitivity showed no mechanical or thermal allodynia. Detailed evaluation of motor behaviors highlighted slight defects in fine motor coordination in the QuilA-EAE mice but without impact on pain evaluation. Finally, no anxiety-related or cognitive impairment was observed during the peak of sensitive symptoms. Pharmacologically, as previously described, we found that pregabalin, a treatment commonly used in neuropathic pain patients, induced an analgesic effect on mechanical allodynia. In addition, we showed an anti-hyperalgesic thermal effect on this model. Our results demonstrate that this QuilA-EAE model is clearly of interest for studying pain symptom development and so could be used to identify and evaluate new therapeutic targets. The presence of interfering symptoms still needs to be further characterized.

Multimodal emotion perception in young and elderly patients with multiple sclerosis

BACKGROUND

Studies suggest that emotion recognition and empathy are impaired in patients with MS (pwMS). Nonetheless, most studies are restricted to young samples, to facial emotion recognition and to self-report assessments of empathy. The aims of this study are to determine the impact of MS and age on multimodal emotion recognition (facial emotions and vocal emotional bursts) and on socioemotional sensitivity (as reported by the participants and their informants). We also aim to investigate the associations between emotion recognition, socioemotional sensitivity, and cognitive measures.

METHODS

We recruited 13 young healthy controls (HC), 14 young pwMS, 14 elderly HC and 15 elderly pwMS. They underwent a short neuropsychological battery, an experimental emotion recognition task including facial emotions and vocal emotional bursts. Both participants and their study informants completed the Revised-Self Monitoring Scale (RSMS) to assess the participant's socioemotional sensitivity.

RESULTS

There was a significant effect of age and group on recognition of both facial emotions and emotional vocal bursts, HC performing significantly better than pwMS, and young participants performing better than elderly participants (no interaction effect). The same effects were observed on self-reported socioemotional sensitivity. However, lower socioemotional sensitivity in pwMS was not reported by the informants. Finally, multimodal emotion recognition did not correlate with socioemotional sensitivity, but it correlated with global cognitive severity.

CONCLUSION

PwMS present with multimodal emotion perception deficits. Our results extend previous findings of decreased emotion perception and empathy to a group of elderly pwMS, in which advancing age does not accentuate these deficits. However, the decreased socioemotional sensitivity reported by pwMS does not appear to be observed by their relatives, nor to correlate with their emotion perception impairments. Future studies should investigate the real-life impacts of emotion perception deficits in pwMS.

Impact of disease-modifying therapies on MRI and neurocognitive outcomes in relapsing-remitting multiple sclerosis: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Disease-modifying therapies (DMTs) are the mainstay of treatment for relapsing-remitting multiple sclerosis (RRMS). There is established evidence that DMTs are effective at reducing relapse rate and disease progression in RRMS, but there has been less consideration to the synthesis of MRI and neurocognitive outcomes, which play an increasingly important role in treatment decisions. The aim of this systematic review and network meta-analysis is to examine the relative efficacy, acceptability and tolerability of DMTs for RRMS, using MRI and neurocognitive outcomes.

METHODS AND ANALYSIS

We will search electronic databases, including MEDLINE, Embase and the Cochrane Central Register of Controlled Trials, with no date restrictions. We will also search the websites of international regulatory bodies for pharmaceuticals and international trial registries. We will include parallel group randomised controlled trials of DMTs including interferon beta-1a intramuscular, interferon beta-1a subcutaneous, interferon beta-1b, peginterferon beta-1a, glatiramer acetate, natalizumab, ocrelizumab, alemtuzumab, dimethyl fumarate, teriflunomide, fingolimod, cladribine, ozanimod, mitoxantrone and rituximab, either head-to-head or against placebo in adults with RRMS. Primary outcomes include efficacy (MRI outcomes including new T1/hypointense lesions and T2/hyperintense lesions) and acceptability (all-cause dropouts). Secondary outcomes include gadolinium-enhancing lesions, cerebral atrophy and tolerability (dropouts due to adverse events). Neurocognitive measures across three domains including processing speed, working memory and verbal learning will be included as exploratory outcomes. Data will be analysed using a random-effects pairwise meta-analysis and a Bayesian hierarchical random effects network meta-analysis to evaluate the efficacy, acceptability and tolerability of the included DMTs. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings. The review will be reported using the Preferred Reporting Items for Systematic Reviews incorporating Network Meta-Analyses statement.

ETHICS AND DISSEMINATION

This protocol does not require ethics approval. Results will be disseminated in a peer-reviewed academic journal.

PROSPERO REGISTRATION NUMBER

CRD42021239630.

Associations between socioemotional alterations, quality of life, and social functioning in multiple sclerosis: A scoping review

The main aim of the present scoping review is to systematically review the available studies that investigated the associations between socioemotional alterations (i.e., social cognition impairments/alexithymia/difficulties in emotion regulation) and both reduced QoL and social functioning in patients with Multiple Sclerosis (MS). The articles were selected from the PubMed, PsycINFO, and Scopus databases. The main exclusion criteria were qualitative studies, articles that did not use validated instruments, and studies that did not investigate the association between socioemotional skills and QoL/social functioning in MS. Of the eight studies fulfilling the inclusion criteria, six found significant associations between social cognitive and emotion regulation abilities and QoL/social functioning in patients with MS, while two found no significant relationships particularly between the performance on social cognition tasks and QoL measures. Overall, the majority of findings seem to highlight that socioemotional alterations contribute to impaired QoL and social functioning in MS. However, given the still limited evidence, future studies are needed to replicate and confirm the available results, paying attention to two principal aspects: the use of standardized and ecological tasks for the assessment of social cognition skills and the recruitment of samples involving patients with different types of MS.

Baseline characteristics and effects of fingolimod on cognitive performance in patients with relapsing-remitting multiple sclerosis

Background and purpose

Studies reporting the baseline determinants of cognitive performance and treatment effect on cognition in patients with multiple sclerosis (MS) are limited. We investigated the baseline correlates of cognition and the long‐term treatment effects of fingolimod 0.5 mg once daily on cognitive processing speed and attention in patients with relapsing‐remitting MS.

Methods

This post hoc analysis pooled data from the phase 3 FREEDOMS and FREEDOMS II trials (N = 1556). We assessed the correlation between baseline patient demographic and disease characteristics and baseline 3‐second Paced Auditory Serial Addition Test (PASAT‐3) scores (Spearman's rank test) and the changes from baseline in PASAT‐3 (mixed model repeated measures model) in the fingolimod and placebo (up to 24 months) or placebo‐fingolimod switched (from Month 24 up to 120 months) groups. Additionally, the predictive value of PASAT‐3 score for future disease outcomes was assessed (Cox or logistic regression models).

Results

Among the variables assessed, lower PASAT‐3 score at baseline correlated with higher disease burden (total brain volume, T2 lesion volume, and Expanded Disability Status Scale score), longer disease duration and older age (p < 0.0001 for all). Fingolimod significantly improved PASAT‐3 scores from baseline versus placebo at 6 (1.3; p = 0.0007), 12 (1.1; p = 0.0044) and 24 months (1.1; p = 0.0028), with a sustained effect (overall treatment effect p = 0.0012) up to 120 months. Improvements were seen regardless of baseline cognitive status (PASAT quartile). Baseline PASAT‐3 score was predictive of both clinical and magnetic resonance imaging measures of disease activity at Month 24 (p < 0.001 for all).

Conclusion

Early fingolimod treatment may offer long‐term cognitive benefit in patients with relapsing‐remitting MS.

Understanding visual-spatial perceptual deficits in individuals with multiple sclerosis: an analysis of patient performance on the Hooper Visual Organization Test and Visual Form Discrimination

Purpose: Although the cognitive sequelae of multiple sclerosis have been recognized for more than four decades, the focus of research has been on studying the more common deficits of the disease, including those involving memory and information processing speed. Less understood and investigated are the visual-spatial perceptual disturbances of multiple sclerosis, which can be difficult to assess and interpret given the potential confounds associated with the physical problems and other cognitive disturbances of the disorder.Materials and methods: This study examined the visual-spatial perceptual deficits of multiple sclerosis in 40 participants diagnosed with this condition using two measures generally unaffected by the aforementioned confounds, the Hooper Visual Organization Test and Visual Form Discrimination.Results: Results revealed both measures to be sensitive to the impairments of multiple sclerosis but suggested that they are assessing somewhat different aspects of visual-spatial perception in this population, given their relationship with one another and with disease-related variables.Conclusions: In this light, findings indicate that a complete and accurate understanding of the visual-spatial perceptual sequelae of multiple sclerosis requires the administration of more than a single measure.

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.

Predicting Neuropsychological Impairment in Relapsing Remitting Multiple Sclerosis: The Role of Clinical Measures, Treatment, and Neuropsychiatry Symptoms

OBJECTIVE

This retrospective observational study aimed to define neuropsychological impairment (NI) profiles and determine the influence of clinical, demographic, and neuropsychiatric measures in specific cognitive domains in a cohort of relapsing-remitting multiple sclerosis (RRMS) patients.

METHODS

Ninety-one RRMS patients underwent a neurological examination and a brief neuropsychological assessment. Patients were classified according to the disease-modifying therapies (DMTs) received (platform or high-efficacy). Differences between groups and multiple regression analyses were performed to determine the predictive value of the assessed measures in cognitive performance.

RESULTS

More than two-thirds of the patients showed NI. Specifically, mild to moderate NI was presented in approximately half of the participants. Paced Auditory Serial Addition Test (PASAT-3) and Symbol Digit Modalities Test (SDMT) were the most frequently impaired cognitive tests (45.3% and 41.3%, respectively) followed by phonemic verbal fluency (PVF) (27.8%). Expanded Disability Status Scale (EDSS), age, depressive symptoms, and disease duration were the best predictors of SDMT (R2 = .34; p < .01), whereas disease duration, EDSS, and anxiety-state levels predicted PASAT-3 (R2 = .33, p < .01). Educational level, age, EDSS, and depressive symptoms demonstrated the strongest association with PVF (R2 = .31, p < .01).

CONCLUSIONS

Our results indicated a significant prevalence of NI in RRMS patients that was not dependent on the DMT type. In addition to the meaningful working memory (PASAT-3) and information processing speed (SDMT) impairments found, PVF deficits may also be an important marker of cognitive impairment in RRMS patients. This study supports the relevance of standard clinical measures and reinforces the importance of quantifying clinical and neuropsychiatric symptoms to predict subsequent cognitive performance on a similar multiple sclerosis phenotype and disease stage.

A Retrospective Exploratory Analysis on Cardiovascular Risk and Cognitive Dysfunction in Multiple Sclerosis

Background. Cardiovascular comorbidities have been associated with cognitive decline in the general population. Objectives. To evaluate the associations between cardiovascular risk and neuropsychological performances in MS. Methods. This is a retrospective study, including 69 MS patients. For all patients, we calculated the Framingham risk score, which provides the 10-year probability of developing macrovascular disease, using age, sex, diabetes, smoking, systolic blood pressure, and cholesterol levels as input variables. Cognitive function was examined with the Brief International Cognitive Assessment for MS (BICAMS), including the Symbol Digit Modalities Test (SDMT), the California Verbal Learning Test-II (CVLT-II), and the Brief Visuospatial Memory Test-Revised (BVMT-R). Results. Each point increase of the Framingham risk score corresponded to 0.21 lower CVLT-II score. Looking at Framingham risk score components, male sex and higher total cholesterol levels corresponded to lower CVLT scores (Coeff = −8.54; 95%CI = −15.51, −1.57; and Coeff = −0.11; 95%CI = −0.20, −0.02, respectively). No associations were found between cardiovascular risk and SDMT or BVMT-R. Conclusions. In our exploratory analyses, cardiovascular risk was associated with verbal learning dysfunction in MS. Lifestyle and pharmacological interventions on cardiovascular risk factors should be considered carefully in the management of MS, given the possible effects on cognitive function.

Reliability and validity of Arabic version of the brief international cognitive assessment for multiple sclerosis: Egyptian dialect

Background

Given the diversity of multiple sclerosis (MS) symptoms including cognitive impairment in certain domains, the need to develop a rapid and at the same time thorough tool for cognitive assessment is mandatory and represents an unmet need in the clinical and research fields of MS. The Brief International Cognitive Assessment for MS (BICAMS) is a good and practical tool to achieve this mission but is not present in the Arabic language for Arabic speaking countries yet.

Objectives

To assess the reliability and validity of Arabic version of the BICAMS (Egyptian dialect).

Methods

Ninety Egyptian MS patients and 85 matched healthy controls underwent neuropsychological testing using the BICAMS Arabic version (Egyptian dialect) battery including the Symbol Digit Modality Test (SDMT), California Verbal Learning Test 2nd edition (CVLT-II), and revised Brief Visuospatial Retention Test- (BVRT-R). Test–retest data were obtained from MS patients 2 weeks after the initial assessment. Mean differences between both groups were assessed controlling for age, gender, and educational level.

Results

The MS patients scored significantly lower on the SDMT, CVLT-II, and BVMT-R tests compared to healthy controls (p<0.001). For MS patients’ group, intra-observer (test–retest) reliability was satisfactory for SDMT, CVLT-II total, and BVRT-R total with r values of 0.85, 0.61, and 0.68, respectively.

Conclusion

BICAMS Arabic version is a reliable and valid tool for cognitive assessment of Arabic speaking MS patients in different clinical and research settings.

Neurocognitive impairment and social cognition in multiple sclerosis

PURPOSE/AIM OF THE STUDY

The impairment of neurocognitive functions occurs in all subtypes of multiple sclerosis, even from the earliest stages of the disease. Commonly reported manifestations of cognitive impairment include deficits in attention, conceptual reasoning, processing efficiency, information processing speed, memory (episodic and working), verbal fluency (language), and executive functions. Multiple sclerosis patients also suffer from social cognition impairment, which affects their social functioning. The objective of the current paper is to assess the effect of neurocognitive impairment and its potential correlation with social cognition performance and impairment in multiple sclerosis patients.

MATERIALS AND METHODS

An overview of the available-to-date literature on neurocognitive impairment and social cognition performance in multiple sclerosis patients by disease subtype was performed.

RESULTS

It is not clear if social cognition impairment occurs independently or secondarily to neurocognitive impairment. There are associations of variable strengths between neurocognitive and social cognition deficits and their neural basis is increasingly investigated.

CONCLUSIONS

The prompt detection of neurocognitive predictors of social cognition impairment that may be applicable to all multiple sclerosis subtypes and intervention are crucial to prevent further neural and social cognition decline in multiple sclerosis patients.

A Multidimensional Assessment of Metacognition Across Domains in Multiple Sclerosis

OBJECTIVE

In neurological diseases, metacognitive judgements have been widely used in order to assess the degree of disease awareness. However, as yet little research of this type has focused on multiple sclerosis (MS).

METHOD

We here focused on an investigation of item-by-item metacognitive predictions (using feeling-of-knowing judgements) in episodic and semantic memory and global metacognitive predictions in standard neuropsychological tests pertinent to MS (processing speed and verbal fluency). Twenty-seven relapsing-remitting MS (RR-MS) patients and 27 comparison participants took part.

RESULTS

We found that RR-MS patients were as accurate as the group of comparison participants on our episodic and semantic item-by-item judgements. However, for the global predictions, we found that the MS group initially overestimated their performance (ds = .64), but only on a task on which performance was also impaired (ds = .89; processing speed). We suggest that MS patients, under certain conditions, show inaccurate metacognitive knowledge. However, postdictions and item-by-item predictions indicate that online metacognitive processes are no different from participants without MS.

CONCLUSION

We conclude that there is no monitoring deficit in RR-MS and as such these patients should benefit from adaptive strategies and symptom education.

Memory in multiple sclerosis: A reappraisal using the item specific deficit approach

OBJECTIVE

As many as 65% of people with multiple sclerosis (MS) have clinically significant memory impairment, but the nature of this deficit is controversial. Some investigations suggest that an inability to retrieve newly learned information from memory is prominent, whereas others imply that compromised acquisition accounts for impairment. Prior research has not simultaneously evaluated acquisition and retrieval processes in MS, and fewer have attempted to account for initial acquisition when studying retrieval. The Item Specific Deficit Approach (ISDA) offers a method of quantifying acquisition, retrieval, and retention processes, with the latter two mechanisms being adjusted for initial acquisition. To simultaneously quantify acquisition and retrieval abilities, the ISDA was applied to list learning performance in two independent samples of people with MS and corresponding healthy comparison groups.

PARTICIPANTS AND METHODS

Study 1 included 85 people with MS and 47 healthy individuals. Study 2 involved a separate sample of 79 people with MS and 22 healthy people. They were administered neuropsychological batteries, and participants with MS were classified as globally impaired or unimpaired. The California Verbal Learning Test-II was administered to assess new-learning in both studies, and responses were scored using the ISDA.

RESULTS

Both studies revealed that cognitively impaired people with MS manifest weaknesses involving acquisition and retrieval. Nearly identical effect sizes emerged across samples, with cognitive impairment achieving a medium effect upon acquisition and a large effect upon retrieval.

CONCLUSIONS

These findings accord well with previous research showing diminished acquisition and retrieval among people with MS. The results may also reconcile contradictory findings in the extant literature by showing that memory impairment in MS is not exclusively attributable to either acquisition or retrieval. Rather, both processes may manifest across people with MS. The replication across samples with nearly identical effect sizes implies that these effects are reliable and possess external validity. These data hold implications for memory rehabilitation interventions involving people with MS, and suggest that acquisition and retrieval processes should be addressed in treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Correlates of the personality change judgments of individuals who have MS

Objectives: This is the first study to estimate prevalence of self-reported personality change (PC) in people with multiple sclerosis (MS). Methods developed in traumatic brain injury studies explore physical, and psychosocial triggers for PC judgments.Participants: 69 MS clinic attendees living with their partner.Measures: Participants rated the degree of PC. 28 Current and pre-MS characteristics were rated. The Multiple Sclerosis Impact Scale, the MS Neuropsychological Questionnaire, the Beck Depression Inventory-FastScreen, and the Hospital Anxiety and Depression Scale quantified neuropsychological status. The Family Questionnaire, McMaster Assessment Device and the Social Provisions Scale sampled perceived social influences.Results: 54% perceived substantial PC. Current characteristics predicted PC better than perceived behavior changes. PC was associated with specific characteristics denoting stress reactions, emotional distress, perceived cognitive impairment and poorer family functioning. PC was not significantly related to severity of physical symptoms or social support. This study also suggested that the specific characteristics questionnaire probed at least 2 components of reconstructed identity: PC/Reactivity and Disability.Conclusions: This study raises methodological concerns about measures that simply sum ratings of characteristics related to self-identity. It also proposes possible ways of collaborating with individuals in their efforts to respond constructively to PC and other changes. .

Vision, attention, and driving

Safe driving demands the coordination of multiple sensory and cognitive functions, such as vision and attention. Patients with neurologic or ophthalmic disease are exposed to selective pathophysiologic insults to driving-critical systems, placing them at a higher risk for unsafe driving and restricted driving privileges. Here, we evaluate how vision and attention contribute to unsafe driving across different patient populations. In ophthalmic disease, we focus on macular degeneration, glaucoma, diabetic retinopathy, and cataract; in neurologic disease, we focus on Alzheimer's disease, Parkinson's disease, and multiple sclerosis. Unsafe driving is generally associated with impaired vision and attention in ophthalmic and neurologic patients, respectively. Furthermore, patients with ophthalmic disease experience some degree of impairment in attention. Similarly, patients with neurologic disease experience some degree of impairment in vision. While numerous studies have demonstrated a relationship between impaired vision and unsafe driving in neurologic disease, there remains a dearth of knowledge regarding the relationship between impaired attention and unsafe driving in ophthalmic disease. In summary, this chapter confirms-and offers opportunities for future research into-the contribution of vision and attention to safe driving.

Testing social cognition in multiple sclerosis: Difference between emotion recognition and theory of mind and its influence on quality of life

BACKGROUND

Deficits in social cognition can occur in multiple sclerosis (MS) patients, and different methods are utilized for its assessment. The aim of this study was to compare two tests of social cognition in a cohort of multiple sclerosis patients with respect to other clinical variables. Additionally, the impact of social cognition on quality of life was investigated.

METHODS

In total, 50 patients were included in the study. Two tests of social cognition, emotion recognition and theory of mind, were performed and controlled for disease disability, depression, fatigue, and cognition in a multiple linear regression. Assessment of quality of life was also conducted.

RESULTS

Accuracy on emotion recognition was better compared to theory of mind (86.5 ± 9.5% and 63.6 ± 10.1%, respectively). Cognition was associated with both social cognition tasks, accounting for more variance in the emotion recognition task. Quality of life was not related to social cognition.

CONCLUSION

Studies on social cognition in MS have to keep in mind the higher degree of cognitive influence of emotion recognition compared to theory of mind.

Altered phase and nonphase EEG activity expose impaired maintenance of a spatial-object attentional focus in multiple sclerosis patients

Some of the anatomical and functional basis of cognitive impairment in multiple sclerosis (MS) currently remains unknown. In particular, there is scarce knowledge about modulations in induced EEG (nonphase activity) for diverse frequency bands related to attentional deficits in this pathology. The present study analyzes phase and nonphase alpha and gamma modulations in 26 remitting-relapsing multiple sclerosis patients during their participation in the attention network test compared with twenty-six healthy controls (HCs) matched in sociodemographic variables. Behavioral results showed that the MS group exhibited general slowing, suggesting impairment in alerting and orienting networks, as has been previously described in other studies. Time–frequency analysis of EEG revealed that the gamma band was related to the spatial translation of the attentional focus, and the alpha band seemed to be related to the expectancy mechanisms and cognitive processing of the target. Moreover, phase and nonphase modulations differed in their psychophysiological roles and were affected differently in the MS and HC groups. In summary, nonphase modulations can unveil hidden cognitive mechanisms for phase analysis and complete our knowledge of the neural basis of cognitive impairment in multiple sclerosis pathology.

The relationship between cognition, depression, fatigue, and disability in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic, progressive, and neurodegenerative central nervous system disorder. MS usually causes disability, cognitive deficiency, fatigue, and depression symptoms.

OBJECTIVES

To assess cognitive functions of people with MS (pwMS) and investigate the impact of depression, fatigue, and disability on cognitive functions.

METHODS

We administered the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery to assess 200 pwMS. The Expanded Disability Status Scale (EDSS) was used to evaluate disability levels. Fatigue Severity Scale (FSS) and the Beck Depression Inventory (BDI) were used, respectively, for fatigue and depression levels.

RESULTS

EDSS and FSS scores were significantly higher in those with a disease duration of 5 years or more. Those with the EDSS ≥ 4 were found to have lower BICAMS performances and higher FSS scores. There was a significant difference in Symbol Digit Modalities Test (SDMT) performances between the groups with and without fatigue (FSS ≥ 4 and FSS < 4, respectively). When depression and fatigue symptoms concur or in the existence of just one of them or none of them, significant differences in terms of SDMT performances have been shown.

CONCLUSION

The level of disability and fatigue adversely affects the cognitive functions of pwMS; depression has no significant effect. BICAMS that is specific for MS can be beneficial to assess the cognitive state of pwMS.

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.

Clinical features and physical performance in multiple sclerosis patients with and without cognitive impairment: a cross-sectional study

The factors associated with cognitive functions in patients with multiple sclerosis (PwMS) are not yet clear. The aims of this study were (1) to compare clinical features and physical performance in healthy controls, and PwMS with and without cognitive impairment, and (2) to determine the relationship between cognitive domains and demographics characteristics, clinical features and physical performance in PwMS. A total of 112 PwMS and 25 healthy controls participated in this study. Cognitive functions were evaluated by Brief Repeatable Battery of Neuropsychological Tests (BRB-N). Based on cognitive performances by BRB-N, PwMS were divided into two groups as MS patients with impaired (MS-I, n: 57) and with normal (MS-N, n: 55) cognitive functions. For clinical features, fatigue, mood and sleep quality were evaluated by the Fatigue Impact Scale, Beck's Depression Inventory, Pittsburgh Sleep Quality Index, respectively. For physical performances, balance and walking capacity were evaluated by posturography and Six-Minute Walking Test, respectively. The results showed that the education years, postural stability and walking capacity in MS-N and healthy controls were higher than in MS-I (P < 0.05). In addition, visuospatial memory was correlated with both postural stability under all sensory conditions and walking capacity; verbal memory was correlated with education years, postural stability on eyes closed-foam surface and walking capacity; verbal fluency was correlated with only walking capacity; information processing speed was correlated with education years, postural stability under all sensory conditions and walking capacity (P < 0.001). This study suggests that the interventions that aim to improve physical performance might protect and even improve cognitive functions in PwMS.

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.

[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.

An integrative cognitive rehabilitation using neurologic music therapy in multiple sclerosis: A pilot study

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease, affecting both the sensorimotor and cognitive systems. The typical pattern of cognitive impairment includes reduced speed of information processing, decreased phonological and semantic speech fluency, deficits in verbal and visual episodic memory, as well as attention and executive dysfunctions. We aimed to investigate the influence of the neurologic music therapy (NMT) on mood, motivation, emotion status, and cognitive functions in patients with MS.

METHODS

Thirty patients with MS were randomly divided in 2 groups: the control group (CG) undergoing conventional cognitive rehabilitation (CCR), 6 times a week for 8 weeks, and the experimental group (EG) undergoing CCR 3 times a week for 8 weeks plus NMT techniques, performed 3 times a week for 8 weeks. All the participants were submitted to the same amount of treatment. Each patient was evaluated before (baseline: T0) and immediately after the end of each training (T1).

MAIN OUTCOMES MEASURES

We used as main outcome measure: the brief repeatable battery of neuropsychological test to assess various cognitive abilities; and the multiple sclerosis quality of life-54 (MSQoL-54).

RESULTS

Both the groups benefit from 8 weeks of CR. In particular, the EG got better results in cognitive function, with regard to selective reminding test long term storage (P < .000), long term retrieval (P = .007), and delayed recall of the 10/36 spatial recall test (P = .001), as compared with the CG. Moreover, the improvement in emotional status, motivation, mood and quality of life (with regard to the mental component; P < .000) was more evident in the EG.

CONCLUSIONS

NMT could be considered a complementary approach to enhance CCR in patients affected by MS.

A Neuropsychological Rehabilitation Program for Cognitive Impairment in Psychiatric and Neurological Conditions: A Review That Supports Its Efficacy

Neuropsychological rehabilitation has been the focus of much scientific research over the past decades due to its efficacy in different pathologies. Advances in the neuropsychology field have led to improvements and changes in neuropsychological interventions, which in turn have given rise to different approaches and rehabilitation programs. REHACOP is an integrative neuropsychological rehabilitation program designed by specialist neuropsychologists. With an integrated bottom-up and top-down approach, REHACOP includes neurocognition, social cognition, and daily living tasks hierarchically organized on an increasing level of difficulty. Task arrangement is addressed to maximize improvements and transfer effects into participant's daily living. To date, REHACOP has been implemented on different clinical samples such as patients with schizophrenia, multiple sclerosis (MS), and Parkinson's disease (PD). This manuscript presents the efficacy data of REHACOP across these three populations and discusses it in the context of the available literature. Overall, the magnitude of improvements obtained by means of REHACOP ranged from medium to high across samples. These changes were not restricted to specific neurocognitive domains since participants attending the REHACOP program also showed changes in social cognition and daily functioning variables by means of both direct and transfer effects. Results regarding REHACOP's efficacy in psychiatric and neurological conditions have contributed to expanding the existing evidence about the use of structured neuropsychological rehabilitation. In addition, the results obtained after its implementation highlighted the need and importance of designing and implementing integrative neuropsychological rehabilitation programs that are focused not only on cognition per se but also on participants' performance in daily living.

Changes in Cognitive Performance With Age in Adults With Multiple Sclerosis

BACKGROUND

Cognitive impairment is one of the most common consequences of multiple sclerosis (MS), yet there is a shortage of data regarding how cognition changes during the life span of individuals with MS. This information is of increasing importance given the growing proportion of older adults with MS.

OBJECTIVE

To study possible changes in cognitive function in correlation with increasing age in individuals with MS.

METHODS

Participants (N=129) were recruited and a priori allocated into one of three age groups (young, middle-aged, and older). All participants completed the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) during a single laboratory testing session. The BICAMS measures cognitive processing speed as well as verbal and visuospatial learning and memory.

RESULTS

A multivariate analysis of variance indicated that cognitive function significantly differed by age group, and these differences were not explained by amount of physical activity, years of education, years since diagnosis, or race. Older adults displayed significantly worse cognitive processing speed than young and middle-aged adults. The older and middle-aged adults also demonstrated significantly worse visuospatial learning and memory than the younger adults. Effect sizes indicated that cognitive processing speed and verbal learning and memory were more affected in late adulthood than early adulthood, whereas visuospatial learning and memory was affected similarly in early and late adulthood.

CONCLUSIONS

Older adults with MS demonstrated significant impairments in cognitive function compared to young and middle-aged adults with MS. Future studies should determine the predictors of cognitive decline in this age cohort.

Cognitive functions and disability progression in relapsing-remitting multiple sclerosis: A longitudinal study

Longitudinal studies have shown inconsistent findings regarding the association between cognition, demographic characteristics, and clinical decline in relapsing-remitting multiple sclerosis (RRMS). Our objective was to further explore these relations, over time, while also considering age and sex. A total of 183 patients with RRMS were assessed at two time points, using a neuropsychological battery and the Expanded Disability Status Scale (EDSS). For the first assessment, participants were divided by age (<29, 30-39, 40-49, 50-60) and sex. Next, they were divided according to their participation in one of three interval assessment points: 2-3, 4-5, and 6-8 years. Cognitive function was not correlated with disease duration but was negatively correlated with EDSS score. Men under 29 and women under 39 showed negative correlations between cognitive and clinical impairment. Executive functions, attention, and information processing speed (IPS) showed cognitive decline between the first and second assessments. Furthermore, at the 4-5 year interval IPS predicted EDSS scores, while at the 6-8 year interval it was IPS and visuo-spatial ability. Therefore, relation between clinical status and cognition is not consistent across different age and sex groups. Additionally, cognitive deterioration is only partially evident longitudinally; however, IPS appears to be the most sensitive in predicting one's future clinical condition.

Outcomes of natalizumab treatment within 3 years of relapsing-remitting multiple sclerosis diagnosis: a prespecified 2-year interim analysis of STRIVE

Background

STRIVE is a multicenter, observational, open-label, single-arm study of natalizumab in anti–JC virus (JCV) seronegative patients with early relapsing-remitting multiple sclerosis (RRMS). The objective of this prespecified 2-year interim analysis was to determine the effectiveness of natalizumab in establishing and maintaining no evidence of disease activity (NEDA) in early RRMS.

Methods

Patients aged 18–65 years had an RRMS diagnosis < 3 years prior to screening, an Expanded Disability Status Scale (EDSS) score ≤ 4.0, and anti-JCV antibody negative status. Magnetic resonance imaging was performed at baseline and yearly thereafter. Cumulative probabilities of 24-week–confirmed EDSS worsening and improvement were evaluated at 2 years. NEDA (no 24-week–confirmed EDSS worsening, no relapses, no gadolinium-enhancing lesions, and no new/newly enlarging T2-hyperintense lesions) was evaluated over 2 years. The Symbol Digit Modalities Test (SDMT) and Multiple Sclerosis Impact Score (MSIS-29) were assessed at baseline and 1 and 2 years. Statistical analysis used summary statistics and frequency distributions.

Results

The study population (N = 222) had early RRMS, with mean (standard deviation [SD]) time since diagnosis of 1.6 (0.77) years and mean (SD) baseline EDSS score of 2.0 (1.13). NEDA was achieved in 105 of 187 patients (56.1%) during year 1 and 120 of 163 (73.6%) during year 2. Over 2 years, 76 of 171 patients (44.4%) attained overall NEDA. Probabilities of 24-week–confirmed EDSS worsening and improvement were 14.1% and 28.4%, respectively. After 2 years, patients exhibited significant improvements from baseline in SDMT (n = 158; mean [SD]: 4.3 [11.8]; p < 0.001) and MSIS-29 physical (n = 153; mean [SD]: − 3.9 [14.7]; p = 0.001), psychological (n = 152; mean [SD]: − 2.0 [7.9]; p < 0.001), and quality-of-life (n = 153; mean [SD]: − 6.0 [21.3]; p < 0.001) scores.

Conclusions

These results support natalizumab’s effectiveness over 2 years, during which nearly half of early RRMS patients achieved NEDA. During year 2, nearly 75% of patients exhibited NEDA. Over 2 years, patients continued to experience significant cognitive and quality-of-life benefits. These results are limited by the lack of a comparator group to determine the extent of a placebo effect.

Trial registration

clinicaltrials.gov, NCT01485003, registered 5 December 2011.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1337-z) contains supplementary material, which is available to authorized users.

Visual but not verbal working memory interferes with balance in patients after optic neuritis suggestive of multiple sclerosis

BACKGROUND

Subtle cognitive deficits are present in almost half of the patients with clinically isolated syndrome (CIS) suggestive of multiple sclerosis (MS). Similarly, subtle balance deficits can be detected at the earliest stages of the disease. To assess cognitive-motor interference (CMI) in nondisabled CIS patients, we studied postural performance using dual task paradigm in CIS patients presenting with optic neuritis.

METHODS

We prospectively included 20 patients with visual acuity of 0.8 or more within the 3 months from unilateral ON. We also included 20 age, weight, height and education matched healthy subjects. Baseline cognitive performance of the patients was assessed using neuropsychological tests. Balance was studied by posturography (Po) and center of pressure (CoP) measures (maximal medio-lateral, maximal antero-posterior amplitudes, maximal CoP velocity and total CoP path. CMI between static balance and WM was investigated using a dual-task paradigm in three conditions: Po alone, Po+Brooks' visual working memory (WM) task and Po+2-back verbal WM task.

RESULTS

The two most commonly affected cognitive domains in the patients were attention (52% of the patients) and executive functions (45% of the patients). Static balance as measured by higher maximal CoP velocity while standing alone (p = 0.02) was impaired in patients. Significantly lower maximal m-l CoP amplitude (p = 0.01) and total CoP path (p = 0.004) in the Po + Brooks' task condition compared to Po alone were observed in the group of ON patients but not in healthy subjects. The cost of dualtasking was highest in the ON patients under Po + Brooks' task (p = 0.04 for the total CoP path parameter).

CONCLUSION

Static balance and cognition are impaired in the earliest MS. CMI between static balance and working memory is higher in the patients and while loading visual working memory. Dual-task paradigms should be used in rehabilitation programmes for patients at the very beginning of the disease.

The Role of Language in Alexithymia: Moving Towards a Multiroute Model of Alexithymia

Alexithymia is characterized by difficulty identifying and describing one’s own emotion. Identifying and describing one’s emotion involves several cognitive processes, so alexithymia may result from a number of impairments. Here we propose the alexithymia language hypothesis—the hypothesis that language impairment can give rise to alexithymia—and critically review relevant evidence from healthy populations, developmental disorders, adult-onset illness, and acquired brain injury. We conclude that the available evidence is supportive of the alexithymia–language hypothesis, and therefore that language impairment may represent one of multiple routes to alexithymia. Where evidence is lacking, we outline which approaches will be useful in testing this hypothesis.

Preserved canonicality of the BOLD hemodynamic response reflects healthy cognition: Insights into the healthy brain through the window of Multiple Sclerosis

The hemodynamic response function (HRF), a model of brain blood-flow changes in response to neural activity, reflects communication between neurons and the vasculature that supplies these neurons in part by means of glial cell intermediaries (e.g., astrocytes). Intact neural-vascular communication might play a central role in optimal cognitive performance. This hypothesis can be tested by comparing healthy individuals to those with known white-matter damage and impaired performance, as seen in Multiple Sclerosis (MS). Glial cell intermediaries facilitate the ability of neurons to adequately convey metabolic needs to cerebral vasculature for sufficient oxygen and nutrient perfusion. In this study, we isolated measurements of the HRF that could quantify the extent to which white-matter affects neural-vascular coupling and cognitive performance. HRFs were modeled from multiple brain regions during multiple cognitive tasks using piecewise cubic spline functions, an approach that minimized assumptions regarding HRF shape that may not be valid for diseased populations, and were characterized using two shape metrics (peak amplitude and time-to-peak). Peak amplitude was reduced, and time-to-peak was longer, in MS patients relative to healthy controls. Faster time-to-peak was predicted by faster reaction time, suggesting an important role for vasodilatory speed in the physiology underlying processing speed. These results support the hypothesis that intact neural-glial-vascular communication underlies optimal neural and cognitive functioning.

Assessment and Impact of Cognitive Impairment in Multiple Sclerosis: An Overview

Cognitive impairment affects 40⁻60% of patients with multiple sclerosis. It may be present early in the course of the disease and has an impact on a patient's employability, social interactions, and quality of life. In the last three decades, an increasing interest in diagnosis and management of cognitive impairment has arisen. Neuropsychological assessment and neuroimaging studies focusing on cognitive impairment are now being incorporated as primary outcomes in clinical trials. However, there are still key uncertainties concerning the underlying mechanisms of damage, neural basis, sensitivity and validity of neuropsychological tests, and efficacy of pharmacological and non-pharmacological interventions. The present article aimed to present an overview of the assessment, neural correlates, and impact of cognitive impairment in multiple sclerosis.

Multiple Immune-Inflammatory and Oxidative and Nitrosative Stress Pathways Explain the Frequent Presence of Depression in Multiple Sclerosis

Patients with a diagnosis of multiple sclerosis (MS) or major depressive disorder (MDD) share a wide array of biological abnormalities which are increasingly considered to play a contributory role in the pathogenesis and pathophysiology of both illnesses. Shared abnormalities include peripheral inflammation, neuroinflammation, chronic oxidative and nitrosative stress, mitochondrial dysfunction, gut dysbiosis, increased intestinal barrier permeability with bacterial translocation into the systemic circulation, neuroendocrine abnormalities and microglial pathology. Patients with MS and MDD also display a wide range of neuroimaging abnormalities and patients with MS who display symptoms of depression present with different neuroimaging profiles compared with MS patients who are depression-free. The precise details of such pathology are markedly different however. The recruitment of activated encephalitogenic Th17 T cells and subsequent bidirectional interaction leading to classically activated microglia is now considered to lie at the core of MS-specific pathology. The presence of activated microglia is common to both illnesses although the pattern of such action throughout the brain appears to be different. Upregulation of miRNAs also appears to be involved in microglial neurotoxicity and indeed T cell pathology in MS but does not appear to play a major role in MDD. It is suggested that the antidepressant lofepramine, and in particular its active metabolite desipramine, may be beneficial not only for depressive symptomatology but also for the neurological symptoms of MS. One clinical trial has been carried out thus far with, in particular, promising MRI findings.