Cognitive rehabilitation program in patients with multiple sclerosis: A pilot study

INTRODUCTION

In recent years, there has been an increase of studies dedicated to cognitive rehabilitation in patients with multiple sclerosis (MS); however, few of these analyze the impact on such variables as cognitive reserve. The study aims to explore the effects of a cognitive rehabilitation program comprising a combination of cognitive and physical exercises, as well as group sessions to improve cognitive performance, emotional state, and cognitive reserve index.

METHOD

Fifty patients with MS were subdivided into 2 groups: the control group, which performed aerobic exercise (n=25), and the experimental group (n=25), which participated in the integrated cognitive rehabilitation program (ICRP). All participants were evaluated 3 times (baseline, post-treatment, and long-term) with the Brief Repeatable Battery of Neuropsychological Tests, Cognitive Reserve Scale, Beck Depression Inventory, and a scale evaluating trait and state anxiety.

RESULTS

Compared with the control group, patients in the experimental group showed improvements in cognitive function, with significant changes in measures of information processing speed, attention, memory, cognitive reserve index, and long-term mood.

CONCLUSIONS

The ICRP was effective in improving cognitive and emotional function in MS, and increased the cognitive reserve index.

Cognitive rehabilitation program in patients with multiple sclerosis: A pilot study

INTRODUCTION

In recent years, there has been an increase of studies dedicated to cognitive rehabilitation in patients with multiple sclerosis (MS); however, few of these analyze the impact on such variables as cognitive reserve. The study aims to explore the effects of a cognitive rehabilitation program comprising a combination of cognitive and physical exercises, as well as group sessions to improve cognitive performance, emotional state, and cognitive reserve index.

METHOD

Fifty patients with MS were subdivided into 2 groups: the control group, which performed aerobic exercise (n=25), and the experimental group (n=25), which participated in the integrated cognitive rehabilitation program (ICRP). All participants were evaluated 3 times (baseline, post-treatment, and long-term) with the Brief Repeatable Battery of Neuropsychological Tests, Cognitive Reserve Scale, Beck Depression Inventory, and a scale evaluating trait and state anxiety.

RESULTS

Compared with the control group, patients in the experimental group showed improvements in cognitive function, with significant changes in measures of information processing speed, attention, memory, cognitive reserve index, and long-term mood.

CONCLUSIONS

The ICRP was effective in improving cognitive and emotional function in MS, and increased the cognitive reserve index.

[Cognitive training combined with aerobic exercises in multiple sclerosis patients: a pilot study]

INTRODUCTION

The scientific evidences associated to the effectiveness of different techniques of cognitive rehabilitation are still contradictory.

AIM

To compare a program of combined training (physical and cognitive) in front of a program of physical training and to observe their effectiveness about the optimization of the cognitive functions in patients with multiple sclerosis (MS).

PATIENTS AND METHODS

It was carried out an experimental study in 32 patients with MS. The patients were distributed in two groups: 16 to the experimental group (combined cognitive training with aerobic exercises) and 16 patients to the control group (aerobic exercises). The intervention was planned for six weeks combining cognitive tasks by means of a game of dynamic board of cubes and signs (TaDiCS ®) and a program of aerobic exercises. The Brief Repeatable Battery of Neuropsychological Test and the Stroop Test were applied to evaluate the cognitive yield. Also, the Beck Depression Inventory was administered.

RESULTS

There were found significant differences in the intergrupal analysis after the intervention in the variable learning and visuoespacial long term memory (p = 0.000), attention (p = 0.026) and inhibitory control (p = 0.007). Also, in the intragroup analysis there were found significant differences in these variables and information processing speed in the group that received the combined training. These patients also showed a significant improvement in the emotional state (p = 0.043).

CONCLUSION

The cognitive training combined with the aerobic exercises is effective to improve the cognitive performance.

Increased regional gray matter atrophy and enhanced functional connectivity in male multiple sclerosis patients

Evidence suggests that sex/gender is an important factor for understanding multiple sclerosis (MS) and that some of its neuropathological consequences might manifest earlier in males. In the present study, we assessed gray matter (GM) volume and functional connectivity (FC) in a sample of female and male MS patients (MSp) and female and male healthy controls (HCs). As compared to female MSp, male MSp showed decreased GM volume in the bilateral frontal areas and increased FC between different brain regions. Because both sets of changes correlated significantly and no differences in cognitive performance were observed, we suggest that the FC increase observed in male MSp acts as a compensatory mechanism for their more extensive GM loss and that it promotes a functional convergence between male- and female-MSp.

Analysis of "task-positive" and "task-negative" functional networks during the performance of the Symbol Digit Modalities Test in patients at presentation with clinically isolated syndrome suggestive of multiple sclerosis

An abnormal pattern of brain activations has been shown in patients with multiple sclerosis during the performance of several cognitive tasks. The aim of this study is to investigate abnormalities of the patterns of activation/deactivation in the functional networks related to "task-positive" and "task-negative" events during the execution of the Symbol Digit Modalities Test (SDMT) in patients with clinically isolated syndromes (CIS) and preserved cognitive abilities. Eighteen CIS patients within 3 months from their first clinical attack and 15 healthy controls (HC) underwent neuropsychological assessment and performed an adapted functional magnetic resonance imaging (fMRI) version of the SDMT. "Task-positive" responses to task execution and "task-negative" activity of the default mode network were compared between groups. A regression analysis was performed to investigate the correlation between fMRI results and T2 lesion load (T2 LL) and brain atrophy. Neuropsychological performance did not differ between groups. Compared to HC, CIS patients exhibited an enhanced deactivation of the "task-negative" network at the level of the posterior cingulate cortex, whereas no differences between groups were found when the patterns of "task-positive" events were compared. A regression analysis detected a correlation (p < 0.001,r ranging from 0.62 to 0.73) between T2 LL and "task-positive" activations of areas that are part of the attention network, comprising the anterior cingulate gyrus, left prefrontal gyrus and inferior parietal lobe. No correlation was found between patterns of functional modifications and brain atrophy. CIS patients experience an enhanced pattern of brain deactivations during cognitive performances, which might contribute to their normal neuropsychological status.

Neural bases of language switching in high and early proficient bilinguals

The left inferior frontal cortex, the caudate and the anterior cingulate have been proposed as the neural origin of language switching, but most of the studies were conducted in low proficient bilinguals. In the present study, we investigated brain areas involved in language switching in a sample of 19 early, high-proficient Spanish-Catalan bilinguals using a picture naming task that allowed contrasting switch and non-switch trials. Compared to the non-switching condition, language switching elicited greater activation in the head of the left caudate and the pre-SMA/ACC. When the direction of the switching was considered, the left caudate was more associated with forward switching and the pre-SMA/ACC with backward switching. The discussion is focused on the relevance of these brain structures in language control in early, high-proficient bilinguals, and the comparison with previous results in late bilinguals.

[A critical analysis of neuroimaging studies in relation to cognitive performance in multiple sclerosis patients]

Studying the cognitive impairment of multiple sclerosis (MS) patients is fundamental for a global understanding of this disease. Neuroimaging techniques might provide crucial data about the nature of this deficit and their progression. Accordingly to this idea, over the last years there has been a marked increase in the number of studies devoted to explore the possible relationship between the cognitive alterations of this clinical population and different sorts of neuropathological indexes provided by both, classical as well as by more recently developed techniques. The results of the studies using structural information provided by structural techniques, have revealed the important role of atrophic processes in the aethiology of cognitive decline in MS patients. However, this information needs to be complemented with newer indexes of neuropathological alterations in 'apparently normal' gray and white matter. On the other hand, functional magnetic resonance imaging studies have provided clear evidence of the existence and functional significance of neuroplastic processes that can mask the relationship between morphological markers of tissue damage and cognitive performance of MS patients. Those neuroplastic processes need to be taken into account as they might compensate the cognitive decline of this clinical population. In summary, the present review tries to provide a critic and integrative view of different studies assessing the relationship between cognitive impairment in MS patients and different kinds of information provided by neuroimaging techniques.

Functional magnetic resonance imaging correlates of cognitive performance in patients with a clinically isolated syndrome suggestive of multiple sclerosis at presentation: an activation and connectivity study

Background/Objective: To assess whether abnormalities on functional magnetic resonance imaging (fMRI) are related to cognitive function in patients at presentation with clinically isolated syndrome (CIS) suggestive of multiple sclerosis.

Methods: Eighteen patients with CIS and 15 healthy controls (HCs) performed an adapted fMRI version of the Paced Auditory Serial Addition Test (PASAT). According to their PASAT performance, CIS patients were divided into two groups: 10 with a low PASAT performance (<1 SD from the mean value of HCs) were considered ‘cognitive impairment’ (CI); eight patients were defined as ‘cognitively preserved’ (CP). Between-group differences in the patterns of brain activations and effective connectivity were assessed.

Results: During PASAT, compared to HCs, CIS patients showed increased activations of the bilateral inferior parietal lobe (IPL), bilateral precuneus, bilateral middle frontal gyrus (MFG), left anterior cingulate cortex (ACC), left claustrum, right thalamus and right caudate nucleus. When CIS patients were analyzed, the CI group had a more significant activation of the bilateral IPL than HCs and CP patients. Compared to CP patients, they also had more significant recruitment of the right superior parietal lobe, right cerebellum, left MFG and left ACC. The analysis of effective connectivity showed stronger connections between several regions of the right hemisphere involved in working memory function in CI patients versus CP and HC.

Conclusions: During performance of the PASAT, CIS patients show abnormalities in the patterns of cortical recruitment and connectivity related to the level of their cognitive impairment.

Voxelwise assessment of the regional distribution of damage in the brains of patients with multiple sclerosis and fatigue

BACKGROUND AND PURPOSE

Fatigue affects up to 90% of patients with MS. We assessed the regional distribution of lesions and atrophy of the normal-appearing WM and GM in patients with RRMS with fatigue compared with HC and patients with similar characteristics, but without fatigue.

MATERIALS AND METHODS

From 14 patients with RRMS without fatigue, 10 with RRMS with fatigue, and 14 HC, we acquired brain dual-echo and high-resolution T1-weighted scans. Voxel-wise distributions of GM, WM damage, and T2 lesions were compared between patients with fatigued and nonfatigued MS by using SPM5 software. We report results at P < .05, FWE corrected.

RESULTS

T2 lesion distribution and regional WM atrophy did not differ between patients with fatigued and nonfatigued MS. Compared with HC, patients with MS had significant WM atrophy in the posterior part of the corpus callosum and significant GM atrophy of the left superior frontal sulcus, left precentral gyrus, posterior cingulate cortex, right thalamus, and left middle frontal gyrus. No additional areas of atrophy were found in patients with nonfatigued MS compared with HC, whereas patients with fatigued MS also had atrophy of the left central sulcus. Atrophy in the left central sulcus and the precentral gyrus was more severe in patients with fatigued versus nonfatigued MS. In patients with MS, significant correlations were found between fatigue severity and GM atrophy in the left precentral gyrus (r = -0.73, P < .0001 uncorrected).

CONCLUSIONS

Atrophy of the primary sensorimotor area is likely to contribute to MS-related fatigue.

[Neuropsychological evaluation in multiple sclerosis]

INTRODUCTION

In recent years, advances have occurred in the description of cognitive alterations in multiple sclerosis (MS) patients and the development of tools for their assessment. However, in the clinical practice, the neuropsychological assessment of these patients is often non-specific and lacks appropriate standardization. Therefore the development of neuropsychological tests and batteries sensitive and specific for detecting the cognitive alterations in MS patients has become an important subject of study. AIM. To provide a short review about the recent developments in the neuropsychological assessment of MS patients.

DEVELOPMENT

We introduce and discuss various sensitive and valid tests that assess cognitive functions often altered in MS patients. In addition, because of their possible impact on cognitive performance, we also present guidelines for evaluating other frequently associated problems (such as mood disorders and fatigue) in MS patients.

CONCLUSIONS

The use of sensitive and specific tests makes possible to assess the neuropsychological alterations associated with MS, however, the adaptation of such tests to languages other than English (i.e. Spanish) has just begun. Besides assessing cognitive functioning, the neuropsychological assessment of MS patients should also involve the evaluation of other variables (such as depression or fatigue) that may influence cognitive performance. Improvements in assessing these domains should help to provide better and more specific protocols for the neuropsychological evaluation of MS patients.

Cortical reorganization during PASAT task in MS patients with preserved working memory functions

Cortical reorganization in multiple sclerosis (MS) is defined as a compensatory mechanism which requires MS patients to overactivate specific brain areas in order to perform the task as controls. To investigate this process with the Paced Auditory Serial Addition Test (PASAT) task, we selected 15 MS patients who performed the PASAT task within-normal limits and 10 healthy controls. Once selected, we used functional magnetic resonance imaging (fMRI) to investigate brain areas involved in PASAT performance in both groups. Results showed that the task activated the left frontal (BA6 and 9) and parietal cortex (BA7 and 40) in both groups, but MS patients showed a stronger activation in the left prefrontal cortex (BA9, 44 and 45) when compared with controls. These results confirmed those obtained post hoc by Audoin et al. [Audoin, B., Ibarrola, D., Ranjeva, J.P., Confort-Gouny, S., Malikova, I., Ali-Chérif, A.M., Pelletier, J., Cozzone, P., et al., 2003. Compensatory cortical activation observed by fMRI during cognitive task at the earliest stage of MS. Hum. Brain Mapp. 20, 51-58], and we interpreted this as showing true cortical reorganization.

Memory lateralization with 2 functional MR imaging tasks in patients with lesions in the temporal lobe

BACKGROUND

Previous studies to determine memory lateralization with functional MR imaging (fMRI) have used encoding or recall tasks. The convergence between the results of both tasks, however, is unknown.

OBJECTIVE

The objective of this study was to investigate hemispheric asymmetries of temporal lobe activity (parahippocampus and fusiform gyri) in patients with temporal lesions by using both kinds of fMRI tasks.

METHODS

By using blood oxygenation level-dependent fMRI, hemispheric asymmetries of 25 consecutive patients admitted for presurgical evaluation of memory and 12 healthy control participants were studied. Activation was induced by using the picture-encoding task (processing of complex scenes) and the hometown-walking task (requiring mental navigation through one's hometown by using landmarks given by participants themselves).

RESULTS

Results in the control group showed that both tasks activated the parahippocampus similarly. The picture-encoding task, however, yielded greater posterior activations in the parahippocampus than did the hometown-walking task. As observed in other studies, more than half the patients showed contralesional representation of memory in each task. It is important to note that estimated memory lateralization from each task was different in 30% of patients, and several cases showed clear discrepancies between both tasks.

CONCLUSION

Although previous studies showed that both tasks were useful for evaluating memory lateralization, the present study suggested that the administration of both tasks is necessary for presurgical evaluation of memory lateralization in patients with lesions in the temporal lobe. Therefore, both encoding and recall processes should at least be considered in the evaluation of memory.

[The cognitive rehabilitation process in a case of bithalamic infarction]

INTRODUCTION

One of the fundamental lines followed by Neuropsychology today focuses on rehabilitation processes and their effectiveness. Cognitive rehabilitation is an eclectic process that is dependent on a number of variables. This variability makes it necessary to establish a work plan that guides the intervention carried out by professionals and also makes it clear what objectives are to be achieved, as well as the strategies and tools that must be used to reach them. The purpose of this study is to offer a practical examination of the different points that must be developed in a cognitive rehabilitation process--exemplified here in a case of bithalamic infarction.

CASE REPORT

From a single case and from the specific needs of the individual, a thorough work plan is drawn up. This plan includes a description of everything from the choice of a practical framework for intervention and its underlying principles up to the different training processes, learning techniques and tools that were used and finally proved to be effective. The efficacy and safety of the different strategies and tools used are demonstrated by the short and long term results of the different neuropsychological examinations carried out, which at the same time proved the effectiveness of the work plan that was selected for application.

CONCLUSIONS

A clear understanding of the value of the cognitive rehabilitation processes chosen for use helps to improve the way clinical work is carried out, with the common purpose of restoring neuropsychological deficits and increasing the individual's independence and quality of life.

[Memory evaluation using functional magnetic resonance: applications in preoperative patients and in Alzheimer s disease]

The assessment of memory functions related to medial temporal lobe has become one of the most important issues on current neuropsychology. On this communication, we review the results which our research group has achieved using two functional magnetic resonance Image procedures to assess memory function: Hometown walking task and an encoding/retrieval task using complex images. Nine patients with tumoural temporal lesions performed the hometown walking task. The results of these patients showed either a bilateral or contralesional representation of memory function. These results confirm those obtained by Jokeit, Okujava y Woermann (2001), and they seem to prove that this protocol is useful to determine the preservation of memory function in the non damaged hemisphere. On the other hand, the images encoding/retrieval task has been run by two groups of four patients diagnosed as Alzheimer disease and mild cognitive impairment, and another group of five patients who participated as a control group. According to our hypothesis, the results have shown a lower activation at the left parahippocampal gyrus in mild cognitive impairment and Alzheimer disease patients than controls, just as a lower bilateral activation in the same structure for the Alzheimer group than the control group. As a whole, our results show how important may become functional magnetic resonance image for neuropsychological assessment of memory, and as a diagnostic tool for CNS diseases.