Date Presented 04/22/21
Computer-based programs, conventional cognitive rehabilitation, neurologic music therapy, and noninvasive brain stimulation are effective in improving memory and learning, processing speed, language, executive function, or general cognitive skills. However, the retention of treatment effects and the generalizability of the cognitive improvement to the daily occupations are not clear. Including a predetermined single outcome, functional and long-term outcomes are needed in future studies.
Primary Author and Speaker: Yu-Chih Chen
Contributing Authors: Nicole Gerhardt, Christina Calhoun Thielen, Winnie Dunn, and Mary Jane Mulcahey
PURPOSE: This systematic review is to provide up-to-date evidence on cognitive rehabilitation interventions for people with multiple sclerosis (MS) and to inform clinical practice and future research. RATIONALE: 40-70% of MS clients have cognitive impairments that affect their daily functions (Pineau et al., 2019). It is therefore important to keep abreast of the latest cognitive intervention studies by providing an updated systematic review followed previously published one (Goverover et al., 2018) to inform practice.
DESIGN: A systematic review.
METHOD: We searched Medline, PsycINFO, CINAHL, and PubMed from 2016 to March 2020, using Boolean operators to combine the following search terms: multiple sclerosis, MS, cognitive, cognitive dysfunction, cognitive rehabilitation, remediation, intervention, training, and stimulation. Only studies published in English were included. After removing duplicates, two reviewers independently assessed each study based on predetermined exclusion criteria, including 1) not in MS population, 2) not an intervention study design, 3) not related to cognitive interventions, 4) included a pediatric population, 5) used an exercise, dietary, or pharmacological intervention, 6) was a review, 7) was a theoretical article, or 8) was not peer-reviewed. Following this, two reviewers extracted data regarding participant characteristics, cognitive domain treated, interventions used, and outcomes. The level of evidence of each study was rated based on American Academy of Neurology Classification of Evidence Schemes (AAN Class). Any discrepancy in evidence level was resolved by reviewing AAN rating manual and discussion.
RESULTS: An initial search yielded 781 articles. After a full review, 23 studies were included. We rated 2 studies as Class I evidence (Chiaravalloti et al., 2018; Lincoln et al., 2020), 14 as Class II, and 7 as Class III. Cognitive domains treated included attention, memory and learning, processing speed, language, executive functioning, and non-specified general cognitive skills. Interventions included computer-based programs (CBP), conventional cognitive rehabilitation (CCR), neurologic music therapy (NMT), and non-invasive brain stimulation (NIBS) technique. Of these four interventions, CCR was shown to improve memory and learning, processing speed, executive function, and general cognitive skills. Many studies used a combined approach, with CCR plus CBP, and were able to improve processing speed, language, executive function, and general cognitive skills. Using CBP alone also showed improvement in language. A combination of CCR and NIBS showed improvement in processing speed as well as memory and learning; a combination of CCR and NMT showed improvement in memory and learning. The effect of interventions in improving attention is inconclusive. For the outcome measures, 70% of the studies in this review did not include long-term or functional outcomes in their designs.
CONCLUSION: Although most of the studies were Class II evidence-level as a result of a lack of a clearly-defined primary outcome, four types of intervention or combinations of interventions resulted in improvements in cognitive performances. The retention of treatment effects and the generalizability to real-world occupational performance are unknown, as there were only a few studies that included functional and long-term outcomes in their design. Future studies with improved methodologies are needed and the exploration of using mixed cognitive interventions can be a future research direction.
IMPACT STATEMENT: Cognition is a foundation of performing daily occupations. Identifying effective evidence-based treatments to ameliorate cognitive deficits for improving MS clients’ daily functions is critical to OT practice.
References
Chiaravalloti, N. D., Goverover, Y., Costa, S. L., & DeLuca, J. (2018). A Pilot Study Examining Speed of Processing Training (SPT) to Improve Processing Speed in Persons With Multiple Sclerosis. Frontiers in neurology, 9, 685. https://doi.org/10.3389/fneur.2018.00685
Goverover, Y., Chiaravalloti, N. D., O'Brien, A. R., & DeLuca, J. (2017). Evidenced-Based Cognitive Rehabilitation for Persons With Multiple Sclerosis: An Updated Review of the Literature From 2007 to 2016. Archives of Physical Medicine and Rehabilitation, 2(99), 390-407. https://doi.org/10.1016/j.apmr.2017.07.021
Lincoln, N. B., Bradshaw, L. E., Constantinescu, C. S., Day, F., Drummond, A. E. R., Fitzsimmons, D., Harris, S., Montgomery, A. A., das Nair, R., Morgan, M., Scott, J., Evans, S., McKeown, S., Bharadia, T., Moore, P., Young, C., Sharrack, B., Isaac, C., Griffths, D., & Fixter, V. (2020). Cognitive rehabilitation for attention and memory in people with multiple sclerosis: a randomized controlled trial (CRAMMS). Clinical rehabilitation, 34(2), 229-241. https://doi.org/10.1177/0269215519890378
Pineau, F., Socha, J., Corvol, J., Louapre, C., Assouad, R., Maillart, E., Lubetzki, C., & Papeix, C. (2019). Impact of an adaptive program for cognitive and emotional deficits (ADACOG program) in multiple sclerosis patients with cognitive impairments. Revue Neurologique, 175(5), 305-312. https://doi.org/10.1016/j.neurol.2018.08.008
