cognitive rehabilitation in ms

Cognitive Rehabilitation

in Multiple Sclerosis

Erdil ARSOY, M.Sc.

Haydarpasa Numune Training Hospital - MS Unit

May 2017

Index

1. Introduction

2. Cognitive Rehabilitation

• Evaluation

• Computer-Based Rehabilitation

• Exercise Modules

3. Expire and Control

4. Patient Examples

Introduction

% 40–65 of multiple sclerosis patients show cognitive impairment1

In early phase of MS impairments manifest themselves as:

• Information processing speed

• Sustained attention

• Verbal memory

• Verbal fluency

• Working memory2.

1- Chiaravalloti, Nancy D., and John DeLuca. "Cognitive impairment in multiple sclerosis." The Lancet Neurology 7.12 (2008): 1139-1151.

2- Benedict, Ralph HB, et al. "Validity of the minimal assessment of cognitive function in multiple sclerosis (MACFIMS)." Journal of the International

Neuropsychological Society 12.04 (2006): 549-558.

In late phase of illness impairments manifest themselves as:

• In addition to decreasing deficits in sustained attention, working

memory and verbal influency

• Decreases in aquiring new verbal information3.

3- Bobholz, Julie A., and Stephen M. Rao. "Cognitive dysfunction in multiple sclerosis: a review of recent developments." Current opinion in

neurology 16.3 (2003): 283-288.

Introduction

Cognitive impairments in MS lead to decline in:

• Daily-life activites

• Business life

• Social and leisure activities

• Perception of health

• Consequently in quality of life4

4- Rao, S. M., Leo, G. J., Bernardin, L., & Unverzagt, F. (1991). Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction.

Neurology, 41(5), 685-691.

Introduction


What is the aim of CR?

• Restore the cognitive functions due to impairments

• Improve connected treatments

• Decrease maladaptive behavioral patterns

• Enhance treatment of MS functionality5

* Main aim is not to achieve a cognitive but improve a daily life task

5- Kreutzer, J. S., Caplan, B., & DeLuca, J. (2011). Encyclopedia of Clinical Neuropsychology; Springer, ss: 628-630.

What is the logic behind CR?

Neuroplasticity; brain’s ability of reconstruction and create new

interneuronal connections via environmental factors and learning

Features of neuroplasticity are:

• Intensity

• Duration

• Conditioning

• Imitation6

6- https://www.slideshare.net/smarkbarnes/brain-science-applying-neuroplasticity-principles-to-higher-education-1340661


Test batteries which identify cognitive impairments in MS are:

BRB-N

Selective Reminding Test

SDMT

PASAT

Verbal Fluency Test

10/36 Spatial Recall Test

MSNQ

Cognitive Rehabilitation - Evaluation

CB rehabilitation modules includes:

• Attention

• Memory

• Problem Solving

• Visual Intelligence

• Verbal Intelligence

Cognitive Rehabilitation – Computer-Based Rehab.

CR Main Screen

Attention module includes:

• Basic attention tasks

• Complex attention tasks

• Sustained attention tasks

Cognitive Rehabilitation – Exercise Modules

CR Attention Module Screen

Memory module includes:

• Short-term memoy tasks

• Long-term memory tasks

• Visual/verbal memory tasks


CR Memory Module Screen

Problem Solving module includes:

• Cognitive flexibility tasks

• Set shifting tasks

• Categorical thinking tasks


CR Problem Solving Module Screen


Visual Int. module includes:

• Instant visual memory tasks

• Processing speed tasks

• Visual organization tasks

CR Visual Int. Module Screen


Verbal int. module includes:

• Selective attention tasks

• Set shifting tasks

• Categorical thinking tasks

CR Verbal Int. Module Screen

Daily exercises + evaluation outcomes

45 - 60 min a day

5 days a week

Expire and Control

CR Patient Control Screen

Weekly Follow-Up (phone/e-mail)

Difficulties in follow-up (+/-)

Evaluation about exercises

Which exercies completed along the week?

How many hours did patient study a day ?

Was any extra exercises given?

Evaluation of mental condition

Expire and Control

CR Weekly Follow-up Sheets

Montly Follow-Up

Evaluation of general condition

(MusiQOL)

Daily-life activities and coping strategies

Possible interventions

Expire and Control

CR Montly Follow-up Sheets

A.Y. (F, 34)

• Highschool

• Duration of MS: 9 years

• Sum of MS episodes: 8

• Last episode: June 16

• EDSS: 2,5

• Beck: 14

Scores before CR

• SRT: 5/8/8/8/10/11 LTM: 10

• 10/36: 7/4/7 LTM: 3

• SDMT: 29

• PASAT: 48

• WLT (Sum): 62

• Stroop (Time Dif): 42.0 sec

Exercises

• Visual memory, instant memory,

processing speed, working memory

Patient Examples – 1

Purple lines: overall patient average; Orange lines: patients’ average

Top left: Overall averages; top-right: visual int. module averages; bottom

left: attention module averages; bottom right: verbal int. module averages

I.G. (M, 50)

• Preschool



• Last episode: May 16

• EDSS: 2,5

• Beck: 15

Scores before CR

• SRT: 5/5/6/5/8/7 LTM: 5

• 10/36: 2/3/3 LTM: 4

• SDMT: 29

• PASAT: 53

• WLT (Sum): 61

• Stroop (Time Dif.): 34.0 sec

Exercises

• Instant verbal memory, long-term

memory, processing speed, visual

attention


Top left: Overall averages; top-right: visual int. module averages; bottom

left: attention module averages; bottom right: memory module averages


M.O. (F, 31)

• Preschool



• Last episode: Nov 12

• EDSS: 1,5

• Beck: 1

Scores before CR

• SRT: 4/5/6/8/8/9 LTM: 6

• 10/36: 1/4/5 LTM: 3

• SDMT: 50

• PASAT: 48

• WLT (Sum): 57

• Stroop (Time Dif.): 38.6 sec

Exercises

• Short-term visual memory, long-term

verbal memory, visual attention,

processing speed


Top left: Overall averages; top-right: memory module averages; bottom left:

problem solving module averages; bottom right: visual int. module averages


cognitive rehabilitation in ms

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