Aim and logic of cognitive rehabilitation for MS patients and relatives - 6th of MS Patients' School - Haydarpasa Numune Training Hospital

1. Cognitive Rehabilitation
in Multiple Sclerosis
Erdil ARSOY, M.Sc.
Haydarpasa Numune Training Hospital - MS Unit
May 2017

2. Index
1. Introduction
2. Cognitive Rehabilitation
• Evaluation
• Computer-Based Rehabilitation
• Exercise Modules
3. Expire and Control
4. Patient Examples

3. 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.

4. 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

5. 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

6. Cognitive Rehabilitation
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.

7. 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
Cognitive Rehabilitation

8. 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

9. CB rehabilitation modules includes:
• Attention
• Memory
• Problem Solving
• Visual Intelligence
• Verbal Intelligence
Cognitive Rehabilitation – Computer-Based Rehab.
CR Main Screen

10. Attention module includes:
• Basic attention tasks
• Complex attention tasks
• Sustained attention tasks
Cognitive Rehabilitation – Exercise Modules
CR Attention Module Screen

11. Memory module includes:
• Short-term memoy tasks
• Long-term memory tasks
• Visual/verbal memory tasks
Cognitive Rehabilitation – Exercise Modules
CR Memory Module Screen

12. Problem Solving module includes:
• Cognitive flexibility tasks
• Set shifting tasks
• Categorical thinking tasks
Cognitive Rehabilitation – Exercise Modules
CR Problem Solving Module Screen

13. Cognitive Rehabilitation – Exercise Modules
Visual Int. module includes:
• Instant visual memory tasks
• Processing speed tasks
• Visual organization tasks
CR Visual Int. Module Screen

14. Cognitive Rehabilitation – Exercise Modules
Verbal int. module includes:
• Selective attention tasks
• Set shifting tasks
• Categorical thinking tasks
CR Verbal Int. Module Screen

15.  Daily exercises + evaluation outcomes
 45 - 60 min a day
 5 days a week
Expire and Control
CR Patient Control Screen

16. 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

17. Montly Follow-Up
 Evaluation of general condition
(MusiQOL)
 Daily-life activities and coping strategies
 Possible interventions
Expire and Control
CR Montly Follow-up Sheets

18. 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

19. I.G. (M, 50)
• Preschool
• Duration of MS: 4 years
• Sum of MS episodes: 3
• 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
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: memory module averages
Patient Examples – 2

20. M.O. (F, 31)
• Preschool
• Duration of MS: 13 years
• Sum of MS episodes: 2
• 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
Purple lines: overall patient average; Orange lines: patients’ average
Top left: Overall averages; top-right: memory module averages; bottom left:
problem solving module averages; bottom right: visual int. module averages
Patient Examples – 3