COGNITIVE REHABILITATION IN MS

Krishna N. Sharma. MPT (Neuro)*

INTRODUCTION that connect with primary sensory, motor, speech,

and integration areas of the cerebrum. It may result
Cognition refers to the ‘higher’ brain
in poor recognition of deficits as well as an
functions e.g. memory and reasoning. Sometimes
inability to store and retrieve new information. The
the MS patients associate the cognitive
combination of these two issues becomes a major
dysfunction to severity of physical symptoms or to
obstacle in the way to rehabilitation.10
duration of the disease which is actually a
misbelief.1,2 Cognitive problems are one of the
Testing Cognitive Dysfunctions:
most frequent symptoms of MS, which is evident
Neuropsychological testing can assist in
in about 50% of the patients.3,4 Approximately
determining the degree of cognitive impairment in
10% to 20% patients show significant cognitive
patients with MS. Wallin et al (2006) et al.
dysfunction. Symptoms may be exaggerated by
categorized the tests for cognitive dysfunctions
underlying depression.5 The most often affected
associated with MS in three main schools of
cognitive functions are - memory, attention, speed
thought:11
of processing, abstract reasoning, verbal fluency,
and executive functions.6,7,8 Widespread
1. Short screening with traditional measures
deterioration of intellectual function in MS is rare.9
in a neurologist’s office i.e. BRB-N (Brief
Repeatable Battery of Neuropsychological
Why do they occur?
Tests). It is composed of the Buschke
The Cognitive problems in MS are actually
Selective Reminding Test, the 7/24 Spatial
the result of demyelination in the cerebral tracts
Recall Test, the Paced Auditory Serial

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 ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

Addition Test (PASAT), and the Designing Interventions:

Controlled Oral Word Association Test Designing intervention is the second step of
(COWAT).12 the cognitive rehabilitation. It is intended to
2. Testing by a neuropsychologist with a improve the patient's ability to function in all
minimal (but comprehensive) aspects - personal, family, social, and vocation
neurocognitive battery i.e. MACFIMS life. Since the disease is unpredictable,
(Minimal Assessment of Cognitive progressive, and fluctuating in nature and there is a
Function in Multiple Sclerosis). It is complex interaction of motor, sensory, cognitive,
composed of PASAT, COWAT, SDMT functional, and affective impairments, it requires
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etc. periodic reassessment, monitoring, and
3. Testing with automated, computerized rehabilitative interventions. The therapist
measures in a neurologist’s office or as recognizes the deficit and includes the functionally
part of a clinical trial i.e. ANAM oriented therapeutic tasks accordingly.
(Automated Neuropsychological There are two approaches - Restorative
Assessment Metrics). It is composed of Strategies and Compensatory Strategies, which are
Procedural Reaction Time, Code believed to be helpful in the cognitive
Substitution, Sternberg Memory Search dysfunctions. Since the effectiveness of
14
etc. Restorative Strategies to cognitive rehabilitation is
largely inconclusive15, Compensatory strategies
Such an evaluation could be helpful in the (i.e. teaching to use intact skills with/without
following ways: external aids) are widely used and are suggested
• It can identify impaired and intact by most authors.
functions.
• The MS patient as well as the family
Compensatory Strategies-
members may have a better understanding
of the nature and extent of the illness. • Cognitive Structuring- The therapist
• The evaluation may help the person applies suitable learning theory and make
develop realistic vocational and other life the patient practice the cognitive task to
goals. turn it in a routine behaviors.
The results can suggest compensatory techniques. • Substitution Strategies- The therapist
teaches to use the intact cognitive abilities
to circumvent the impaired abilities. For
example- Using intact visual memory in
place of impaired verbal memory function.
• Scheduling and Timelines- The patients
are encouraged to use schedulers and
alarms.

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 Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

• Using the recording devices- It helps the

patients remember and store the important
details.
• Memory strategies- The patients are taught
and encouraged to use mnemonics, lists,
clustering, and visualization techniques
etc. to remember things.
• Assistive Technology- The patients are
advised to use handheld computers,
electronic calendars, and memory logs etc. An MS Patient using COGNIsoft-I for Cognitive
• Creating structured environment- It helps Rehabilitation
the patients find their things on certain
Tips:
fixed places to avoid the hassle in
• The activities should be conducted in quiet
forgetting and searching things.
places to avoid distractions.
• The sessions should be well-designed and
Restorative Strategies-
engaging.
Though so many verities of therapeutic tasks/
• The activity should be demonstrated first.
games/ activities are available for restoring or
• The instructions should be simple and
improving cognition, there is lack of evidence-
short.
based-practice of the restorative strategies for the
• The activities should be carried out with
cognitive deficits associated with MS. There are
the concept of Errorless Learning22 in
very less researches which confirm significant
mind. Application of the principles of
improvement by the cognitive games.16,17
Spaced Retrieval Learning,23 Story
There are many toy games for cognitive
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Memory Technique, etc. would enhance
rehabilitation e.g.- Peg Board, Puzzle-cubes,
the outcome.
Quoridor, Tenzi, Fiddlesticks etc. But in this age
• Instructions may be given in the forms of
of computer and technology few application
Audio/ video tape, printed material also. It
softwares e.g.- COGNIsoft-I, BrainTrain, MSTY
would help them remembering the
Games etc; and online cognitive rehabilitation
activities even when they are at home.
games available on multiplesclerosis.com18,
BICBrainInjuryCentre.co.uk19, Peartrees.com20, • The exercises should be done for the

Mind360.com21 etc. are proving to be effective and shorter periods of time to avoid cognitive

easily administrable. fatigue.

New skills should not be taught before the
previous skill has been strongly established.

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CORRESPONDING AUTHOR:

* Senior Physiotherapist. Multiple Sclerosis Society of India (Mumbai Chapter), Mumbai, India.
Cont: +91-9320699167. Email: dr.krisharma@gmail.com

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