Cognitive function in multiple sclerosis improves with telerehabilitation: Results from a randomized controlled trial

Abstract

Cognitive impairment affects more than half of all individuals living with multiple sclerosis (MS). We hypothesized that training at home with an adaptive online cognitive training program would have greater cognitive benefit than ordinary computer games in cognitively-impaired adults with MS. This was a double-blind, randomized, active-placebo-controlled trial. Participants with MS were recruited through Stony Brook Medicine and randomly assigned to either the adaptive cognitive remediation (ACR) program or active control of ordinary computer games for 60 hours over 12 weeks. Training was remotely-supervised and delivered through a study-provided laptop computer. A computer generated, blocked stratification table prepared by statistician provided the randomization schedule and condition was assigned by a study technician. The primary outcome, administered by study psychometrician, was measured by change in a neuropsychological composite measure from baseline to study end. An intent-to-treat analysis was employed and missing primary outcome values were imputed via Markov Chain Monte Carlo method. Participants in the ACR (n = 74) vs. active control (n = 61) training program had significantly greater improvement in the primary outcome of cognitive functioning (mean change in composite z score±SD: 0·25±0·45 vs. 0·09±0·37, p = 0·03, estimated difference = 0·16 with 95% CI: 0·02–0·30), despite greater training time in the active control condition (mean±SD:56·9 ± 34·6 vs. 37·7 ±23 ·8 hours played, p = 0·006). This study provides Class I evidence that adaptive, computer-based cognitive remediation accessed from home can improve cognitive functioning in MS. This telerehabilitation approach allowed for rapid recruitment and high compliance, and can be readily applied to other neurological conditions associated with cognitive dysfunction.Trial Registration: Clinicaltrials.gov NCT02141386

Feasibility of remotely supervised transcranial direct current stimulation and cognitive remediation: A systematic review

“…There were 24 studies total that met the inclusion criteria. There was wide variability in the populations targeted including, but not limited to, schizophrenia [43,52,54,55,57,61] and individuals who were at risk of developing psychosis [45], multiple sclerosis [24,26,51], dementia [27][28][29], Parkinson's disease [26,49], and brain injury [50,58] (see Table 3 for details).…”

“…Of the 24 studies examined, seven studies utilized principles of cognitive remediation [28,29,44,48,58,60,61], whereas the other 17 studies utilized cognitive training exclusively. Participants completed tasks individually (n = 14/24 studies) [24,26,44,45,48,49,51,52,[54][55][56][57][58][59], or with a partner (n = 10/24 studies) [27-29, 43, 46, 47, 50, 53, 60, 61]. Studies used printed materials (n = 7/24 studies) [27-29, 48, 50, 60, 61] and internet-based and/or computer-based programs (n = 18/24 studies) [24, 26, 43-49, 51, 59] to deliver the intervention to participants.…”

“…Software also varied quite extensively in studies that utilized a computer. Posit Science was used in six different studies [24,43,45,51,52,56], however, the program varied in its usage and utility.…”

“…Training and guidance. Participant training ranged in duration and intensity and consisted of no training and self-guided treatment (n = 4/24) [44,47,51,58], having one session of training in a group or alone (n = 6/24) [26,43,46,48,53,54], weekly training [50], observational training [27,28,59] or training on an as-needed basis [52]. Training generally involved printed instruction sheets and recommended strategies for daily activities, which were explained prior to starting the intervention [60], education surrounding the human brain, cognition and how cognition affects daily functioning [43,48], educational handbooks, worksheets and information about compensatory strategies [48], as well as the protocol for the computer software [56].…”

“…Fidelity monitoring. Most research provided ongoing monitoring and support by a study technician (n = 20/24 studies) [24,26,29,43,44,45,46,47,48,49,50,51,52,[54][55][56][57][58][59][60]. Software programs that allowed for monitoring/real time feedback were utilized in most studies (n = 14/24) [24, 26, 44-52, 55, 56, 60].…”