Multiple Sclerosis Journal

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A new cognitive rehabilitation programme for patients with multiple sclerosis: the 'MS-line! Project' Jordi Gich, Jordi Freixenet, Rafael Garcia, Joan Carles Vilanova, David Genís, Yolanda Silva, Xavier Montalban and Lluís Ramió-Torrentà Mult Scler published online 5 December 2014 DOI: 10.1177/1352458514561905 The online version of this article can be found at: http://msj.sagepub.com/content/early/2014/11/30/1352458514561905

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MSJ0010.1177/1352458514561905Multiple Sclerosis JournalJ Gich, J Freixenet

MULTIPLE SCLEROSIS MSJ JOURNAL

Short Report

A new cognitive rehabilitation programme for patients with multiple sclerosis: the ‘MS-line! Project’

Multiple Sclerosis Journal 1­–5 DOI: 10.1177/ 1352458514561905 © The Author(s), 2014. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav

Jordi Gich, Jordi Freixenet, Rafael Garcia, Joan Carles Vilanova, David Genís, Yolanda Silva, Xavier Montalban and Lluís Ramió-Torrentà

Abstract Background: Cognitive rehabilitation is often delayed in multiple sclerosis (MS). Objective: To develop a free and specific cognitive rehabilitation programme for MS patients to be used from early stages that does not interfere with daily living activities. Methods: MS-line!, cognitive rehabilitation materials consisting of written, manipulative and computerbased materials with difficulty levels developed by a multidisciplinary team. Results: Mathematical, problem-solving and word-based exercises were designed. Physical materials included spatial, coordination and reasoning games. Computer-based material included logic and reasoning, working memory and processing speed games. Conclusions: Cognitive rehabilitation exercises that are specific for MS patients have been successfully developed.

Correspondence to: Lluís Ramió-Torrentà Neurology Department, Neurodegenerative Diseases and Neuroimmunology Unit, Dr Josep Trueta University Hospital, Ctra. de França, s/n, 17007 - Girona, Spain. llramio.girona.ics@gencat. cat Jordi Gich David Genís Yolanda Silva Lluís Ramió-Torrentà Neurology Department, Dr Josep Trueta University Hospital, Girona, Spain

Keywords:  Multiple sclerosis, cognitive impairment, cognitive rehabilitation programme, MS-line! Project, neuropsychological assessment, neurorehabilitation

Jordi Freixenet Rafael Garcia Institute of Informatics and Applications, University of Girona, Spain

Date received: 12 May 2014; revised: 27 July 2014; 6 October 2014; accepted: 7 October 2014

Joan Carles Vilanova Radiology Service, Clínica Girona, Spain

Introduction Cognitive impairment, which can have a significant impact on quality of life, has a prevalence in multiple sclerosis (MS) of between 43% and 65%, and can have an early onset. The most frequently impaired cognition-related domains are memory, processing speed, attention, and executive function.1 Cognitive dysfunction has only recently been recognised as an important symptom in MS and treatment for it is often delayed particularly as patients tend to prioritise their work over attending cognitive rehabilitation sessions. However, cognitive rehabilitation therapy should begin upon a confirmed diagnosis of MS in the absence of effective pharmacological therapies and, to this end, new interventions are required.2 The publication in 2005 of neuroimaging studies showing brain neuroplasticity or compensatory mechanisms in the early phases of MS before the appearance of cognitive decline provided the stimulus to develop MS-line!3 This evidence, together with the

identification of a gap between initial diagnosis and the moment when patients started neurorehabilitation, showed the need to develop an MS-specific programme. The exercises developed take into account the cognitive alterations found in MS (memory, executive function and processing speed) and are aimed at functional restitution based on the hypothesis of neuroplasticity.

Xavier Montalban Multiple Sclerosis Centre of Catalonia (Cemcat), Department of NeurologyNeuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain

MS-line! provides a new, freely available, cognitive rehabilitation programme for MS patients that can be used at home from the early stages of the disease without affecting daily activities. Material and methods MS-line! was developed by a multidisciplinary team of neuropsychologists, linguists, speech therapists, software engineers, computer technicians, mathematicians and other professionals between 2005 and 2008 at the MS Unit of Dr Josep Trueta University Hospital.

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Multiple Sclerosis Journal  Written, manipulative, and computer-based materials with up to five difficulty levels with clues and an attractive design to enhance adherence were included. In the case of computer-based materials, games available on the internet were adapted. Three topics thought to be of general interest – ‘Wonders of the World’, ‘Cinema’, and ‘Arts’ – were selected to create virtual rooms where patients have to learn specific written texts with visual media in an unlimited time period before responding to questions about the text, first as a free recall exercise but then with the prompt of multiple choice answers if required. Results The following materials were developed. Written material This consisted of mathematical, problem-solving and word-based exercises. There were: 128 mathematical problems (four levels of difficulty); 435 problemsolving exercises related to memory (three levels), calculation (three levels), mental agility (three levels), verbal intelligence (three levels), spatial orientation (three levels), attention (three levels), logic (three levels), numerical intelligence (three levels), and language and communication (three levels); 114 riddles based on puns, anagrams and double meanings and ten wordplay games in which new words are generated from the letters of an existing word (called Enigmarius and Verbàlia, respectively); and 24 crossword and 24 word search puzzles with 120 pictures by type of puzzle. Other ‘mathemagic’ materials, combining magic and mathematics, consisted of three main types of exercises: two mathemagic squares linked to logical series of numbers to complete each one, 39 logical series of numbers (three levels) and ten mathemagic games. Manipulative material This consisted of spatial games with blocks to create geometric figures (Structuro, Volumes a Construire and Soma 4), Krur (traditional African game played with seeds), Origami (seven figures with different levels of difficulty), ten two-handed coordination games (e.g. making circles with the right hand on the stomach while gently tapping the head with the left hand), five- and seven-piece Tangram and individual games such as Space Shuttle and Peg-Solitaire Hoppers. The daily five-minute exercise was chosen from Soma 4, five-piece Tangram, Space Shuttle and Peg-Solitaire Hoppers.

Computer-based material This included logic and reasoning games, such as Krur, Codebreaker, Thinkin (ten different calculation, reasoning, and memory games), Gtans (e.g. sevenpiece Tangram), Tuxmath (adaptation of Scrabble with arithmetic operations), Mahjong (traditional Chinese game), Connect Four (also known as Four-in-a-Line), computer chess, Traffic (a game simulating traffic) and Sudoku (logic-based, number-placement puzzle); working memory games such as Vertical 1, 2 and 3 and Horizontal 1, 2 and 3, visuospatial memory games such as Concentration and Lpairs; and language games such as Anagramarama, proverbs (rearranging words to produce a well-known proverb), Hangman and Word Hunt (timed word search puzzle); spatial orientation games such as Tetris; working memory games, comprising memorising sequences of letters, anagrams, arithmetic operations, and block counting (three-dimensional block figures that can be rotated); and processing speed games such as SDLPong (pingpong against the computer), Lbreakout (bricks are dissolved using a mouse-controlled ball) and a series of virtual rooms to navigate through. Several of the New Wonders of the World and the Great Pyramid of Giza were chosen to create the first series of virtual rooms. Each room contained four pictures, each with an explanatory text and five questions. Virtual rooms related to cinema showed a history of modern cinema decade by decade. Each room contained four pictures representing four films, each with five accompanying questions. Finally, virtual rooms related to arts included American impressionism and seventeenthcentury Italian paintings from the Thyssen-Bornemisza Museum collection (Spain). There were five questions per painting. Discussion We have designed a new cognitive rehabilitation programme for MS patients called MS-line! Although cognitive rehabilitation programmes have previously been developed and some have been developed for domain-specific cognitive functions, these programmes have not tended to target specific neurological diseases, focussing rather on general cognitive impairment, and some have been profit orientated (Table 1). MS-line! will be distributed free of charge via the project website (access will be given to patients on receiving a clinical report by a neurologist). The first material, called MS-line! Memory, will be aimed at memory rehabilitation (virtual rooms) (www.ms-line. org from June 2015, in English, Spanish and Catalan)

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J Gich, J Freixenet et al. Table 1.  Cognitive rehabilitation programmes used in MS patients. Programme / author

Cognitive functions

Advantages

Disadvantages

Published by

Results

Aixtent®; New version CongniPlu®

Aixtent: Attentional functions. CogniPlus: Attention, memory, executive functions, neglect, visuospatial skills.

Available in 14 languages Different levels of difficulty Modules can be purchased according to needs.

Sold exclusively to professionals Not specific to MS.

Plohmann et al.4 n = 22. No control group EDSS: 3.8 ± 1.8 Years of education: 13 ± 2 Years of evolution: 16 ± 9

Improves attention and fatigue.

Rehacom® www. rehacom. com Hasomed

Attention, memory, executive functions, visual field.

Has been used in several cognitive investigations in MS. Available in 18 languages New versions are periodically introduced.

Sold exclusively to professionals Not specific to any MS.

Mattioli et al.5 Study group: n = 10 EDSS: 2.5. Years of education: 8 Years disease of evolution: 16 Control group: n = 10 EDSS: 1.5 Years of education: 9 Years of evolution: 18 Solari et al.6 Rehacom in both treatment groups: specific exercises (memory & attention) and control group (constructional and visuospatial coordination). Specific intervention (SG): n = 42. EDSS: 3.0. Education: 47% Elementary school 53% High school Unspecific intervention: n = 40. EDSS: 4.0. Education: 45% Elementary school 55% High school Tesar et al.7 Study group: n = 10 EDSS: 4.5 Years of education: NR Years of evolution disease: 8,0 Control group: n = 10 EDSS: 4.4 Years education: NR Years of evolution: 10.5

Improves attention, information processing, executive functions, and depression.

Brissart et al.8 n = 24 No control group 10 sessions in 6 months EDSS: 2.8 Years of education: 11 Years of evolution: 11

Improves verbal memory, visuospatial memory, verbal fluency, and response to conflicting orders.

ProcogSEP® Brissart and Leroy

Semantic memory, language, visuospatial skills, episodic memory, verbal and visual working memory, verbal fluency, attention, calculation, associative memory, and executive functions.

Developed for patients with cognitive impairment in MS.

Few sessions (10 sessions over a 6 month period).

Both groups improve No differences between groups Data does not support specific cognitive rehabilitation.

Improves executive functions and spatial constructional abilities.

(Continued)

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Multiple Sclerosis Journal  Table 1. (Continued) Programme / author

Cognitive functions

Advantages

Disadvantages

Published by

Results

MindFit® New version CogniFit Personal Coach

Attention, language, executive functions, memory, processing speed, and spatial perception.

Can be done at home Distributed by pharmacological company and free for patients with MS Several levels of difficulties Programme allows customisation.

Not specific to MS.

Shatil et al.9 Study group: n = 59 EDSS: 3.1. Years of education: unknown Years of evolution: unknown Control group: n = 48 EDSS: 2.7 Years of education: unknown Years of evolution: unknown

Improves general memory, visual working memory and verbal working memory Provides adherence data for home-based exercises.

Brain Gym®

Attentional functions, memory and executive functions (planning and verbal tasks)

Home-based exercises

No longer available.

Brenk et al.10 Study group: n = 27 EDSS: < 5. Years of education: unknown Years of evolution: unknown Healthy control group: n = 14 (matched by age, sex and IQ).

Improves short term and working memory, complex attention functions, and visuoconstructive performances Verbal long term memory deteriorated.

VILAT G.1 Hildebrandt

Memory. Working memory.

Home-based exercises.

No longer available.

Improves working memory and long term memory.

BrainStim Penner IK

Working memory (orientation, visuospatial skill, visual memory of objects and numbers).

Different levels of difficulty Initially developed for MS.

Not yet available.

Hildebrandt et al.11 Study group: n = 17 EDSS: 2.9. Years of education: 11 Years of evolution: 11 Control group: n=25 EDSS: 2.7 Years of education: 11 Years of evolution: 8 Vogt et al.12 Study group: n = 15 EDSS: 3.2 Years of evolution: 9 Control group: n = 15 Years of evolution: 12 EDSS: 3.2

Improves working memory and fatigue.

EDSS: Expanded Disability Status Scale.

and a full range of material will be released in the following months. MS-line! provides a wide range of exercises aimed at reducing the impact of neurological deterioration on patients with MS (Table 2). Although validation is still required, a pilot study, presented in an accompanying paper, suggests that this programme has the potential to achieve this aim. Acknowledgements Mathematical problems were designed by Estalmat Group under the coordination of Josep Grané. Problem-solving exercises were developed by

Agustín Fonseca and Sergio F. Aldrey. Enigmarius and Verbàlia were created by Màrius Serra. Crossword and word search puzzles were developed by Faustino Dieguez-Vide. Mathemagic puzzles were created by Fernando Blasco. Structuro and Volumes a construire were distributed by Nathan. Origami figures were created by Miquel Noguera. Seven-piece Tangram was distributed by Miniland. Peg-Solitaire Hoppers was created by Nob Yoshigahara and distributed by ThinkFun and Mercurio Distribuciones. As well as the authors, Josep Quintana, and Mariano Cabezas, from the University of Girona, and Eva Palacios, Emma Rodríguez Noriega, Rebeca Menéndez helped in the selection and adaptation of computer-based

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J Gich, J Freixenet et al. Table 2.  Strengths of MS-line! MS-line! summary: 1. Specifically created for MS patients to fill the current gap in time between disease diagnosis and the initiation of a fully integrated neurorehabilitation programme/centre. 2. The material has several degrees of difficulty (three levels for written materials and up to five levels for computerbased materials). 3. In order to promote adherence: - Clues are provided to solve problems (the aim is for patients to be able to solve problems for themselves generating a positive effect and avoiding frustration). - Material has been designed in as attractive a manner as possible. - Family members are involved in the treatment. 4. It is designed for home use from the early stages of the disease and to avoid interfering with daily activities. 5. MS-line! will be a freely accessible cognitive rehabilitation programme, available in English from 2015.

games. Agustín Fonseca helped in the design of the Virtual Rooms. The Thyssen-Bornemisza Museum (Madrid, Spain) gave permission to use their existing virtual visits to the space. We are very grateful to all of the above for their disinterested cooperation.

Neurol Neurosurg Psychiatry 1998; 64: 455–462. 5. Mattioli F, Stampatori C, Zanotti D, et al. Efficacy and specificity of intensive cognitive rehabilitation of attention and executive functions in multiple sclerosis. J Neurol Sci 2010; 288: 101–105.

Conflict of interest The authors declare that there is no conflict of interest with any financial organisation regarding the material discussed in the manuscript.

6. Solari A, Motta A, Mendozzi L, et al. Computeraided retraining of memory and attention in people with multiple sclerosis: a randomized, double-blind controlled trial. J Neurol Sci 2004; 22: 99–104.

Funding This work was supported by Biogen Idec, Merck Serono, Bayer Healthcare, Teva Pharmaceutical Industries, La Caixa, Fundación Obra Social Caja Madrid and Acadèmia de Ciències Mèdiques i de la Salut de Catalunya i de Balears.

7. Tesar N, Bandion K and Baumhackl U. Efficacy of a neuropsychological training programme for patients with multiple sclerosis – a randomised controlled trial. Wien Klin Wochenschr 2005; 117: 747–754.

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8. Brissart H, Leroy M and Debouverie M. Cognitive rehabilitation in multiple sclerosis: preliminary results and presentation of a new program, PROCOG-SEP. Rev Neurol (Paris) 2010; 166: 406–411. 9. Shatil E, Metzer A, Horvitz O, et al. Home-based personalized cognitive training in MS patients: a study of adherence and cognitive performance. NeuroRehabilitation 2010; 26: 143–153. 10. Brenk A, Laun K and Haase CG. Short-term cognitive training improves mental efficiency and mood in patients with multiple sclerosis. Eur Neurol 2008; 60: 304–309. 11. Hildebrandt H, Lanz M, Hahn HK, et al. Cognitive training in MS: effects and relation to brain atrophy. Restor Neurol Neurosci 2007; 25: 33–43. 12. Vogt A, Kappos L, Stöcklin M, et al. BrainStimWirksamkeit eines neu entwickelten kognitiven trainingsprogramms bei MS. Neurol Rehabilitation 2008; 14: 93–101.

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