Yolanda Virué Lapuente, an occupational therapist with clinical experience in the management of adults with Multiple Sclerosis, shows us in this article what the most effective interventions can be, with greater adherence and optimal duration, with the use of new technologies applied to cognitive functions in patients with multiple sclerosis.

What is multiple sclerosis?

Multiple sclerosis is an inflammatory, demyelinating and neurodegenerative disease, whose target is the myelin of the central nervous system, which is damaged by the formation of plaques or inflammatory lesions that subsequently lead to scarring (gliosis) and consequent demyelination, causing the signs and symptoms of the disease.

Although multiple hypotheses have been considered, the cause of the disease is not known with certainty. Attempts have been made to look for the origin of the causes and development of this disease in environmental factors, viral factors, genetic basis and immunological factors, without yet finding a clear and objective answer.

Demyelination affects multiple locations of the central nervous system, leaving plaques of sclerosis in the white matter, hence the name multiple sclerosis. This demyelination process produces an alteration in the jumping conduction of the myelinated pathways, slowing and even blocking the conduction of the nerve impulse.

Epidemiology

The most recent prevalence studies indicate that the detection of multiple sclerosis has increased considerably worldwide in recent decades. In United States, multiple sclerosis affects about 1.000.000 people, being a region with a medium-high prevalence of the disease throughout its geography. In Europe the figure is around 770,000 and, in the world, it is estimated that some 2,500,000 people suffer from it. Multiple sclerosis is the most common non-traumatic disabling neurological disorder in young adults. Its onset occurs at a young age, around 30 years of age, affecting mostly women in a proportion of three out of four people.

Clinical forms

Multiple sclerosis is usually classified on the basis of its course, with three types being described:

• Recurrent-remitting (RR), which is the most common, appearing in 85% of cases. Symptoms appear within hours or a few days and after total or partial remission, the patient remains without further clinical manifestations for a variable period that may last months or years. Subsequently, the patient relapses and this process is repeated successively.

• Primarily progressive (PP), which appears in 15% of patients, means that the disease progresses without flare-ups from the onset with temporary stabilizations and improvements, but disability continues to worsen gradually over time.
• Secondary progressive (SP), which appears in 10% of patients, initially manifests as relapsing-remitting and then progresses slowly and progressively. It is more frequent above the age of 40 years.

And the isolated clinical syndrome, which does not yet meet the requirements to be considered as a diagnosis of multiple sclerosis and is therefore not considered by some as a type. It refers to a first episode of neurological symptoms caused by inflammation and demyelination in the central nervous system, with complete or partial recovery.

Functional implications

Multiple sclerosis, when affecting any part of the central nervous system, causes multiple symptoms in the neurological sphere. Its course is usually fluctuating, but without treatment, it usually leads to varying degrees of disability, which in a high percentage of cases makes it impossible to carry out normal or usual activities of daily living. Moreover, if we take into account the age at which it arises, its impact is very significant from a personal, family and social point of view, interfering in their vital development and altering their plans in the most active phase of their lives.

Numerous studies affirm that cognitive impairment is present in 40 to 70% of patients with multiple sclerosis, affecting the speed of information processing, attention, memory and executive functions. And although the chronic phases of the disease are more frequently associated with cognitive impairment, some recent studies have shown that this impairment may be detectable from the onset of the disease.

All these alterations in cognitive functions in patients have a major impact on their occupations, such as activities of daily living, and can have a significant impact on employment and quality of life, depending on the condition and stage of the disease.

Some of the activities of daily living in which patients with multiple sclerosis may have difficulties are the selection of clothing appropriate to the climate, knowing how to place the necessary utensils for hygiene or following the appropriate steps to properly perform the transfer from the wheelchair to the bed, among others. In the instrumental activities of daily living, difficulties are encountered in adapting the speed of the electric wheelchair to the conditions of the environment, calculating the return of money in a purchase, etc. In the area of work, they may present problems in the active search for employment.

Types of intervention using new technologies

Most of the intervention strategies addressed in many studies are through video games and computers at home, stimulating cognitive functions such as working memory, attention, processing speed and visuospatial skills, showing a very high adherence to treatment (over 90%) and improvements in the cognitive functions studied.

• Video games: we found interventions that generally used tablets and video game consoles with which participants played video games controlled in real time and which were adapted to the level of each participant to provide a challenge at all times. As in De Giglio’s study with the Italian version of Nintendo’s Dr. Kawashima’s Brain Training.

• Computer: at home, providing also all the necessary accessories and assistance from a technician in order to solve possible problems or incidents. The games were visually attractive, with a brief instruction at the beginning of each exercise, adaptive and adjustable in difficulty according to the participant’s improvement.

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• Semi-immersive virtual reality: interventions based on virtual reality training that consisted of providing cognitive rehabilitation through a semi-immersive virtual reality system, creating a sensory room in which the participant can live an immersive experience in different realistic scenarios through sensory involvement that facilitates rehabilitation. Exercises could be modified in real time and adapted to the specific abilities of the participant and by monitoring their movements, as in Maggio’s study using the BTS Nirvana system.

Regarding the duration and follow-up of the interventions, the vast majority of studies perform sessions of between 25 and 30 minutes, five days a week, for six, eight or twelve weeks at home. Throughout the intervention, participants made several visits, the first being at the beginning to complete the cognitive assessment, the second to determine the effectiveness of the treatment with another assessment, and the third after the end of the intervention and after eight weeks without treatment to assess the permanence of the effects.

Conclusions

This article aims to bring together the different resources and tools that have been used in different studies and that have studied their effects for the different professionals who, on a daily basis, are dedicated to the rehabilitation of patients with multiple sclerosis. The aim is to offer them more innovative options, based on new technologies, so that they can apply them when carrying out their treatments, taking advantage of everything they have to offer.

We are at a time when new lines of treatment for patients with multiple sclerosis are appearing with force, which take advantage of new technologies not only to address the symptoms but also to overcome barriers often of distance, availability or cost for the patient, allowing them to receive treatment in a much simpler way. In addition, it is important to consider how the type of treatment, because of the medium in which it is treated, with a computer, a video console, etc., is perceived by the patient as a game that achieves greater motivation and adherence to treatment.

In view of the above, the results show a more significant improvement in the treatments that included the use of video and computer games with exercises that were progressively adapted to the improvement perceived by the patient.

This type of treatment also coincides with the fact that they are the most adhered to by the patient because they are considered more attractive, more personalized and adapted to his or her needs.

Regarding the optimal duration of the treatment with the aim of being able to detect significant improvements derived from it, all the treatments studied have a duration of between six and twelve weeks, eight weeks being the most recurrent and understood to be sufficient time to be able to appreciate these improvements.

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