How New Technologies Provide Benefits in Cognitive Treatments for Patients with Multiple Sclerosis

In this article, Yolanda Virué Lapuente, an occupational therapist with clinical experience treating adults with multiple sclerosis, shows us which interventions may be most effective, with the highest adherence and optimal duration, using new technologies applied to cognitive functions in patients with multiple sclerosis.

What is multiple sclerosis?

Multiple sclerosis is an inflammatory, demyelinating, neurodegenerative disease that targets the myelin of the central nervous system. The myelin is damaged by the formation of inflammatory plaques or lesions that later lead to scarring (gliosis) and the resulting demyelination, causing the signs and symptoms of the disease.

Although many hypotheses have been considered, the cause of the disease is not known for certain. Researchers have looked for the origin and development of this disease in environmental factors, viral factors, genetics, and immunological factors, without yet finding a clear, objective answer.

Demyelination affects multiple locations in the central nervous system, leaving sclerotic plaques in the white matter, hence the name multiple sclerosis. This demyelination disrupts saltatory conduction along myelinated pathways, slowing or even blocking the conduction of nerve impulses.

Epidemiology

The most recent prevalence studies indicate that detection of multiple sclerosis has increased considerably worldwide in recent decades. In Spain, multiple sclerosis affects around 55,000 people, and the country as a whole is a medium-to-high prevalence region. In Europe, the figure is around 770,000, and worldwide an estimated 2,500,000 people have it. Multiple sclerosis is the most common non-traumatic disabling neurological disorder in young adults. It usually begins at a young age, around 30, and mainly affects women, who account for three out of every four cases.

Clinical forms

Multiple sclerosis is usually classified according to its course, and three types are described:

• Relapsing-remitting (RR), the most common, occurs in 85% of cases. Symptoms appear over hours or a few days and, after complete or partial remission, the patient has no further clinical signs for a variable period that can last months or years. The patient then relapses again, and the process repeats.
• Primary progressive (PP), which occurs in 15% of patients, means the disease progresses without relapses from the start, with periods of stabilization and temporary improvement, but disability gradually worsens over time.
• Secondary progressive (SP), which occurs in 10% of patients, initially presents as relapsing-remitting and later progresses slowly and steadily. It is more common after age 40.

And clinically isolated syndrome, which does not yet meet the criteria for a diagnosis of multiple sclerosis, so some don’t consider it 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

Because multiple sclerosis can affect any part of the central nervous system, it causes many neurological symptoms. Its course usually fluctuates, but without treatment it tends to lead to varying degrees of disability, which in a high percentage of cases makes it impossible to carry out everyday activities normally. In addition, given the age at which it appears, its personal, family, and social impact is very significant, interfering with life plans during the most active stage of people’s lives.

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

All these cognitive impairments significantly affect patients’ 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 include choosing clothing appropriate for the weather, knowing where to place the items needed for personal hygiene, or following the right steps to transfer from a wheelchair to a bed, among others. In instrumental activities of daily living, they may have difficulty adjusting the speed of a power wheelchair to the environment or calculating change when shopping. At work, they may have problems actively looking for a job.

Types of intervention using new technologies

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

• Video games: these interventions generally used tablets and game consoles on which participants played video games monitored in real time that adapted to each participant’s level so that they were always challenging, as in De Giglio’s study with the Italian version of Nintendo’s Dr. Kawashima’s Brain Training.
• Computers: at home, with all the necessary accessories and technical support provided to solve any problems or issues. The games were visually appealing, with brief instructions at the start of each exercise, and they were adaptive, with difficulty graded according to the participant’s improvement.

• Semi-immersive virtual reality: interventions based on virtual reality training that provided cognitive rehabilitation through a semi-immersive virtual reality system, creating a sensory room in which participants can have an immersive experience in different realistic scenarios through sensory involvement that supports rehabilitation. The exercises could be modified in real time and adapted to the participant’s specific abilities while monitoring their movements, as in Maggio’s study using the BTS Nirvana system.

Regarding the duration and follow-up of the interventions, most studies use 25- to 30-minute sessions, five days a week, for six, eight, or twelve weeks at home. During the intervention, participants made several visits: the first at the start to complete the cognitive assessment, the second to determine the effectiveness of treatment with another assessment, and the third after the intervention ended and about eight weeks without treatment had passed, to assess whether the effects lasted.

Conclusions

This article aims to bring together the different resources and tools that have been used and studied in different studies, for the professionals who work every day on the rehabilitation of patients with multiple sclerosis. The goal is to give them more innovative, technology-based options they can use in their treatments, making the most of everything these technologies can offer.

We are at a time when new lines of treatment for patients with multiple sclerosis are emerging strongly, taking advantage of new technologies not only to address symptoms but also to overcome barriers such as distance, availability, or cost for the patient, making it much easier for them to receive treatment. It’s also important to consider how the type of treatment, because of the medium used (a computer, a game console, etc.), is perceived by the patient as a game, which leads to greater motivation and treatment adherence.

For all these reasons, the results show more significant improvement in treatments that included video games and computers, with exercises that gradually adapted to the patient’s perceived improvement.

These treatments are also the ones with the highest patient adherence, since patients find them more engaging, more personalized, and better suited to their needs.

As for the optimal duration of treatment needed to detect significant improvements, all the treatments studied lasted between six and twelve weeks, with eight weeks being the most common and considered sufficient to see these improvements.

References

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“This article has been translated. Link to the original article in Spanish:”
Cómo las nuevas tecnologías producen beneficios en los tratamientos cognitivos en pacientes con esclerosis múltiple