John DeLuca, PhD, on Cognitive Rehabilitation Tools for Relapsing-Remitting MS

In this podcast, Dr DeLuca discusses the clinical course and prognosis of cognitive impairment in relapsing-remitting multiple sclerosis, as well as cognitive rehabilitation tools that are currently available and on the horizon (transcript below).

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John DeLuca, PhD, is the Senior Vice President for Research at the Kessler Foundation, and a professor in the Department of Physical Medicine & Rehabilitation and of Neurology & Neurosciences at Rutgers New Jersey Medical School.

References:

• DeLuca J, Chiaravalloti ND, Sandroff BM. Treatment and management of cognitive dysfunction in patients with multiple sclerosis. Nat Rev Neurol. 2020;16:319-332. doi:10.1038/s41582-020-0355-1
• Kalb R, Beier M, Benedict RHB, et al. Recommendations for cognitive screening and management in multiple sclerosis care. Mult Scler J. 2018;24(3):1665-1680. doi:10.1177/1352458518803785

Transcript:

Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. Today, I’m joined by Dr. John DeLuca, who is the Senior Vice President for Research at the Kessler Foundation, and a professor in the Department of Physical Medicine & Rehabilitation and of Neurology & Neurosciences at Rutgers New Jersey Medical School. Thank you for joining me today, Dr. DeLuca.

Dr DeLuca: Thank you. My pleasure.

Christina Vogt: Today, we will be discussing cognitive impairment in relapsing-remitting multiple sclerosis and the cognitive rehabilitation tools that are available and on the horizon for this patient population.

Christina Vogt: So first, could you review the clinical course and prognosis of cognitive impairment in the context of relapsing-remitting MS?

Dr DeLuca: Sure. You know, it was only 3 decades ago that it was thought that cognitive impairment was not a feature of multiple sclerosis. So, we've come a long way. Today, we know that 2 out of every 3 patients with MS have some degree of cognitive impairment. In relapsing remitting MS, that's about 50% of the patients, and it increases with progressive MS. The important thing about cognitive impairment in relapsing remitting MS is that early diagnosis of cognitive impairment can have a significant impact on understanding the progression and treatment of the disease.

So, for example, we know that diagnosis of cognitive impairment early in a disease, even at diagnosis, can have a significant predictor of future decline, cognitive decline. It predicts the change from relapsing remitting to progressive MS, and it's also highly correlated with gray matter volume loss. So, the combination at diagnosis of gray matter volume loss and cognitive impairment has a huge predictive value in care for our patients. So, we know that the National MS Society has put out guidelines for cognitive care, published in 2018 in Multiple Sclerosis Journal by Kalb et al, and there they talk about establishing a baseline early on in the disease of cognitive impairment followed up by annual evaluations. These are really important because now, we can track and follow patients with cognitive impairment and with highly predictive value.

Christina Vogt: Could you discuss the different cognitive rehabilitation tools that are available for patients with relapsing remitting MS? What is currently considered standard-of-care for the management of cognitive dysfunction in this patient population?

Dr DeLuca: When we talk about cognitive rehabilitation, in general we talk about restorative approaches and compensatory approaches. In general, the compensatory approaches have better outcomes, but the restorative approaches have significant importance as well. There's really good data on cognitive rehabilitation in persons with MS. There's now more than 80 published papers, with the vast majority showing significant improvement not only in cognitive performance, but everyday life activity, and tied to a variety of brain metrics, functional imaging metrics that are associated with improvements.

In general, the restorative approaches have been primarily utilization of computer programs, programs designed to improve cognitive processing, and those programs have shown to be fairly effective. On the compensatory side, there are a number of approaches. One that we've developed was called the Modified Story Memory Technique, which is really designed to teach patients techniques to, in the use in their everyday lives to improve their memory performance. And, what I like about these techniques is, it's an interactive intervention where the patients learn how to utilize this in their everyday life. The restorative approaches tend to be more exercises to try to strengthen existing cognitive impairments. They both have a value, and I think it's important to realize that they are different, and they may be a different value depending on the course of the disease.

So, when you talk about standard of care, unfortunately, standard of care right now is pretty much, people don't do much. And that's really, really problematic for our patients. Again, you're talking about 2 or three 3 patients who have cognitive impairment. It's time to provide the care, and the data is there for cognitive rehabilitation. The National MS Society in their guidelines say that patients should receive care, and when you have good data and you have the guidelines to improve actual cognitive performance in everyday life, it's time to do that. So, I think standard-of-care needs to become that patients who have cognitive impairment are referred for cognitive rehabilitation.

Christina Vogt: In your recent article, “Treatment and management of cognitive dysfunction in patients with multiple sclerosis,” which was published in Nature Reviews Neurology, you and your colleagues noted that alternative treatment approaches for mitigating cognitive problems are greatly needed for patients with MS. What are some promising approaches on the horizon for cognitive impairment in patients with relapsing-remitting MS?

Dr DeLuca: Well, the alternative approaches we were referring to are alternatives to disease-modifying therapies. While the disease-modifying therapies have been very important in multiple sclerosis, they have little to no impact on cognition. The data is very, very poor on disease-modifying therapies. Therefore, what's required are the interventions that have been developed, which are behavioral. Those are primarily cognitive rehabilitation that I alluded to earlier, and on the horizon are a variety of techniques associated with exercise. Exercise holds great promise with improving not only cognition, but a variety of symptoms in MS. The data on exercise right now are not 100% clear. There's really been a vast improvement in terms of the number of papers on exercise, but that's something that's going to be down the road. But really, the important thing is to focus that cognitive rehabilitation approaches have really shown to be effective, and they can really be utilized in a variety of different ways.

Christina Vogt: What are the next steps in terms of future research in this area?

Dr DeLuca: There's a lot to do with future research. You know, while the data is really good right now with cognitive rehabilitation, it's not perfect. There still remain a number of questions. We don't know when to start therapy. We don't know necessarily the best duration of that therapy. We don't know what the best dosage of that therapy should be. They may be dependent on a variety of clinical factors and person factors such as degree of cognitive impairment, and it would be expected that they probably would need follow up–booster sessions, for example.

So, I think there's a lot to do in understanding the future for cognitive rehabilitation because MS, as everybody knows, is a very individualized disease, and providing cognitive rehabilitation, while it can significantly improve everyday life, in isolation may not be the best thing either. Consider a family that's undergoing divorce, or consider involvement of drug or alcohol abuse or whatever else might be going on in their individual lives. Cognitive rehabilitation should be coupled with other forms of therapy, depending on the situation in that particular family.

So, there’s a lot of promise out there, and when you think about what may be coming down the road, there are a number of studies that have shown that cognitive rehabilitation can be provided in the patient's home through the internet. They need to be done with a therapist, a therapist’s guidance and supervision, but it's been shown to be fairly effective. But once again, I think it's important to recognize you need to consult with a rehabilitation specialist, and you need to be able to consult with someone in your community who can provide these kinds of therapies. Recommending a computer program that you might see commercially available in the media as some kind of intervention is not treatment. Computerized programs that are designed to be rehabilitation and designed to be delivered by professionals is treatment. So, we have to really think about what that might be. It's important to find people in your community that can provide the treatment. Rehabilitations specialists–they are there. You may have to do a little work to find them, but they are there, and there are variety of ways to help you to find them.

Christina Vogt: And then lastly, what key takeaways do you hope to leave with neurologists on this topic?

Dr DeLuca: We've known now for a long time that cognitive impairment is part of the disease. It significantly affects the patients, significantly affects the patient's family, social situation, occupational aspects. It's a real problem. It's time to provide the treatment that is actually available, and it is available. I urge you to review the Kalb et al paper to look at very specific guidelines that are outlined by the National MS Society. I think it's time that patients get the treatment that they deserve. And, in the end, while cognitive rehabilitation is the primary approach, I think down the road we're going to be able to provide a variety of different approaches: Cognitive rehabilitation, coupled with perhaps exercise, and hopefully down the road, medication, because pharmacological approaches right now really do not show any real benefit to cognitive dysfunction. So, right now, the patients need the care that is available.

Christina Vogt: Thanks again for joining me today, Dr DeLuca.

Dr DeLuca: Thank you. It's really my pleasure.

Christina Vogt: For more podcasts like this, visit Consultant360.com.