Brain Performance In Patients With Multiple Sclerosis Improved By Cognitive Rehabilitation

In a new study published in the March issue of Radiology, functional magnetic resonance imaging (fMRI) shows that cognitive rehabilitation changes brain function and improves cognitive performance in patients with relapsing-remitting multiple sclerosis(MS). 

"These results prompt the use of specific computer-based rehabilitation programs to treat deficits in selected neuropsychological domains in patients with relapsing-remitting MS," said the study's lead author, Massimo Filippi, M.D., professor of neurology at the San Raffaele Vita-Salute University and director of the "BrainMap" interdepartmental research program and the Neuroimaging Research Unit, Department of Neuroscience, Scientific Institute San Raffaele, Milan, Italy. "They also suggest that fMRI might provide useful metrics to monitor the effects of rehab in MS." 

MS is a nervous system disease affecting the brain and spinal cord. MS damages a material called the myelin sheath that surrounds and protects nerve cells. This damage disrupts messages between the brain and other parts of the body, leading to symptoms such as muscle weakness, coordination and balance difficulties, numbness, problems with vision, memory loss and other cognitive issues. MS affects women more than men and often becomes symptomatic between the ages of 20 and 40. 

In relapsing-remitting MS, the most common type, patients experience a series of attacks followed by partial or complete disappearance of symptoms. The interval between relapses can range from weeks to years. 

Cognitive impairment affects a large proportion of patients with MS in the areas of attention, information processing, executive functions, memory and visual-spatial abilities. Cognitive dysfunction impacts a range of activities, including work, driving and social integration. 

For the study, Dr. Filippi and colleagues recruited 20 patients with relapsing-remitting MS. Patients were randomized into two groups of 10. The first group received a 12-week program of computer-assisted cognitive rehabilitation of attention and information processing and executive functions, and the second (control) group received no cognitive rehabilitation. 

Aspects of the rehabilitation program included a day-planning task, which employed realistic simulations of a set of scheduled dates and duties to address the patient's ability to organize, plan and develop solution strategies; and an attention task requiring the patient to simulate driving a train, carefully observing the control panel of the train and the countryside while encountering several distractions at increasing levels of difficulty. 

All of the patients underwent neuropsychological assessment and MRI exams at baseline and after 12 weeks. As compared to their performance at baseline, the patients in the treatment group improved in tests of attention and information processing and executive functions. The fMRI results showed modifications in activity in several brain regions in the rehabilitation group, compared to the non-rehabilitation group. These fMRI modifications were correlated with cognitive improvement. 

Analysis after cognitive rehabilitation found no structural changes in the gray matter or normal-appearing white matter of the brain in the treatment group. 

"The findings demonstrated that computer-assisted cognitive rehabilitation in patients with MS results in an improvement of the trained cognitive functions," Dr. Filippi said. "However, the structural integrity of the brain's gray matter and white matter showed no modifications in these patients, suggesting an impairment of structural plasticity." 


Source:http://www.medicalnewstoday.com/releases/242002.php

Kurtzke Expanded Disability Status Scale

Based on the findings, a patient may be rated according to several clinical scales. The most widely accepted clinical rating scale is the 10-point Kurtzke Expanded Disability Status Scale, developed originally in 1955 as the Disability Status Scale, which is as follows:


o Grade 0 - Normal neurologic examination (all grade 0 in FS, cerebral grade 1 acceptable)

o Grade 1.0 - No disability, minimal signs in 1 FS (ie, grade 1 excluding cerebral grade 1)

o Grade 1.5 - No disability, minimal signs in more than 1 FS (more than 1 grade 1 excluding cerebral grade 1)

o Grade 2.0 - Minimal disability in 1 FS (1 FS grade 2, others 0 or 1)

o Grade 2.5 - Minimal disability in 2 FS (2 FS grade 2, others 0 or 1)

o Grade 3.0 - Moderate disability in 1 FS (1 FS grade 3, others 0 or 1) or mild disability in 3 or 4 FS (3/4 FS grade 2, others 0 or 1) though fully ambulatory

o Grade 3.5 - Fully ambulatory but with moderate disability in 1 FS (1 grade 3) and 1 or 2 FS grade 2, or 2 FS grade 3, or 5 FS grade 2 (others 0 or 1)

o Grade 4.0 - Fully ambulatory without aid; self-sufficient; up and about some 12 h/d despite relatively severe disability, consisting of 1 FS grade 4 (others 0 or 1) or combinations of lesser grades exceeding limits of previous steps; able to walk without aid or rest approximately 500 m

o Grade 5.0 - Ambulatory without aid or rest for approximately 200 m; disability severe enough to impair full daily activities (eg, to work full day without special pzrovisions; usual FS equivalents are 1 grade 5 alone, others 0 or 1; or combinations of lesser grades usually exceeding specifications for step 4.0)

o Grade 5.5 - Ambulatory without aid or rest for approximately 100 m; disability severe enough to preclude full daily activities (usual FS equivalents are 1 grade 5 alone; others 0 or 1; or combinations of lesser grades usually exceeding those for step 4.0)

o Grade 6.0 - Intermittent or unilateral constant assistance (cane, crutch, or brace) required to walk approximately 100 m with or without resting (usual FS equivalents are combinations with more than 2 FS grade 3+)

o Grade 6.5 - Constant bilateral assistance (canes, crutches, or braces) required to walk approximately 20 m without resting (usual FS equivalents are combinations with more than 2 FS grade 3+)

o Grade 7.0 - Unable to walk beyond approximately 5 m even with aid; essentially restricted to wheelchair; wheels self in standard wheelchair and transfers alone; up and about approximately 12 h/d (usual FS equivalents are combinations with more than 1 FS grade 4+; very rarely, pyramidal grade 5 alone)

o Grade 7.5 - Unable to take more than a few steps; restricted to wheelchair; may need aid in transfer; wheels self but cannot carry on in standard wheelchair a full day; may require motorized wheelchair (usual FS equivalents are combinations with more than 1 FS grade 4+)

o Grade 8.5 - Essentially restricted to bed much of the day; has some effective use of arms; retains some self-care functions (usual FS equivalents are combinations, generally 4+ in several systems)

o Grade 9.0 - Helpless bed patient; can communicate and eat (usual FS equivalents are combinations, mostly grade 4+)

o Grade 9.5 - Totally helpless bed patient; unable to communicate effectively or eat/swallow (usual FS equivalents are combinations, almost all grade 4+)

o Grade 10.0 - Death due to MS

The scale ranges from 0-10 in 0.5 increments. The scores from grades 0-4 are derived from Functional System (FS) scales that evaluate dysfunction in 8 neurologic systems, including pyramidal, cerebellar, brainstem, sensory, bladder and bowel, vision, cerebral, and "other."

o Limitations of the Expanded Disability Status Scale are that it (1) is heavily dependent on mobility; (2) is somewhat subjective in certain areas (eg, bowel and bladder function); (3) is insensitive to small changes; and (4) does not present an accurate picture of the patient's cognitive abilities and functional abilities in performing activities of daily living (ADL).

• Additional useful scales include the Ambulation Index, which is based solely on the ability to walk 25 feet, and the Scripps Neurologic Rating Scale, developed by Sipe in 1984. Both environmental factors and a genetic predisposition, which affect an individual's chance of acquiring the disease, appear to play a role.

If an individual lives in an area with low incidence of MS until age 15 years, that person's risk is low; however, if an individual lives in an area with a high incidence until age 15 years, the risk of developing MS is high. Certain ethnic groups (eg, Eskimos), despite living in areas of higher incidence, do not have high incidence of MS. Treatment