Brain training: a cognitive rehabilitation programme evaluated


6 April 2020

The study in brief

About half of all people with MS have difficulties at some time with aspects of thinking such as memory, concentration or problem solving, known as cognitive problems. In this study, a programme designed to improve cognitive skills (CRAMMS) was tested in a large clinical trial.

449 people were recruited from five MS centres in England. 245 were assigned to the cognitive rehabilitation programme (CR group) and 204 received standard advice on how to manage cognitive difficulties from an MS nurse or occupational therapist (SA group).

The CR group met in small groups for 10 weekly sessions presented by a psychologist. The sessions covered techniques and exercises to retrain cognitive skills and taught practical ways to cope with memory issues in daily life. You can read manuals for presenters and participants online.

The main measure of the study was the psychological impact of MS on quality of life at 12 months. Participants also completed cognitive tests at the beginning of the study, and at 6 and 12 months.

There was no difference in psychological impact of MS between the two groups at 12 months. However, there was a small improvement in psychological impact of MS for the CR group at 6 months. Other measures showed some improvements; at 6 and 12 months, those in the CR group reported fewer memory problems in day to day life (as reported by both participants as well as relatives) and better mood. There were no differences in cognitive tests, levels of fatigue, employment status or stress experienced by carers at both 6 and 12 months.

The researchers questioned whether quality of life was appropriate as the main measure of effectiveness. Quality of life is complex and influenced by many factors; it may be unrealistic to expect to achieve a measurable improvement from a treatment which focuses on a single aspect of MS.

The researchers conclude that the results support providing cognitive rehabilitation, given the short-term improvements and the lack of alternative, more effective, treatments. They also suggest that future studies should consider how improvements can be maintained and whether or not some people benefit more than others.

The study in more detail

Background

About half of all people with MS have difficulties at some time with aspects of thinking such as memory, concentration or problem solving, known as cognitive problems. They can have a big impact on work, social and family life, and consequently quality of life. Cognitive rehabilitation aims to retrain cognitive skills and help people learn ways to cope with cognitive problems. In this study, a programme developed to improve cognitive skills was tested in a large clinical trial.

How this study was carried out

Participants who reported having day to day cognitive difficulties which were confirmed by cognitive tests were recruited from five MS centres in England. Out of a total of 449 people, 245 were assigned to the cognitive rehabilitation programme (CR group) and 204 received standard advice on how to manage cognitive difficulties from an MS nurse or occupational therapist (SA group).

A trainee psychologist presented the cognitive rehabilitation programme to groups of four to six participants who met weekly for 10 sessions. The content of sessions was set out in two manuals, one for presenters and one for participants (you can read the manuals for trainer and participant). The sessions covered techniques and exercises to retrain cognitive skills and taught practical ways to cope with memory issues in daily life.

Participants and a partner or friend were asked to complete a number of questionnaires at the beginning of the study, and at 6 months and 12 months. The main measure for the effectiveness of the programme was the psychological impact of MS on quality of life at 12 months. To get a standardised measure of concentration, planning and memory, participants also completed a set of cognitive tests at the beginning of the study, and at 6 and 12 months.

What was found?

There was no difference in psychological impact of MS between the two groups at 12 months. However, there was a small improvement in psychological impact of MS for the cognitive rehabilitation group at 6 months.

Other measures showed some improvements; at 6 and 12 months, those in the CR group reported fewer memory problems in day to day life (as reported by both participants as well as relatives) and better mood. Participants in the CR group gave positive feedback; they reported that they found the programme helpful in reducing cognitive problems and had more confidence in daily life.

There were no differences between the two groups for cognitive tests, levels of fatigue, employment status or measures of carer stress at both 6 and 12 months.

Delivering the cognitive rehabilitation programme cost slightly less than giving standard advice.

Strengths of the study include the large number of participants; in this study there were 449 participants compared to an average of 42 participants in previous studies of cognitive rehabilitation. The attendance rate was good with most people attending most of the sessions; reasons for not attending were largely due to illness or holidays.

What does it mean?

The study failed to show a long-term effect of the cognitive rehabilitation programme on quality of life, but there was an improvement in the short term. There was also evidence that cognitive rehabilitation improved both memory problems in daily life and mood.

The researchers questioned whether quality of life was appropriate as the main measure of effectiveness. They point out that quality of life is complex and influenced by many factors. While improving quality of life is an important overall aim, it may be unrealistic to expect to achieve this from a treatment which focuses on a single aspect of MS. They recommend that future studies of cognitive rehabilitation use measures which more directly assess the impact of cognitive ability in daily life.

Overall, the researchers conclude that the results support providing cognitive rehabilitation, given the short-term improvements and the lack of alternative, more effective, treatments. They also suggest that future studies should consider how improvements can be maintained and whether or not some people benefit more than others.

Lincoln NB, Bradshaw LE, Constantinescu CS, et al.
Cognitive rehabilitation for attention and memory in people with multiple sclerosis: a randomized controlled trial (CRAMMS).
Clinical Rehabilitation 2020;34(2):229-241.
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Read an in-depth report of this study

More about cognitive problems and ways to manage them

If something is difficult, we tend to avoid doing it. This is likely to result in a decline in ability as we get out of practice at that task. Cognitive rehabilitation involves strengthening brain function and retraining neural pathways using a series of challenging exercises.

This approach used to be reserved for the most severe cases of cognitive decline. Cognitive rehabilitation is now recognised as being effective earlier on in MS as well, where previously you might have been advised to simply take the strategic approach to managing the situation. Cognitive rehabilitation works best if the exercises you do are properly tailored to match the situations you have trouble with.

There are two main approaches to tackling problems; internal strategies which involve retraining memory and concentration through exercises and repetition (just like you would do physical exercises to improve muscle strength and mobility), and external strategies which involve using tools and aids, such as setting reminders on mobile phones or writing down appointments in a diary.

Read more about thinking and memory problems.

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