When people picture someone with multiple sclerosis (MS), they might think of a patient in a wheelchair or with a severe disability of some sort. While MS can be debilitating for many patients, physical disability is not the only consequence of the disease; the mind may also be affected.
MS is a disease of the central nervous system in which the immune system attacks the protective layer around your nerves—called the myelin. Damage to this layer can disrupt communication between the brain, spinal cord and other areas of the body. Over time, the nerves themselves can become permanently damaged.
Symptoms of MS differ from patient to patient and depend on which nerves have been affected. Some patients may lose the ability to speak clearly or see through one eye, while others may lose the ability to walk. Other symptoms can include numbness or weakness in one or more limbs, double or blurred vision, tingling or pain in parts of the body, feelings of electric shock with certain head movements, lack of coordination, fatigue and dizziness.
Beyond the physical effects of the disease, MS can also have an impact on cognition, or thinking and memory. More specifically, cognition is how we focus our attention, learn and remember, problem solve, plan, use language and do a whole variety of other mental tasks.
As of late, the New Jersey-based Kessler Foundation has had its focus on cognitive MS research. Two of the foundation's researchers are particularly interested in the impact of MS on memory and how to treat memory loss in patients with MS.
Nancy Chiaravalloti, PhD, Director of Neuropsychology, Neuroscience and Traumatic Brain Injury Research at Kessler Foundation and Associate Professor of Physical Medicine and Rehabilitation at UMDNJ – New Jersey Medical School, was recently awarded a $43,494 grant from the National Multiple Sclerosis Society to study the effectiveness of a new treatment for memory loss in patients with MS.
Dr. Chiaravalloti's study will assess the effectiveness of a memory treatment program intended to improve learning and memory of information that patients require daily. The treatment program will last for eight sessions. Participants' memory skills will be tested before and after they complete the program.
“If effective, this treatment could have a positive impact on the everyday cognitive functioning and overall quality of life of persons with MS,” Dr. Chiaravalloti said in a Kessler Foundation news release.
“Development of new strategies to improve memory in individuals with MS is an important area of research at Kessler Foundation,” said John DeLuca, PhD, VP of Research & Training at Kessler Foundation.
The National Multiple Sclerosis Society also awarded a $619,618 grant to Dr. Chiaravalloti's colleague, Victoria Leavitt, PhD, also of Kessler Foundation and UMDNJ – New Jersey Medical School. Dr. Leavitt's research will investigate a brain marker that may be able to predict memory decline in patients with MS.
“Finding the way to predict memory decline is an essential first step towards eventually finding the way to prevent memory decline in persons with MS,” said Dr. DeLuca. “At present, clinicians have no tool for identifying patients at risk. The goal of this study is to evaluate a brain marker that will provide a way to identify which patients may benefit from early behavioral and pharmacological interventions.”
Dr. Leavitt works closely with both Dr. DeLuca and Dr. Chiaravalloti.
DailyRx News recently spoke with Dr. Chiaravalloti about the impacts of MS on memory, current treatments and the research she and her colleagues are conducting.
dailyRx: How does MS affective cognitive function, specifically memory?
Dr. Chiaravalloti: Cognitive impairment is common in MS, with prevalence rates ranging from 43 percent to 70 percent. Impacted cognitive domains include attention, information processing efficiency, executive functioning, processing speed, and episodic memory. Most commonly, cognitive deficits present in the domains of speed of processing and new learning and memory. The most common clinical cognitive profile is one of specific and sometimes subtle cognitive deficits, rather than overt dementia.
Work from our lab, as well as others, has shown that the memory problems that patients with MS experience are in learning new information, not retrieving previously learned information from memory storage. Patients have trouble remembering things such as tasks they need to do in a given day, an address or a list of items. They may have difficulty learning and remembering how to do a new task. These are all everyday applications of memory abilities.
It is this cognitive profile that makes persons with MS particularly appropriate for interventions targeting specific cognitive functions, such as new learning and memory or processing speed. If they are not showing a general cognitive decline, the cognitive decline is most often specific and subtle.
dailyRx: What are the current strategies to protect or improve memory in patients with MS?
Dr. Chiaravalloti: Research on cognitive rehabilitation efficacy in MS remains sparse, but there is some evidence that cognitive rehabilitation can be effective in MS. Evidence is building in support of some existing structured treatment protocols.
Our research at Kessler Foundation has shown that the modified “Story Memory Technique” (mSMT), which consists of training in context and imagery, improves learning and memory in MS. This treatment protocol also has demonstrated specific changes in the brain through changes in functional MRI from pre- to post-treatment.
Several other studies have also shown promising results when administering cognitive remediation targeted at specific domains of cognitive functioning and specifically memory. However, one problem the field has is that these protocols are not available clinically yet. Clinicians have simply not picked up on them and started using them, which is what we need to happen to really start helping people. We have released the mSMT to three rehabs in the country to try to get clinicians to start using it.
We have additional evidence that there are several techniques in cognitive psychology that can help improve the memory of persons with MS. That is what the newly funded study is focused on – taking these strategies and combining them into a structured treatment protocol that clinicians can use with patients.
dailyRx: Could you explain your research and its goals?
Dr. Chiaravalloti: Published evidence from our lab shows that combination therapy is better than using one therapy in isolation.
The newly funded study entails the application of three techniques that we have demonstrated can improve a person’s memory ability in a structured treatment protocol. It is an 8-session treatment that begins with education about memory abilities, what memory is – and is not – and how memory is impacted in MS. As treatment continues, two sessions are spent on each of three techniques that the patient is taught to apply to everyday memory situations.
The first technique is self-generation, which has been demonstrated to be effective in increasing one’s ability to learn and remember new information in both healthy populations and MS. The concept of self-generated learning states that recall and recognition of information is significantly better when subjects generate their own correct responses to a problem compared to when the correct responses are provided to them.
Spaced learning is the second technique. It posits that learning trials spaced over time result in significantly better memory performance than consecutive learning trials.
The third technique taught to the patient is retrieval practice, which is a robust cognitive phenomenon by which memory retrieval of previously learned material via testing (e.g., quiz) improves subsequent recall more than simply restudying the material.
Accumulated evidence demonstrating that each of these techniques improves learning and memory performance in MS supports the notion that the known deficit in new learning and memory can be specifically targeted and effectively treated through cognitive rehabilitation.
The newly funded study will test this treatment protocol with 20 patients with MS to see if it improves neuropsychological functioning and daily life functioning.
dailyRx: How does this research expand upon what is known about cognitive treatment options for patients with MS?
Dr. Chiaravalloti: This deliverable from this research is an empirically validated new treatment for learning and memory deficits in MS. The study will provide evidence in support of the use of this treatment protocol or refuting its utility. Hopefully, when we are finished, we will have a new treatment for memory deficits that we can apply clinically to persons with MS.
dailyRx: Which MS patients are most at risk of cognitive decline?
Dr. Chiaravalloti: We know that patients with secondary progressive MS are at higher risk for cognitive decline, but they also had the disease longer. However, many people early in the disease and with other types of MS also have cognitive problems while others never experience cognitive problems.
In addition, some of our other work shows that persons with lower cognitive reserve are at higher risk for cognitive decline. The term cognitive reserve refers to the notion that people with richer history of intellectually-stimulating lifestyles (e.g., reading, education) are better able to cope with more neurologic disease before suffering cognitive/memory decline. That is, the same degree of brain disease (neuropathology) affects cognition/memory less in persons with a history of intellectual enrichment. However, we do not have definitive predictors of future cognitive decline, which is what Dr. Leavitt seeks to identify.
dailyRx: Are there ways to predict which patients are at risk?
Dr. Chiaravalloti: Not at this time. We have data on which we can hypothesize who might be at risk (such as those with secondary progressive MS and those with lower cognitive reserve as mentioned above), but we cannot predict exactly who is most at risk at this time. Dr. Leavitt’s work seeks to identify a biomarker that can predict memory decline.
dailyRx: What role does risk prediction play in the treatment of MS-related cognitive decline?
Dr. Chiaravalloti: Risk prediction is important because it will allow early intervention. Early intervention is spoken about a great deal in other illnesses and injuries (i.e., autism). It is key to optimizing functioning.
What we hope to be able to do at some point is predict who is most at risk for decline and enroll those patients in clinical protocols that teach memory strategies, improve overall cognitive skills and facilitate the acquisition of new skills.
The theory is that the healthier the brain is, the more one can gain from treatment. If persons with MS learn how to apply strategies that improve their memory early in the disease, they will have those tools to apply later, when their memory is functioning poorly.
Of course the alternative to predicting those at risk for decline would be to treat everyone. However, that is not the best use of resources. It would be more beneficial to all to focus the treatments on those who are at risk.
Dr. Leavitt’s research will help us identify those at risk for decline. It is a very important study to the MS population.