Study: 12 weeks of home cognitive training improved memory in people with multiple sclerosis
- 107 adults with relapsing forms of multiple sclerosis were assigned to training (n = 59) or control (n = 48) and assessed with a 15-task neuropsychological exam at baseline and after 12 weeks.[1]
- The training group improved significantly over controls on 3 memory-based abilities, general memory, visual working memory and verbal-auditory working memory, with large reported effect sizes (partial η² of 0.207, 0.196 and 0.191; all p ≤ 0.003 adjusted for baseline and age).[1]
- 71.2% of the training group (42 of 59) used the home program unprompted, and 37.3% (22 of 59) completed the full 24-session regimen with no reminders.[1]
- What it does not show: participants were not randomized and controls received no comparison activity, so practice and placebo effects cannot be ruled out; the authors call for large-scale, randomized studies.
Cognitive impairment is one of the most common consequences of multiple sclerosis (MS): prevalence estimates range from 43% to 65%, with memory, attention, processing speed and executive functions among the most affected domains, and it has been linked to lower employment and poorer quality of life (Rao et al., 1991). At the time of this study, no established pharmacological therapy existed for MS-associated cognitive impairment.[2]
A 2010 study in NeuroRehabilitation addressed a practical question earlier trials had left open: would people with MS, left entirely unprompted, voluntarily keep up a home-based cognitive training regimen, and would their cognitive performance change over 12 weeks versus an untrained control group? Most prior computer-assisted rehabilitation in MS had been clinic-based (O'Brien et al., 2008).
What the study tested
This was a single-center interventional study conducted at the Multiple Sclerosis & Brain Research Centre, Carmel Medical Centre, Haifa, Israel, between 14 November 2005 and 22 November 2006. The protocol was approved by the centre's ethics committee (HT2917) and all participants gave written informed consent before baseline assessment.
A total of 107 individuals were enrolled and assigned to a training group (n = 59) or a control group (n = 48). All had relapsing-remitting or relapsing-progressive MS, dominant-hand functioning, a home computer and an interest in taking part; people with primary progressive MS, other neurological disease, substance dependence or major depression were excluded. Because adherence was the primary goal, participants were allocated to training first, with those lacking a home internet connection going to control. The groups were well matched at baseline (Table 1) on age, Expanded Disability Status Scale (EDSS) score, depression and fatigue.[1]
The intervention was CogniFit Personal Coach (CPC), a home-based, individualized computerized program. A baseline neuropsychological evaluation, the N-CPC, a 15-task battery of memory, attention and eye-hand coordination tests validated against standard instruments including the CANTAB and the Stroop, assigned each person scores on 17 cognitive abilities, then trained them through 21 tasks chosen to fit the individual. Training consisted of 24 sessions, each with three tasks and requiring 20 to 30 minutes, done three times a week for 12 weeks. Controls received no training and were offered the software as a gift afterward. To preserve the test of unprompted adherence, patients' doctors initiated no training-related contact during the study.
The primary outcome was the change in N-CPC scores from baseline to the 12-week follow-up; depression (Zung scale), disability (EDSS) and fatigue (Fatigue Severity Scale) were also assessed at both visits.
What it found
Of the 107 enrolled, 46 completed the full 12-week study, 22 training, 24 control (24 of 48 controls, 50.0%, declined the second examination). Significant within-group N-CPC gains appeared in 11 cognitive abilities in the training group versus 7 in controls; the key comparison, however, was between groups.[1]
By analysis of covariance, the training group improved significantly more than controls on three memory-based abilities: general memory, visual working memory and verbal-auditory working memory. The reported between-group effect sizes were large by Cohen's conventions, partial η² of 0.207, 0.196 and 0.191, respectively.[1]
| Cognitive ability | Training: baseline → post | Control: baseline → post | ANCOVA p (adj.) | Effect size (partial η²) |
|---|---|---|---|---|
| General memory | 0.24 → 1.13 | 0.63 → 0.56 | 0.002 | 0.207 |
| Visual working memory | 0.20 → 0.54 | 0.29 → 0.45 | 0.003 | 0.196 |
| Verbal-auditory working memory | 0.18 → 1.09 | 0.66 → 0.53 | 0.003 | 0.191 |
| Naming | 0.42 → 0.68 | 0.06 → 0.54 | 0.851 | 0.001 |
After controlling for baseline and age, training significantly explained 9% to 21% of the between-group differences; with those influences included, the models explained an average of 40% (range 12% to 60%). A post-hoc analysis of the raw memory-task data showed gains in both memory accuracy and recall speed. On three attention tasks the training group also outperformed controls on two measures: faster action during an alert state and sustained attention in a high-vigilance visuo-motor task.[1]
No significant change in depression (Zung) or disability (EDSS) appeared in either group. Fatigue (FSS) stayed stable in controls but rose in the trained group (F = 5.76, p < 0.021), which the authors note did not appear to compromise cognitive performance.[1]
Adherence, could people keep going unprompted?
Because earlier MS trials had been clinic-based and prompted, the primary aim was to measure spontaneous adherence. Among the 59 people in the training group, 42 (71.2%) used the program at home unprompted, with no reminders. Of those who began, 57.6% completed more than half the prescribed sessions, and 22 (37.3%) completed the entire 24-session regimen; 17 (28.8%) never started.[1]
Adherence was uneven by age. In the training group, but not in controls, non-completers were significantly younger than completers (mean 40.1 vs 49.9 years; p = 0.001), and increasing age correlated with higher disability (EDSS) scores (r = 0.39, p < 0.05). The authors concluded that almost 60% of the training group persevered autonomously through at least half of the prescribed sessions.[1]
Limitations, what this does NOT show
The authors are explicit about the constraints:
No true randomization and no active control. Because the study was dedicated to voluntary, unprompted adherence, participants were not randomly assigned and controls received no comparison activity. The authors note that "true subject randomization and the intention-to-treat principle were not adopted in this study," and call for trials using an active comparator.
Small completer sample. Only 46 of the 107 enrolled completed the study (22 training, 24 control), so the comparisons rest on modest numbers. Training completers were also significantly older than control completers (mean 49.9 vs 42.3 years; p < 0.01), which the authors argue would, if anything, work against the training group.[1]
No health or quality-of-life endpoints, and fatigue rose in the trained group. The study measured cognitive performance, not function or quality of life. Whether the gains persist after training ends, and the optimal dose, remain untested. The authors frame the results as support for large-scale studies, not proof.
Where this fits in the broader evidence
An evidence review had found few high-quality cognitive-rehabilitation studies in MS, most clinic-based rather than at home (O'Brien et al., 2008). This 2010 study extended a line of research, the same personalized program had previously improved cognitive skills in healthy elderly people, with and without mild cognitive impairment (Giladi et al., 2008), into a relapsing-MS population training unsupervised at home. See also the research index, the scoping review, and the condition overview on cognitive training in multiple sclerosis.
References
- Home-based personalized cognitive training in MS patients: A study of adherence and cognitive performance. NeuroRehabilitation 2010, 26(2), 143–153. doi:10.3233/NRE-2010-0546 The study covered on this page. 107 adults with relapsing MS; 12-week home training; gains over controls on 3 memory abilities; 71.2% trained unprompted.
- Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology 1991, 41(5), 685–691. doi:10.1212/wnl.41.5.685
- Cognitive training improves performance in elders: a randomized, double blind study. Alzheimer's & Dementia 2008, 4(4, Suppl.), T196. doi:10.1016/j.jalz.2008.05.733
- Evidence-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature. Arch. Phys. Med. Rehabil. 2008, 89(4), 761–769. doi:10.1016/j.apmr.2007.10.019
- The fatigue severity scale. Arch. Neurol. 1989, 46(10), 1121–1123. doi:10.1001/archneur.1989.00520460115022