Cognitive impairment, a research priority for the MS Society of Canada, affects a significant proportion of people living with MS.
Multiple sclerosis (MS) can cause a reduction in brain size (also called brain atrophy). Research has shown that this atrophy and lesions developed in MS can be linked to the presence of cognitive difficulties. Cognitive difficulties affect up to seventy percent of individuals living with progressive MS, predominantly impacting information processing and speed, learning and memory, executive function and perceptual processing. Also, individuals themselves have voiced cognitive impairment as an area of concern that needs to be addressed.
Five years ago, I traveled around the country and engaged the MS Community (researchers, caregivers, individuals living with MS) to find out what areas of research are important to them—cognition and mental health was one of them!
The good news? There is evidence to suggest that cognitive rehabilitation has the potential to improve cognitive function.
There is a need for effective cognitive rehabilitation for those living with MS. Cognitive rehabilitation aims to enhance a person’s ability to process and interpret information, and to improve the ability to function in family and community life. A few studies have already evaluated cognitive rehabilitation strategies to improve various areas of cognition, including memory, communication, and attention skills.
While a great deal of progress has been made in identifying treatments for cognitive dysfunction, there is more research that needs to be conducted. Many studies lack control (mock treatment) group, are not large enough to make adequate conclusions from the interventions, or are limited to the MS population in general (all types of MS) or only people with relapsing-remitting MS.
Cognition and Exercise
One promising intervention that may improve cognition is exercise. Historically, individuals living with MS were advised to avoid physical exertion for fear that physical activity will make them feel worse. Over the past few decades, new research has uncovered considerable benefits associated with increased physical activity, and perceptions among the MS community have shifted toward encouraging a more active lifestyle. There is evidence that physical activity and exercise can help to maintain the individual’s independence, enhance their quality of life, and lead to improved cognitive functioning due to the beneficial effects of physical activity on brain health.
However, the effects of exercise on cognition has been predominantly evaluated on persons with relapsing-remitting MS. Furthermore, different exercise interventions have shown mixed results on cognition which could be attributed to differences in exercises methodologies (exercise type, intensity, frequency and program duration) used between studies. There is a need to perform randomized control trials, with larger sample sizes, longer durations, and broader evaluations to better assess the role of exercise on cognition.
Furthermore, when looking at rehabilitation in MS, a single intervention may not be sufficient in improving symptoms – synergistic approaches may be required. Therefore, strategies that combine two interventions, such as cognitive rehabilitation and exercise, may have the potential to produce the greatest improvements in MS.
MS Society-supported research aims to improve cognition by combining cognitive rehabilitation and exercise
Recently, we announced support of a $5 million project which will test if cognitive rehabilitation, or exercise, or a combined approach of cognitive rehabilitation and exercise will improve cognitive function in individuals living with progressive MS. This clinical study is the first of its kind to use a large sample that incorporates many countries and has the potential to define how best to treat cognitive dysfunction in people diagnosed with progressive MS.
The researcher leading the effort to improve cognition in people diagnosed with progressive MS
The researcher leading this large project on improving cognitive function through a randomized clinical trial is Dr. Anthony Feinstein. Dr. Anthony Feinstein is a Neuropsychiatrist and Associate Scientist at Sunnybrook Health Sciences Centre. He is also a Professor of Psychiatry at the University of Toronto.
Dr. Feinstein has researched behavioral disorders in people with MS for 26 years and runs a busy clinical practice in which over 80 percent of the patients have MS. Dr. Feinstein’s studies entail detailed neuropsychological testing, brain imaging (both structural and functional) and quantification of mood symptoms. More recently, Dr. Feinstein has also begun a series of studies looking at how cannabis might affect cognition and brain imaging in people with MS. Currently, the Society is supporting two projects led by Dr. Feinstein, one is the clinical trial for improving cognition and another which is evaluating the effects of cannabis on cognition.
Learn more about Dr. Feinstein:
How did you become interested in MS research? What inspires you to continue advancing research in this field?
I first became interested in multiple sclerosis research after my residency, which was in London, England. My PhD was devoted to detecting cognitive difficulties in people with MS and looking for correlates with brain MRI. This was a nascent field at the time and as such there was a very small literature on these topics. After completing my PhD, I continued to pursue my interest in multiple sclerosis. Indeed, it is fair to say that it was through my PhD that I developed a lifelong interest in this particular disorder and the behavioral consequence of it.
I continue to remain an active researcher because there are so many unanswered questions. MS is a fascinating disease and the degree to which it can affect behavior across a wide domain has yet to be fully explored. While much more is known about the behavioral consequence of MS now compared to when I first entered the field the advances in technology are continuing to open up new research possibilities which ultimately benefits patient care.
What do you enjoy most about doing research and what are some of the challenges you face?
What I enjoy most about research is trying to be innovative. While I recognize that replication is, of course, important and essential, coming up with new findings which can affect the quality of patient care is rewarding. The challenges faced are those of obtaining funding in an increasingly competitive research environment and retaining bright young investigators who often want to move on to other opportunities because of better financial and work-related opportunities.
Describe the importance and level of collaboration in your research?
Collaboration is essential for my research. To begin with, I could not begin to do my research without having good relationships with my colleagues in Neurology who refer patients to me, both clinically and for research purposes. I also collaborate with colleagues in Neuroimaging and Neuropsychology and more recently, Engineering. These links are pivotal to the success of my research work.
How important is the support from the MS Society in enabling you to conduct research?
The support from the Multiple Sclerosis Society of Canada has been integral to my research success. The Society has funded my studies looking at brain MRI correlates of depression, the development of computerized tests of cognition for people with MS, a series of studies exploring the cognitive and imaging changes linked to cannabis use in people with MS, the studies investigates the prevalence, clinical significance and cognitive correlates of pseudobulbar affect in people with MS and more recently the large multi-centre study looking at cognitive rehabilitation and exercise in people with progressive MS.
Interested in learning more about the clinical trial?