Critically Appraised Topic

Touro University Nevada School of Occupational Therapy

Lauren Hoppe, OTS & Emily Matthews, OTS
Focused Question:
Are home based interventions effective to increase executive functions of individuals with
Multiple Sclerosis?

Prepared By:
Lauren Hoppe, OTS & Emily Matthews, OTS
Department of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89074

Date Review Completed:

October 5, 2014
Clinical Scenario:
An estimated 400,000 people in the United States have been diagnosed with Multiple Sclerosis
(MS), a progressive disease causing demyelination of the neurons in the central nervous system.
Areas affected by multiple sclerosis include; motor function, visual systems, sensory functions
and cognition. In fact, an estimated 50-75% of people diagnosed with MS are thought to have
cognitive deficits secondary to the disease and while numerous studies have been conducted to
address psychological and physical deficits of the disease, there has been little evidence-based
interventions developed to help combat cognitive deficits. Psychoneurological studies have
found that people with MS experience the most cognitive issues with memory, attention,
information processing, verbal learning, and visuospatial abilities. These deficits can have a huge
impact on the lives of people with MS, because those who suffer cognitive impairments required
a greater amount of assistance, were less likely to continue working, or engage in social
activities, and had more difficulty carrying out their identified roles. (Stuifbergen, Becker Perez,
Morison, Kullberg & Todd, 2012). MS typically affects young adults in the prime of their lives
and cognitive impairment can dramatically affect job performance, family life and social
situations (Gentry, Wallace, Kvarfordt & Lynch, 2008).

Executive functions is a set of mental processes that includes; attention, working memory,
sequencing, problem solving, information processing and planning, as well as the initiation and
monitoring of action. The deficiency of executive functions in numerous clinical groups is a
topic of much debate, as are current attempts to formulate the analogous intervention and
rehabilitation systems of these dysfunctions (Chan, Shum, Toulopoulou & Chen, 2008). The
study of impairments of cognition correlated to MS is an emerging field. Limited studies validate
the effectiveness of any therapeutic intervention for this issue. Most of the literature on
rehabilitative interventions for cognitive impairment with adult populations comes from brain
injury researchers, yet even in that field, a scarcity of intervention studies have been able to
determine functional improvement in real-world settings (Carney, Chestnut, Maynard, Mann,
Paterson & Helfand, 1999).

The focus question of this CAT specifically looked into home based interventions to help combat
these cognitive deficits. These home based interventions referred to any intervention taking place
outside of a clinic or interventions that can be done within the clients home. This includes group
interventions taking place in the community, computer-based programs that can be done in the
home or exercise programs that can be done within the home.

This CAT will highlight evidence-based intervention approaches for managing the declining of
executive functioning as a common, debilitating, and poorly managed consequence of MS. With
improved executive functioning, adults with MS can gain functional outcomes to participate in
activities of daily living and instrumental activities of daily living in a meaningful way.
Summary of Key Findings:
Summary of Levels I, II and III:
Computer-aided retraining of memory and attention is not an effective intervention to
support the efficacy of specific memory and attention retraining in multiple sclerosis for
individuals with cognitive impairments (Solari, Motta, Mendozzi, Pucci, Forni,
Mancardi, & Pozzilli, 2004, Level I).
Computer based training programs specifically made for impaired attention abilities
yields adaptive neural plasticity of the associated neural network. When CR is tailored
to 1 specific cognitive domain, significant and more effective results can be found
(Cerasa, Gioia, Valentino, Nistic, Chiriaco, Pirritano, Tomaiuolo, Mangone, Trotta,
Talarico, Bilotti, & Quattrone, 2013, Level I).
Exercise may have therapeutic potential for neuropsychiatric symptoms such as
depression, fatigue and cognitive impairment in MS (Briken, Gold, Patra, Vettorazzi,

Harbs, Tallner, & Heesen, 2013, Level I).

Computer based interventions that also included translation of skills into everyday life
showed a decrease in cognitive deficits (Stuifbergen, et.al., 2012, Level I).
Group therapy sessions focusing on story memory techniques showed no long term
effects (Chiaravalloti, N. D., Deluca, J., Moore, N. B., & Ricker, J. H, 2005, Level I)
Computer based intervention programs focusing on memory tasks did show significant
improvement in memory tasks and only patients with low brain atrophy benefited from
the treatment (Hildebrandt, et.al., 2007, Level I).
Using a PDA significantly improved participants functional performance and
satisfaction with functional performance in everyday life tasks (Gentry, Wallace,
Kvarfordt & Lynch, 2008, Level III).
Participants who improved their physical fitness demonstrated improvement in
psychomotor speed, visual speed, working memory, executive function, and divided
attention (Beier, Bombardier, Hartoonian, Motl, & Kraft , 2014, Level III).

Summary of Level IV and V:

Not included in review.

Contributions of Qualitative Studies:

Not included in review.

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
Occupational therapists (OT) can create memory programs within community or group setting to
provide strategies for improving the patients cognitive ability and overall health and well-being.
Within group session patients benefit from the psychosocial aspect group interventions (Carr,
Nair & Schwartz, 2014, Level I).
Clinical importance suggests that occupational therapists can design compensatory strategies to
manage patients cognitive deficits to increase function in day to day living to learn and retain
information more easily (Stuifbergen et al., 2012, Level I).
Long term effects were not sustained through use of story memory techniques, therefore
clinicians should look into other strategies that provide long term effects or develop a strategy
for continued practice after termination of intervention to increase long term effects
(Chiaravalloti N. D., Deluca, J., Moore, N. B., & Ricker, J. H, 2005, Level I).
Interventions should be used with clients reporting significant cognitive deficits and may not be
the most beneficial for those with mild cognitive deficits (Hildebrandt et al, 2007, Level I).
The use of isolated computer assisted memory and attention retraining in MS patients are no

better than non-specific interventions improving these functions (Solari et al., 2004, Level I).
Patients with MS that have attention deficits should be given computer assisted cognitive rehab
in one specific domain to increase executive functioning skills (Ceresa et al., 2013, Level I).
Occupational therapy practitioners may use physical exercise adjunct with other interventions to
increase cognition in patients who suffer from MS (Beier et al., 2014, Level 3; Briken et al.,
2013, Level I).
Teaching compensatory strategies with the use of a personal digital assessment (PDA) has been
found to be a successful intervention for accommodating cognitive impairments related to MS
(Gentry et al., 2008, Level III).

Program development:
OTs should encourage clients to participate in home programs, if given, so clients can gain the
most benefit from the program and implement what they learn in group therapy into real life
situations (Carr, Nair & Schwartz, 2014, Level I).
Occupational therapists should develop client-centered programs that meet the individual needs
of the client (Stuifbergen, et al., 2012, Level I).
Story memory techniques showed poor long term effects and practitioners should not solely rely
on this form of intervention to aid in clients memory deficits (Chiaravalloti, et al., 2005, Level I).
Those with significant cognitive deficits may not benefit from treatment (Hildebrandt et al, 2007,
Level I).
Practitioners should not independently rely on isolated computer cognitive retraining
intervention to help with patients memory and attention deficits and instead should combine with
other interventions, including the use of compensatory strategies (Solari et al., 2004, Level I).
Occupational therapists should be able to determine deficits in cognitive abilities in patients with
MS through standardized cognitive assessments. Addressing cognition should be a part of all
practice settings (Ceresa et al., 2013, Level I).
Physical fitness should be used in conjunction with other occupational therapy services for
encouraging more independence in participation of occupations and meaningful activities (Beier
et al., 2014, Level 3).
Practitioners that have an interest in exercise fitness and/or executive functioning may find
special training in this area beneficial, but current evidence does not specify that it should be a
necessary component for treating cognition in patients with MS (Briken et al., 2013, Level I).
Current evidence supports the use of PDAs to improve cognitive impairments in individuals with
MS. OT practitioners should implement the use of PDAs to help with cognition with individuals
with MS who are open to learn how to use this technology (Gentry et al., 2008, Level III).

Societal needs:

 Memory deficits is a common problem for people with MS. Group intervention is cost effective,
and allows clients to interact with other people going through the same things which may have
psychosocial benefits (Carr, Nair & Schwartz, 2014, Level I; Stuifbergen, et al., 2012, Level I;
Solari et al., 2004, Level I).
Compensatory strategies will allow those with cognitive deficits adjust to daily life and keep
them engaged in their daily roles and within the community (Chiaravalloti, N. D., Deluca, J.,
Moore, N. B., & Ricker, J. H, 2005, Level I).
More resources are needed for home-based interventions for patient with MS to address
cognitive functioning (Hildebrandt et al, 2007, Level I).
Occupational therapy practitioners should consider maximizing the use of computer assisted
cognitive rehabilitation interventions. This will help alleviate attention deficits in patients with
MS so they can increase their participation in daily activities and reduce their dependence on
others (Ceresa et al., 2013, Level I).
The link of physical exercise to increase cognition of individuals with MS shows the value of
physical finesses therapeutic effect. This information will help with the advocacy of getting
individuals involved in more daily exercise to increase their cognition and reduce their
dependence on other resources which will ultimately reduce costs (Beier et al., 2014, Level 3;
Briken et al., 2013, Level I).
With more affordable prices for PDAs, patients with MS can improve functional performance
and be more independent in daily activities. This will improve their well- being and make them
more productive in society (Gentry, Wallace, Kvarfordt & Lynch, 2008, Level III).

Healthcare delivery and policy:

More research and resources are needed for home-based interventions for patients with MS to
address executive functioning impairments (Carr, Nair & Schwartz, 2014, Level I; Stuifbergen,
et.al., 2012, Level I; Chiaravalloti, Deluca, Moore & Ricker, 2005, Level I;Hildebrandt et al,
2007, Level I; Solari et al., 2004, Level I; Ceresa et al., 2013, Level I; Briken et al., Level I,
2013;Beier, Bombardier, Hartoonian, Motl, & Kraft , 2014, Level III;Gentry, Wallace, Kvarfordt
& Lynch, 2008, Level III).

Education and training of OT students:

OT students should be aware and educated on how to run group interventions as well as familiar
with evidence-based memory rehabilitation interventions (Carr, Nair & Schwartz, 2014, Level I;
Stuifbergen et al., 2012, Level I).
For use of the specific MAPSS-SS group intervention requires education and training. However,
developing compensatory strategies, retraining skills and environmental/lifestyle support is well
within the scope of occupational therapy and occupational therapists have the skill sets to create
a client centered skills plan. Use of home intervention should be utilized to ensure skills are

generalizable to real life situations (Stuifbergen et al., 2012, Level I).

Students should familiarize themselves with different compensatory strategies used to help
combat different aspects of executive functioning and be well versed in modalities to help with
attention and cognition for individuals who suffer from MS (Chiaravalloti et al., 2005, Level I;
Hildebrandt et al., 2007, Level I; Solari et al., 2004, Level I).
Students should be exposed to cognitive rehabilitation interventions to help clients with MS that
are experiencing attention deficits. This specialized training should continue to provide an
excellent service delivery to patients with MS (Ceresa et al., 2013, Level I).
It is important that OT programs stress to the students the importance of physical activity on
health and wellbeing, and its potential positive effects on client factors to promote participation
in everyday activities of patients (Beier, Bombardier, Hartoonian, Motl, & Kraft , 2014, Level
III; Briken et al., 2013, Level I).
OT students should be aware of general assistive technology applications for multiple practice
settings and be encouraged to pursue continuing education in assistive technology if there is a
special interest (Gentry, Wallace, Kvarfordt & Lynch, 2008, Level III).
Refinement, revision, and advancement of factual knowledge or theory:

Supplementary research needs to be performed with larger sample sizes and additional
randomized controlled trials to determine the level of effectiveness of home interventions on
cognition for MS patients (Carr, Nair & Schwartz, 2014, Level I; Stuifbergen et.al., 2012, Level
I; Chiaravalloti et al., 2005, Level I; Hildebrandt et al, 2007, Level I; Solari et al., 2004, Level I;
Ceresa et al., 2013, Level I; Briken et al., Level I, 2013; Beier et al., 2014, Level III; Gentry et
al., 2008, Level III).

Review Process:
Focused question in a PIO format related to occupational therapy was used.
Focused question and rationale were approved by instructor.
Four databases were searched using the key search terms listed below.
The comprehensive literature search chart was completed and submitted for review each week
for a total of 7 weeks.
Each article was reviewed using a critical review form (CRF) and submitted via Blackboard for
instructor approval.
The course instructor reviewed the comprehensive literature search each week and gave
feedback.
A total of 204 articles were found. Articles were excluded according to the below-mentioned
exclusion criteria. Nine articles were included in the final evidence table.
Evidence table was submitted for review.
Instructor reviewed the evidence table.
CAT worksheet was completed and submitted for review.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:
Participants with a diagnosis of multiple sclerosis (MS), articles from 2004-2014, executive
functioning impairments, cognitive deficits and community interventions.
Exclusion Criteria:
Participants with a diagnosis other than MS, interventions taking place in the clinic, non-english
articles and pharmacological interventions.
Search Strategies:
Categories

Key Search Terms

Patient/Client Population

Multiple Sclerosis, MS, Cognitive impairment

Intervention

Computer based, home based, community, exercise, group

interventions, physical fitness, assistive technology

Outcomes

Treatment outcome, activities of daily living, ADL, cognition,

attention, memory, compensatory strategies, learning, fluency

Databases and Sites Searched

PUBMED, EBSCO, GoogleScholar.com, and ERIC

Quality Control/Peer Review Process:

The instructor provided a list of topics to perform a CAT and a PIO question was formed for
instructor approval. After the focus question was approved, a comprehensive literature search
was submitted via Blackboard for review. The exclusion criteria for the CAT was established. Of
the acquired articles, nine articles met the criteria to be included in the CAT. Next, the evidence
table was submitted for review. The instructor reviewed the evidence table and gave feedback.
Finally, the information from all nine articles was compiled in this CAT.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence

Study Design/Methodology of Selected Articles

Number of Articles
Selected

Systematic reviews, meta-analysis, randomized

controlled trials

II

Two groups, nonrandomized studies (e.g., cohort,

case-control)

III

One group, nonrandomized (e.g., before and after,

pretest, and posttest)

IV

Descriptive studies that include analysis of outcomes

(single subject design, case series)

Case reports and expert opinion, which include

narrative literature reviews and consensus statements

Other

Qualitative Studies

0
TOTAL:

Limitations of the Studies Appraised:

Levels I, II, and III
Small sample size (Carr, Nair & Schwartz, 2014, Level I; Chiaravalloti et al., 2005,
Level I; Cerasa et al., 2013, Level I).
No standardized memory test was used and memory issues were self-reported (Carr,
Nair & Schwartz, 2014, Level I; Stuifbergen et al., 2007, Level I).
Co-treatment bias occurred because the control group and treatment group were allowed
to continue with other treatments such as OT and physiotherapy (Carr, Nair & Schwartz,
2014, Level I; Stuifbergen et al., 2012, Level I).
Using a multicomponent intervention (Stuifbergen et al., 2012, Level I).
No placebo group (Hildebrandt, et al., 2007, Level I).
The control group was larger than the intervention group due to dropouts (Hildebrandt et
al., 2007, Level I).
The researchers did not create an adequate sham intervention for the control group and
therefore could have possibly underestimated the treatment study intervention (Solari et
al., 2004, Level I).
Participants included only had the relapsing remitting MS and not the other types of
MS (Cerasa et al., 2013, Level I).
The study only tested aerobic physical exercise (Briken et al., 2013, Level I).
The sample was not randomized or fully representative of the MS population (Gentry et
al., 2008, Level 3).

Levels IV and V
No articles were considered.
Articles Selected for Appraisal:
Beier, M., Bombardier, C. H., Hartoonian, N., Motl, R. W., & Kraft, G. H. (2014). Improved
physical fitness correlates with improved cognition in multiple sclerosis. Archives of
Physical Medicine and Rehabilitation. doi: 10.1016/j.apmr.2014.02.017

Briken, S., Gold, S. M., Patra, S., Vettorazzi, E., Harbs, D., Tallner, A., Schulz, K., & Heesen, C.
(2013). Effects of exercise on fitness and cognition in progressive MS: a randomized,
controlled pilot trial. Multiple Sclerosis Journal, 0(0) 19. doi:
10.1177/1352458513507358

Carr, S., das Nair, R., Schwartz, A., & Lincoln, N. (2014). Group memory rehabilitation for
people with multiple sclerosis: a feasibility randomized controlled trial. Clinical
Rehabilitation, 28(6), 552-561. doi: 10.1177/0269215513512336

Cerasa, A., Gioia, M. C., Valentino, P., Nistic, R., Chiriaco, C., Pirritano, D.,Tomaiuolo, F.,
Mangone, G.,Trotta, M., Talarico, T., Bilotti, G. & Quattrone, A. (2013). ComputerAssisted Cognitive Rehabilitation of Attention Deficits for Multiple Sclerosis A
Randomized Trial With fMRI Correlates. Neurorehabilitation and Neural Repair, 27(4),
284-295. doi: http://dx.doi.org/10.1177/1545968312465194

Chiaravalloti, N. D., Deluca, J., Moore, N. B., & Ricker, J. H. (2005). Treating learning
impairments improves memory performance in multiple sclerosis: a randomized clinical

trial. Multiple Sclerosis (13524585), 11(1), 58-68. doi:10.1191/1352458505ms1118oa

Gentry, T., Wallace, J., Kvarfordt, C., & Lynch, K. B. (2008). Personal digital assistants as
cognitive aids for individuals with severe traumatic brain injury: A community-based
trial. Brain Injury, 22(1), 19-24. doi: 10.1080/02699050701810688

Hildebrandt, H., Lanz, M., Hahn, H. K., Hoffmann, E., Schwarze, B., Schwendemann, G., &
Kraus, J. A. (2007). Cognitive training in ms: effects and relation to brain atrophy.
Restorative Neurology & Neuroscience, 25(1), 33-43. Retrieved from
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid= 1cb034aa-d685-427c-994117cf2cef3e49%40sessionmgr4001&vid=4&hid=4101

Solari, A., Motta, A., Mendozzi, L., Pucci, E., Forni, M., Mancardi, G., & Pozzilli, C. (2004).
Computer-aided retraining of memory and attention in people with multiple sclerosis: a
randomized, double-blind controlled trial. Journal of the Neurological Sciences, 222(1),
99-104. doi: 10.1016/j.jns.2004.04.027

Stuifbergen, A., Becker, H., Perez, F., Morison, J., Kullberg, V., & Todd, A. (2012). A
randomized controlled trial of a cognitive rehabilitation intervention for persons with
multiple sclerosis. Clinical Rehabilitation, 26(10), 882-893.
doi:10.1177/0269215511434997

Other References:
Carney, N., Chestnut, R. M., Maynard, H., Mann, N. C., Paterson, P., & Helfand, M. (1999).
Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A
systematic review. Journal of Head Trauma Rehabilitation, 14, 277307. Retrieved from
http://search.ebscohost.com/loginaspx?direct=true&db=cmedm&AN=10381980&site=eh
ost-live/

Chan, R. C., Shum, D., Toulopoulou, T., & Chen, E. Y. (2008). Assessment of executive
functions: Review of instruments and identification of critical issues. Archives of Clinical
Neuropsychology, 23(2), 201-216. doi: http://dx.doi.org/10.1016/j.acn.2007.08.010

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05