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MS research update – Relapses and brain fog – 5 June 2018

Summary

Many people with MS talk about 'brain fog' or 'cog fog’ to describe the feeling that their thinking processes not as organised or reliable as they used to be before they had MS. This study assessed memory and thinking (cognition) to see how it changed during and after a relapse.

60 people experiencing a relapse, 30 people with stable MS and 30 people who did not have MS took part in this study. Cognition was assessed using BICAMS, a set of tests which measure different aspects of thinking and memory and are quick and easy to complete. For people who were experiencing a relapse, the tests were given during the relapse, and then one and three months after the relapse. The group with stable MS and the group without MS were tested just once.

The scores on all tests were lower in people with MS, both relapsing and stable, than in those without MS. The score for the test which measures information processing speed was worse in relapsing MS than in stable MS. Scores for tests which assess visual and verbal memory were not significantly different for relapsing MS and stable MS. Within the relapsing group, scores improved one month after relapse.

The study confirms that relapses can have an impact on cognition, with information processing speed being most affected, so it would be wise to avoid making big decisions during a relapse. The good news is that processing speed improves quite quickly and is back to levels typical for people with MS after just one month.

The researchers comment that cognition is not often monitored during clinic appointments and recommend that BICAMS would be a quick and effective way to do this, particularly for people having a relapse.


Background

Many people with MS talk about 'brain fog' or 'cog fog' to describe the feeling that their thinking processes are sometimes not as organised or reliable as they used to be before they had MS. Cognition is the medical term for thinking, and problems with thinking and memory are known as cognitive problems. This study used a quick and easy assessment of cognition to see how it changed during and after a relapse.

How this study was carried out

The study recruited 60 participants with MS who were experiencing a relapse, 30 participants with stable MS and 30 participants who did not have MS. Cognition was assessed using BICAMS (Brief International Cognitive Assessment for Multiple Sclerosis), a set of three tests which evaluate different aspects of thinking and memory and are quick and easy to complete. For people who were experiencing a relapse, the tests were given during the relapse, and then one and three months after the relapse. The group with stable MS and the group without MS were tested just once.

What was found

The scores for all three BICAMS tests were lower in people with MS, both relapsing and stable, than in those without MS.

The score for the SDMT (Symbol Digit Modalities Test), which measures information processing speed, was worse in relapsing MS than in stable MS. Scores for BVMT (Brief Visuospatial Memory Test) and CVLT (California Verbal Learning Test) which assess visual and verbal memory were not significantly different for relapsing MS and stable MS.

Within the relapsing group, scores for all three BICAMS tests improved one month after relapse. CVLT, which assesses verbal memory, improved further at three months after the relapse; the researchers suggest this could be due to a practice effect, in other words, the result of taking the test several times.

Various factors affected the improvement of cognition after a relapse, with higher education and younger age being associated with higher SDMT scores. The researchers also found a greater improvement in visuospatial memory (BVMT) in men and greater improvements in verbal memory (CVLT) in women.

What does it mean?

The study confirms that relapses can have an impact on cognition, with information processing speed being most affected, so it would be wise to avoid making big decisions during a relapse. The good news is that processing speed improves quite quickly and is back to levels typical for people with MS after just one month.

The researchers comment that more than half of people with MS will have problems with thinking and memory problems, yet cognition is not routinely monitored during clinic appointments. They recommend that cognition should be assessed during a relapse and that BICAMS is a quick and effective way to do this. Of the three BICAMS tests, SDMT may be the most suitable to identify people who are experiencing a cognitive relapse.

Processing speed is the pace at which you take in information, make sense of it and begin to respond. Some neuropsychologists think that reduced information processing speed is the underlying reason for all cognitive difficulties in MS. In everyday life, reduced information processing speed might be most noticeable as reduced concentration or finding it hard to stay focussed in a noisy or distracting environment.

Giedraitiene N, et al.
Cognition during and after multiple sclerosis relapse as assessed with the brief international cognitive assessment for multiple sclerosis.
Sci Rep. 2018 May 25;8(1):8169.
Abstract
Read the full text of this paper

More about thinking process and memory during relapses

Because a relapse is often stressful, many people can feel distracted and a bit overwhelmed and may have problems thinking through complex tasks. These thinking problems are fairly common during a relapse but should become less of a problem as you recover.

During some relapses, you may have more obvious problems with thinking. You may find that your speed of thinking is slower and that you have trouble concentrating. If these symptoms have come on quite suddenly, it’s possible your relapse is directly affecting your thinking processes - this is called a cognitive relapse.

These symptoms will usually settle down. If they interfere with your ability to do important tasks, an occupational therapist or neuropsychologist can work with you to develop strategies to help you manage. You'll find all sorts of tips and tricks to help with cognitive symptoms on the MS Trust website StayingSmart.

Cognitive problems during a relapse may have an impact on work. Taking time off work may not be possible and some people with MS have no alternative but to continue to work during a relapse. If this is the case, it may help to let your manager or supervisor know that you are having a relapse. It may be possible to arrange for you to do some work from home, take some flexi-time or have longer or more flexible breaks during your working day depending on your needs. 

Read more about relapses

Read more about thinking and memory problems

Research by topic areas...

Diagnosis

van der Vuurst de Vries RM, Wong YYM, Mescheriakova JY, et al.
High neurofilament levels are associated with clinically definite multiple sclerosis in children and adults with clinically isolated syndrome.
Mult Scler. 2018 May 1:1352458518775303. [Epub ahead of print]
abstract
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Disease modifying drugs

Yildiz O, Mao Z, Adams A, et al.
Disease activity in progressive multiple sclerosis can be effectively reduced by cladribine.
Mult Scler Relat Disord. 2018 May 31;24:20-27. [Epub ahead of print]
abstract

Trojano M, Butzkueven H, Kappos L, et al.
Natalizumab treatment shows low cumulative probabilities of confirmed disability worsening to EDSS milestones in the long-term setting.
Mult Scler Relat Disord. 2018 May 2;24:11-19. [Epub ahead of print]
abstract
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Gärtner J, Chitnis T, Ghezzi A, et al.
Relapse rate and MRI activity in young adult patients with multiple sclerosis: a post hoc analysis of phase 3 fingolimod trials.
Mult Scler J Exp Transl Clin. 2018 May 25;4(2):2055217318778610.
abstract
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Conway DS, Cecilia Vieira M, Thompson NR, et al.
Patient-reported disease-modifying therapy adherence in the clinic: a reliable metric?
Mult Scler J Exp Transl Clin. 2018 May 23;4(2):2055217318777894.
abstract
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Frau J, Sormani MP, Signori A, et al.
Clinical activity after fingolimod cessation: disease reactivation or rebound?
Eur J Neurol. 2018 May 31. [Epub ahead of print]
abstract

Buonomo AR, Zappulo E, Viceconte G, et al.
Risk of opportunistic infections in patients treated with alemtuzumab for multiple sclerosis.
Expert Opin Drug Saf. 2018 Jun 11:1-9. [Epub ahead of print]
abstract

Chalmer T, Baggesen LM, Nørgaard M, et al.
Early versus later treatment start in multiple sclerosis a register based cohort study.
Eur J Neurol. 2018 May 30. [Epub ahead of print]
abstract

Cree BAC, Arnold DL, Cascione M, et al.
Phase IV study of retention on fingolimod versus injectable multiple sclerosis therapies: a randomized clinical trial.
Ther Adv Neurol Disord. 2018 May 20;11:1756286418774338.
abstract
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Vollmer B, Honce JM, Sillau S, et al.
The impact of very short transition times on switching from natalizumab to fingolimod on imaging and clinical effectiveness outcomes in multiple sclerosis.
J Neurol Sci. 2018 Jul 15;390:89-93.
abstract

Le Page E, Edan G.
Induction or escalation therapy for patients with multiple sclerosis?
Rev Neurol (Paris). 2018 May 21. pii: S0035-3787(17)30788-9. [Epub ahead of print]
abstract

Berntsson SG, Kristoffersson A, Boström I, et al.
Rapidly increasing off-label use of rituximab in multiple sclerosis in Sweden - Outlier or predecessor?
Acta Neurol Scand. 2018 May 24. [Epub ahead of print]
abstract

Alcalá C, Gascón F, Pérez-Miralles F, et al.
Efficacy and safety of rituximab in relapsing and progressive multiple sclerosis: a hospital-based study.
J Neurol. 2018 May 21. [Epub ahead of print]
abstract

Mills EA, Mao-Draayer Y.
Aging and lymphocyte changes by immunomodulatory therapies impact PML risk in multiple sclerosis patients.
Mult Scler. 2018 May 1:1352458518775550. [Epub ahead of print]
abstract

Glusman M, Bruce A, Thelen J, et al.
Discontinuing treatment against medical advice: the role of perceived autonomy support from providers in relapsing-remitting multiple sclerosis.
Ann Behav Med. 2018 May 16. [Epub ahead of print]
abstract

Hormones and MS

Rankin K, Bove R.
Caring for women with multiple sclerosis across the lifespan.
Curr Neurol Neurosci Rep. 2018 May 23;18(7):36.
abstract

Other treatments

Jensen MP, Battalio SL, Chan JF, et al.
Use of neurofeedback and mindfulness to enhance response to hypnosis treatment in individuals with multiple sclerosis: results from a pilot randomized clinical trial.
Int J Clin Exp Hypn. 2018 Jul-Sep;66(3):231-264.
abstract

Mallada Frechín J.
Effect of tetrahydrocannabinol:cannabidiol oromucosal spray on activities of daily living in multiple sclerosis patients with resistant spasticity: a retrospective, observational study.
Neurodegener Dis Manag. 2018 May 31. [Epub ahead of print]
abstract

Tourbah A, Gout O, Vighetto A, et al.
MD1003 (high-dose pharmaceutical-grade biotin) for the treatment of chronic visual loss related to optic neuritis in multiple sclerosis: a randomized, double-blind, placebo-controlled study.
CNS Drugs. 2018 May 28. [Epub ahead of print]
abstract
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Markovà J, Essner U, Akmaz B, et al.
Sativex as add-on therapy vs. further optimized first-line antispastics (SAVANT) in resistant multiple sclerosis spasticity: a double-blind, placebo-controlled randomised clinical trial.
Int J Neurosci. 2018 May 24:1-26. [Epub ahead of print]
abstract

Marck CH, De Livera AM, Brown CR, et al.
Health outcomes and adherence to a healthy lifestyle after a multimodal intervention in people with multiple sclerosis: Three year follow-up.
PLoS One. 2018 May 23;13(5):e0197759.
abstract
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Paediatric MS

Boesen MS, Koch-Henriksen N, Thygesen LC, et al.
Infections seem to be more frequent before onset of pediatric multiple sclerosis: A Danish nationwide nested case-control study.
Mult Scler. 2018 May 1:1352458518771871. [Epub ahead of print]
abstract

Provision of care

Visaria J, Thomas N, Gu T, et al.
Understanding the patient's journey in the diagnosis and treatment of multiple sclerosis in clinical practice.
Clin Ther. 2018 May 23. pii: S0149-2918(18)30186-3. [Epub ahead of print]
abstract
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Psychological aspects

Bruce JM, Jarmolowicz DP, Lynch S, et al.
How patients with multiple sclerosis weigh treatment risks and benefits.
Health Psychol. 2018 Jun 4. [Epub ahead of print]
abstract

Realmuto S, Dodich A, Meli R, et al.
Moral cognition and multiple sclerosis: a neuropsychological study.
Arch Clin Neuropsychol. 2018 May 30. [Epub ahead of print]
abstract

Rehabilitation

Alghwiri AA, Khalil H, Al-Sharman A, et al.
Depression is a predictor for balance in people with multiple sclerosis.
Mult Scler Relat Disord. 2018 May 26;24:28-31. [Epub ahead of print]
abstract

Reilly S, Hynes SM.
A cognitive occupation-based programme for people with multiple sclerosis: a study to test feasibility and clinical outcomes.
Occup Ther Int. 2018 May 2;2018:1614901.
abstract
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Thirumalai M, Rimmer JH, Johnson G, et al.
TEAMS (tele-exercise and multiple sclerosis), a tailored telerehabilitation mhealth app: participant-centered development and usability study.
JMIR Mhealth Uhealth. 2018 May 24;6(5):e10181.
abstract
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Giunti G, Guisado Fernández E, Dorronzoro Zubiete E, et al.
Supply and demand in mhealth apps for persons with multiple sclerosis: systematic search in app stores and scoping literature review.
JMIR Mhealth Uhealth. 2018 May 23;6(5):e10512.
abstract
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Baird JF, Sandroff BM, Motl RW.
Therapies for mobility disability in persons with multiple sclerosis.
Expert Rev Neurother. 2018 Jun;18(6):493-502.
abstract

Dennett R, Gunn H, Freeman JA.
Effectiveness of and user experience with web-based interventions in increasing physical activity levels in people with multiple sclerosis: a systematic review.
Phys Ther. 2018 May 15. [Epub ahead of print]
abstract

Relapses

Bsteh G, Hegen H, Ladstätter F, et al.
Transient impairment of olfactory threshold in acute multiple sclerosis relapse.
Mult Scler Relat Disord. 2018 May 18;23:74-77. [Epub ahead of print]
abstract

Stem cells

von Wunster B, Bailey S, Wilkins A, et al.
Advising patients seeking stem cell interventions for multiple sclerosis.
Pract Neurol. 2018 May 30. pii: practneurol-2018-001956. [Epub ahead of print]
abstract

Fernández O, Izquierdo G, Fernández V, et al.
Adipose-derived mesenchymal stem cells (AdMSC) for the treatment of secondary-progressive multiple sclerosis: A triple blinded, placebo controlled, randomized phase I/II safety and feasibility study.
PLoS One. 2018 May 16;13(5):e0195891.
abstract
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Symptoms and symptom management

Scherder RJ, Kant N, Wolf ET, et al.
Sensory function and chronic pain in multiple sclerosis.
Pain Res Manag. 2018 Apr 23;2018:1924174.
abstract
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Fenu G, Arru M, Lorefice L, et al.
Does focal inflammation have an impact on cognition in multiple sclerosis? An MRI study.
Mult Scler Relat Disord. 2018 May 16;23:83-87. [Epub ahead of print]
abstract

Etoom M, Khraiwesh Y, Lena F, et al.
Effectiveness of physiotherapy interventions on spasticity in people with multiple sclerosis. a systematic review and meta-analysis.
Am J Phys Med Rehabil. 2018 May 22. [Epub ahead of print]
abstract

Vitamin D

Hart PH, Jones AP, Trend S, et al.
A randomised, controlled clinical trial of narrowband UVB phototherapy for clinically isolated syndrome: The PhoCIS study.
Mult Scler J Exp Transl Clin. 2018 Apr 27;4(2):2055217318773112.
abstract
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Zheng C, He L, Liu L, et al.
The efficacy of vitamin D in multiple sclerosis: A meta-analysis.
Mult Scler Relat Disord. 2018 May 12;23:56-61. [Epub ahead of print]
abstract

Work

van Gorp DAM, van der Klink JJL, Abma FI, et al.
The capability set for work - correlates of sustainable employability in workers with multiple sclerosis.
Health Qual Life Outcomes. 2018 Jun 1;16(1):113.
abstract
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