Monday, 19 March 2012

Memory rehabilitation does not work in MS

das Nair et al.  Memory Rehabilitation for people with multiple sclerosis. Cochrane Database Syst Rev. 2012 Mar 14;3:CD008754. 

BACKGROUND: Impairments in cognitive function, particularly memory, are common in MSers and these can potentially affect their ability to complete functional activities. There is evidence from single-case or small group studies that memory rehabilitation can be beneficial for MSers but findings from randomised controlled trials (RCTs) and systematic reviews have been inconclusive.

OBJECTIVES: To determine the effectiveness of memory rehabilitation for MSers who have memory problems, and the effect of such interventions on functional abilities.

MAIN RESULTS: Eight studies, involving 521 participants, were included. The interventions involved various memory retraining techniques, such as computerised programmes and training on internal and external memory aids. Control groups varied in format from assessment-only groups, discussion and games, non-specific cognitive retraining and attention or visuospatial training. The analysis showed no significant effects of memory rehabilitation on memory function or functional abilities immediately or long-term. No significant effect of intervention was found, either immediately or long-term, on subjective reports of memory problems and on Quality of Life. On Activities of Daily Living, no immediate treatment effect was observed, but on long-term follow up the intervention group performed significantly worse than the control group.


CONCLUSIONS: There is no evidence to support the effectiveness of memory rehabilitation on memory function or functional abilities in MSers. However, this conclusion has been arrived because of the limited quality of some of the primary studies reviewed in this area. Further robust, RCTs of higher methodological quality and better quality of reporting are needed.

"This analysis is very disappointing; in short memory rehabilitation does not work in MS. Should we give up on this? No, what we need to do is consider why these therapies are failing. I believe it is because MS is a progressive disease and if you try rehabilitation without addressing the underlying mechanism responsible for progression how could memory rehabilitation work. It is trying to retrain a brain that is degenerating. We need to stop progression first, i.e. ongoing loss of neurons and axons, and then we may get better results with rehabilitation. How do we stop disease progression? Easier said than done! I think we need combination therapies; some that target inflammation and other targeting neuroprotection; this is what we plan to test in our oxcarbazepine trial. Oxcarbazepine will added on top of standard anti-inflammatory therapies. Let's hope it gets funded."

"Another message hidden in this data is the one I always come back to; we need to treat MS early and as aggressively as possible to prevent the damage for occurring in the first place. This is easier said than done in the current economic climate and whilst the European regulators have the mind set that they are the ones who will decide what risks MSers should be exposed to. The current licenses of the more aggressive DMTs are narrow and their commercial price positions them as second-line  treatments. I am not optimistic that this is going to change sometime soon!"

3 comments:

  1. It's sad that alemtuzumab is going to take 12-18 months to go through the paperwork with the various authorities, whereas at the moment it is comparatively 'cheap', but once it's got the go ahead from the govt. agencies it's producers will call it Lemtrada and it will cost much more. I hope neuros have got some friendly concologists to stockpile it for them, although I can understand the big Pharmas wanting to make money- look at the loss they will probably take on laquinimod.

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  2. "It's sad that alemtuzumab"

    It will take time and they will jack up the price.

    This why the MS Socieites should be lobbied to get iv. cladribine through the pipeline. It is out of patent it works as well as lemtrada based on phase III data and does not have the autoimmune risk of alemtuzumab.

    Oral cladribine was not withdrawn because it did not work!!! and I suspect the safety profile of iv. cladribine is no worse than the the others out there. You can have a cheap drug that works...
    do the study and set a cat amongst the pigeons.

    Come on NICE be NICE for a change and put this on the agenda.

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