Introduction
Methods
Participants and Study Setting
Standard Clinical and Cognitive Measures
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Demographic (age, gender, ancestry, education, employment) variables were obtained from all participants, and MS type, duration since first symptoms, Neurostatus Expanded Disability Status Scale (EDSS) [17] and MS DMT were obtained from the medical record for MS participants. The neurological evaluation included:
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MS Functional Composite 4 (MSFC4) components, as outlined by Cohen et al. [18].
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Walking speed: Timed 25 Foot Walk (T25FW).
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Dexterity: nine-hole peg test (9HPT).
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Vision: Sloan low-contrast letter acuity test (LCVA).
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Cognition: the paced auditory serial addition task (PASAT) was replaced by the SDMT [19] as the SDMT is more congenial for patients and clinicians, rapid, and forms a component of the BICAMS. Serial versions of the test were used to minimize practice effects.
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Paper and pencil cognitive tests.
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Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS), a standardized, internationally validated battery requiring 15 min or less.
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Information processing speed: SDMT (as above; written version was administered to allow adequate comparison with the digital tools) [19].
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Verbal memory (immediate recall): CVLT II Trials 1–5 [20]. Serial versions of the test were used to minimize practice effects.
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Visual memory (immediate recall): Brief Visuospatial Memory Test Revised (BVMT-R) [21].
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Patient-reported mood was assessed using the 14-item Hospital Anxiety and Depression Scale (HADS) [22, 23], a self-report instrument containing seven questions probing anxiety and seven questions for depression, each scored separately in a Likert fashion (0 through 3). Scores 0–7 are categorized as normal, 8–10 mild, 11–14 moderate, and 15–21 severe [24]. A threshold score of 8 or greater on the HADS depression subscale provides a sensitivity of 90% and specificity of 87.3% for major depression, and on the anxiety subscale provides a sensitivity of 88.5% and a specificity of 80.7% for generalized anxiety disorder only [23].
Digital Cognitive Measures
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Detection task (DET): a reaction time task assessing psychomotor function. The subject presses the ‘Yes’ key as quickly as possible when the central card turns face-up. The face-up card displayed is always the same joker card. The primary outcome on this task is reaction time.
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Identification task (IDN): a choice reaction time task assessing visual attention. A card is turned over in the center of the screen, and the subject should respond ‘Yes’ if the face-up card is red, or ‘No’ if it is black. Jokers are used again to ensure that playing cards presented in the next task were not previously seen. The primary outcome on this task is reaction time.
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One card learning (OCL): assesses visual recognition memory and attention. Cards are sequentially shown and subjects are instructed to respond ‘Yes’ if the face-up card has appeared in the task before, and ‘No’ if it has not yet appeared. Normal playing cards are displayed without jokers. The primary outcome on this task is accuracy of responses.
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One back task (ONB): assesses working memory and attention. Subjects are instructed to respond ‘Yes’ if the face-up card is exactly the same as the immediately previous card, or ‘No’ if it is not. The primary outcome on this task is reaction time.
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The UCSF match test: match is a 2-min test of executive functions and processing speed that is based on the SDMT but delivered on a tablet using the TabCAT software platform (memory.ucsf.edu/TabCAT). Respondents are shown a number/symbol key at the bottom of the screen. Using this key as a reference, they are asked to tap the symbol that corresponds to a series of number cues as quickly and accurately as possible. In comparison to SDMT, it places less demand on motor functions and literacy because subjects tap rather than write their responses; also, it can be self-administered. Performance is scored by the total correct in 2-min. The Match shows expected correlations with traditional neuropsychological tests and regional gray matter volumes [26].
Digital Treatment for Cognitive Deficits
Ethical Approvals
Statistical Analyses
Results
Participant Characteristics
N
| 21 |
Age, years | |
Mean (SD) | 53.8 (11.6) |
Sex | |
Female | 18 (86%) |
Handedness | |
Right-handed | 20 (95%) |
Education, years | |
Mean (SD) | 15.8 (2.5) |
Employment | |
Part- or full-time employed | 7 (33%) |
Ethnicity | |
Not Hispanic | 21 (100%) |
Race | |
White | 20 (95%) |
Black or African American | 1 (5%) |
MS type | |
RR | 15 (71%) |
PP | 4 (19%) |
SP | 2 (10%) |
Disease duration | |
Mean (SD) | 14.5 (9.6) |
EDSS | |
Mean (median, SD, IQR, range) | 3.1 (2.5, 2.0, [2.0–3.5], [0–7]) |
SDMT correct | |
Mean (SD) | 47.4 (10.3) |
CVLT II total | |
Mean (SD) | 55.2 (12.7) |
BVMT total recall | |
Mean (SD) | 27.0 (8.2) |
Feasibility of In-Home Digital Treatment for Cognitive Deficits: User Experience
Predictors of Persistence with the Training Sessions
Changes in Cognitive Scores after 4 Weeks of Digital Treatment
Test | Domain | Pre, mean (sd) | Post, mean (sd) |
N
|
p
|
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BICAMS | |||||
SDMT | Processing speed | 48.3 (10.4) | 51.9 (10.8) | 18 |
0.003
|
CVLT-II | Verbal memory | 54.8 (13.3) | 55.3 (12.0) | 19 | 0.385 |
BVMT-R | Visual memory | 27.5 (8.5) | 27.6 (6.9) | 19 | 0.465 |
Computerized | |||||
Cogstate | |||||
DET | Psychomotor function | 2.6 (0.09) | 2.5 (0.06) | 14 |
0.006
|
IDN | Visual attention | 2.7 (0.07) | 2.7 (0.08) | 14 | 0.755 |
OCL | Visual memory, attention | 0.97 (0.17) | 1.01 (0.14) | 14 | 0.147 |
ONB | Working memory, attention | 2.88 (0.09) | 2.86 (0.10) | 14 | 0.082 |
Match | Processing speed | 50.9 (7.1) | 53.1 (8.0) | 16 |
0.006
|