**6. Multi‐disciplinary MS treatment**

### **6.1. Cognitive disorders therapy in MS**

Pharmacotherapy for cognitive impairment in MS is currently the subject of intense research. First and foremost, a preventive effect of early initiation and immunomodulatory therapy, in association with the possible development of cognitive disorders, is assumed. The primary point is to prevent axonal loss and the development of atrophy. Very few randomized trials have been carried out so far. Acetylcholinesterase inhibitors have currently been examined, through only with questionable or entirely negative results. No effective pharmacological treatment for cognitive disorders in MS has yet been found [34]. The pharmacological manip‐ ulation of depression is also significant, however, and should always be combined with psychotherapy in MS patients. Moreover, depression can be enhanced by a variety of bio‐ psychosocial factors, such as reduced work performance or increased neurological symptoms.

#### **6.2. Neuropsychological rehabilitation and the cognitive deficit psychotherapy**

Kalb and Reitman [35] report the so‐called cognitive rehabilitation as the basic therapy for cognitive deficits. They present two approaches: The first is to restore functions, such as through direct training and exercising of skills that are altered in neuropsychological tests (this approach, however, has a limited benefit in improving daily activities in MS patients) and the second approach is more compensatory, and closer to current neuropsychology, with its desire to improve a function through substitution, that is, the individual use of residual cognitive abilities in order to improve the quality of life through behavioral and cognitive therapy. The first approach is based on a more experimental approach, while the second is more clinical. It concerns creating an individual plan, "customized" for each patient.

This plan is based on neuropsychological assessment and interviews with the patient and their family. The evidence for the efficacy of cognitive rehabilitation in MS is, unfortunately, quite limited and contradictory. Memory rehabilitation studies suggest that individualized com‐ puter programs focused on patient‐specific difficulties could be most effective. The most beneficial in the rehabilitation of executive functions is perhaps a direct instruction by a therapist, that is, paper and pencil method. The main problem of cognitive training in MS remains to be particularly its unavailability for patients and their often low motivation. It is therefore very important to maintain employability of patients for as long as possible and motivate them toward mental activity.

For these purposes, teams of multi‐disciplinary experts work with people with MS, where a neurologist, psychologist, psychiatrist, speech therapist, occupational therapist, physiothera‐ pist, and a psychotherapist cooperate in complex, holistic, all‐day programs, based on cognitive as well as emotional, behavioral, and physiological changes. Even though it is impossible to increase one's premorbid IQ and brain volume, we can work on cognitively stimulating leisure activities. It is also very important to motivate the patient to lead an active life that includes adherence to the prescribed pharmacotherapy, but also an active attitude toward physiotherapy, psychotherapy, and cognitive training. It is the combination of physiotherapy and cognitive training that has the correct effect on the neurogenesis and formation of new synapses.

The specific model of psychosocial support for patients with MS at different levels, which has the characteristics of a cognitive‐behavioral supportive therapy and family therapy, includes [35]: (1) psychoeducation, that is, education leading to the understanding of the disease, explanation of adaptive coping strategies; (2) diagnostics/treatment of emotional or cognitive problems; (3) family intervention, that is, how to organize family support for members with MS for adaptive coping with the illness; (4) work support for MS patients, that is, to work productively in a field for as long as they are able and interested, and vice versa, to stop working if necessary; (5) individual psychosocial assistance to individuals with MS. In addition to professional psychotherapy, a support group of people with the same disease, but also of family, friends, possibly a cultural‐social or religious community, is appropriate.

#### **6.3. Disability, employability, and MS**

The organization of care for MS patients is similar around the world. A patient with a benign course of the disease is usually checked by a neurologist twice a year; more complicated patients are consulted in centers for MS that are a part of most university neurological clinics. In the case of a more severe disability, it is advisable to contact social services or long‐term care. Neuropsychological approaches, however, show that employability can also be predicted by a short battery of tests that focuses on relevant domains, such as the aforementioned battery BICAMS [36]. The issue of employment restrictions, disability, work, and life disability due to MS is illustrated in the following case report.

#### *6.3.1. Case report 5*

(BWCS), Impact of Visual Impairment Scale (IVIS), Perceived Deficits Questionnaire (PDQ), Mental Health Inventory (MHI), and MOS Modified Social Support Survey (MSSS). The scales

Pharmacotherapy for cognitive impairment in MS is currently the subject of intense research. First and foremost, a preventive effect of early initiation and immunomodulatory therapy, in association with the possible development of cognitive disorders, is assumed. The primary point is to prevent axonal loss and the development of atrophy. Very few randomized trials have been carried out so far. Acetylcholinesterase inhibitors have currently been examined, through only with questionable or entirely negative results. No effective pharmacological treatment for cognitive disorders in MS has yet been found [34]. The pharmacological manip‐ ulation of depression is also significant, however, and should always be combined with psychotherapy in MS patients. Moreover, depression can be enhanced by a variety of bio‐ psychosocial factors, such as reduced work performance or increased neurological symptoms.

**6.2. Neuropsychological rehabilitation and the cognitive deficit psychotherapy**

concerns creating an individual plan, "customized" for each patient.

Kalb and Reitman [35] report the so‐called cognitive rehabilitation as the basic therapy for cognitive deficits. They present two approaches: The first is to restore functions, such as through direct training and exercising of skills that are altered in neuropsychological tests (this approach, however, has a limited benefit in improving daily activities in MS patients) and the second approach is more compensatory, and closer to current neuropsychology, with its desire to improve a function through substitution, that is, the individual use of residual cognitive abilities in order to improve the quality of life through behavioral and cognitive therapy. The first approach is based on a more experimental approach, while the second is more clinical. It

This plan is based on neuropsychological assessment and interviews with the patient and their family. The evidence for the efficacy of cognitive rehabilitation in MS is, unfortunately, quite limited and contradictory. Memory rehabilitation studies suggest that individualized com‐ puter programs focused on patient‐specific difficulties could be most effective. The most beneficial in the rehabilitation of executive functions is perhaps a direct instruction by a therapist, that is, paper and pencil method. The main problem of cognitive training in MS remains to be particularly its unavailability for patients and their often low motivation. It is therefore very important to maintain employability of patients for as long as possible and

For these purposes, teams of multi‐disciplinary experts work with people with MS, where a neurologist, psychologist, psychiatrist, speech therapist, occupational therapist, physiothera‐ pist, and a psychotherapist cooperate in complex, holistic, all‐day programs, based on

can also be presented individually.

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**6. Multi‐disciplinary MS treatment**

**6.1. Cognitive disorders therapy in MS**

motivate them toward mental activity.

A doctor, surgeon specialist, formerly a chief physician, 50 years old, with remitting MS. MRI scans revealed the cerebrospinal form with multiple plaques in the white matter of the brain and spinal cord; the demyelinating plaque findings are unchanged for 3 years. The patient was recommended to a cognition assessment for his memory problems, was dismissed from the surgical specialty, and thus works as a GP, which does not satisfy him. He is divorced and has problems with his second wife, who is a nurse, approximately 25 years younger. The wife is hostile, blames him for the change of social status. Neuropsychologically, only his psychomo‐ tor speed and motor dexterity are slightly reduced, which exhibits moderate depression in emotional experience, not suicidal. Couples therapy was recommended to address the changes in his professional situation and partner quality of life, together with a psychiatric consultation.

#### **7. Conclusion**

This article summarizes a neuropsychologist's perspective on cognitive skills in MS. When evaluating the cognitive level of patients, the comprehensive or screening assessment should examine specific domains that may not correlate with the length of the illness, neurological objective findings, the amount of plaque on MRI scans, and the MS form or type. Cognitive disorders are a significant predictor of quality of life during all stages of MS; they reduce physical independence and the ability to perform both activities of daily life and of employ‐ ment, they influence one's coping and compliance to the treatment and their rehabilitation potential. The employability of people with MS can thus be easily predicted by the severity of cognitive disorders and their premorbid cognitive reserves, rather than by physical disability. The neuropsychological assessment of cognitive functions in MS should be a part of care for patients with MS and a part of a multi‐disciplinary approach to neurorehabilitation.
