SMART Rehab: exploring the effects of Strengthening Mental Abilities with Relational Training on Cognitive Functioning for people with Multiple sclerosis

Background: Multiple Sclerosis (MS) is a progressive neurodegenerative disease that impacts on a range of both proximal and distal outcomes. People with MS commonly experience cognitive problems that have been shown to affect important aspects of life such as employment, mood, and quality of life. Whilst the disease is progressive, and the damage widespread, recovery from damage through neuronal plasticity does occur. There is growing evidence base in cognitive rehabilitation offerings but limited in quality to draw firm recommendations and studies not reporting a clear theoretical underpinning of their interventions hinders development. Training (SMART: Strengthening Mental Abilities with Relational Training) of Derived Relational Responding, a fundamental component of a well-established behavioural theory of cognition – Relational Frame Theory – has been shown to improve cognitive performance as measured by Intelligence Quotient tests. Studies have begun initial applications of relational responding training in cognitive rehabilitation studies. Objectives: The primary objective was to explore the effects of SMART on both objective and subjective assessments of cognitive functioning for people with MS. Secondary objectives were to assess changes in secondary outcomes (mood, fatigue, quality of life), explore the relationship between relational responding and outcomes, and investigate the acceptability, practicality, and feasibility of the intervention. Method: The study has a multiple baseline design with a feedback interview. The study aimed to recruit nine participants. Participants completed a battery of neuropsychological assessments in addition to secondary outcome measures. Participants then completed their respective baselines. They then began a 12-week intervention of 45- minutes of training per week. Participants completed subjective assessments on a weekly basis and relational skills assessments every other week. The full battery was administered again at week six of the intervention, and again one week after the intervention had ended. A feedback interview, conducted by independent researchers, was delivered a week after the intervention ended. The full test battery was administered a final time at a three-month follow-up [1]. Results: A total of eight participants were enrolled into the study. Weekly measurements of subjective cognitive performance showed no phase contrasts. Objective measurements showed improvements. Processing speed outcomes improved in 87.5% of participants and this also represented a clinically significant improvement for 100% of participants who were in a clinically impaired range at intake. 50% of participants improved in the Repeatable Battery for the Assessment of Neuropsychological Status Total Score. Feedback interviews made recommendations to increase the intensity and duration of the intervention. Relational abilities improved in all but one participant. Secondary outcomes remained stable. Conclusions: These preliminary findings on objective assessments are promising though are questioned by the lack of subjectively reported improvements. The relationship between relational skills and improved outcomes was inconclusive. The intervention appears to have been acceptable to participants, providing support for further development