Using Nonpharmacological Interventions to Promote Healthier Lifestyles in Multiple Sclerosis

Michelle Chen, PhD

In multiple sclerosis (MS), cognitive impairment is a common symptom. In a recent review conducted by Michelle Chen, PhD, and colleagues, the findings showed evidence that cognitive rehabilitation programs are efficacious as a treatment for cognitive dysfunction related to MS.¹ Prior to the review, there was limited evidence on the effectiveness of disease-modifying therapies for cognitive dysfunction. Chen and colleagues recommend that clinicians consider this approach as a low-cost, low risk, yet effective treatment for their patients.

Chen, neuropsychologist, Rutgers University, was recently awarded a grant to study health and lifestyle behaviors as a way to prevent MS disease progression. In an interview with NeurologyLive^®, Chen discussed tracking behavior change in MS through the use of digital interventions and wearable devices.

NeurologyLive®: Could you expand more on your recently awarded grant?

Michelle Chen, PhD: We know that there are certain health and lifestyle risk factors for cognitive decline in just the general older adult population. There are certain things that are associated with an increased risk of dementia and cognitive decline. For example, having a lot of vascular risk conditions such as high blood pressure, diabetes, those kinds of conditions can be associated with more decline on unhealthy behaviors such as not really exercising or not engaging in mentally stimulating activities, or socialize, or having good sleep; those are also associated with worse cognitive decline later on as well. But this isn't really established for people with preexisting neurological conditions. For people with MS, usually the onset is earlier in age, usually between 20 and 50 years old. For a lot of people, when they're young, they've already had MS and they're living through with a disease their whole life.

It's unclear whether these risk factors are established in the general population for those without this preexisting neurological condition. This study is released to try to establish an evidence base, most importantly longitudinally following people over time. Whereas most of the research in this area have been just cross sectional, meaning that we're only looking at people at a certain time point. It's hard to say “is this really going to lead to less decline later on if they're engaging in healthier behavior?” That's what the study is about and there's two main studies as part of this grant. One follows people over time 5 years, so it'd be 4-year follow up with a whole study that will take about 5 years to complete. Every year, they would get cognitive testing, they will also complete a lot of different surveys about their lifestyle. Another part of the study is to look at longer term decline. We're going to reevaluate people who have already been previously evaluated many years ago, and then evaluating them again now to see whether any of their lifestyle behavior is related to less decline later on. Those are the two main studies that will help us answer this question of, ‘if you engage in these healthy behaviors, do they protect your cognition in the long term among people with MS?’

What made you want to start this project and continue on with this research in your field?

I'm a clinical neuropsychologist, too, so besides doing research, I also see patients and evaluate their cognition. I always recommend things, different brain health recommendations, such as sleep better, exercise more, engage in cognitively stimulating activities. I really emphasize those parts because I know that those things are good for brain health. That is something that I feel more people should know about and more people should do to optimize brain health. It's an area that I've always been interested in because those are the areas in which we can change and modify for someone.

If someone is going to develop dementia, there's really no treatments to help them get better. We might be able to delay the decline but that's really all we can do and there's no cures. That's why I want to focus on things that people can do to try to live as healthy as possible. The same thing with like preventing heart disease, we're basically trying to live as healthy lifestyle as you can to try to prevent heart disease and the same thing with dementia. But I think dementia is even harder just because we don't understand as much of it. From what we do understand, I want to make sure that it is well known for everyone else that these are the things that you can do right now. It's not just fate, whether you develop dementia or not.

What’s your thoughts on the various nonpharmacological interventions to prevent the disease progression?

I think they're very important, that's part of my long term goals of eventually developing lifestyle interventions. For me, I also have a focus on digital intervention using mobile devices, or wearable devices where you can deliver interventions in real time. I endorse nonpharmacological interventions. I think those are the interventions that can probably help the patient's function better in general, because right now there aren't any medications that are specifically going to make you really function that much better. But then I think there's a lot of behavior and lifestyle changes that can be made, that can make people's lives a lot easier.

Also, in terms of prevention with dementia or even just cognitive decline due to MS, once you start having the symptoms, it might be too late to intervene. That’s not saying that when you intervene, it's not going to do anything. But I think there's a lot of push now to look at preclinical stages, where maybe you're not symptomatic but maybe there's already a disease process going or there's something going on in your brain that's not necessarily manifesting your life. Before you even start having symptoms is the time to really start doing things that are preventative like sleep better, engage in more exercise. I think that's going to make the biggest difference. I think prevention will make the biggest difference, population wise, to help tackle this crisis of now more and more people are being diagnosed with cognitive disorders.

What types of devices, digital interventions and wearable devices, have you used or recommended for your patients?

I haven't recommended specific devices but there are a variety of commercially available devices. For example, I think the easiest things to keep track of are probably exercise and sleep because a lot of smartwatches, or rings, or various apps, can monitor these things. I don't think I've found one particular to recommend to patients, certain devices are better than other. I don't want to endorse a particular device, because I think all commercial devices have pros and cons for each one. For my own research, I use a different use, like a research grade version that's not as user friendly. I think for people who are not doing research, the most important thing is no matter what apps or devices they're using, making sure they're consistently monitoring themselves and making changes accordingly. If you're sedentary for the whole week, maybe it's time to start moving. Certain devices tell you to like get up to walk around when you're sedentary for a long time. I think those are great, because it just gives you that reminder of doing that.

For me, my future goal and research is to do something similar. Maybe targeting exercise, getting people to exercise more, but maybe having a more sophisticated intervention, rather than just tell them to get up and walk around. I'm a psychologist, I'm also using theories of behavior change and how we usually work with patients and have helped them to engage in a healthier lifestyle. I think that can be integrated into this intervention digitally later on. The beauty about digital interventions is not just that you can just deliver them to people in real time, and they don't have to come into a clinic for that, but you can also use the sensors in the wearables to inform the intervention. Again, exercise is the best example because it's really the one thing where we can measure the best out of like all other symptoms, where like, if step counts are low, they were sedentary, and that will trigger an intervention.

Transcript edited for clarity.

REFERENCES
1. Chen MH, Chiaravalloti ND, DeLuca J. Neurological update: cognitive rehabilitation in multiple sclerosis. J Neurol. 2021;268(12):4908-4914. doi:10.1007/s00415-021-10618-2