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Which is the goal of cognitive rehabilitation in multiple sclerosis: the improvement of cognitive performance or the perception of cognitive deficits?

We read with interest the article by Mäntynen et al.1 who showed that computer-based short-term strategy-oriented cognitive rehabilitation (CR) does not improve cognitive functions but reduced perception of cognitive disability in patients with multiple sclerosis (MS). Statistically speaking, the present study is robust, based on a clinically wellselected and large cohort of MS patients and characterized by strict selection criteria with a particular focus on the presence of attention deficits. The article by Mäntynen et al.1 is part of a trend to tailor neurorehabilitation programs to a specific cognitive deficit. In fact, recent studies2,3 demonstrated that when CR is focused on a specific cognitive domain, significantly positive results are achieved in the MS population. Nevertheless, the reported findings raise a question about which is the desired outcome by which progress can be measured. Indeed, as stated by Mäntynen et al.1, “when considering the progressive nature of the disease, it could be argued that the main goal for the intervention might not be improvement of cognitive test performances, but learning to cope with the cognitive deficits”. Although there are some studies confirming this hypothesis, the vast majority of studies (meeting the assessment criteria for a high-quality protocol) reported improvement in cognitive performance without significant decrease in patients’ self-reports of everyday cognitive problems,2,3 or viceversa.1 Overall, the mission of the CR is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. Therefore, the ultimate goal of CR should be to enable people with disabilities to function as adequately as possible in their most appropriate environment. Given the relevance of CR services for persons with MS, to avoid the confusion of one external clinical reader and undermine the importance of this non-pharmacological intervention, a need exists to establish empirically based recommendations concerning the clinical practice of CR, as already applied to patients with brain injury or stroke.4 At this moment there is insufficient information to support evidence-based clinical protocols for CR in patients with MS. CR in MS is in its relative infancy, and studies on the clinical effectiveness of CR are discouraged by the idea that MS is a progressive disease and it may not be economically prudent to treat the resultant cognitive deficits. Similarly to what was affirmed by O’Brien et al.,5 we strongly disagree with this view. We feel that this field of study requires a task force in order to establish recommendations for future research, mainly highlighting the need for applying a holistic CR approach, where the interlinked cognitive, emotional, and psychosocial functioning should be all targeted in future treatment programs.