Cognition and the Science of Non-Invasive Brain Stimulation in MS

Cognition and the Science of Non-Invasive Brain Stimulation in MS

Episode 196 – Podcast Transcript

[(0:25)] Stephanie Buxhoeveden: Welcome to the Can Do MS podcast. I’m your host Stephanie Buxhoeveden. I live with MS, and I’m also a clinician and MS researcher. I’m excited to welcome Dr. Leigh Charvet, a neuropsychologist at NYU, who partners with people affected by MS to develop accessible home-based approaches to cognitive rehab and mental health. Hi, Leigh, welcome.

[(0:45)] Leigh: Hi. Thank you so much for having me. It’s really an honor to be here.

[(0:49)] Stephanie: I’m very excited about this topic, and let’s start right at the source of what causes people to worry the most, which is cognitive symptoms in MS and cognitive changes, and I think when people hear that they think dementia or memory loss, but that’s not really actually what we see in most people. Right?

[(1:07)] Leigh: Right, so, uh, and that is absolutely a source of so much fear. Um, and so, you know, I think I’ve described early on in my career, I was hopeful to try to get it on the map as an invisible symptom, and certainly people can have cognitive changes, but what it’s really that awareness has actually become a fear factor for a lot of people. Um, and so I just think that it’s that misunderstood factor. Um, so broadly I explained that MS can mean slowing, right? We have a little bit of slowing in terms of-of-of processing, um, certainly with motor signals and then with-with cognitive signals too, so it can be a slowing of information processing, but it doesn’t usually mean anything more than that, so you… so there’s ways to reinforce that.

Or to have improved information processing without actually having what we would typically consider as cognitive impairment, and then we also don’t see it progress which is something that people really fear, is that if they have some kind of cognitive change or cognitive involvement, that it’s gonna get worse over time or they’re gonna lose their ability to function, and again that’s typically not the case. Um, so-so at the most, even with people who have more advanced cognitive involvement, we see it fluctuate over time. Probably with background disease activity, and it’s rare to see that progressive, what we would think of especially in terms of dementia or something like that. It would be rare to, um, see some kind of progressive cognitive change.

[(2:47)] Stephanie: That’s really comforting to hear and resonates with a lot of patient stories that I hear. Right? It’s usually things like, I can’t keep up with conversations as they’re happening, or I’m losing track when I’m multitasking. That’s very common for me. Um, and that’s very different than I can’t remember who my family is.

[(3:06)] Leigh: Exactly, and-and-and with supports and-and with-with some adjustment, most people can still function well, and so I think I don’t even like to call it cognitive impairment because that kind of changes the way we even perceive ourselves, and I think a lot of times people even in anticipation of potential cognitive change can limit what they wanna do or try to achieve, or may change the way their… the loved one… their loved ones or the people around them see them, and-and I just think that that’s particularly painful and-and can be avoidable. Um, and so while I certainly wanna support an understanding of how MS can cause cognitive involvement, and I certainly don’t wanna overlook those who do.

It’s a, it’s a minority, but some people do have really a leading cognitive impairment and cognitive change, but that’s unusual, but that does happen and I wanna validate that for everybody, but the broad message especially for younger adults when they’re diagnosed, is not that we expect cognitive change even, and definitely not cognitive impairment to the, to the point that they wouldn’t be able to function, and I-I just want people to be able to count on the ability to function and still pursue all the goals that they would have otherwise without a diagnosis.

[(4:19)] Stephanie: I wish I’d had that advice when I first started out, ’cause that… it really is so scary, uh, especially us being mostly young when we’re diagnosed and starting our careers.

[(4:29)] Leigh: Yeah, it’s younger and younger now, right. With accurate diagnosis, and so yeah.

[(4:33)] Stephanie: That’s-that’s really good to hear, and 1 thing that ties into this that you and I have talked about before, is this attribution bias or the tendency to assume every cognitive symptom is due to MS even when there might be other factors.

[(4:47)] Leigh: That’s exactly it, so that information processing is certainly something that we find with people living with MS, but not specific to MS, so it’s a varied non-specific finding that can be heavily influenced by many factors including stress, fatigue, sleep deprivation, medications, all kinds of things, um, can just contribute to our experience of, you know, what people might call a brain fog or feeling just slower in their processing, and, um, I find kind of that we have this attribution bias I like to think about it, which means that we just attribute everything reported to the MS and nothing else, so for instance I can have a patients with, you know, very stressful lives, you know, going through like emotional events.

Um, maybe, you know, on multiple, multiple medications that all could affect cognitive functioning. Um, all kinds of things, right? And then but, um, uh, then we think if we find that they have some cognitive slowing, we-we’ll say, “Well, that’s your MS affecting you.” And I think that we just need to see it as broad and multifactorial, and the most important part of that too is that a lot of those other factors are what we call modifiable factors, so while the MS we’re working on modifying in one way, you know, but that’s more of a constant because people are diagnosed with MS, but there’s many other contributing factors particularly with cognition, um, that can be modifiable and contribute to amplifying, or worsening your experience of whatever cognitive involvement you may have.

[(6:20)] Stephanie: Yeah, and I know when I was still seeing patients, whenever somebody told me they were having cognitive symptoms, the first thing I ruled out was depression.

[(6:28)] Leigh: Yeah. Right. I think that that’s really under-recognized is that depression is a very clear cognitive signature, and do you know what it is? It’s slowed information processing, so again it’s not specific, and I-I wanna also point out that when you have that slowed information processing, you can experience that. A lot of people experience that is memory problems or word language changes, and a lot of it is just that information processing, ’cause that’s at the basis we, you know, we can think about it as an iceberg or cognitive function or pyramid if you wanna think about it in those kind of visualizations. That you have to get the information in and hold it in like a hopper in your working memory to analyze it and encode it to even learn it before you-you recall or work with it.

What people experience is forgetfulness is often just overwhelm with cognitive load. It’s difficult to process information in the first place, so it’s all that front end of the system that then is experienced as a lot of different kind of cognitive lapses.

[(7:28)] Stephanie: Oh yeah. That a 100% resonates with me. You know, I’ve learned that if I’m in the middle of an intense task and somebody comes up to me and interrupts that, that’s when I’ll miss a step. Or that’s when, um, I’m more apt to make a mistake at work and so I’ve just… recognizing that has helped me definitely tailor my environment to it, and that definitely is reassuring because it… I know that it’s a problem. I’m aware of it but I also know that there are things I can do to compensate for it.

[(8:02)] Leigh: I think too that we don’t expect it to get worse. I just say that to my patients now, uh, out front, because again I just see the fear, you know, that people are functioning really well, but they’re so afraid of what it’s gonna mean for their work life or their family life, or will I be able to provide for my family? Will I be functioning in the future? And I… that… I just think that living with that painful burden of what if for that fear is I… as you know, is just like such a-a horrible burden. I… it truly is horrible and-and unnecessary.

[(8:33)] Stephanie: Yeah. The pressure, the pressure is so hard to deal with.

[(8:36)] Leigh: Then also, you know, we’re not the best, uh, historically and currently at measuring cognitive impairment, and I just wanna point out that recently there is really good review. Like every single grant that I’ve written, I write a lot of research grants and it starts out with saying like, most people are up to 70%, um, very common. You’ll see that-that-that statistics cited all the time, have some degree of people call it cognitive impairment, which really it’s just cognitive slowing a little bit. Um, but meeting that threshold and they-they’ve actually, uh, reanalyzed, um, in a better way, all of, all of the available studies, and it’s much less. It’s about 1 and 3, um, really at most, and I would point out that that’s even before we had really high efficacy DMTs, so I would think it would be even less to have cognitive involvement.

I’m not even talking about, you know, actual cognitive impairment that we would think of.

[(9:29)] Stephanie: Yeah, and we didn’t talk about 1 hot topic and its involvement with cognition, which is cannabis use.

[(9:35)] Leigh: Right? Yeah, so that, um, you know, I was mentioning the multifactorial contributions Yeah. To cognitive slowing and cannabis, it has a really poor cogni… well, you know, if we think cognitive signature, um, or cognitive effect, so it is not a friend to cognitive functioning and information processing speed. Um, and it stays in your system a long time too, so-so people who use it, um, you know, we’re just trying to raise awareness. I’m not, you know, totally against or and definitely not pro cannabis, but I wanna raise awareness, right? So that, you know, if you think about somebody who’s suffering from cognitive lapses or feels less clear, also it contributes we’ve seen to mood.

Um, uh, cannabis can definitely be a factor in all that, and the way we know is actually they’ve done really nice studies taking… measuring people living with MS, who use cannabis daily for instance, and stop and they have improved cognitive functioning and improved mood, so again, you know, just that kind of reverse con-confirmation, um, supported by what we know increasingly with the broader cannabis use literature is that it just definitely can influence cognitive functioning, so that’s something to be very much aware of, um, why we’re using, why people use it, you know, and make sure that you’re using it for reasons that it’s really benefiting you and that it’s, you know, just again, to look at everything, you know, medication review, you know, just to see so you’re aware of what may be contributing in addition to just having MS.

[(11:08)] Stephanie: Yeah, absolutely, and it’s the same as a lot of these other MS symptoms like fatigue, like mood, like spasticity, what you eat, what you drink, the way you move, how you’re sleeping, it all factors into your MS symptoms.

[(11:23)] Leigh: I think that that’s really important to remember when we look at studies of cognition longitudinally, so we follow the same patients. Certainly clinically when I see people even, you know, in progressive forms repeating cognitive function. There is not a very clear at all linear decline in even cognitive processing speed. It seems to be variable and I think that that is just again another reinforcing factor of why there’s so many other modifiable contributing factors, so-so people have… it goes up and down, um, but it doesn’t go continually down so that people will have basically overall the same degree of what we call cognitive involvement across 10 years.

Um, and so that’s just again, uh, I really wanna highlight those things first just as a way we approach it, right? And then, um, professionally approach it too with that bias, and then, um, also just to-to get ahead of some of the messages that are hitting people in clinic, particularly when we screen for things. I think when we screen for it, we sometimes say we expect this, um, if we screen for it, and, you know, again it’s just really being aware of the messages that are hitting people. Um, and-and because there’s so much, uh, potential for harm with that and self limitation.

[(12:38)] Stephanie: Yeah. Yeah. That definitely feels like a weight off my shoulders, um, as a young professional, right? Knowing that, knowing that research is really comforting, and speaking of research, let’s talk about, you are incredible research on brain stimulation, which, yeah,

[(12:53)] Leigh: Yeah, so it all kind of comes together. It seems like I’m over all over the place, but it-it was really the cognition, right? That-that brought me to brain stimulation, so just-just in general, I… you know, I… as a neuropsychologist, you-you say, okay, here’s some cognitive involvement you have, and then everybody always says, okay, what do I do about it? You know. Or so-so we’re like, well, uh, you know, ’cause there’s not a lot of great go-to options, right? And there’s absolutely no medication that can improve cognitive functioning in MS or otherwise, and so we’re really with what we know for behavioral modification and that kind of thing, but there’s-there’s definitely a wide open gap, um-um, unmet need as we say, for-for-for, um, cognitive rehabilitation.

Particularly that people can access, so I started out with these brain training games which work by the way, um, uh, doing a home-based study because you need a whole lot of it, so-so in my original study we did, um, sixty hours over twelve weeks, uh, of… so that’s a lot of training, um, and, and found benefit but I came to the world, and this was over 12 years ago believe it or not, but I was at home in people’s homes, not me personally but with computers and monitoring people, but that’s the way to do it. We were just overwhelmed with people really want this accessible treatment. Um, and if we add the… I-I came to the world of non-invasive brain stimulation because there’s an overarching idea and-and really proven now that if you add stimulation, mild gentle stimulation to the region of the brain that’s engaged in the task.

That is… that you’re trying cognitive training, for instance, same in motor, same in language. Um, you can boost and reinforce that outcome, and so you-you make it stronger and more enduring, and truthfully I was like, is there any way we can get this benefit without doing sixty hours over twelve weeks? So-so that was really how I-I, you know, I’m not a… I didn’t have a background in engineering, anything like that. I came to it that way as an early adopter, both of home-based cognitive rehabilitation, and then to see if we could add the TDCS to the home setting, so that then brought me into the world of non-invasive brain stimulation, which is really exponentially growing and-and as a whole nother therapeutic category.

Over the past decade in particular, it’s been quite the ride of-of just, uh, e-expansion in all kinds of directions that are very exciting and very promising for the future, but my specialty was that I paired with, uh, the biomedical engineers to really optimize equipment to go to people’s homes right away, and so, um, it’s home-based that, you know, where our specialty is, and so we started that way right away, um, at home knowing that we needed so many sessions, and this is before telemedicine was even adopted, but so we had a rigorous protocol where we’re with people through video visits, but they’re using all the equipment at home and people living with MS were have just been incredible partners.

Really co-collaborators and all of the design of this, because, you know, uh, literally any headsets you see out there, our protocol, it’s all just with conversations with people telling us like it is, and it’s completely patient led, so we listen, you know, what do you think? How do you evaluate this? So we were pairing it with cognitive training, um, and that brought us, you know, into many trials looking at fatigue cognition. Now we’re studying it in depression, we’ve also applied it e motor functioning, so you can do it in all different ways. Um, but-but that was really the origin story of how I got into this non-invasive brain stimulation world.

[(16:40)] Stephanie: Yeah, and it’s so interesting, right? And it’s just a very mild electrical current, right? So people are barely feeling it. Yep, and, and let’s talk about what it is and what it isn’t.

[(16:50)] Leigh: Yeah. Yeah. I was thinking, lemme explain, so-so-so think of, you know, broad umbrellas of technologies, so there’s 2, so we’re talking about stimulating the brain electrically in some way or another, um, or ultimately electrically there’s different pathways to get there but you’re modifying it, uh, the brain’s activity, um, through devices, and so there’s invasive brain stimulation where you have implants that do that, so that’s 1 world, and then there’s a whole world that I’m in of non-invasive brain stimulation. Within that world if you think of a huge umbrella, there’s many technologies you can hear about and are emerging, but the 2 dominant ones are transcranial magnetic stimulation or TMS, which is probably what most people have heard of.

It was the first, and, um, up until last week the only, uh, uh, approved one here in the United States. Um, and so these are large machines on site. Um, and TDCS is what I work with which is called Transcranial Direct Current Stimulation. Um, it’s a little bit milder than TMS, but there… all of this is used in general for the same targeting. We use TDCS because the-the machines it’s incredible record of safety and tolerability and the machines can go home, so they’re portable and it’s wearable technology. Um, and so and TDCS has been extensively studied right alongside TMS and-and last week actually, um, just got FDA approval for treatment of depression in the United States.

[(18:27)] Stephanie: I did see that. Yeah, I saw that in my newsfeed and I thought of you.

[(18:32)] Leigh: Yeah. Really a watershed moment for the United States with with TDCS. You know, it’s a, it’s a long road still to getting insurance coverage and insurance coverage for the way we use it, but just encouraging, um-um, because these technologies are-are a nice to be alongside medication offerings and-and to-to boost rehab. There’s so many potential, um, applications and to improve quality of life. Um, so we’re really excited about the field and it just keeps growing, and again, you know, just because of my fortunate position to be working with people living with MS, they’ve really… you know, people living with MS have truly been at the forefront of developing these technologies.

Especially for home-based use, so, um, our lab I believe I think we have, um, you know, up there with the most TDCS ever administered believe it or not, like it’s more than thirty thousand home-based sessions now that we’ve done. Um, we have a clinical service also alongside our-our large research program where we all reach people across the United States. They don’t ever come to our lab. It’s completely contactless.

[(19:37)] Stephanie: I love that. Anything home-based I think is so convenient and easy, and I love how you described it as basically a-a tool that just turns up the effectiveness or turns up the volume, uh, on whatever rehab you’re doing, right?

[(19:53)] Leigh: Yeah, so, and that, you know, we talk about umbrellas, so certainly all of brain stimulation has an origin and treating mood disorders and the whole story there, and that’s where TMS started with treating… treatment of depression, and now TDCS just got approved, so that’s one, um, approach. Um, and so that’s kind of on in its own is a treatment or modifying networks that really support mood and emotion regulation and distress, and then in neuro rehabilitation which we think of with recovery, pairing it with that cognitive training, motor training, language training, whatever is the relative weakness, is-is really, um, the boost that we look for.

Um, and so really can be added on, um, to almost any type of rehabilitation activity that you’re doing, um, with really exciting potential for trans… you know, boosting that transfer to real world activities.

[(20:49)] Stephanie: I think that’s really exciting, and you’ve talked about your work with Brain HQ. Can you tell us a little bit about what that looks like, how that program works and what you’ve seen?

[(21:00)] Leigh: For sure, so-so brain training games, online brain training games are really an innovation and cognitive rehabilitation because of the number of trials that can be done, right? So learning trials, it’s like you-you’re presented with something, can you learn, can you learn from it? And-and there’s just no way that one-on-one with a human of any… in any scenario can match the driving of learning that an online adaptive cognitive training program can do, and what I mean by adaptive is that the algorithms in these training programs keep you engaged so that if you slow down, they slow down with you, and if you can speed up they speed up with you, so they keep you going and in the, in the buffer zone so that you’re continuously learning and-and they adapt with you.

Um, so these are online, so the really, that was the big breakthrough with these. You know, we call it adaptive cognitive training, and there are online programs of which Brain HQ is the most studied and has the most neuroscience backing. Um, and the reason that we used it from the beginning, and that was the training that we used in that first trial that I told you about, and the first trial showed so twelve weeks, hour a day, 5 days a week, uh, it’s a lot of training, right? But people did it and we compared it to ordinary games that had like what we call face validity. They look like or we all think that, you know, they help us cognitively and they’re not bad, but it just doesn’t drive it in that way.

Like, you know, crosswords or word searches or Sudoku or whatever, and so that… so we compared those 2, so it was an active comparator, so the people who did the brain HQ had significantly greater gains on a neuropsych battery, so sec… so not only did they, you know, improve across the gains, which is great, but it… they had a secondary transfer of benefit to measurable outcomes on a neuropsych battery, so that’s really powerful. You know, the effect is overall mild, some people have it much more than others, but, um, the other thing that we believe and it’s harder to show, um, but a lot of broader research with these games shows that it also stores up your function, so over time it prevents decline so there’s a lot of benefit to doing these.

Um, so that was what we started with, and then we added the TDCS, uh, targeting it to the region, that’s engaged, the frontal regions that are engaged with the cognitive training, so that’s the area if you think of that would light up. Uh, and an MRI if you were doing the cognitive training, and then we direct the current there too, so it’s that paired or synergistic reinforcing of the cognitive training.

[(23:40)] Stephanie: Yeah, and-and that’s really helping like processing speed, attention, word finding, multitasking.

[(23:48)] Leigh: Exactly. That’s exactly it, so that’s an exact example of, um, boosting information processing speed, so incoming and sorting that out, managing it, speeding it up, you know, handling the speed as-as secondary transfer. Then once you have that speeded information processing or stored up information processing, you experience a transfer to all these other cognitive operations that depend on that as the base of the pyramid of cognitive functioning, so that’s the, that’s the idea there.

[(24:18)] Stephanie: Did you see any effect on fatigue?

[(24:21)] Leigh: Right, so we started studying a home-based, um, with the TDCS, that-that intervention paired together, and people started saying, oh my gosh, I feel so much less fatigue, right? So we were so excited because as you know, right, neck and neck with-with cognitive impairment or cognitive concerns is fatigue that people are so troubled by or in reports so frequently, so we were… we-we did a trial where we, you know, a randomized trial, sham. Sham is what you call the placebo in-in this brain stimulation world, and so we wanted to see if fatigue would improve and-and it did, so in our pilot trial we had an improvement in fatigue, which we were just, you know, everybody’s very excited, so maybe we’ve kind of cracked the code here with fatigue after so many things have failed, so the National MS Society supported us to do a larger trial.

One interesting feature of this trial though was that they had us rigorously exclude people who have depression which-which, um, if, you know, when we measure depression and fatigue it’s… there’s a lot of corresponding features, right? Like so if there’s a checklist for 1, you know, so-so that kind of, uh, made things a little bit different, I think is one of the features of this trial, so they were non-depressed but reporting fatigue and, um, they did the cognitive training and the cognitive outcomes were secondary, so they didn’t have to be enrolled on the basis of cognitive impairment, and it was really a broad, broad representation of people, um, in the study, and so, um, at the end of this trial where we did thirty sessions, there was no difference in fatigue outcome.

This was really counter to what not only in MS but in many other conditions, people were reporting fatigue benefit with-with-with the TDCS, so it’s important to note that both the active and sham groups got significantly better, so their fatigue dropped clinically significantly, which typically fatigue will stay relatively stable, so one takeaway is that they both… you know, it worked but for the whole group, so it didn’t differentiate between active or sham stimulation, so-so-so this requires a lot of thinking about like, what do we have here and what does this tell us? And so one of the things maybe because we didn’t have the other arms, is that the brain HQ part is the fatigue driving the fatigue benefit, which is possible because that’s in the frontal regions too.

Um, a methods issue was that we had a strange sham in this trial that-that-that had a lot of like, uh, on and off to try to mimic the current. We were worried that it wouldn’t be blinded, so-so was that active in some way? You know, was another question or probably the biggest scenario, likely case is that what’s been reported for fatigue benefit is really that component of depression that overlaps with fatigue, and so when we excluded for depression, which so reliably responds to TDCS, maybe we were not showing the difference in the other aspects of fatigue.

[(27:29)] Stephanie: Yeah. I think, uh, I think that makes a lot of sense, ’cause clearly fatigue and cognition and depression cluster together.

[(27:36)] Leigh: It’s so… you know, we need biomark, I mean we need markers to kind of like some kind of objective marker ’cause it’s self-report, and so these trials are over and over really limited by self-report in some ways when-when we study these things, and so, um, we need better measures too, but the interesting story there was that wasn’t the pattern we saw for cognition. Instead, the… it… the-the active versus sham did separate out for the cognitive outcomes, so if you had active TDCS versus a sham or placebo, here, you had greater benefit on secondary cognitive measures at trial end. Again over and over if you’re doing any kind of training, if you have TDCS on board or stimulation paired with that, you see a boost.

Um, and we-we’ve-we’ve seen it with motor functioning. Um, my colleague for instance, uh, studied seated pedaling, transferred a gait outcomes. Um, and that’s something we hope to do in a really large way at home. Um, but that’s very exciting. We’ve showed it with hand functioning. Um, and so there’s… you know, and then in other conditions it’s the same with language and that kind of thing, so-so the boost is real and, um, that’s something that we would absolutely try to like to try to get clinical guidelines around, and-and really determine the best way to optimize that for clinical treatment and get it into clinic.

[(29:03)] Stephanie: Yeah, and you all do a lot of research. I know people listening to this probably the first question they’re gonna have is, how do I get access to this care? Yeah. You do offer some telehealth TDCS services at NYU, correct?

[(29:18)] Leigh: We do, so, okay, so we actually have trials running now. Um, 1 in… 1 we’re doing, uh, trial against, so kindly supported from the National MS Society to look at TDCS for the treatment of depression specifically in MS. Um, so you may be following the literature. There’s a-a big question about what’s the role of MS in depression, so is it something specific? Um, or you know, is there an immune component? For instance, is there something unique about MS depression? Um, but certainly so many people live with depression and MS, and we’re looking also here the secondary outcome is how it improves symptom burden, right? Because depression, as we talked about earlier, is an amplifier.

It turns up or down what you, what you have on board already, so if we can relieve the depression, will that re… can we show that that turns down the volume on symptom burden as well? So, um, that’s a study that, you know, um, any… almost anybody living with MS is welcome, you know, who has depression is welcome to reach out to us to see if they can participate, so that’s one thing we’re actively recruiting and really excited to be able to offer. Um, and then we have a clinical TDCS service. Um, so that launched in 2019. We can provide TDCS for any purpose.

It’s customized treatment, for instance to add on to physical or occupational or speech and language or cognitive rehab, any of that or-or to pair with brain training games or to treat depression, um, to-to anybody in the United States. You know, they go through an evaluation process with us. Um, so we’re certainly welcome. Um, we certainly welcome any… to talk to anybody who’s interested in that as well. Um, the unfortunate or obstacle with our service, um, we’re very glad to be able to offer it. It’s… NYU allows us to offer it through something called innovative care, but the difficulty is that insurance does not cover it at this time.

That’s one of the reasons we are so excited to see movement in with the regulatory approval last week for depression with TDCS, because that’s the first step and a major as I said, watershed event towards moving this to something that insurance can cover, which is what it should do.

[(31:43)] Stephanie: Yeah, amazing, and we will put information on how people find those studies and find your telehealth, uh, resources in the, in the podcast description.

[(31:54)] Leigh: That’s great. Yeah. We appreciate it.

[(31:56)] Stephanie: Yeah, and as we wrap up, um, what are some key takeaways for our audience today?

[(32:01)] Leigh: I think just with our cognition, it’s just that not, you know, not living with that additional burden of fear or dread that, you know, there’s on-coming cognitive decline. I don’t think that anybody who’s diagnosed with MS should assume that they’re gonna have cognitive involvement or cognitive decline, and if you do have cognitive changes, you know, certainly wanna validate that as well, and definitely some people do, but there’s things that you can’t change, you know, with… unfortunately we can’t change having MS at this moment in time, but there is a lot of modifiable factors that you can change, that are probably what’s contributing to the fluctuation over time that you see and experience.

There’s things that you can do that will help, so I think that’s a big takeaway is just to really, you know, think about the messaging that you’re getting with cognition, and to-to hold on to optimism and just not to assume things like that. That-that you know, that it’s a risk to your functioning and that kind of thing, or that you’re completely helpless if you feel that you’ve had… your cognition slipping. Another big takeaway was that it is such an exciting time for these non-invasive brain stimulation therapeutics because technology is just booming. They’re home-based and so the accessibility is amazing and it’s just offers a whole new field of therapeutics that are really helpful.

Well tolerated like… and I mean well tolerated, like they’re not painful to go through or anything like that, and these non-drug options that can improve your quality of life are, you know, very near term so it’s really exciting in that way as well.

[(33:40)] Stephanie: Yeah, very exciting. We’ll definitely be keeping an ear out for what comes of your work, and hopefully we’ll have you back to update us on how this…

[(33:50)] Leigh: Definitely. Thank you so much. Yeah, we really appreciate it. Thank you for your interest and you know, again, it’s a… you know, it takes a village. We’re all in this together to-to-to move things forward.

[(33:59)] Stephanie: Awesome. Thank you so much for being here.

[(34:02)] Leigh: Yeah, thank you.

[(34:04)] Stephanie: Thank you for listening to this episode of the Can Do MS podcast. If you like this episode, please leave us a rating and review on Apple Podcasts or Spotify. We really appreciate your feedback. We’d also like to thank all of our generous sponsors for their support of this episode of the Can Do MS podcast. Until next time, be well and have a great day.

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