The Effect of Cognitive Exercise on Upper Extremity Functions, Balance and Cognitive Functions in Multiple Sclerosis

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) was developed to assess basic cognitive abilities. It is a standardized method used between 6-70 years of age. This scale consists of 6 main sections and 26 subtests including orientation, visual perception, spatial perception, motor praxis, visual motor organization and thinking ability. It takes approximately 30-45 minutes to administer.

Manual Ability Measure-36: The scale includes 23 items with a wide range of difficulty that measure the functional level of patients.

Nine Hole Peg Test: Evaluates unilateral fine motor skills in the upper extremity. It requires the participants to first insert the nine sticks one by one into the nine holes and then remove them as quickly as possible against the clock.

Box and Block Test: It is used to measure hand gross skill performance.The patient is asked to transfer the maximum number of blocks, one at a time, from one compartment of a wooden box divided into two compartments to the other within 60 seconds.

Jebsen - Taylor Hand Function Test: It is an standardized test used to measure fine and gross motor functions of the hand by simulating daily life activities. It consists of 7 subtests: writing, simulated number spinning, lifting small objects, simulated feeding, stacking, moving large light and heavy objects.

The Finger to Nose Test is a practical test commonly used to assess coordination. The patient moves his/her arm from the fully extended position to the bent position, touches his/her finger to his/her nose and opens his/her arm again. The patient performs this movement consecutively. Another common one is that the patient touches his/her index finger to the clinician's index finger and then touches his/her own nose, this movement is repeated many times while the clinician continuously changes the position of his/her finger.

Timed Up and Go Test: It is a method that evaluates the person's ability to move and requires both static and dynamic balance. In the test, the person is asked to get up from the chair, walk 3 meters at a safe and normal speed, turn, walk back and sit on the chair and the time is recorded in seconds. A shorter time indicates better balance and mobility. The starting position of the test is standardized.

Berg Balance Scale: clinically evaluates functional balance and consists of 14 items related to functional tasks. These activities are ranked from the easiest to the most difficult. The items of the scale include activities requiring both dynamic and static balance. For each item, the level of competence in the activity is indicated by 5 points (0-4), with 0 being "unable" and 4 being "independent and safe". The maximum score is 56 points, with higher scores indicating better balance.

Modified Fatigue Impact Scale: Will be used to measure fatigue. It is a modified version of the Fatigue Impact Scale based on items from interviews with MS patients about how fatigue affects their lives. It provides information about the effects of fatigue over the past four weeks in the physical (9 items), psychosocial (2 items) and cognitive (10 items) domains. The scale uses a 5-point Likert scale with 0 being 'Never' and 4 being 'Always'. An overall Modified Fatigue Impact Scale score of 38 or above is indicative of MS-related fatigue.

Position Sense: Shoulder position sense will be measured for position sense measurement. Acumar dual digital inclinometer (Acu360, Acumar, Lafayette, USA) will be used to assess shoulder position sense. Before starting the tests, the test will be taught to the individuals both verbally and with practice in order to minimize the error rate. Shoulder abduction and flexion will be calculated at 30° and 60ᵒ. For both movements, the shoulder will start in neutral rotation position. Individuals will first be made to perform passive movement. After 3 seconds in this position, the shoulder will be brought to the neutral position. Afterwards, the individual will be asked to actively move the shoulder to the desired angle and movement and hold this position for 3 seconds with their eyes closed and express it aloud. Measurements will be repeated in both limbs (non-dominant and dominant) and a rest period of 60 seconds will be allowed between trials.

The Expanded Disability Status Scale (EDSS) will be used to determine the disability level of the patients. The scale consists of two parts. The functional systems section (pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual, cerebral or other) is graded from "0" no disability to "5" or "6" severe disability. The second section, assessing ambulation status, is based on the individual's functional system score and walking distance and is graded from "0" normal health to "10" death. The EDSS score of patients with mild-to-moderate (1-5.5) disabilities who will participate in the study will be determined by a specialist neurologist.

Standardized Mini Mental Test (SMMT): It will be used to identify people who do not have cognitive problems, which is an inclusion criterion in the first stage. It is a short, easy-to-administer and standardized test that allows cognitive assessment in a short time and is used to determine the cognitive level globally. The test consists of five sub-headings: orientation, memory, attention, calculation, recall and language and is evaluated on a 30-point scale. Traditionally, scores between 24 and 30 are considered normal.