Clinical bottom line
Cognitive rehabilitation interventions targeting executive function in multiple sclerosis (MS) show promise in improving cognitive flexibility, problem-solving, and daily functioning. Emerging approaches combining traditional cognitive training with neurofeedback or immersive technologies may enhance these benefits. However, evidence remains preliminary and heterogeneous, warranting cautious interpretation. Clinicians should consider integrating tailored cognitive rehabilitation into multidisciplinary MS care, emphasizing individualized goals and ongoing assessment.
What the evidence shows
Executive dysfunction is a common and impactful cognitive deficit in MS, affecting planning, working memory, and cognitive flexibility, which in turn impair social cognition and daily activities (Pennington et al., 2023). Traditional cognitive rehabilitation approaches, including strategy training and computerized exercises, have demonstrated moderate improvements in executive function domains (Langdon et al., 2010; Krasny-Pacini et al., 2019). These interventions aim to enhance neural plasticity and compensate for cognitive deficits through repetitive, targeted practice.
Recent studies highlight innovative modalities that may augment executive function recovery. Motamedi et al. (2026) reported that combining cognitive rehabilitation with neurofeedback therapy yielded significant gains in executive control and cognitive flexibility compared to cognitive training alone in people with MS. This suggests that real-time neural feedback may reinforce cognitive strategies and improve self-regulation.
Additionally, immersive virtual reality (VR) and gaming technologies are emerging as engaging platforms for cognitive rehabilitation. Maggio et al. (2024) reviewed the use of immersive VR environments in neurological disorders, including MS, noting potential benefits in motivation and multisensory integration that could translate to executive function improvements. Jaradat et al. (2023) systematically reviewed gaming technology interventions in MS, finding evidence for enhancements in both motor and cognitive domains, although executive function-specific outcomes require further clarification.
Social cognition disruptions in MS, closely linked to executive dysfunction, also represent a critical rehabilitation target. Pennington et al. (2023) emphasized that addressing executive deficits may indirectly improve social cognitive abilities, which are essential for interpersonal functioning.
Caveats and uncertainty
The current evidence base is limited by small sample sizes, heterogeneous intervention protocols, and variability in outcome measures. Many studies are pilot or feasibility trials lacking long-term follow-up, making durability of cognitive gains uncertain. The optimal intensity, duration, and combination of cognitive rehabilitation modalities remain undefined.
Neurofeedback and immersive VR approaches, while promising, require specialized equipment and training, potentially limiting accessibility in routine clinical settings. The degree to which improvements in executive function translate into meaningful real-world functional gains is not yet fully established.
Furthermore, MS is a heterogeneous disease with variable cognitive profiles; thus, interventions may not be universally effective. Individual factors such as disease stage, fatigue, mood, and comorbidities can influence rehabilitation responsiveness.
How this may change practice
Physical medicine and rehabilitation clinicians should consider incorporating cognitive rehabilitation targeting executive function as part of comprehensive MS management, particularly for patients reporting executive difficulties affecting daily life. Tailoring interventions to individual cognitive profiles and functional goals is essential.
Emerging combined approaches, such as cognitive training plus neurofeedback, may offer enhanced benefits but currently require referral to specialized centers or research programs. Use of immersive VR and gaming technologies may improve patient engagement and adherence, though clinicians should weigh resource availability.
Routine cognitive screening and monitoring should be integrated into MS care pathways to identify candidates for rehabilitation and track progress. Multidisciplinary collaboration with neuropsychologists, occupational therapists, and speech-language pathologists can optimize intervention planning.
Ongoing research participation should be encouraged to advance evidence on efficacy, mechanisms, and best practices for executive function rehabilitation in MS.