Time from injury and age interact in relationship with perceived quality of life outcomes following vocation-focused neuropsychological rehabilitation.

At the group level, community-based neuropsychological rehabilitation interventions with a vocational focus are generally effective among individuals with brain injuries. However, individual participants vary significantly in the extent of their improvement, prompting attempts to elucidate individual, injury-related, and environmental factors affecting prognosis. In this study, we examined the relationships between one such factor - "time from injury" (the time between injury and intervention) - and two outcome measures: employment status and perceived quality of life (PQoL), in 157 brain injury survivors, before and after a holistic neuropsychological vocational rehabilitation program. We also examined whether relationships between the variables were moderated by age at onset of treatment and injury severity. In the entire sample, both the proportion of employed participants and average PQoL increased following program participation. Neither, time from injury, severity, nor age at onset of treatment predicted the increase in employment proportion, and severity was not a significant predictor of PQoL. However, an interactive effect indicated that when treatment was started at a younger age, longer time from injury predicted higher levels of PQoL, but when treatment was started at older ages, longer time from injury predicted lower levels of PQoL. When interpreted alongside existing literature, these results suggest that delaying vocational components of rehabilitation can be beneficial for younger participants, while the effectiveness of vocational rehabilitation can be maximized by starting as early as possible among older participants. Most importantly, regardless of age, it appears that vocational rehabilitation can be effective even when initiated many years after injury.

Assessment of the unmediated relationship between neurological impairment and health-related quality of life following spinal cord injury.

Objective: To assess the unmediated association between neurological impairment and quality of life (QoL) among persons with spinal cord injury (SCI), in the context of both early post-acute and long-term rehabilitation settings.Design: An observational prospective cross-sectional study.Setting: Two neurological rehabilitation centers, specializing in spinal cord injury, within a university hospital.Methods: 156 adults with spinal cord injury in the early post-acute and chronic stages of rehabilitation.Outcome Measures: Participants were categorized into tetraplegia or paraplegia groups based on neurological level of injury, and into complete or incomplete groups based on American Spinal Injury Association (ASIA) Impairment Scale (AIS) score. QoL was assessed by means of the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF), Satisfaction with Life Scale (SWLS), Life Satisfaction Questionnaire (LISAT-9), and Personal Well-Being Index (PWI).Results: WHOQOL-BREF and PWI predicted Level of Injury group classification and WHOQOL-BREF predicted Setting group classification. None of the questionnaires differentiated between the Type of Injury groups. At the early post-acute stage of rehabilitation, the QoL scores of participants with tetraplegia and paraplegia did not differ significantly, while significantly higher QoL scores were revealed in paraplegics in the long-term setting group.Conclusions: A direct, unmediated effect of severity of neurological impairment was revealed with the WHOQOL-BREF, which distinguished between the tetraplegia and paraplegia groups, but not between the complete and incomplete injuries. QoL was significantly higher in paraplegia than in tetraplegia following the early post-acute stage of rehabilitation.

Functional outcomes following inpatient rehabilitation of Guillain-Barré syndrome patients: Intravenous immunoglobulins versus plasma exchange.

BACKGROUND: Treatment with either Intravenous immunoglobulin (IVIg) or plasma exchange (PE) in patients with Guillain-Barré Syndrome (GBS) showed equivalent efficacy as attested by a commonly used disability scale. However, it has been suggested that this scale may not be sensitive enough to detect subtle functional changes between the two treatments since it mainly focuses on walking capability and respiratory function. OBJECTIVE: To evaluate functional outcomes following treatment with IVIg or PE using comprehensive scales that incorporate parameters of basic activities of daily living. METHODS: A retrospective cohort study was conducted between 2007 and 2013 in an inpatient neurologic rehabilitation department. The study group included 70 individuals with GBS: 39 were treated with PE and 31 with IVIg. A comparison of functional outcomes was performed using Functional Independence Measure (FIM), rehabilitation efficiency (REy), rehabilitation effectiveness (REs), and the GBS disability scale (GDS). RESULTS: Both treatments had a comparable effect on the various functional outcomes. Patients showed a significant increase in total FIM scores (30 points on average) during rehabilitation mainly as a result of an increase in motor sub-scores. A mean improvement of 1.23 (SD 0.9) in GDS was also observed. On average, individuals with GBS spent 20 days combined in the acute departments and 61 days in the rehabilitation department, with length of stay being similar for both treatments. CONCLUSIONS: IVIg and PE treatments have similar basic activities of daily living (ADL) functional outcomes. Nevertheless, due to the different mechanism of actions of these treatments and the multitude of GBS variants, it is possible that further comprehensive assessment tools may demonstrate differences in activity and participation of individuals with GBS.

How, when, and for whom: decisions regarding remote neuropsychological assessment during the 2020 COVID-19 pandemic.

Neuropsychological assessment provides crucial information about cognitive, behavioral, and socioemotional functioning in medical, educational, legal, and social contexts. During the 2020 COVID-19 pandemic, the Israeli Ministry of Health initially mandated that all psychological assessments be postponed. However, as referrals to time-sensitive, high-need, and high-stakes assessments began to accumulate, it became necessary to consider remote solutions. In the current paper, we describe the considerations that affected the transition to remote activity in a prominent Israeli provider of neuropsychological assessment and rehabilitation services, referring to technological and environmental conditions, cognitive requirements, and tasks, as well as to legal, regulatory, and funding issues. After discussing how assessments should be conducted to maximize feasibility and validity while minimizing risks to clients and clinicians, we propose a preliminary model for deciding whether specific referrals warrant remote administration. The model delineates key factors in decisions regarding remote assessment, emphasizing the distinct roles of the referring clinician and the neuropsychologist who conducts the assessment, and highlighting the need for collaboration between them. The abrupt need for remote assessments during the pandemic required a quick response with little preparation. The lessons learned from this process can be applied in the future, so that the need for remote services can be met with greater certainty and uniformity.

Oculomotor anticipation reveals a multitude of learning processes underlying the serial reaction time task.

Sequence learning is the cognitive faculty enabling everyday skill acquisition. In the lab, it is typically measured in speed of response to sequential stimuli, whereby faster responses are taken to indicate improved anticipation. However, response speed is an indirect measure of anticipation, that can provide only limited information on underlying processes. As a result, little is known about what is learned during sequence learning, and how that unfolds over time. In this work, eye movements that occurred before targets appeared on screen in an ocular serial reaction time (O-SRT) task provided an online indication of where participants anticipated upcoming targets. When analyzed in the context of the stimuli preceding them, oculomotor anticipations revealed several simultaneous learning processes. These processes influenced each other, as learning the task grammar facilitated acquisition of the target sequence. However, they were dissociable, as the grammar was similarly learned whether a repeating sequence inhabited the task or not. Individual differences were found in how the different learning processes progressed, allowing for similar performance to be produced for different latent reasons. This study provides new insights into the processes subserving sequence learning, and a new method for high-resolution study of it.

Neuropsychological assessment in the Israeli healthcare system: a practitioners' survey.

BACKGROUND: The current study examines self-reported professional practices and attitudes of Israeli neuropsychologists, in an attempt to understand how they contribute to funding of neuropsychological assessment (NPA) through the Israeli healthcare system. METHODS: Two hundred seventy-nine neuropsychologists (176 board-certified experts and 103 interns) participated in an online survey that targeted characteristics of NPA practice in Israel, attitudes toward NPA, and familiarity with healthcare referral procedures. RESULTS: Overall, 68% of respondents conducted NPA, with a smaller proportion of experts (56%) doing so than interns (88%). The most common purpose of NPA was to provide treatment recommendations, and respondents listed indications for NPA that matched indications for neuropsychological rehabilitation. Almost two thirds of respondents reported that none of the NPAs that they performed received healthcare funding. While all practitioners believed that the healthcare system should fund NPA, the majority demonstrated lack of familiarity with referral procedures. CONCLUSIONS: To increase referral rates and create effective neuropsychological services within the Israeli healthcare system, neuropsychologists should work more closely with physicians in integrated care teams. In addition, they should engage in greater advocacy activities that will emphasize the need for publicly funded NPA.

Examining implicit procedural learning in tetraplegia using an oculomotor serial reaction time task.

BACKGROUND AND OBJECTIVE: Clinical observations indicate that implicit procedural learning, a central component of physical and psychosocial rehabilitation, is impeded following spinal cord injury. In accordance, previous research has revealed a specific deficit in implicit sequence learning among individuals with paraplegia using a standard, manual version of the serial reaction time task. To extend these findings and shed light on the underlying sources of potential spinal cord injury-related deficits in sequence learning, we used an ocular activated serial reaction time task to compare sequence learning performance between individuals with tetraplegia and healthy controls. PARTICIPANTS AND MEASURES: Twelve participants with spinal cord injury in C5-T1 were compared to 12 matched control participants on measures derived from an ocular activated serial reaction time task. Depression and additional cognitive measures were assessed to explore the source and specificity of potential sequence learning deficits. RESULTS: Like controls, and in contrast with previous findings in paraplegia, the spinal cord injury group showed intact implicit sequence learning, evidenced by declining reaction times and improved anticipation over the first six blocks of the serial reaction time task, and an advantage for the initial learning sequence over a novel interference sequence. CONCLUSIONS: The ocular activated serial reaction time task elicited a performance pattern similar to standard motor versions, such that participants with tetraplegia demonstrated unimpaired sequence learning. This suggests that previously reported implicit sequence learning deficits in spinal cord injury directly involved motor functioning rather than cognitive aspects of the task, and that the ocular activated sequence learning task could be a valid alternative for assessing implicit sequence learning in populations that cannot perform spinal-cord dependent motor tasks. Implications for post-spinal cord injury rehabilitation and adjustment are discussed.

Familiarity with Neuropsychological Assessment among Israeli Physicians.

OBJECTIVE: The current study examines whether Israeli physicians are familiar with neuropsychological assessment (NPA) in general and with referral to NPA in particular. METHOD: In total, 274 physicians in relevant fields participated in an online survey that targeted levels of familiarity with NPA, beliefs about assessment needs, and actual referral practices. RESULTS: Israeli physicians see many patients with neuropsychological difficulties, but assess fewer patients for these difficulties by themselves. Approximately 80% of participants reported that they had heard of NPA before, but only 25% knew how to refer patients to NPA. Familiarity was greater among neurologists and neurosurgeons than among family doctors. CONCLUSIONS: Physicians had only general knowledge about NPA, with little practical understanding of how to refer patients to such a service. To increase referral rates and create consistent demand for effective neuropsychological services, neuropsychologists should engage in greater advocacy activity that will lead to clarification of referral procedures.

Efficacy of Postacute Neuropsychological Rehabilitation for Patients with Acquired Brain Injuries is Maintained in the Long-Term.

OBJECTIVES: We examined the long-term maintenance of treatment outcomes in patients with acquired brain injuries who participated in community-based neuropsychological rehabilitation (NR) programs, in a prospective, within-subject, longitudinal, partial double-blind cohort study. METHODS: One hundred forty-three patients (39 females, mean age 33.5 years) who had experienced a brain injury (BI) (mean time since injury 3.95 years) were referred to a postacute community-based NR institute. Patients participated in one of the three programs aimed at improving their functional outcome: comprehensive-holistic neuropsychological rehabilitation, vocational-focused neuropsychological rehabilitation, and individual neuropsychological rehabilitation. Self-reported data regarding employment, community integration, perceived quality of life (PQoL), and mood were collected at program start and end, and annually for 3 years post program completion. Group placement was based on clinical considerations, such that the study did not aim to compare the programs, but rather to assess their long-term benefits. RESULTS: Employment status and stability, community integration, and PQoL improved significantly after program completion and continued to improve for the following 3 years. The proportion of individuals with mood disturbances did not change during or after the programs. CONCLUSIONS: A clear consensus regarding BI rehabilitation is that long-term maintenance of treatment outcomes is imperative to its efficacy. Our findings suggest that postacute NR programs provide participants with various tools, skills, and psychological perspectives that they continue to gain from and generalize to real life after program completion, reflecting transformational processes with stable long-term benefits.

Split-arm swinging: the effect of arm swinging manipulation on interlimb coordination during walking.

Human locomotion is defined by bilateral coordination of gait (BCG) and shared features with the fore-hindlimb coordination of quadrupeds. The objective of the present study is to explore the influence of arm swinging (AS) on BCG. Sixteen young, healthy individuals (eight women; eight right motor-dominant, eight left-motor dominant) participated. Participants performed 10 walking trials (2 min). In each of the trials AS was unilaterally manipulated (e.g., arm restriction, weight on the wrist), bilaterally manipulated, or not manipulated. The order of trials was random. Walking trials were performed on a treadmill. Gait kinematics were recorded by a motion capture system. Using feedback-controlled belt speed allowed the participants to walk at a self-determined gait speed. Effects of the manipulations were assessed by AS amplitudes and the phase coordination index (PCI), which quantifies the left-right anti-phased stepping pattern. Most of the AS manipulations caused an increase in PCI values (i.e., reduced lower limb coordination). Unilateral AS manipulation had a reciprocal effect on the AS amplitude of the other arm such that, for example, over-swinging of the right arm led to a decrease in the AS amplitude of the left arm. Side of motor dominance was not found to have a significant impact on PCI and AS amplitude. The present findings suggest that lower limb BCG is markedly influenced by the rhythmic AS during walking. It may thus be important for gait rehabilitation programs targeting BCG to take AS into account.NEW & NOTEWORTHY Control mechanisms for four-limb coordination in human locomotion are not fully known. To study the influence of arm swinging (AS) on bilateral coordination of the lower limbs during walking, we introduced a split-AS paradigm in young, healthy adults. AS manipulations caused deterioration in the anti-phased stepping pattern and impacted the AS amplitudes for the contralateral arm, suggesting that lower limb coordination is markedly influenced by the rhythmic AS during walking.

In a context of time: the impact of delay and exposure time on the emergence of memory context effects.

Research on context-mediated facilitation of recognition memory distinguishes between the effects of reinstating the exact same context previously associated with a target and a context that is familiar but not directly associated with the target. As both effects are difficult to produce reliably in recognition experiments, attention has turned to measures that may explain inconsistencies, such as the extent to which instructions encourage association between targets and contexts. The aim of the current study was to examine the distinctive and interactive effects of three factors that may lead to variability in context effects (CEs), namely type of instructions given at learning, delay between learning and test, and exposure time for targets and contexts at learning. Using a comprehensive paradigm developed by Vakil and colleagues, with photographs of faces serving as target and context stimuli, both exposure time and delay were shown to be associated with the occurrence of CEs and appeared to interact with one another in determining the nature of these effects. Unlike several previous studies, false alarms did not increase when foils were presented with familiar contexts. Also unexpectedly, the instruction manipulation did not appear to strengthen target-context binding. It may instead have increased attention to contexts at the expense of targets, as suggested by the finding that direct memory for context improved under associative instruction conditions. Overall, the study demonstrates the importance of understanding and controlling various factors that may potentially influence the emergence of both reinstatement and familiarity-based CEs, among them exposure time and learning-to-test delay.

Anticipation measures of sequence learning: manual versus oculomotor versions of the serial reaction time task.

The serial reaction time (SRT) task has generated a very large amount of research. Nevertheless the debate continues as to the exact cognitive processes underlying implicit sequence learning. Thus, the first goal of this study is to elucidate the underlying cognitive processes enabling sequence acquisition. We therefore compared reaction time (RT) in sequence learning in a standard manual activated (MA) to that in an ocular activated (OA) version of the task, within a single experimental setting. The second goal is to use eye movement measures to compare anticipation, as an additional indication of sequence learning, between the two versions of the SRT. Performance of the group given the MA version of the task (n = 29) was compared with that of the group given the OA version (n = 30). The results showed that although overall, RT was faster for the OA group, the rate of sequence learning was similar to that of the MA group performing the standard version of the SRT. Because the stimulus-response association is automatic and exists prior to training in the OA task, the decreased reaction time in this version of the task reflects a purer measure of the sequence learning that occurs in the SRT task. The results of this study show that eye tracking anticipation can be measured directly and can serve as a direct measure of sequence learning. Finally, using the OA version of the SRT to study sequence learning presents a significant methodological contribution by making sequence learning studies possible among populations that struggle to perform manual responses.

Specific Deficit in Implicit Motor Sequence Learning following Spinal Cord Injury.

BACKGROUND: Physical and psychosocial rehabilitation following spinal cord injury (SCI) leans heavily on learning and practicing new skills. However, despite research relating motor sequence learning to spinal cord activity and clinical observations of impeded skill-learning after SCI, implicit procedural learning following spinal cord damage has not been examined. OBJECTIVE: To test the hypothesis that spinal cord injury (SCI) in the absence of concomitant brain injury is associated with a specific implicit motor sequence learning deficit that cannot be explained by depression or impairments in other cognitive measures. METHODS: Ten participants with SCI in T1-T11, unharmed upper limb motor and sensory functioning, and no concomitant brain injury were compared to ten matched control participants on measures derived from the serial reaction time (SRT) task, which was used to assess implicit motor sequence learning. Explicit generation of the SRT sequence, depression, and additional measures of learning, memory, and intelligence were included to explore the source and specificity of potential learning deficits. RESULTS: There was no between-group difference in baseline reaction time, indicating that potential differences between the learning curves of the two groups could not be attributed to an overall reduction in response speed in the SCI group. Unlike controls, the SCI group showed no decline in reaction time over the first six blocks of the SRT task and no advantage for the initially presented sequence over the novel interference sequence. Meanwhile, no group differences were found in explicit learning, depression, or any additional cognitive measures. CONCLUSIONS: The dissociation between impaired implicit learning and intact declarative memory represents novel empirical evidence of a specific implicit procedural learning deficit following SCI, with broad implications for rehabilitation and adjustment.

Effectiveness of multi-disciplinary rehabilitation for patients with Neuromyelitis Optica.

INTRODUCTION: Neuromyelitis optica (NMO), previously considered a subtype of multiple sclerosis (MS), is now known to be a unique disorder associated with autoantibodies against aquaporin-4. The rehabilitation protocols for MS have been applied to NMO, without specific measures of efficacy. PURPOSE: The evaluation of the effectiveness of an MS type inpatient rehabilitation program for patients with NMO. PATIENT AND METHODS: Retrospective chart reviews of 15 inpatients with NMO and 32 inpatients with MS. Clinical severity was assessed by the Expanded Disability Status Scale (EDSS), functional assessments were scored using the Functional Independence Measure (FIM), the Montebello Rehabilitation Factor Score (MRFS), and the Functional Ambulation Category (FAC). There was a higher percentage of women in the NMO group (87% vs 56% P = 0.003). The MS group had significantly more cognitive and communication deficits (P = 0.003 and P = 0.00001). No significant differences were found in admission FIM, EDSS and FAC scores. RESULTS: Both groups benefitted, however at discharge, the NMO group showed greater improvement in FIM scores (NMO admission 79 ± 24, discharge 98 ± 21; MS admission 80 ± 28, discharge 89 ± 28); and lower EDSS score (NMO from 7.2 ± 1.4 to 6.3 ± 1.4; MS from 7.4 ± 1.4 to 7 ± 1.5). CONCLUSIONS: Inpatient multidisciplinary rehabilitation programs available for the patients with MS may be successfully implemented for patients with NMO.

Safety and tolerance of the ReWalk™ exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study.

OBJECTIVES: The objective of the study was to evaluate the safety and tolerance of use of the ReWalk™ exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury. STUDY DESIGN: Case series observational study. SETTING: A national spinal cord injury centre. METHODS: Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured. RESULTS: There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently. CONCLUSION: Volunteer participants were able to ambulate with the ReWalk™ for a distance of 100 m, with no adverse effects during the course of an average of 13-14 training sessions. The participants were generally positive regarding the use of the system.