An Umbrella Review of Self-Management Interventions for Health Conditions With Symptom Overlap With Traumatic Brain Injury

OBJECTIVE

To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI.

DESIGN

An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI.

METHOD

A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2).

RESULTS

A total of 26 reviews met the inclusion criteria, covering a range of chronic conditions and a range of outcomes. Seven reviews were of moderate or high quality and focused on self-management in persons with stroke, chronic pain, and psychiatric disorders with psychotic features. Self-management interventions were found to have positive effects on quality of life, self-efficacy, hope, reduction of disability, pain, relapse and rehospitalization rates, psychiatric symptoms, and occupational and social functioning.

CONCLUSIONS

Findings are encouraging with regard to the effectiveness of self-management interventions in patients with symptoms similar to those of TBI. However, reviews did not address adaptation of self-management interventions for those with cognitive deficits or for populations with greater vulnerabilities, such as low education and older adults. Adaptations for TBI and its intersection with these special groups may be needed.

Prevalence and Associated Clinical Characteristics of Walking-Related Motor, Cognitive, and Fatigability in Progressive Multiple Sclerosis: Baseline Results From the CogEx Study

BACKGROUND

People with progressive multiple sclerosis (PMS) present motor (eg, walking) and cognitive impairments, and report fatigue. Fatigue encompasses fatigability which is objectively measured by the capacity to sustain a motor or cognitive task.

OBJECTIVE

To investigate the prevalence of walking and cognitive fatigability (CF) and the associated clinical characteristics in a large sample of PMS patients.

METHODS

PMS patients (25-65 years old) were included from 11 sites (Europe and North America), having cognitive impairment (1.28 standard deviation below normative data for the symbol digit modality test [SDMT]). Walking fatigability (WF) was assessed using the distance walk index (DWI) and CF using the SDMT (scores from the last 30 seconds compared to the first 30 seconds). Additional measures were: cognitive assessment-Brief International Cognitive Assessment for multiple sclerosis (MS), cardiorespiratory fitness, 6-minute walk, physical activity, depressive symptoms, perceived fatigue-Modified Fatigue Impact Scale (MFIS), MS impact-MSIS-29, and walking ability.

RESULTS

Of 298 participants, 153 (51%) presented WF (DWI = -28.9 ± 22.1%) and 196 (66%) presented CF (-29.7 ± 15%). Clinical characteristics (EDSS, disease duration, and use of assistive device) were worse in patients with versus without WF. They also presented worse scores on MSIS-29 physical, MFIS total and physical and reduced physical capacity. CF patients scored better in the MSIS-29 physical and MFIS psychosocial, compared to non-CF group. Magnitude of CF and WF were not related.

CONCLUSIONS

Half of the cognitively-impaired PMS population presented WF which was associated with higher disability, physical functions, and fatigue. There was a high prevalence of CF but without strong associations with clinical, cognitive, and physical functions.

TRIAL REGISTRATION NUMBER

The "CogEx-study," www.clinicaltrial.gov identifier number: NCT03679468.

Multiple sclerosis is associated with differences in semantic memory structure

OBJECTIVE

Although language is often considered to be largely intact in multiple sclerosis (MS), word-finding difficulties are a common complaint. Recent work suggests that declines in language are not solely the result of motoric and cognitive slowing that is most strongly associated with MS. Network science approaches have been effectively used to examine network structure as it relates to clinical conditions, aging, and language. The present study utilizes a network science approach to investigate whether individuals with MS exhibit less interconnected and resilient semantic networks compared to age-matched neurotypical peers.

METHOD

We used semantic fluency data from 89 participants with MS and 88 neurotypical participants to estimate and analyze the semantic network structure for each participant group. Additionally, we conducted a percolation analysis to examine the resilience of each network.

RESULTS

Network measures showed that individuals with MS had lower local and global clustering coefficients, longer average shortest path lengths, and higher modularity values compared to neurotypical peers. Small-worldness, network portrait divergence measures, and community detection analyses were consistent with these results and indicated that macroscopic properties of the two networks differed and that the semantic network for individuals with MS was more fractured than the neurotypical peer network. Moreover, a spreading activation simulation and percolation analysis suggested that the semantic networks of individuals with MS are less flexible and activation degrades faster than those of age-matched neurotypical participants.

CONCLUSIONS

These differing semantic network structures suggest that language retrieval difficulties in MS partially result from decline in language-specific factors. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The effects of cognitive rehabilitation combined with aerobic exercise or stretching-and-toning on new learning and memory in persons with moderate-to-severe TBI: Protocol for a randomized controlled trial

This paper describes the protocol for a Phase I/II, parallel-group, blinded randomized controlled trial that compares the effects of 12-weeks of combined learning and memory rehabilitation with either aerobic cycling exercise or stretching on cognitive, neuroimaging, and everyday life outcomes in 60 persons with moderate-to-severe traumatic brain injury (TBI) who demonstrate impairments in new learning. Briefly, participants will undergo baseline testing consisting of neuropsychological testing, neuroimaging, daily life measures, and cardiorespiratory fitness. Following baseline testing, participants will be randomized to one of 2 conditions (30 participants per condition) using concealed allocation. Participants will be masked as to the intent of the conditions. The conditions will both involve supervised administration of an enhanced, 8-week version of the Kessler Foundation modified Story Memory Technique, embedded within either 12-weeks of supervised and progressive aerobic cycling exercise training (experimental condition) or 12-weeks of supervised stretching-and-toning (active control condition). Following the 12-week intervention period, participants will complete the same measures as at baseline that will be administered by treatment-blinded assessors. The primary study outcome is new learning and memory impairment based on California Verbal Learning Test (CVLT)-III slope, the secondary outcomes include neuroimaging measures of hippocampal volume, activation, and connectivity, and the tertiary outcomes involve measures of daily living along with other cognitive outcomes. We further will collect baseline sociodemographic data for examining predictors of response heterogeneity. If successful, this trial will provide the first Class I evidence supporting combined memory rehabilitation and aerobic cycling exercise training for treating TBI-related new learning and memory impairment.

Task-Based and Resting-State Cortical Functional Differences After Spinal Cord Injury: A Pilot Functional Near-Infrared Spectroscopy Study

Brain reorganization following spinal cord injury (SCI) has been well-established using animal and human studies. Yet, much is unknown regarding functional recovery and adverse secondary outcomes after SCI. Functional near-infrared spectroscopy (fNIRS) is a neuroimaging technique that offers methodological flexibility in a real-world setting. We used fNIRS to examine the cortical functional differences between 12 males with thoracolumbar SCI (46.41 ± 11.09 years of age) and 12 healthy males (47.61 ± 11.94 years of age) during resting state and task conditions-bilateral finger tapping (FT), mental imagery of bilateral FT with action observation (FTI+AO), and bilateral ankle tapping (AT). We found an overall decrease in hemodynamic response of the SCI group during all three task conditions. Task modulated functional connectivity (FC) computed using beta series correlation technique was compared using independent sample t-tests at α = 0.05. Connectivity between the right mediolateral sensorimotor network (SMN) and the right medial SMN was reduced during the FT task in SCI. A mixed analysis of variance revealed that the FC within the right mediolateral SMN was reduced during FT but preserved during FTI+AO (i.e., comparable to controls) in the SCI group. Lower FC of these regions was associated with longer injury durations. Additionally, we found a general decrease in resting state FC of the SCI group, specifically in the Slow-3 frequency range (0.073 to 0.1 Hz). These results, though preliminary, are consistent with past studies and highlight the potential of fNIRS in SCI and rehabilitative research.

Cognitive rehabilitation and aerobic exercise for cognitive impairment in people with progressive multiple sclerosis (CogEx): a randomised, blinded, sham-controlled trial

BACKGROUND

Cognitive dysfunction in people with relapsing-remitting multiple sclerosis can improve with cognitive rehabilitation or exercise. Similar effects have not been clearly shown in people with progressive multiple sclerosis. We aimed to investigate the individual and synergistic effects of cognitive rehabilitation and exercise in patients with progressive multiple sclerosis.

METHODS

CogEx was a randomised, sham-controlled trial completed in 11 hospital clinics, universities, and rehabilitation centres in Belgium, Canada, Denmark, Italy, UK, and USA. Patients with progressive multiple sclerosis were eligible for inclusion if they were aged 25-65 years and had an Expanded Disability Status Scale (EDSS) score of less than 7. All had impaired processing speed defined as a performance of 1·282 SD or greater below normative data on the Symbol Digit modalities Tests (SDMT). Participants were randomly assigned (1:1:1:1), using an interactive web-response system accessed online from each centre, to cognitive rehabilitation plus exercise, cognitive rehabilitation plus sham exercise, exercise plus sham cognitive rehabilitation, or sham exercise plus sham cognitive rehabilitation. The study statistician created the randomisation sequence that was stratified by centre. Participants, outcome assessors, and investigators were blinded to group allocation. The study statistician was masked to treatment during analysis only. Interventions were conducted two times per week for 12 weeks: cognitive rehabilitation used an individualised, computer-based, incremental approach to improve processing speed; sham cognitive rehabilitation consisted of internet training provided individually; the exercise intervention involved individualised aerobic training using a recumbent arm-leg stepper; and the sham exercise involved stretching and balance tasks without inducing cardiovascular strain. The primary outcome measure was processing speed measured by SDMT at 12 weeks; least squares mean differences were compared between groups using linear mixed model in all participants who had a 12-week assessment. The trial is registered with ClinicalTrials.gov, NCT03679468, and is completed.

FINDINGS

Between Dec 14, 2018, and April 2, 2022, 311 people with progressive multiple sclerosis were enrolled and 284 (91%) completed the 12-week assessment (117/311 [38%] male and 194/311 [62%] female). The least squares mean group differences in SDMT at 12 weeks did not differ between groups (p=0·85). Compared with the sham cognitive rehabilitation and sham exercise group (n=67), differences were -1·30 (95% CI -3·75 to 1·16) for the cognitive rehabilitation plus exercise group (n=70); -2·78 (-5·23 to -0·33) for the sham cognitive rehabilitation plus exercise group (n=71); and -0·71 (-3·11 to 1·70) for the cognitive rehabilitation plus sham exercise group (n=76). 11 adverse events possibly related to the interventions occurred, six in the exercise plus sham cognitive rehabilitation group (pain, dizziness, and falls), two in the cognitive rehabilitation plus sham exercise group (headache and pain), two in the cognitive rehabilitation and exercise group (increased fatigue and pain), and one in the dual sham group (fall).

INTERPRETATION

Combined cognitive rehabilitation plus exercise does not seem to improve processing speed in people with progressive multiple sclerosis. However, our sham interventions were not inactive. Studies comparing interventions with a non-intervention group are needed to investigate whether clinically meaningful improvements in processing speed might be attainable in people with progressive multiple sclerosis.

FUNDING

MS Canada.

Profiling cognitive-motor interference in a large sample of persons with progressive multiple sclerosis and impaired processing speed: results from the CogEx study

BACKGROUND

Performing cognitive-motor dual tasks (DTs) may result in reduced walking speed and cognitive performance. The effect in persons with progressive multiple sclerosis (pwPMS) having cognitive dysfunction is unknown.

OBJECTIVE

To profile DT-performance during walking in cognitively impaired pwPMS and examine DT-performance by disability level.

METHODS

Secondary analyses were conducted on baseline data from the CogEx-study. Participants, enrolled with Symbol Digit Modalities Test 1.282 standard deviations below normative value, performed a cognitive single task ([ST], alternating alphabet), motor ST (walking) and DT (both). Outcomes were number of correct answers on the alternating alphabet task, walking speed, and DT-cost (DTC: decline in performance relative to the ST). Outcomes were compared between EDSS subgroups (≤ 4, 4.5-5.5, ≥ 6). Spearman correlations were conducted between the DTCmotor with clinical measures. Adjusted significance level was 0.01.

RESULTS

Overall, participants (n = 307) walked slower and had fewer correct answers on the DT versus ST (both p < 0.001), with a DTCmotor of 15.8% and DTCcognitive of 2.7%. All three subgroups walked slower during the DT versus ST, with DTCmotor different from zero (p's < 0.001). Only the EDSS ≥ 6 group had fewer correct answers on the DT versus ST (p < 0.001), but the DTCcognitive did not differ from zero for any of the groups (p ≥ 0.039).

CONCLUSION

Dual tasking substantially affects walking performance in cognitively impaired pwPMS, to a similar degree for EDSS subgroups.

The influence of information processing speed on benefit from learning and memory rehabilitation in TBI: a sub-analysis of the TBI-MEM trial

OBJECTIVE

This study examined the influence of processing speed (PS) on benefit from treatment with the Kessler Foundation modified Story Memory Technique® (KF-mSMT®), a cognitive rehabilitation intervention shown to improve new learning and memory in traumatic brain injury (TBI).

SETTING

Non-profit research center.

PARTICIPANTS

62 participants with moderate-to-severe TBI were included, 31 assigned to the treatment group and 31 to the placebo-control group.

DESIGN

Double-blind, placebo-controlled, randomized clinical trial. The present study represents a post-hoc analysis to examine the role of PS on treatment efficacy.

MAIN MEASURES

Baseline and follow-up neuropsychological assessment including the California Verbal Learning Test, Second Edition (CVLT-II), Memory Assessment Scales - Prose Memory (MAS-PM) and the Symbol Digit Modalities Test (SDMT).

RESULTS

A treatment effect was not observed on the CVLT-II learning slope in the treatment group relative to the placebo group post-treatment, after co-varying for education, baseline CVLT slope and PS performance. However, performance on a measure of PS, the SDMT, was a significant predictor of post-treatment change following KF-mSMT® treatment. PS was not a significant predictor of benefit from treatment as documented by the MAS-PM immediate or delayed recall score, both of which showed a significant treatment effect.

CONCLUSION

Performance on measures of cognitive dysfunction aside from learning and memory impact the benefit from KF-mSMT® treatment. Implications for cognitive rehabilitation for individuals with TBI are discussed.

Traumatic brain injury as a chronic disease: insights from the United States Traumatic Brain Injury Model Systems Research Program

Traumatic brain injury (TBI) is a global health priority, associated with substantial burden. Historically conceptualised as an injury event with finite recovery, TBI is now recognised as a chronic condition that can affect multiple domains of health and function, some of which might deteriorate over time. Many people who have had a TBI remain moderately to severely disabled at 5 years, are rehospitalised up to 10 years post-injury, and have a reduced lifespan relative to the general population. Understanding TBI as a chronic disease process can be highly informative for optimising care, which has traditionally focused on acute care. Chronic brain injury care models must be informed by a holistic understanding of long-term outcomes and the factors that can affect how care needs evolve over time. The United States Traumatic Brain Injury Model Systems of Care follows up individuals with moderate-to-severe TBI for over 30 years, allowing characterisation of the chronic (2-30 years or more post injury) functional, cognitive, behavioural, and social sequelae experienced by individuals who have had a moderate-to-severe TBI and the implications for their health and quality of life. Older age, social determinants of health, and lower acute functional status are associated with post-recovery deterioration, while younger age and greater functional independence are associated with risky health behaviours, including substance misuse and re-injury. Systematically collected data on long-term outcomes across multiple domains of health and function are needed worldwide to inform the development of models for chronic disease management, including the proactive surveillance of commonly experienced health and functional challenges.

Bridging Big Data: Procedures for Combining Non-equivalent Cognitive Measures from the ENIGMA Consortium

Investigators in neuroscience have turned to Big Data to address replication and reliability issues by increasing sample sizes, statistical power, and representativeness of data. These efforts unveil new questions about integrating data arising from distinct sources and instruments. We focus on the most frequently assessed cognitive domain - memory testing - and demonstrate a process for reliable data harmonization across three common measures. We aggregated global raw data from 53 studies totaling N = 10,505 individuals. A mega-analysis was conducted using empirical bayes harmonization to remove site effects, followed by linear models adjusting for common covariates. A continuous item response theory (IRT) model estimated each individual's latent verbal learning ability while accounting for item difficulties. Harmonization significantly reduced inter-site variance while preserving covariate effects, and our conversion tool is freely available online. This demonstrates that large-scale data sharing and harmonization initiatives can address reproducibility and integration challenges across the behavioral sciences.

Abnormal thalamic functional connectivity correlates with cardiorespiratory fitness and physical activity in progressive multiple sclerosis

BACKGROUND

Altered thalamic volumes and resting state (RS) functional connectivity (FC) might be associated with physical activity (PA) and cardiorespiratory fitness (CRF) in people with progressive multiple sclerosis (PMS).

OBJECTIVES

To assess thalamic structural and functional alterations and investigate their correlations with PA/CRF levels in people with PMS.

METHODS

Seven-day accelerometry and cardiopulmonary exercise testing were used to assess PA/CRF levels in 91 persons with PMS. They underwent 3.0 T structural and RS fMRI acquisition with 37 age/sex-matched healthy controls (HC). Between-group comparisons of MRI measures and their correlations with PA/CRF variables were assessed.

RESULTS

PMS people had lower volumes compared to HC (all p < 0.001). At corrected threshold, PMS showed decreased intra- and inter-thalamic RS FC, and increased RS FC between the thalamus and the hippocampus, bilaterally. At uncorrected threshold, decreased thalamic RS FC with caudate nucleus, cerebellum and anterior cingulate cortex (ACC), as well as increased thalamic RS FC with occipital regions, were also detected. Lower CRF, measured as peak oxygen consumption (VO_2peak), correlated with lower white matter volume (r = 0.31, p = 0.03). Moreover, lower levels of light PA correlated with increased thalamic RS FC with the right hippocampus (r = - 0.3, p = 0.05).

DISCUSSION

People with PMS showed widespread brain atrophy, as well as pronounced intra-thalamic and thalamo-hippocampal RS FC abnormalities. White matter atrophy correlated with CRF, while increased thalamo-hippocampal RS FC was associated to worse PA levels. Thalamic RS FC might be used to monitor physical impairment and efficacy of rehabilitative and disease-modifying treatments in future studies.

A virtual reality program to assess cognitive function in multiple sclerosis: A pilot study

Introduction: Cognitive impairment is a debilitating symptom in people with multiple sclerosis (MS). Most of the neuropsychological tasks have little resemblance to everyday life. There is a need for ecologically valid tools for assessing cognition in real-life functional contexts in MS. One potential solution would involve the use of virtual reality (VR) to exert finer control over the task presentation environment; however, VR studies in the MS population are scarce.

Objectives: To explore the utility and feasibility of a VR program for cognitive assessment in MS.

Methods: A VR classroom embedded with a continuous performance task (CPT) was assessed in 10 non-MS adults and 10 people with MS with low cognitive functioning. Participants performed the CPT with distractors (i.e., WD) and without distractors (i.e., ND). The Symbol Digit Modalities Test (SDMT), California Verbal Learning Test—II (CVLT-II), and a feedback survey on the VR program was administered.

Results: People with MS exhibited greater reaction time variability (RTV) compared to non-MS participants, and greater RTV in both WD and ND conditions was associated with lower SDMT.

Conclusions: VR tools warrant further research to determine their value as an ecologically valid platform for assessing cognition and everyday functioning in people with MS.

Structural and functional magnetic resonance imaging correlates of fatigue and dual-task performance in progressive multiple sclerosis

BACKGROUND

Frontal cortico-subcortical dysfunction may contribute to fatigue and dual-task impairment of walking and cognition in progressive multiple sclerosis (PMS).

PURPOSE

To explore the associations among fatigue, dual-task performance and structural and functional abnormalities of frontal cortico-subcortical network in PMS.

METHODS

Brain 3 T structural and functional MRI sequences, Modified Fatigue Impact Scale (MFIS), dual-task motor and cognitive performances were obtained from 57 PMS patients and 10 healthy controls (HC). The associations of thalamic, caudate nucleus and dorsolateral prefrontal cortex (DLPFC) atrophy, microstructural abnormalities of their connections and their resting state effective connectivity (RS-EC) with fatigue and dual-task performance were investigated using random forest.

RESULTS

Thirty-seven PMS patients were fatigued (F) (MFIS ≥ 38). Compared to HC, non-fatigued (nF) and F-PMS patients had significantly worse dual-task performance (p ≤ 0.002). Predictors of fatigue (out-of-bag [OOB]-accuracy = 0.754) and its severity (OOB-R² = 0.247) were higher Expanded Disability Status scale (EDSS) score, lower RS-EC from left-caudate nucleus to left-DLPFC, lower fractional anisotropy between left-caudate nucleus and left-thalamus, higher mean diffusivity between right-caudate nucleus and right-thalamus, and longer disease duration. Microstructural abnormalities in connections among thalami, caudate nuclei and DLPFC, mainly left-lateralized in nF-PMS and more bilateral in F-PMS, higher RS-EC from left-DLPFC to right-DLPFC in nF-PMS and lower RS-EC from left-caudate nucleus to left-DLPFC in F-PMS, higher EDSS score, higher WM lesion volume, and lower cortical volume predicted worse dual-task performances (OOB-R² from 0.426 to 0.530).

CONCLUSIONS

In PMS, structural and functional frontal cortico-subcortical abnormalities contribute to fatigue and worse dual-task performance, with different patterns according to the presence of fatigue.

Depression, Anxiety, and Suicidality in Individuals With Chronic Traumatic Brain Injury Before and During the COVID-19 Pandemic: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine the prevalence, severity, and correlates of depression, anxiety, and suicidal ideation in people with traumatic brain injury (TBI) assessed before and during the COVID-19 pandemic.

DESIGN

Retrospective cohort study using data collected through the Traumatic Brain Injury Model Systems (TBIMS) network at 1, 2, 5, 10, 15, 20, 25, or 30 years post TBI.

SETTING

United States-based TBIMS rehabilitation centers with telephone assessment of community residing participants.

PARTICIPANTS

Adults (72.4% male; mean age, 47.2 years) who enrolled in the TBIMS National Database and completed mental health questionnaires prepandemic (January 1, 2017 to February 29, 2020; n=5000) or during pandemic (April 1, 2022 to June 30, 2021; n=2009) (N=7009).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 questionnaire.

RESULTS

Separate linear and logistic regressions were constructed with demographic, psychosocial, injury-related, and functional characteristics, along with a binary indicator of COVID-19 pandemic period (prepandemic vs during pandemic), as predictors of mental health outcomes. No meaningful differences in depression, anxiety, or suicidal ideation were observed before vs during the COVID-19 pandemic. Correlations between predictors and mental health outcomes were similar before and during the pandemic.

CONCLUSIONS

Contrary to our predictions, the prevalence, severity, and correlates of mental health conditions were similar before and during the COVID-19 pandemic. Results may reflect generalized resilience and are consistent with the most recent findings from the general population that indicate only small, transient increases in psychological distress associated with the pandemic. While unworsened, depression, anxiety, and suicidal ideation remain prevalent and merit focused treatment and research efforts.

Kessler Foundation Strategy-Based Training to Enhance Memory (KF-STEM™): Study protocol for a single site double-blind randomized, clinical trial in Multiple Sclerosis

New learning and memory impairments are common in Multiple Sclerosis (MS) and negatively impact everyday life, including occupational and social functioning. Despite the demand for learning and memory treatments, few cognitive rehabilitation protocols are supported by Class I research evidence, limiting the degree to which effective treatments may be utilized with persons with MS. The present double-blind, placebo controlled randomized clinical trial (RCT) examines the efficacy of an 8-session cognitive rehabilitation protocol encompassing training in the application of three strategies with the strongest empirical evidence (self-generation, spaced learning and retrieval practice) to treat impaired learning and memory in persons with MS, Kessler Foundation Strategy-based Training to Enhance Memory (KF-STEM™). A sample of 120 participants with clinically definite MS who have impairments in new learning and memory will be enrolled. Outcomes will be assessed via three mechanisms, an Assessment of Global Functioning, which examines everyday functioning and quality of life, a Neuropsychological Evaluation to examine objective cognitive performance, and functional Magnetic Resonance Imaging to examine the impact of treatment on patterns of cerebral activation. We will additionally evaluate the longer-term efficacy of KF-STEM™ on everyday functioning and neuropsychological assessment through a 6-month follow-up evaluation and evaluate the impact of booster sessions in maintaining the treatment effect over time. The methodologically rigorous design of the current study will provide Class I evidence for the KF-STEM™ treatment protocol for persons with MS.

The Utility of the Patient Health Questionnaire (PHQ-9) Sleep Disturbance Item as a Screener for Insomnia in Individuals With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To examine the utility of the sleep disturbance item of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for insomnia among individuals with moderate to severe traumatic brain injury (TBI).

SETTING

Telephone interview.

PARTICIPANTS

A sample of 248 individuals with a history of moderate to severe TBI participated in an interview within 2 years of their injury.

DESIGN

Observational, cross-sectional analysis.

MAIN MEASURES

The PHQ-9 was administered along with the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Sleep Hygiene Index, Epworth Sleepiness Scale, and the Insomnia Interview Schedule.

RESULTS

Receiver operating characteristic curve analysis was conducted for the PHQ-9 sleep item rating against a set of insomnia criteria to determine an optimal cutoff score. A cutoff of 2 on the PHQ-9 sleep item maximized sensitivity (76%) and specificity (79%), with an area under the curve of 0.79 (95% CI, 0.70-0.88). The 2 groups formed using this cutoff differed significantly on all sleep measures except the Epworth Sleepiness Scale.

CONCLUSIONS

The PHQ-9 sleep item may serve as a useful screener to allow for detection of potential sleep disturbance among individuals with moderate to severe TBI. Those who screen positive using this item included in a commonly used measure of depression can be prioritized for further and more comprehensive assessment of sleep disorders.

The relationship between processing speed and verbal and non-verbal new learning and memory in progressive multiple sclerosis

Objective:

Processing speed (PS) deficits are the most common cognitive deficits in multiple sclerosis (MS), followed by learning and memory deficits, and are often an early cognitive problem. It has been argued that impaired PS is a primary consequence of MS, which in turn decreases learning. The current analysis examined the association between PS and learning in a large cohort of individuals with progressive MS.

Methods:

Baseline data from a randomized clinical trial on rehabilitation taking place at 11 centers across North America and Europe were analyzed. Participants included 275 individuals with clinically definite progressive MS (primary, secondary) consented into the trial.

Results:

Symbol Digit Modalities Test (SDMT) significantly correlated with California Verbal Learning Test-II (CVLT-II) ( r = 0.21, p = 0.0003) and Brief Visuospatial Memory Test–Revised (BVMT-R) ( r = 0.516, p < 0.0001). Receiver operating characteristic (ROC) analysis of the SDMT z score to distinguish between impaired and non-impaired CVLT-II performance demonstrated an area under the curve (AUC) of 0.61 (95% confidence interval (CI): 0.55–0.68) and a threshold of −1.62. ROC analysis between SDMT and BVMT-R resulted in an AUC of 0.77 (95% CI: 0.71–0.83) and threshold of −1.75 for the SDMT z score to predict impaired BVMT-R.

Conclusion:

Results indicate little ability beyond chance to predict CVLT-II from SDMT (61%), albeit statistically significant. In contrast, there was a 77% chance that the model could distinguish between impaired and non-impaired BVMT-R. Several potential explanations are discussed.

Changes in alcohol use and mood during the COVID-19 pandemic among individuals with traumatic brain injury: A difference-in-difference study

Objective

To evaluate the impact of COVID-19 pandemic exposure on changes in alcohol use and mood from years 1 to 2 after traumatic brain injury (TBI).

Methods

We used a difference-in-difference (DiD) study design to analyze data from 1,059 individuals with moderate-to-severe TBI enrolled in the TBI Model Systems (TBIMS) National Database. We defined COVID-19 pandemic exposure as participants who received their year 1 post-injury interviews prior to January 1, 2020, and their year 2 interview between April 1, 2020 and January 15, 2021. Pandemic-unexposed participants had both year 1 and 2 follow-up interviews before January 1, 2020. We measured current alcohol use as any past month alcohol use, average number of drinks per drinking occasion, and past month binge drinking. We measured depression symptoms using Patient Health Questionnaire-9, and anxiety symptoms using the Generalized Anxiety Disorder-7.

Results

We found persons with TBI exposed to the pandemic had greater increases in the average number of drinks per occasion from year 1 to 2 post-injury compared to pandemic-unexposed individuals (β = 0.36, 95% CI: 0.16, 0.57, p = 0.001), with males, adults <65 years old, and Black and Hispanic subgroups showing the greatest increases in consumption. Though average consumption was elevated, changes in rates of any alcohol use or binge drinking by pandemic exposure were not observed. Overall, there were no significant changes in depressive and anxiety symptoms over time between pandemic exposed and unexposed groups; however, pandemic-exposed Hispanics with TBI reported significant increases in anxiety symptoms from year-1 to year-2 post-injury compared to pandemic-unexposed Hispanics (β = 2.35, 95% CI: 0.25, 4.47, p = 0.028).

Conclusion

Among persons living with TBI, those exposed to the pandemic had significant increases in average alcohol consumption. Pandemic-exposed Hispanics with TBI had large elevations in anxiety symptoms, perhaps reflecting health inequities exacerbated by the pandemic, and suggesting a need for targeted monitoring of psychosocial distress.

Responsiveness of the Traumatic Brain Injury Quality of Life Cognition Banks in Recent Brain Injury

Patient report of functioning is one component of the neurocognitive exam following traumatic brain injury, and standardized patient-reported outcomes measures are useful to track outcomes during rehabilitation. The Traumatic Brain Injury Quality of Life measurement system (TBI-QOL) is a TBI-specific extension of the PROMIS and Neuro-QoL measurement systems that includes 20 item banks across physical, emotional, social, and cognitive domains. Previous research has evaluated the responsiveness of the TBI-QOL measures in community-dwelling individuals and found clinically important change over a 6-month assessment interval in a sample of individuals who were on average 5 years post-injury. In the present study, we report on the responsiveness of the TBI-QOL Cognition–General Concerns and Executive Function item bank scores and the Cognitive Health Composite scores in a recently injured sample over a 1-year study period. Data from 128 participants with complicated mild, moderate, or severe TBI within the previous 6 months were evaluated. The majority of the sample was male, white, and non-Hispanic. The participants were 18–92 years of age and were first evaluated from 0 to 5 months post-injury. Eighty participants completed the 1-year follow-up assessment. Results show acceptable standard response mean values (0.47–0.51) for all measures and minimal detectable change values ranging from 8.2 to 8.8 T-score points for Cognition–General Concerns and Executive Functioning measures. Anchor rating analysis revealed that changes in scores on the Executive Function item bank and the Cognitive Health Composite were meaningfully associated with participant-reported changes in the areas of attention, multitasking, and memory. Evaluation of change score differences by a variety of clinical indicators demonstrated a small but significant difference in the three TBI-QOL change scores by TBI injury severity grouping. These results support the responsiveness of the TBI-QOL cognition measures in newly injured individuals and provides information on the minimal important differences for the TBI-QOL cognition measures, which can be used for score interpretation by clinicians and researchers seeking patient-reported outcome measures of self-reported cognitive QOL after TBI.

The efficacy of speed of processing training for improving processing speed in individuals with multiple sclerosis: a randomized clinical trial

OBJECTIVE

The current study examines the efficacy of speed of processing training (SOPT) to improve processing speed (PS) in individuals with multiple sclerosis (MS). Outcomes included changes in the useful field of view (UFOV) and neuropsychological evaluation (NPE).

METHODS

This double-blind, placebo-controlled randomized clinical trial included 84 participants with clinically definite MS and impaired PS, 43 in the treatment group and 41 in the placebo control group. Participants completed a baseline NPE and a repeat NPE post-treatment. The treatment group was randomized to booster sessions or no contact. Long-term follow-up assessments were completed 6 months after treatment.

RESULTS

A significant effect of SOPT was observed on both the UFOV (large effect) and pattern comparison with a similar pattern of results noted on letter comparison, albeit at a trend level. The treatment effect was maintained 6 months later. The impact of booster sessions was not significant. Correlations between degree of improvement on the UFOV and the number of levels completed within each training task were significant for both speed and divided attention indicating that completion of more levels of training correlated with greater benefit.

CONCLUSION

SOPT is effective for treating PS deficits in MS with benefit documented on both the UFOV and a neuropsychological measure of PS. Less benefit was observed as the outcome measures became more distinct in cognitive demands from the treatment. Long-term maintenance was observed. The number of training levels completed within the 10-sessions exerted a significant impact on treatment benefit, with more levels completed resulting in greater benefit.

Feasibility of cognitive rehabilitation in patients with advanced multiple sclerosis: A pilot study

Background

The feasibility of cognitive rehabilitation is rarely investigated in patients with advanced multiple sclerosis.

Methods

Eighteen patients with advanced multiple sclerosis (median EDSS = 7.5) were randomized into restorative or compensatory cognitive rehabilitation. Feasibility was determined by adherence rate, completion rate, patient satisfaction, self-reported fatigue, training difficulty, and training duration.

Results

Adherence rates and completion rates were over 70%, and patients were highly satisfied in both groups. Energy levels decreased minimally during the sessions (pre = 6.9 vs post = 6.4). Training difficulty (4.6) and duration (5.7) were close to ideal (scale 1-10, 5 = ideal).

Conclusions

Cognitive rehabilitation, with minor adjustments, appears feasible in patients with advanced multiple sclerosis.

Cardiorespiratory fitness and free-living physical activity are not associated with cognition in persons with progressive multiple sclerosis: Baseline analyses from the CogEx study

BACKGROUND

Aerobic exercise training (physical activity for improving cardiorespiratory fitness) represents a promising approach for managing cognitive impairment in multiple sclerosis (MS). However, there is limited evidence that levels of physical activity and fitness are associated with cognition in progressive MS.

OBJECTIVE

We examined associations among cardiorespiratory fitness, moderate-to-vigorous physical activity (MVPA), and cognitive performance in a large, international progressive MS sample.

METHODS

Two hundred forty European and North American persons with progressive MS underwent cardiorespiratory fitness measurement on a recumbent stepper, wore an ActiGraph GT3X + accelerometer for 7 days for measuring MVPA, and underwent the Brief International Cognitive Assessment in MS.

RESULTS

Cardiorespiratory fitness was not significantly correlated with Symbol Digit Modalities Test (SDMT; r = -0.01; r = -0.04), California Verbal Learning Test-II (CVLT-II; r = 0.05; r = 0.05), or Brief Visuospatial Memory Test-Revised (BVMT-R; r = -0.14; r = -0.14) z-scores controlling for age, sex, and education. MVPA and SDMT (r = 0.05), CVLT-II (r = -0.07), and BVMT-R (r = 0.01) z-scores were not significantly correlated.

CONCLUSION

Cardiorespiratory fitness and MVPA were not associated with cognition in this large progressive MS sample, yet these outcomes represent critical manipulation checks for documenting the success of the CogEx trial. This highlights the importance of examining other exercise-related mechanisms-of-action for improving cognition in progressive MS.

The preliminary effects of moderate aerobic training on cognitive function in people with TBI and significant memory impairment: a proof-of-concept randomized controlled trial

This single-blinded RCT investigated cognitive effects of aerobic exercise in persons with TBI-related memory impairment. Five participants . were randomly assigned to 12-weeks of either supervised moderate intensity aerobic cycling or an active control. Outcome measures included neuropsychological assessments and structural neuroimaging (MRI,). The exercise group demonstrated greater improvements on auditory verbal learning (RAVLT; d=1.54) and processing speed (SDMT; d=1.58). The exercise group showed larger increases in volume of the left hippocampus (d=1.49) and right thalamus (d=1.44). These pilot data suggest that 12-weeks of moderate intensity aerobic cycling may improve memory and processing speed in those with TBI-related memory impairments.

Methylphenidate may improve mental fatigue in individuals with multiple sclerosis: A pilot clinical trial

BACKGROUND

Fatigue is the most common symptom in multiple sclerosis (MS), previously attributed to dopamine imbalance. Evidence suggests that methylphenidate, a psychostimulant that increases striatal and prefrontal dopamine levels, is effective in reducing fatigue in various disorders. However, its effect on state vs. trait mental fatigue in MS is yet to be examined.

METHODS

This pilot study investigates the efficacy of methylphenidate on decreasing self-reported mental fatigue in 12 individuals with MS in a double-blind, placebo-controlled, cross-over randomized clinical trial.

RESULTS

Our results show that "state", but not "trait" MS-related fatigue, was reduced after 4 weeks of methylphenidate administration as compared to placebo.

A-17 Self-Generation Improves Prospective Memory Performance in Individuals with Moderate–Severe Traumatic Brain Injury

Objective

Self-generation has long been studied in healthy adults as a method to improve encoding of new information. The present study applied this strategy to prospective memory (PM; the ability to remember future intentions) in individuals with traumatic brain injury (TBI).

Method

Participants included 17 healthy adults and 34 individuals with moderate–severe TBI, who were at least one year post-injury and impaired encoding on a test of verbal learning. Participants completed a 15-minute computer-based lexical decision task in which PM trials were embedded. Following a baseline block of 100 lexical decision trials, participants completed 2 blocks with 5 p.m. targets each. PM targets were learned in a didactic or self-generated fashion using semantically-related word pairs, counterbalanced for order effects.

Results

MANOVAs were conducted for PM accuracy and recognition, with performance in the didactic and self-generation conditions as within-subjects variables and diagnostic group as the between-subjects variable. Only the within-subjects variables were significant [PM accuracy: F(1,49) = 5.228, p = 0.027; PM recognition: F(1,49) = 7.226, p = 0.010]. Within the TBI sample, paired t-tests demonstrated significantly improved PM accuracy [t(33) = −2.069, p = 0.046, Hedge’s g = 0.38] and PM target recognition [t(33) = −2.458, p = 0.019, Hedge’s g = 0.52] under self-generated compared to didactic conditions.

Conclusion

Results indicate that self-generation is an efficacious strategy to improve PM in individuals with moderate–severe TBI and encoding deficits. The lack of interaction suggests that the generation effect is robust enough to provide comparable benefit to both individuals with significant neurocognitive deficits as well as healthy adults. Future efforts should explore the incorporation of self-generation in cognitive rehabilitation protocols for PM in neurologic populations.

The adapted symbol digit modalities test: Examining the impact of response modality

BACKGROUND

Information processing speed is often impaired in neurological disorders, as well as with healthy aging. Thus, being able to accurately assess information processing speed is of high importance. One of the most commonly used tests to examine information processing speed is the Symbol Digit Modalities Test (SDMT), which has been shown to have good psychometric properties.

OBJECTIVES

The current study aims to examine differences between two response modalities, written and oral, on the performance of an adapted version of the Symbol Digit Modalities Test.

METHODS

Ninety-nine individuals completed two alternate forms of the adapted version of the SDMT (aSDMT). Participants were instructed to complete the five lines of the task as quickly and accurately as possible. On one form participants were instructed to provide their response in writing and on the other one, orally. Form and response modality (oral vs. written) were counterbalanced to control for practice effects.

RESULTS

On average, there was a significant difference between response modalities, such that participants needed more time to respond when the response modality was written. For both response modalities, time to complete each line of stimuli decreased as the task progressed. While changes in response time on the first four lines of stimuli on the oral version were not found, there was a substantial improvement in response time on the fifth line. In contrast, on the written version a gradual learning effect was observed, in which response time was the slowest on the first two lines, an intermediate response time was noted on line 3, and the fastest response time was achieved on lines four and five.

CONCLUSION

The current study demonstrates that response modality, oral versus written, can significantly impact performance efficiency (the length of time it takes to complete a task), but not accuracy (total correct responses), on a new adaptation of the SDMT, the aSDMT.

Cognitive-Communication Predictors of Employment Outcomes 1 and 5 Years Posttraumatic Brain Injury

OBJECTIVE

To examine changes in functional memory, problem solving, comprehension, expression, and social communication over the first 2 years posttraumatic brain injury (TBI) and the ability of each to predict return to work (RTW) outcomes at 1 year and 5 years postinjury.

DESIGN

Secondary analysis of data from a multicenter longitudinal cohort study.

SETTING

Acute inpatient rehabilitation facilities and community follow-up.

PARTICIPANTS

A total of 3543 individuals between 16 and 60 years of age who were competitively employed at the time of TBI and had completed year 1, year 2, and year 5 postinjury follow-ups.

MAIN OUTCOME MEASURES

Year 1 and year 5 RTW status (± competitively employed) at the time of study completion.

RESULTS

Greater function across each of the 5 cognitive-communication abilities was associated with RTW success at 1 year and 5 years post-TBI. At discharge, these 5 abilities showed comparable odds of predicting later employment. At year 1 and year 2 follow-ups, independence with problem solving was the most predictive of employment 5 years post-TBI, followed by social interaction, memory, expression, and comprehension.

CONCLUSIONS

An increased rehabilitation focus on functional memory, problem solving, comprehension, expression, and social interaction post-TBI has the potential to improve RTW outcomes.

The role of language ability in verbal fluency of individuals with multiple sclerosis

BACKGROUND

While cognitive deficits in memory and processing speed have been well-documented in individuals with multiple sclerosis (MS), language is largely considered to be intact. Verbal fluency deficits observed in MS are often attributed to impaired processing speed and executive functions rather than language ability. The current study evaluates the contribution of various cognitive factors to verbal fluency including language ability, oral-motor speed, processing speed, and executive functions.

METHODS

We analyzed pre-existing data from seventy-four (74) individuals with MS who completed a battery of neuropsychological tests designed to assess individual ability for various cognitive factors. We conducted linear multiple regression analyses with letter and category verbal fluency as outcome variables and performance on other cognitive domains (e.g., processing speed, executive functioning) as predictors.

RESULTS

Both vocabulary and processing speed predicted letter fluency while only vocabulary predicted category fluency. These findings suggest that the observed verbal fluency deficits in MS may reflect both impaired language ability and processing speed.

CONCLUSION

We propose that further research on language ability in MS is needed to determine if comprehensive neuropsychological test batteries for persons with MS should include tests of language ability to fully understand the cognitive profile of any given patient. Given the importance of language ability, it may be necessary to conduct a more thorough assessment of language in individuals with MS who experience a deficit in this domain.

Smell as a clinical-marker for functional limitations in multiple sclerosis: A pilot study

BACKGROUND

Olfactory dysfunction is a common symptom of multiple sclerosis (MS). The questions of whether and to what degree olfactory dysfunction can serve as a clinical marker of MS disability (i.e. cognitive impairments and functional limitations) are not yet answered. The current study aimed to explore associations between olfactory function (i.e. smell identification) with cognitive capacities, functional performance and quality of life (QOL) in persons with MS.

METHODS

Olfactory function was measured by the University of Pennsylvania Smell Identification Test (UPSIT). Functional ability was assessed by the Actual Reality^TM (AR) task. QOL was assessed by the Multiple Sclerosis Quality of Life-54 (MSQOL-54). Cognition was assessed by the Brief International Cognitive Assessment for MS (BICAMS) in 23 MS patients and 15 matched healthy controls.

RESULTS

MS patients had lower UPSIT scores than healthy controls. Worse UPSIT scores were associated with reduced performances on the BICAMS and AR task as well as lower MSQOL-54 scores. Specifically, UPSIT scores were related to MSQOL-54 scores independent of BICAMS composite scores, while the relationship between UPSIT score and AR performance was mediated by BICAMS composite score.

CONCLUSION

This study confirms previous studies which concluded that olfactory function is impaired in MS. Furthermore, olfactory dysfunction is related to limitations in activity performance and QOL. Taken together with previous studies, olfactory function may be considered as a clinical marker related to MS disability. Longitudinal studies are needed to confirm these results.

The Neural Mechanisms Underlying Processing Speed Deficits in Individuals Who Have Sustained a Spinal Cord Injury: A Pilot Study

Our objective was to determine differences in brain activation during a processing-speed task in individuals with SCI compared to a group of age-matched healthy controls and to a group of older healthy controls. Ten individuals with cervical SCI (C3-C5), 10 age-matched healthy controls and 10 older healthy controls participated in a cross-sectional study in which performance on neuropsychological tests of processing speed and brain activation were the main outcome measures. The brain areas used by the individuals with SCI during the processing-speed task differed significantly from the age-matched healthy controls, but were similar to the older control cohort, and included activation in frontal, parietal and hippocampal areas. This suggests that individuals with SCI may compensate for processing-speed deficits by relying on brain regions that classically support control cognitive processes such as executive control and memory.

The impact of level of injury on patterns of cognitive dysfunction in individuals with spinal cord injury

Context: While it is well recognized that physical and physiological changes are more prominent in individuals with higher neurologic levels of spinal cord injury (SCI), the impact of level of lesion on cognition is less clear. Design: Cross-sectional, 3-group. Setting: Non-profit rehabilitation research foundation. Participants: 59 individuals with SCI (30 with tetraplegia, 29 with paraplegia) and 30 age-matched healthy controls (HC). Interventions: None. Outcome Measures: Neuropsychological tests in the domains of attention, working memory, processing speed, executive control, and learning and memory. Results: Results indicated significantly lower test performance in individuals with paraplegia on new learning and memory testing compared to HC. In contrast, compared to HC the group with tetraplegia, showed a significantly impaired performance on a processing speed task, and both the tetraplegia and the paraplegia groups were similarly impaired on a verbal fluency measure. SCI groups did not differ on any cognitive measure. Conclusion: Individuals with SCI may display different patterns of cognitive performance based on their level of injury.

The emotional impact of the COVID-19 pandemic on individuals with progressive multiple sclerosis

Objective

Individuals with pre-existing chronic illness have shown increased anxiety and depression due to COVID-19. Here, we examine the impact of the COVID-19 pandemic on emotional symptomatology and quality of life in individuals with Progressive Multiple Sclerosis (PMS).

Methods

Data were obtained during a randomized clinical trial on rehabilitation taking place at 11 centers in North America and Europe. Participants included 131 individuals with PMS. Study procedures were interrupted in accordance with governmental restrictions as COVID-19 spread. During study closure, a COVID Impact Survey was administered via telephone or email to all participants, along with measures of depressive symptoms, anxiety symptoms, quality of life, and MS symptomatology that were previously administered pre-pandemic.

Results

4% of respondents reported COVID-19 infection. No significant changes were noted in anxiety, quality of life, or the impact of MS symptomatology on daily life from baseline to lockdown. While total HADS-depression scores increased significantly at follow-up, this did not translate into more participants scoring above the HADS threshold for clinically significant depression. No significant relationships were noted between disease duration, processing speed ability or EDSS, and changes in symptoms of depression or anxiety. Most participants reported the impact of the virus on their psychological well-being, with a little impact on financial well-being. The perceived impact of the pandemic on physical and psychological well-being was correlated with the impact of MS symptomatology on daily life, as well as changes in depression.

Conclusions

Overall, little change was noted in symptoms of depression or anxiety or overall quality of life.

Visual and motor confounds on the symbol digit modalities test

BACKGROUND

Slowed information processing speed is the most prevalent cognitive symptom in persons with multiple sclerosis (MS). The most commonly used instrument to measure information processing speed in MS is the Symbol Digit Modalities Test (SDMT). However, visual, oculomotor, and oralmotor deficits are frequently observed in persons with MS, and performance on the SDMT relies on these visual and motor functions, in addition to cognition.

METHODS

The current study examined the relationship between the SDMT and the King-Devick Test (KDT). The KDT encompasses similar oculomotor and oralmotor demands as the SDMT but requires a smaller attentional load. One hundred and thirty participants with MS completed the oral version of the SDMT and the KDT. Ordinary nonparametric bootstrapped regression models were performed with 1000 bootstrapped samples. Bootstrapped confidence intervals (CIs) were bias-corrected.

RESULTS

KDT performance explained 31% (bootstrapped CI: 18 - 43%) of the variance of SDMT performance (moderate correlation), much more than demographic and disease-related variables (0.7% and 10%, respectively).

CONCLUSIONS

Visual, oralmotor, and oculomotor functions contributed significantly to SDMT performance. Therefore, these sensory and motor functions must be taken into account when interpreting SDMT scores.

Reproductive Health in Women with Physical Disability: A Conceptual Framework for the Development of New Patient-Reported Outcome Measures

Background: Barriers in the built environment, enduring stereotypes and biases, and limited disability competency of health care providers compromise access to and quality of reproductive health care for women with physical disabilities. One way to improve our understanding of critical factors that drive reproductive health inequity and its impact on access to care is to use patient-reported outcome measures (PROMs) that capture relevant and meaningful information about experience. In this study, we developed a conceptual framework as the foundation for relevant and clinically meaningful patient-reported outcome measures targeting the interface of disability and reproductive health. Materials and Methods: We conducted semistructured focus groups and interviews to assess women's experiences around their reproductive health and contextual factors related to disability. We used deductive and inductive qualitative coding approaches to develop the conceptual framework. Results: Eighty-one women between the ages of 16 and 50 with a self-reported physical disability, defined by an impairment of mobility, participated in 13 focus groups (N = 64) and 17 individual interviews. Five major themes characterized the conceptual framework that emerged-knowledge about reproductive health, communication about reproductive health, relationships, the reproductive health care environment, and self-advocacy/identity-all of which had some relationship with five major reproductive health issues-pregnancy and labor/delivery, periods and menstrual management, contraception, sexuality and sexual functioning, and pelvic examinations. Conclusions: This conceptual framework will serve as a foundation for PROM and guide intervention development to reduce reproductive health inequity and improve reproductive health outcomes of women with physical disabilities.

Changes in Activity Participation After Multiple Sclerosis Diagnosis

BACKGROUND

Multiple sclerosis (MS) results in impairments in cognitive and motor skills, which may reduce the level of activity participation in people with MS. This study compares past and current levels of activity participation in adults with MS and controls. The relationship between retained activity participation (since diagnosis) and cognitive, motor, functional status, and depression symptoms of persons with MS was examined.

METHODS

Twenty-seven individuals with MS living in the community and 21 controls completed cognitive and motor tests and rated their activity participation (using the Activity Card Sort), depression symptoms, and functional status.

RESULTS

The MS group reported significantly lower current activity participation than the control group. Percentage of retained activity participation (from prediagnosis to current) in the MS group correlated with time since diagnosis, executive function and motor skill ability, depression symptoms, and current functional status.

CONCLUSIONS

Persons with MS report negative changes in activity participation in most aspects of life after diagnosis. These findings call attention to changes in activity participation in people with MS that are directly related to disease symptoms. Therefore, using a quantitative measure of activity participation-the Activity Card Sort-can provide important information to aid the clinician in developing individualized treatment goals for people with MS.

The application of Strategy-based Training to Enhance Memory (STEM) in multiple sclerosis: A pilot RCT

New learning and memory (NLM) impairments are common in multiple sclerosis (MS), negatively impacting daily life. Few studies seek to remediate these deficits to improve everyday functioning. Self-generation, spaced learning and retrieval practice have been shown to improve NLM in healthy persons and have been incorporated into an 8-session treatment protocol, Strategy-based Training to Enhance Memory (STEM). STEM teaches participants about each of the techniques, how to apply them in daily life and provides practice. Participants are taught to restructure a memory-demanding situation to optimize self-generation, spaced learning and retrieval practice. This pilot double-blind, placebo-controlled, randomized clinical trial (RCT) tested the efficacy of STEM in 20 learning-impaired participants with clinically definite MS (9 treatment, 11 control). Significant treatment effects were noted on self-report measures of daily functioning (primary outcome). Objective neuropsychological testing approached significance, showing a medium-large effect on verbal NLM. Results suggest that STEM may improve everyday functioning in individuals with MS. A full-scale RCT is warranted to validate findings in a larger sample so that findings may be generalized to the broader MS community.

Comparing learning performance on the open trial selective reminding test with the California verbal learning test II in traumatic brain injury

Introduction: Learning and memory deficits are prevalent following moderate to severe traumatic brain injury (TBI), affecting between 54% and 84% of impacted individuals.Objective: The current study examined learning performance on two tests of verbal memory: the OT-SRT and the CVLT-II.Methods: Sixty-eight participants with TBI performed the OT-SRT and the CVLT-II on two different days. Additionally, all participants completed cognitive tests assessing processing speed, working memory and executive functions. By definition, all participants with TBI were identified as having impaired learning on the OT-SRT, however only 38 were also identified as impaired on the CVLT-II. The sample was thus divided into two groups, those who failed both tests (Fail-2) and those who failed only the OT-SRT (Fail-1).Results: The Failed-1 group showed significantly better performance in processing speed, working memory and executive functions compared to the Fail-2 group. On the CVLT-II, the Fail-1 group performed significantly better on the number of words recalled on trials 1 and 5 compared to the Fail-2 group. Both groups performed similarly the OT-SRT.Discussion: The CVLT-II and the OT-SRT are not equivalent tests and should not be used interchangeably.

The efficacy of the modified Story Memory Technique in progressive MS

Background:

Impairments in new learning and memory are common in individuals with multiple sclerosis (MS), negatively impacting everyday life, including occupational and social functioning.

Objective:

This study examined the efficacy of the modified Story Memory Technique (mSMT) in a progressive multiple sclerosis (PMS) sample through a double-blind, placebo-controlled, randomized clinical trial (RCT).

Methods:

Thirty (30) individuals with PMS, naïve to the mSMT, were randomized to the treatment or placebo control group. The Treatment Group completed mSMT training twice per week for 5 weeks while the Placebo Group met with the therapist at the same frequency, engaging in non-training-oriented tasks to control for professional contact and disease alterations.

Results:

The treatment group showed significant improvements in learning compared with the placebo control group, evident on both objective evaluation of new learning and self-report of functioning in daily life. Increased awareness of cognitive deficits was also noted post-treatment.

Conclusion:

These data provide Class I evidence supporting the efficacy of the mSMT in PMS. A behavioral intervention, targeted to specifically strengthen new learning, can significantly improve memory performance in PMS, and this improvement in memory performance is maintained 3 months later.

Patterns of cognitive deficits in persons with spinal cord injury as compared with both age-matched and older individuals without spinal cord injury

Context/Objective: Cognitive deficits can impact as many as 60% of individuals with spinal cord injury (SCI). In an effort to identify the nature of cognitive deficits in SCI, we examined neuropsychological test performance in individuals with SCI, age matched healthy controls and older healthy controls.Design: Participants completed a motor-free neuropsychological test battery assessing attention, working memory, information processing speed, new learning /memory and executive control.Setting: Outpatient rehabilitation research facility.Participants: Participants included 60 individuals with chronic spinal cord injury [SCI; 32 with paraplegia (T2-T12) and 28 with tetraplegia (C3-T1)], 30 age-matched healthy controls (AMHC; 30-40 years old) and 20 older healthy controls (OHC; 50-60 years old).Outcome Measures: Wechsler Intelligence Scale - 3^rd edition (WAIS-III) Digit Span and Letter-Number Sequencing; Symbol Digit Modalities Test (SDMT) - oral version; California Verbal Learning Test-II; Paced Auditory Serial Addition Test (PASAT); Wechsler Abbreviated Scale of Intelligence (WASI); Delis-Kaplan Executive Function System; Verbal Fluency subtest.Results: Significant differences were noted between the SCI and AMHC groups on measures of information processing speed, new learning and memory, and verbal fluency. No significant differences were noted between the groups on tests of attention or working memory.Conclusion: The current study documented differences in specific realms of cognitive functioning between a chronic SCI sample and AMHC. Implications for cognitive rehabilitation and overall quality of life are discussed. Additional research is needed utilizing a more comprehensive battery of motor-free neuropsychological tests that avoid the confound of upper limb motor limitations on cognitive performance.

A Pilot Study Examining Speed of Processing Training (SPT) to Improve Processing Speed in Persons With Multiple Sclerosis

Background: Individuals with Multiple Sclerosis (MS) have significant impairments in processing speed (PS) and such impairments may underlie other cognitive deficits common in MS and limit performance of everyday life activities. Objective: To examine the efficacy of a computerized PS intervention, Speed of Processing Training (SPT), in persons with MS on PS, memory and everyday activities. Methods: Twenty-one individuals with clinically definite MS and an objectively assessed impairment in PS were included in a controlled randomized clinical trial, randomly assigned to a treatment group or a control group. Participants were assessed prior to and within 1 week of completing the treatment. Outcome measures included traditional neuropsychological tests measuring PS and memory, and an assessment of PS in daily life activities. Results: The treatment group showed a significant improvement on neuropsychological tests of PS and new learning and memory. A significant improvement was additionally noted in the treatment group on measures of PS in everyday life. These changes were not observed in the control group. Conclusions: Results provide preliminary data in support of SPT in treating PS deficits in persons with MS. Additional research is needed with larger samples and more comprehensive outcome measures.

The therapeutic value of cranioplasty in individuals with brain injury

PRIMARY OBJECTIVE

To examine the effect of cranioplasty on recovery.

RESEARCH DESIGN

Retrospective cohort study.

METHOD AND PROCEDURES

Retrospective chart review conducted in 2011 and 2012 on adult inpatients with craniectomy who completed a continuous episode of inpatient rehabilitation before and after receiving their cranioplasty. Patients were matched 1:1 or age, gender, functional level at admission, injury severity and length of stay with inpatients who completed rehabilitation before cranioplasty. Main outcome measures include FIM^TM (Functional Independence Measure) and FIM^TM efficiency [(FIM^TM discharge - FIM^TMadmission)/number of days in rehabilitation]. To examine within and between group differences, analyses included paired and independent t-tests, Pearson correlations and chi-square analyses.

RESULTS

Twenty-six individuals (13 from the cranioplasty group and 13 from the comparison group) were analysed. FIM^TM efficiency increased following cranioplasty [0.29 to 0.61; t(12) = -2.77, p = 0.017]. The mean FIM^TM efficiency for the cranioplasty group was below that of the comparison group prior to cranioplasty [0.28 ± 0.37 and 0.39 ± 0.32, p = .41], but increased following cranioplasty [0.61 ± 0.71 and 0.39 ± 0.32, p = .32]. An improvement in FIM^TM efficiency following cranioplasty was more commonly seen among individuals with less severe brain injuries (75%, χ² = 3.8, df = 1, p = 0.053).

CONCLUSION

Rate of recovery increased following cranioplasty and exceeded that of the comparison group suggesting that cranioplasty may contribute to improvement.

The MSOAC approach to developing performance outcomes to measure and monitor multiple sclerosis disability

Background:

The Multiple Sclerosis Outcome Assessments Consortium (MSOAC) was formed by the National MS Society to develop improved measures of multiple sclerosis (MS)-related disability.

Objectives:

(1) To assess the current literature and available data on functional performance outcome measures (PerfOs) and (2) to determine suitability of using PerfOs to quantify MS disability in MS clinical trials.

Methods:

(1) Identify disability dimensions common in MS; (2) conduct a comprehensive literature review of measures for those dimensions; (3) develop an MS Clinical Data Interchange Standards Consortium (CDISC) data standard; (4) create a database of standardized, pooled clinical trial data; (5) analyze the pooled data to assess psychometric properties of candidate measures; and (6) work with regulatory agencies to use the measures as primary or secondary outcomes in MS clinical trials.

Conclusion:

Considerable data exist supporting measures of the functional domains ambulation, manual dexterity, vision, and cognition. A CDISC standard for MS (http://www.cdisc.org/therapeutic#MS) was published, allowing pooling of clinical trial data. MSOAC member organizations contributed clinical data from 16 trials, including 14,370 subjects. Data from placebo-arm subjects are available to qualified researchers. This integrated, standardized dataset is being analyzed to support qualification of disability endpoints by regulatory agencies.