Evaluation of Educational Attainment among School Children from Vulnerable Communities after Interventions of Effortless Walking Versus Strenuous Sporting Activity

Research Article

Evaluation of Educational Attainment among School Children from Vulnerable Communities after Interventions of Effortless Walking Versus Strenuous Sporting Activity

  • Rania Hussein Farraj 1
  • Raed Mualem 1,2,3
  • Gerry Leisman 4,5
  • Shireen Rustom 1
  • Sherif Ganem 2,6
  • Shir Shance 1
  • Maya Rosner 2
  • Cohen Sapir 1
  • Yusra Zbedat 3
  • Igor Waksman 7,8
  • Seema Biswas 7

*Corresponding Author: Raed Mualem, Econeurobiology Research Group, Research Authority, Oranim Academic College, Israel.

Citation: Rania H. Farraj, Raed Mualem, Gerry Leisman, Shireen Rustom, Sherif Ganem, et al., (2024), Evaluation of Educational Attainment among School Children from Vulnerable Communities after Interventions of Effortless Walking Versus Strenuous Sporting Activity, J. Neuroscience and Neurological Surgery, 14(1); DOI:10.31579/2578-8868/298

Copyright: © 2024, Raed Mualem. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Received: 04 January 2024 | Accepted: 26 January 2024 | Published: 08 February 2024

Keywords: education; effortless walking; aerobic exercise; strenuous exercise; anaerobic exercise; cognition; memory; learning

Abstract

Background: This study investigates the impact of effortless walking (aerobic exercise) versus strenuous sporting activity (anaerobic exercise) on educational attainment among elementary school children. The focus is on how different intensities of physical activity affect cognitive functions like memory, concentration, and higher-order thinking skills.

Materials and Methods: The research included 50 fourth-grade students. They underwent tests measuring concentration, recall, understanding, application, and analysis of knowledge, first without exercise, then after effortless walking, and finally following strenuous exercise.

Results: Effortless walking significantly improved concentration (255% increase), recall (54.3% increase), understanding (42% increase), application (33% increase), and analysis of knowledge (66% increase). In contrast, strenuous exercise often resulted in a decrease in these cognitive functions compared to effortless walking.

Conclusion: The study concludes that short periods of non-strenuous exercise like effortless walking before lessons significantly enhance cognitive functions and educational performance in elementary school children, suggesting the integration of aerobic exercise into school routines could be beneficial for academic achievement.

1.Introduction

Movement and human health

There is extensive evidence that supports the positive effects of physical exercise on cognition and learning via enhanced executive functions and spatial memory [1-4] Renewed focus on the importance of exercise in the prevention of childhood obesity has forced schools to re-evaluate the participation of school children in sporting activity [4]. Aerobic exercise and physical activity have been shown to be effective in the prevention of cortical atrophy and cognitive impairment in adults, and in reducing the risk of developing dementia [5]. In this article, the effects of exercise on classroom learning are investigated and reviewed. The focus here is on elementary school children (aged 9-10 years). The importance of this research is the role free of low-cost interventions that enhance cognition and educational attainment – key determinants of health and well-being for individuals and communities as a whole [6]. 

1.2 How Movement affects the brain

Exercise enhances the performance of tasks that require attention, organization, and planning [7-8]. During strenuous activity the brain releases endorphins. These, together with dopaminergic biochemical processes enhance the concentration, cognition and executive functions such as decision making. This process is mediated through the limbic system of the brain that familiarises individuals with their environment [1]. The hippocampus augments the formation of memories. The more physically fit an individual, the larger the hippocampus and better that individual’s spatial memory. Specific exercises may also contribute to nerve protection and synaptic plasticity due to increased levels of brain-derived neurotrophic factor (BDNF) [4]. Anaerobic metabolism associated with strenuous exercise requires cerebral neurons to rely on lactate. The lactate pathway, unique to the brain, allows the brain to convert lactate to pyruvate [9-10]. 

During strenuous exercise, the body's demand for energy often exceeds what can be supplied through aerobic metabolism alone. As a result, muscle cells and other tissues may rely more heavily on anaerobic metabolism, which can lead to an increase in lactate production. Lactate, traditionally considered a byproduct of anaerobic glycolysis, is now recognized as an important substrate for energy production, particularly in the brain under certain conditions [10-14]. Lactate produced in the muscles during intense exercise can be transported to the brain via the bloodstream. Once in the brain, lactate can be taken up by neurons and other brain cells. This uptake is facilitated by specific monocarboxylate transporters (MCTs) that allow lactate to cross cell membranes [10,11,13]. Within neurons, lactate can be converted back into pyruvate by the enzyme lactate dehydrogenase (LDH). Pyruvate can then enter the tricarboxylic acid (TCA) cycle after being converted into acetyl-CoA, ultimately contributing to ATP production, which is essential for cellular energy [13-15].

1.3 The relationship between movement and cognitive abilities

Short periods of walking cause an increase in the secretion of BDNF which plays an important role in increasing hippocampal volume. Aerobic exercise was found to increase hippocampal volume by up to 2% This increase in volume was directly related to improvements in memory performance, with significant correlations found for both the left and right hemispheres of the hippocampus [5]. The mechanism by which exercise increases BDNF levels may involve the ketone body β-hydroxybutyrate (BHB), which is elevated during exercise and has been shown to activate BDNF transcription. However, it is noted that exercise can induce BDNF expression through BHB-independent mechanisms as well [16], The effect persists with regular exercise. This increase is due to the effect of neurotransmitters and dendritic expansion and is also critical for memory formation. Another factor affecting BDNF levels is anterior hippocampal volume. The hippocampus is rich in BDNF. Exercise causes a rapid rise in BDNF. Moderate physical activity may be a simple but important method of improving cognitive development [17]. While precise neurophysiological mechanisms are not yet understood, both acute and chronic physical exercise can induce positive effects on brain function, and this is associated with improvements in cognitive performance. No study has yet been conducted that suggests a link between prolonged physical exertion, cognition, concentration, and memory.

1.4 Study objective

The aim of this research was to investigate the effect of movement on learning by testing two aspects of cognition: (1) attention (2) recall and retrieval of information.

2. Methods

2.1. Participants 

To address the query regarding the determination of the study size and the protocol, the authors followed ethical guidelines as stipulated by the Research Committee of Oranim Academic College, Israel. The study was conducted in compliance with the Ministry of Education of Israel, which waived the requirement for individual consent per child. Instead, written consent was obtained collectively through the parents after the school provided verbal information about the study's focus on cognition and learning.

The sample size included 50 grade four elementary school children, aged between 9-10 years, featuring a gender distribution of 26 males. The cohort was homogenized by the socio-economic status of the participants, all of whom were identified as Arab, encompassing both Christians and Muslims, and classified as 'middle-class' according to the criteria established by Hollingshead and Redlich [18]

2.2. Procedure

The "Simon" type memory and "Feature detection " type concentration tasks (18) were used with a science (chemistry) quiz based on Bloom’s taxonomy of critical thinking developed by the National Center for Science Teaching at Tel Aviv University (www.matar.ac.il) and the Ministry of Education in Israel. The science quiz contained open and closed chemistry questions categorized in terms of lower-order and higher-order thinking [19].

Each pupil performed the memory and concentration tasks and took the chemistry quiz three times. In the first week, the pupils performed the three tests (memory, concentration, and Bloom’s test) without exercise beforehand (resting-basal status) at 10 am on alternate days of the week. In the second week, the pupils performed the three tests after 10 minutes of effortless walking. In the third week, the pupils performed the three tests after 30 minutes of running or cycling (strenuous exercise). In all three weeks the pupils undertook the three tests in the same order but the questions in the chemistry test were different each week (although within the same categories and at the same educational level). Each pupil participant served as his/her own control.  The research design and criteria were based on recent research on the effect of movement on cognitive performance [18]

2.3 Statistical analysis

The statistical analyses were tailored to the nature of the data collected in the study. Quantitative comparisons between the experimental groups and the control group, focusing on memory, concentration, and cognition, were performed using the SPSS software. Since the analysis involved comparing averages and percentages of change between paired groups, paired t-tests were employed for this purpose. A paired t-test, also known as a dependent t-test in SPSS, compares the means between two related groups on the same continuous, dependent variable [20].

3. Results

3.1 Concentration and Recall

The comparative effects of effortless walking versus physical exertion on concentration are presented in Table 1.

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity 

30 min

Percent change

%

t-test
Concentration16.33±1.6441.66±2.84 255% 6.782***
Concentration16.33±1.64 17.66±1.157.7% 0.324*
Concentration 41.66±2.8417.66±1.15-57.6%5.576***

*N.S ***p Less than 0.001 

Table 1: The effect of rest versus effortless walking and strenuous exercise on the ability to concentrate (scores out of 20)

The level of concentration at rest was 16.33 +1.64. This increased by 255Percent as a result of 10 minutes of effortless walking. Strenuous exercise did not significantly affect concentration, but did decrease concentration significantly (by 57.6Percent) compared to effortless walking.

The effect of exercise on memory is shown in Table 2

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity

45 min

Percent change

%

t-test
Recall5.96± 0.829.23 ±1.55 54.3 %3.898 ***
Recall5.96± 0.82 6.06 ±0.191.6%0.291*
Recall 9.23 ±1.556.06 ±0.19- 34.3%6.265***

*N.S, ***p Less than 0.001

Table 2: The effect of rest versus effortless walking and strenuous exercise on memory (recall) (scores out of 20)

The basal level of recall or memory at rest was 5.96 +0.82. This increased significantly by 54.3Percent after 10 minutes of effortless walking.  Strenuous exercise did not result in any significant change compared to rest but decreased recall significantly (34.3Percent) when compared to effortless walking.

3.2 Results of Bloom’s taxonomy tests of critical thinking 

The effect of rest versus effortless walking and strenuous exercise on remembering information (knowledge) is shown in Table 3.

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity 

30 min

Percent change

%

t-test
Knowledge16.66 ±1.0721.36 2.07±  28.6%3.21**
Knowledge16.66 ±1.07 15.00± 2.10-1.5%0.41*
Knowledge 21.36 2.07±15.00± 2.10-42.4%4.41**

*N.S, **p Less than 0.005 (n=50) 

Table 3: The effect of rest versus effortless walking and strenuous exercise on knowledge, (scores out of 20) .

The basal knowledge score at rest was 16.66 + 1.07. This increased by 28.6Percent after effortless walking for 10 minutes (21.36 + 2.07).  After 30 minutes of strenuous exercise there was no significant change in knowledge score compared to the score at rest, but when compared to effortless walking there was a significant decrease in score (by 42.4Percent). 

The effect of movement on the pupils' level of understanding are seen in Table 4.

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity 

30 min

Percent change

%

t-test
Understanding 10.00 ±2.9614 ±2.17 42%4.682**
Understanding 10.00 ±2.96 10.66 1.99±6.1%1.278 *
Understanding  14 ±2.1710.66 1.99±25.3%3.756 **

*N.S, **p Less than 0.005 , (n=50)

Table 4: Effect of rest versus effortless walking and strenuous exercise on understanding (scores out of 20).

The level of understanding at rest was 10.00 + 2.96. Scores in understanding increased significantly (by 42Percent) as a result of 10 minutes effortless walking. Strenuous exercise did not result in a significant change in score compared to resting level scores but decreased scores significantly (by 25.3Percent) when compared to effortless walking.

Effects on the application of knowledge are seen in Table 5.

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity 

30 min

Percent change

%

t-test
Applying 13.00 +1.23 17.33+2.91 33.07%3.626 **
Applying 13.00 +1.23  13.66+1.801.04%0.24*
Applying  17.33+2.9113.66+1.80 -21.17%2.041**

*N.S, **p Less than 0.05, (n=50)

Table 5 : Effect of rest versus effortless walking and strenuous exercise on applying knowledge (scores out of 20).

The application of knowledge score at rest was 13.00 +1.23. This increased significantly (by 33Percent) as a result of effortless walking. Strenuous exercise did not significantly affect scores compared to rest but scores decreased significantly (by 21.1Percent) compared to effortless walking.

The effects on knowledge analysis are shown in Table 6.

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity

30 min

Percent change

%

t-test
Analyzing10.60+2.6017.60+2.95.66%5.789 ***
Analyzing 17.60+2.959.66+2.50-45.1%4.09***
Analyzing10.60+2.60 9.66+2.50-8.86%0.516*

*N.S, ***p Less than 0.001, (n=50)

Table 6 Effect of rest versus effortless walking and strenuous exercise on analysing knowledge (scores out of 20).

Analytical skill scores at rest were 10.60 + 2.60. These significantly increased (by 66Percent) after effortless walking. Compared to resting scores, there was no significant change after strenuous exercise, but strenuous exercise decreased analytical skills significantly (by 45.1Percent) when compared to effortless walking.

Table 7 shows the effects on evaluation of knowledge. 

VariableResting-Basal

Effortless walking

10 min

Exertion Physical activity 30 minPercent change %t-test
Evaluating 10.6+0.9115.30+2.60 44.3%5.23***
Evaluating 10.6+0.91 9.88+0.60-0.72%1.361 *
Evaluating  15.30+2.609.88+0.60 -35.4% %4.46***

*N.S, ***p Less than 0.001, (n=50)   

Table 7: Effect of rest versus effortless walking and strenuous exercise on evaluation of knowledge (scores out of 20).

Evaluation skill scores at rest were 10.60 + 0.91. These increased significantly (by 44.3Percent) after effortless walking. Strenuous exercise did not significantly affect evaluation scores compared to those at rest but in comparison to effortless walking significantly reduced scores (by 35.4Percent). 

4. Discussion

This study is one of the first of its kind to examine the effect of effortless walking (aerobic exercise) and strenuous (anaerobic) exercise on lower and higher order cognitive skills among school pupils in the classroom. This study showed that 10 minutes of effortless walking before class consistently improved concentration, recall and higher order thinking compared to no exercise or strenuous exercise. Complementary research has identified that various activities, including physical movement, musical engagement, adherence to a Mediterranean diet, and interactive computer games, are associated with enhanced scholastic performance (referenced in studies 18, 21, 22, 23). These results suggest that incorporating regular periods of aerobic exercise into the school routine could be instrumental in boosting academic learning outcomes (as supported by references 1, 18, 21, 22, 23). Such an intervention offers a cost-effective and relatively straightforward strategy with the potential for significantly amplifying educational achievement.

4.1 Mechanisms by which aerobic exercise improves brain function 

The differential effects of aerobic versus anaerobic exercise reveal the importance of the intensity of exercise on brain connectivity [24]. Exercise increases the volume of the hippocampal area in the brain by up to 2%, producing new neurons, allowing people to remember familiar environments and to perform tasks that require attention, organization, and planning [1,18] known as activity dependent plasticity [25]. The findings of the present study show that effortless walking does not cause a change in lower-order thinking skills (at the level of recall, knowledge and understanding according to Bloom’s taxonomy), but only in high-order thinking (application, analysis, and synthesis). Bloom's taxonomy is a hierarchical learning pyramid with several stages, arranged according to the complexity of brain function. In order to move from stage to stage in learning, it is necessary to develop brain architecture. Thus, ascending the hierarchical pyramid depends on brain plasticity, and higher-order cognitive skills cannot be reached until lower-order cognitive skills are achieved [1]. While genetic polymorphisms account for variation in BDNF-hippocampal dependent differences in cognitive function among individuals, the effects of aerobic exercise on BDNF secretion mean that learning and memory may be enhanced by positive environmental factors [25].

Aerobic exercise increases cortical activation via the secretion of BDNF. BDNF-related synaptic connections (generating memories and enhancing neuroplasticity) have been detected within seconds. BDNF has been shown to contribute to the expansion of dendrites in rodents and humans [5,7,8,26]. The effect is mediated through cell proliferation or increased dendritic expansion, increasing volume in the hippocampus. These effects are most prominent in early childhood [3].  BDNF synthesis and action is complex. BDNF enhances neuroplasticity via a number of mechanisms including synaptogenesis, neurogenesis, dendritic spine growth, long term potentiation and stimulation of protein synthesis, and in various timeframes; thus, the exact mechanisms regarding exercise are unclear [3]. Increased serum lactate levels in anaerobic exercise or after intravenous infusion of lactate at rest increase serum BDNF levels. BDNF crosses the blood brain barrier in both directions and may thus be measured in the serum [27]. In adults, it seems that exercise and/or training temporarily elevate basal BDNF and possibly upregulate cellular processing of BDNF (i.e. synthesis, release, absorption and degradation). From that point of view, exercise and/or training would result in a higher BDNF synthesis following an acute exercise bout (i.e. compared with untrained subjects). Subsequently, more BDNF could be released into the blood circulation which may, in turn, be absorbed more efficiently by central and/or peripheral tissues where it could induce a cascade of neurotrophic and neuroprotective effects. [28,29]. Similarly, lactate generated during anaerobic exercise also crosses the blood brain barrier. Information about the function of lactate as a signaling molecule is emerging. Lactate and BDNF do interact during exercise but the role of lactate in enhancing or diminishing learning is not clear [5]. Current thinking is that strenuous exercise reduces concentration and impairs higher-order skills and memory [18,27]. The gene known as Sirtuin 1, which has anti-aging properties, plays a crucial role in regulating the secretion of BDNF, a factor essential for cognitive function, hippocampal health, and synaptic plasticity [30-33]. It is imperative to investigate whether aerobic exercise during the school day can enhance plasma Sirtuin 1 levels, thereby influencing BDNF secretion. The interplay between Sirtuin 1 activators and inhibitors may be significant concerning BDNF levels and potentially beneficial for classroom learning [30-33]. Future research should consider examining the effects of aerobic exercise on Sirtuin 1 plasma concentrations and its subsequent impact on learning outcomes, taking into account the delicate balance between activators and inhibitors of Sirtuin 1. 

4.2 Implications for the school timetable

In our view, exercise programmes are built into school timetables worldwide. Exercise plays a large role in school activities, whether competitive sport or classes in physical fitness. This research, focusing on elementary school learning, has shown that a short period of non-strenuous exercise before lessons begin, enhances what is learned in class and performance in assessment of what has been learned. Effortless walking requires only a safe place to walk, is of no cost, and, if shown to consistently improve learning, should become routine practice before all classroom learning (and before assessment). The aim is to improve environmental factors that stimulate and enhance learning. Other factors include music, adequate sleep and a nurturing environment in which to grow and learn. While not all these factors may be mitigated within the school timetable, exercise fits in well during classroom breaks.

4.3 Limitations

While the literature supports the importance of movement in the form of effortless walking in significantly improving children's performance in continuous mory tests that require cognitive-motor interaction and tests to identify attention-related features [1], exact mechanisms remain unclear. As 75% of serum BDNF derives from the brain, serum BDNF levels may be measured and future research in the classroom may include the measurement of brain activity via the collection of BDNF levels or cortical activity using EEG analysis. Similarly, the measurement of serum lactate levels may have a role in further uncovering the mechanism by which aerobic exercise is beneficial to learning while strenuous exercise is determinantal, but, even if invasive blood tests are feasible in children, the information yield should be interpreted with caution. Laboratory studies in rodents indicate positive benefits of lactate [25]. The exact balance of metabolic conditions that stimulate classroom learning requires substantially more research. Mechanisms of interaction between peripheral and central structures, muscle, liver and glucose metabolism should be understood. While the role of BDNF in exercise induced neuroplasticity in adults has been well researched [27], the effects on child development warrant further enquiry. Long lasting neurochemical effects have not been researched, thus, we recommended repeated classroom routine after exercise requires further research.

References

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Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner