Recovery from vestibular dysfunction following Traumatic Brain Injury: A prospective behavioural and neuro-imaging study
Lead Research Organisation:
Imperial College London
Department Name: Brain Sciences
Abstract
Traumatic Brain Injury (TBI) is the commonest cause of chronic disability in young adults. We found that 86% of acute TBI patients have problems with their balance. The problem of imbalance is important for this young working age group since previous studies have shown that following a mild TBI, at 6 months, 66% of TBI patients with balance problems will still be unemployed versus only 25% of those without balance dysfunction. A key step in treating TBI imbalance is to understand the underlying pathophysiology, however previous studies could not identify a clear-cut cause in 25% of TBI patients with chronic imbalance.
Our acute TBI data show that most patients have a type of imbalance that is typical for patients with a loss of function of the inner ear balance organ - the vestibular organ. When we tested acute TBI patients with normal inner ear function we still found the same type of vestibular gait impairment, implying that the problem lay with the brain's processing of the vestibular organ's signals. Whilst screening acute TBI patients we also observed that acute TBI patients appeared to lose the perception of vertigo (the sensation of bodily self-motion) despite overt vestibular activation (vestibular nystagmus, nausea and vomiting). This again implies a failure by the brain to adequately process the inner ear vestibular signals. Taken together, TBI impairs the brain processing of vestibular signals with a major impact upon balance function. But what is the mechanism underlying this impairment of vestibular processing?
Our previous work (Nigmatullina 2015) showed that vertigo perception is mediated by a cerebral cortical network. Congruent with this notion and using a test to quantify the vestibular perception of self-motion, we found that focal cortical damage from stroke did not affect vestibular perception of self-motion (Kaski 2015). In contrast, in our pilot data, we quantitatively show that acute TBI does indeed impair this vestibular perception of self-motion (which we call 'Vestibular Agnosia').
We thus hypothesise that TBI causes a disruption of a cerebral cortical network that processes vestibular signals important for perceiving our sense of bodily motion. We additionally hypothesise that impairment of this vestibular cortical network will also compromise balance, particularly in the dark, since excessive sway (normally indicated by vestibular signals of head motion) will not be detected, leading to falls.
Hence in our study we propose to:
(i) prospectively assess if our vestibular perceptual test (of vestibular agnosia) predicts functional outcome;
(ii) test our hypothesis that vestibular agnosia is a marker of brain network dysfunction;
(iii) develop models linking pathophysiology and symptoms and hence enable us to explain why the persistence of symptoms post-TBI correlates poorly with TBI severity.
The output of this study will thus enable us to:
(i): predict which patients will be at risk of imbalance and falls post-TBI;
(ii) objectively monitor the improvement in brain network dysfunction and hence provide an objective indicator of response to treatment;
(iii) provide a clinical framework to progress the research and treatment of TBI including sports concussion.
Our acute TBI data show that most patients have a type of imbalance that is typical for patients with a loss of function of the inner ear balance organ - the vestibular organ. When we tested acute TBI patients with normal inner ear function we still found the same type of vestibular gait impairment, implying that the problem lay with the brain's processing of the vestibular organ's signals. Whilst screening acute TBI patients we also observed that acute TBI patients appeared to lose the perception of vertigo (the sensation of bodily self-motion) despite overt vestibular activation (vestibular nystagmus, nausea and vomiting). This again implies a failure by the brain to adequately process the inner ear vestibular signals. Taken together, TBI impairs the brain processing of vestibular signals with a major impact upon balance function. But what is the mechanism underlying this impairment of vestibular processing?
Our previous work (Nigmatullina 2015) showed that vertigo perception is mediated by a cerebral cortical network. Congruent with this notion and using a test to quantify the vestibular perception of self-motion, we found that focal cortical damage from stroke did not affect vestibular perception of self-motion (Kaski 2015). In contrast, in our pilot data, we quantitatively show that acute TBI does indeed impair this vestibular perception of self-motion (which we call 'Vestibular Agnosia').
We thus hypothesise that TBI causes a disruption of a cerebral cortical network that processes vestibular signals important for perceiving our sense of bodily motion. We additionally hypothesise that impairment of this vestibular cortical network will also compromise balance, particularly in the dark, since excessive sway (normally indicated by vestibular signals of head motion) will not be detected, leading to falls.
Hence in our study we propose to:
(i) prospectively assess if our vestibular perceptual test (of vestibular agnosia) predicts functional outcome;
(ii) test our hypothesis that vestibular agnosia is a marker of brain network dysfunction;
(iii) develop models linking pathophysiology and symptoms and hence enable us to explain why the persistence of symptoms post-TBI correlates poorly with TBI severity.
The output of this study will thus enable us to:
(i): predict which patients will be at risk of imbalance and falls post-TBI;
(ii) objectively monitor the improvement in brain network dysfunction and hence provide an objective indicator of response to treatment;
(iii) provide a clinical framework to progress the research and treatment of TBI including sports concussion.
Technical Summary
CLINICAL NEED: Traumatic Brain Injury (TBI) is the commonest cause of chronic disability in young adults. We found in 111 consecutive head injury patients (Fig.1), 86% had symptoms and/or signs of imbalance.
IMPACT OF TBI-RELATED VESTIBLAR DYSFUNCTION: Post-TBI imbalance is an independent predictor of failure to return to work but the cause of imbalance in chronic TBI patients is unknown in 25%.
TBI IMPAIRS THE BRAIN'S PROCESSING OF THE VESTIBULAR SIGNAL: Patients without inner ear vestibular function display a complete loss of vestibular responsivity, from loss of the vestibular reflexes, to a particular type of gait dysfunction ('vestibular ataxia') as well as an absence of any perception of vertigo during stimuli that would ordinarily provoke this sensation. In the 84% of acute TBI patients with NORMAL INNER EAR FUNCTION, we found a normal vestibular reflex responsivity (e.g. vestibular nystagmus) however we found a vestibular ataxia and an impaired perception of vertigo. The combination of preserved vestibular reflexes and impaired perception and balance indicate an impaired brain processing of the inner ear vestibular signals. The loss of vestibular sensation of self-motion could itself lead to falls since there is no indication of excessive sway, especially in the dark.
WHAT WE WILL DO: We will prospectively recruit acute TBI patients (and matched controls) and prospectively acquire data on functional outcome, falls, laboratory measures of vestibular function (of reflex, perceptual and balance function) and structural and functional neuro-imaging. We will assess which of the behavioral and neuroimaging factors predict functional outcome and falls at 6 months.
EXPECTED OUTPUTS: We hope to reveal the mechanisms mediating TBI-imbalance enabling a prediction of patients at high risk of imbalance, providing putative mechanisms for developing new treatments as well as objective measures to monitor the response to these treatments.
IMPACT OF TBI-RELATED VESTIBLAR DYSFUNCTION: Post-TBI imbalance is an independent predictor of failure to return to work but the cause of imbalance in chronic TBI patients is unknown in 25%.
TBI IMPAIRS THE BRAIN'S PROCESSING OF THE VESTIBULAR SIGNAL: Patients without inner ear vestibular function display a complete loss of vestibular responsivity, from loss of the vestibular reflexes, to a particular type of gait dysfunction ('vestibular ataxia') as well as an absence of any perception of vertigo during stimuli that would ordinarily provoke this sensation. In the 84% of acute TBI patients with NORMAL INNER EAR FUNCTION, we found a normal vestibular reflex responsivity (e.g. vestibular nystagmus) however we found a vestibular ataxia and an impaired perception of vertigo. The combination of preserved vestibular reflexes and impaired perception and balance indicate an impaired brain processing of the inner ear vestibular signals. The loss of vestibular sensation of self-motion could itself lead to falls since there is no indication of excessive sway, especially in the dark.
WHAT WE WILL DO: We will prospectively recruit acute TBI patients (and matched controls) and prospectively acquire data on functional outcome, falls, laboratory measures of vestibular function (of reflex, perceptual and balance function) and structural and functional neuro-imaging. We will assess which of the behavioral and neuroimaging factors predict functional outcome and falls at 6 months.
EXPECTED OUTPUTS: We hope to reveal the mechanisms mediating TBI-imbalance enabling a prediction of patients at high risk of imbalance, providing putative mechanisms for developing new treatments as well as objective measures to monitor the response to these treatments.
Planned Impact
PATIENTS
Patients' lives are severely disrupted by TBI-related imbalance. An understanding of the causes and treatment that we hope to bring for this condition, will help to ensure patients return to a fulfilling life.
ATHELETES AND SPORTS PHYSICIANS
Concussion is common in some sports. How do you diagnoses a concussion? Am I ready to play again? Objectifying concussion with some of the approaches we will use will hopefully make the approach to concussion in sport more clear-cut.
HEALTHCARE ORGANISATIONS
Is this head inured patient safe to go home? How can we tell? We believe that some of the techniques we will use to interrogate brain health post-TBI may allow a rapid triaging of patients into those requiring discharge versus those requiring admission.
PHARMACEUTICAL COMPANIES
Our study aims to produce a biomarker for brain injury recovery. Such a biomarker will allow Pharma companies to monitor the impact of their therapy in head trauma patients.
Insurance companies. If we can provide a sensitive and specific marker of head injury then such a technique could be sued in the court to assess whether there is persisting brain injury in a chronic symptomatic patient.
Patients' lives are severely disrupted by TBI-related imbalance. An understanding of the causes and treatment that we hope to bring for this condition, will help to ensure patients return to a fulfilling life.
ATHELETES AND SPORTS PHYSICIANS
Concussion is common in some sports. How do you diagnoses a concussion? Am I ready to play again? Objectifying concussion with some of the approaches we will use will hopefully make the approach to concussion in sport more clear-cut.
HEALTHCARE ORGANISATIONS
Is this head inured patient safe to go home? How can we tell? We believe that some of the techniques we will use to interrogate brain health post-TBI may allow a rapid triaging of patients into those requiring discharge versus those requiring admission.
PHARMACEUTICAL COMPANIES
Our study aims to produce a biomarker for brain injury recovery. Such a biomarker will allow Pharma companies to monitor the impact of their therapy in head trauma patients.
Insurance companies. If we can provide a sensitive and specific marker of head injury then such a technique could be sued in the court to assess whether there is persisting brain injury in a chronic symptomatic patient.
Organisations
- Imperial College London (Lead Research Organisation)
- Mayo Clinic Hospital (Collaboration)
- University of Rome Tor Vergata (Collaboration)
- UNIVERSITY OF BIRMINGHAM (Collaboration)
- University of Plymouth (Collaboration)
- University Hospital Zürich (Collaboration)
- UNIVERSITY OF CAMBRIDGE (Collaboration)
- IMPERIAL COLLEGE LONDON (Collaboration)
Publications
Ahmad H
(2017)
Downregulation of early visual cortex excitability mediates oscillopsia suppression.
in Neurology
Allen D
(2017)
Corrigendum: Age-Related Vestibular Loss: Current Understanding and Future Research Directions.
in Frontiers in neurology
Arshad Q
(2017)
Patients with chronic dizziness following traumatic head injury typically have multiple diagnoses involving combined peripheral and central vestibular dysfunction.
in Clinical neurology and neurosurgery
Bednarczuk NF
(2019)
Abnormal visuo-vestibular interactions in vestibular migraine: a cross sectional study.
in Brain : a journal of neurology
Calzolari E
(2021)
Vestibular agnosia in traumatic brain injury and its link to imbalance.
in Brain : a journal of neurology
Ciocca M
(2024)
Vestibular prepulse inhibition of the human blink reflex
Ciocca M
(2023)
Spinal Cord Stimulation for Gait Disorders in Parkinson's Disease and Atypical Parkinsonism: A Systematic Review of Preclinical and Clinical Data.
in Neuromodulation : journal of the International Neuromodulation Society
Connor TA
(2019)
Do equestrian helmets prevent concussion? A retrospective analysis of head injuries and helmet damage from real-world equestrian accidents.
in Sports medicine - open
Cousins S
(2017)
Predictors of clinical recovery from vestibular neuritis: a prospective study
in Annals of Clinical and Translational Neurology
Cronin T
(2017)
Vestibular Deficits in Neurodegenerative Disorders: Balance, Dizziness, and Spatial Disorientation.
in Frontiers in neurology
Description | Association of British Neurologists Acute Neurology Advisory Board |
Geographic Reach | National |
Policy Influence Type | Membership of a guideline committee |
Impact | We are engaged in facilitating the current re-organisation of acute neurology services (and linking it to community services) in the UK. |
Description | Chair of trial steering committee |
Geographic Reach | National |
Policy Influence Type | Membership of a guideline committee |
Impact | I am chair of the steering committee for the VeRMiS trial which is a multi-centre study to assess the effectiveness of vestibular rehabilitation in people with Multiple Sclerosis. The trial outcomes will have imoplications for MS patients in the UK and beyond. Trial registry: https://doi.org/10.1186/ISRCTN27374299 |
URL | https://www.plymouth.ac.uk/research/vermis |
Description | GP referral guidelines for dizziness and imbalance for the North West region of London (population 2 million) |
Geographic Reach | Local/Municipal/Regional |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | The online document also has teaching links, including videos I have made, showing GPs how to treat certain conditions. See: https://www.healthiernorthwestlondon.nhs.uk/sites/nhsnwlondon/files/documents/dizziness_guidelines_v0_6.pdf |
Guideline Title | Head injury: assessment and early management-summary of updated NICE guidance |
Description | Head injury: assessment and early management-summary of updated NICE guidance |
Geographic Reach | Multiple continents/international |
Policy Influence Type | Citation in clinical guidelines |
URL | https://www.bmj.com/content/381/bmj.p1130 |
Description | Member Assoc British Neurologists traumatic brain injury advisory committee |
Geographic Reach | National |
Policy Influence Type | Participation in a guidance/advisory committee |
Description | NICE committee for head injury guidelines |
Geographic Reach | National |
Policy Influence Type | Membership of a guideline committee |
URL | https://www.nice.org.uk/Guidance/CG176 |
Description | Royal College of Physicians - Joint Clinical Neurosciences Committee - Acute Neurology Representative. |
Geographic Reach | National |
Policy Influence Type | Membership of a guideline committee |
Description | Automated Diagnosis of Acute Vertigo |
Amount | £50,000 (GBP) |
Organisation | Imperial Health Charity |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 07/2019 |
End | 07/2020 |
Description | Congressionally Directed Medical Research Program (CDMRP). Title: "Advancing Rehabilitation: Physiological, Psychological and Neuroimaging Measures of Factors that Predispose, Promote, and Perpetutate Post-Traumatic Dizziness" |
Amount | $2,000,000 (USD) |
Organisation | Department of Defense |
Sector | Public |
Country | United States |
Start | 08/2019 |
End | 08/2022 |
Description | HEE/ NIHR ICA Programme Clinical Doctoral Research Fellowship |
Amount | £300,310 (GBP) |
Funding ID | ICA-CDRF-2017-03-070 |
Organisation | National Institute for Health Research |
Department | NIHR Fellowship Programme |
Sector | Public |
Country | United Kingdom |
Start | 04/2018 |
End | 04/2021 |
Description | Low-cost high tech concussion assessment and post-fall health monitoring |
Amount | £230,000 (GBP) |
Organisation | The Racing Foundation |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 03/2019 |
End | 07/2020 |
Description | NIHR Biomedical Research Centre Grant |
Amount | £92,430 (GBP) |
Funding ID | WMCT_P64219 |
Organisation | National Institute for Health Research |
Department | NIHR Imperial Biomedical Research Centre |
Sector | Public |
Country | United Kingdom |
Start | 12/2017 |
End | 01/2019 |
Description | NIHR Imperial BRC Brain Sciences Pilot Project (Exploring management of post-traumatic Benign paroxysmal positional vertigo and falls) |
Amount | £44,100 (GBP) |
Funding ID | PSP959_WBCN |
Organisation | Imperial College London |
Sector | Academic/University |
Country | United Kingdom |
Start | 02/2024 |
End | 03/2025 |
Description | Remote assessment of Acute Stroke with Vertigo - (The ReActiVe study) |
Amount | £85,000 (GBP) |
Funding ID | II2021_17 |
Organisation | Imperial Health Charity |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 05/2021 |
End | 12/2022 |
Description | Spinal cord stimulation for gait dysfunction in Parkinson's disease |
Amount | £205,000 (GBP) |
Funding ID | MR/T023880/1 |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 08/2020 |
End | 09/2023 |
Description | TBI-REPORTER (UK-TBI REpository and data PORTal Enabling discoveRy) |
Amount | £11,177,353 (GBP) |
Funding ID | MR/Y008502/1 |
Organisation | University of Cambridge |
Sector | Academic/University |
Country | United Kingdom |
Start | 09/2023 |
End | 09/2028 |
Description | Trial of spinal cord stimulation to reduce imbalance and falls in Parkinson's Disease |
Amount | £540,000 (GBP) |
Organisation | J P Moulton Charitable Foundation |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 03/2020 |
End | 04/2023 |
Description | mTBI-Predict study |
Amount | £2,000,000 (GBP) |
Funding ID | 1844551 |
Organisation | Ministry of Defence (MOD) |
Sector | Public |
Country | United Kingdom |
Start | 03/2022 |
End | 02/2023 |
Description | BPPV project collaboration |
Organisation | University of Plymouth |
Department | Faculty of Health and Human Sciences |
Country | United Kingdom |
Sector | Hospitals |
PI Contribution | Developed application for new research programme. Expert knowledge and pilot data. |
Collaborator Contribution | Expert knowledge. |
Impact | Successful grant application. |
Start Year | 2018 |
Description | Imperial-Zurich Concussion Collaboration |
Organisation | University Hospital Zürich |
Country | Switzerland |
Sector | Hospitals |
PI Contribution | I visited my our Swiss colleagues in 2017 and again in January 2018 for a Swiss concussion conference when I was accompanied by one of my research team. A Swiss researcher is visiting my lab for 2022-2023 for 1 year. |
Collaborator Contribution | Research ideas, data and personnel exchange. |
Impact | We are held a joint FENS satellite conference in July 2018 in Berlin. |
Start Year | 2018 |
Description | Spinal cord stimulation as a treatment for gait dysfunction in Parkinson's Disease |
Organisation | Imperial College London |
Department | Division of Brain Sciences |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Contributed in collecting pilot data and writing grant applications. My team will provide the scientific testing component needed to assess clinical outcomes as well as to explore the underlying brain mechanisms in any observed therapeutic effect of spinal cord stimulation on imbalance in Parkinson's disease. |
Collaborator Contribution | My partners, Dr Yen Tai and Mr Dipankar Nandi, are experts in the clinical neurology of Parkinson's disease (YT) and functional neurosurgery (DN). |
Impact | Mulit-disciplinary 1. Vestibular Neurology: Dr Barry M seemungal - head Brain Adn Vestibular Group, Imperial College London. 2. Movement Disorders: Dr Yen Tai. Imperial College Healthcare NHSb Trust. 3. Functional Neurosurgery: Prof Dipankar Nandi. Grants 1. MRC CARP grant: £205,000 for Dr Yen Tai, supervised by Dr Barry Seemungal. 2. Moulton Foundation Charity grant: £540,000 for Dr Yen Tai and Dr Barry Seemungal. NHS 1. A new joint clinic: BAN clinic - Balance And Neurodegeneration clinic, bringin together movement disorder and vestibular neurology expertise and the Imperial Balance Labs. |
Start Year | 2019 |
Description | The Mechanisms of Postural Control and Spatial orientation in Dementia |
Organisation | University of Cambridge |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | I am the primary supervision of a PhD student for this project. |
Collaborator Contribution | Professor James Rowe is co-supervising the PhD student for this project. |
Impact | None yet. The project started 3 months ago. |
Start Year | 2018 |
Description | Understanding the mechanisms of chronic dizziness in mild Traumatic head injury |
Organisation | Mayo Clinic Hospital |
Country | United States |
Sector | Hospitals |
PI Contribution | Collaborative approach to understanding the factors predispoing, promoting and perpetuating chronic dizziness post mild traumatic brain injury. |
Collaborator Contribution | We have together written a grant application submitted to the the US military. Outcome awaited. |
Impact | Grant application submitted to the the US military. Outcome awaited. |
Start Year | 2017 |
Description | Understanding the mechanisms of chronic dizziness in mild Traumatic head injury |
Organisation | University of Cambridge |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Collaborative approach to understanding the factors predispoing, promoting and perpetuating chronic dizziness post mild traumatic brain injury. |
Collaborator Contribution | We have together written a grant application submitted to the the US military. Outcome awaited. |
Impact | Grant application submitted to the the US military. Outcome awaited. |
Start Year | 2017 |
Description | Understanding the mechanisms of chronic dizziness in mild Traumatic head injury |
Organisation | University of Rome Tor Vergata |
Country | Italy |
Sector | Academic/University |
PI Contribution | Collaborative approach to understanding the factors predispoing, promoting and perpetuating chronic dizziness post mild traumatic brain injury. |
Collaborator Contribution | We have together written a grant application submitted to the the US military. Outcome awaited. |
Impact | Grant application submitted to the the US military. Outcome awaited. |
Start Year | 2017 |
Description | University of Birmingham - MoD project mTBI-Predict |
Organisation | University of Birmingham |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | 2mn collaborative project investigating mild TBI. I am leading on the vestibular component of this project. |
Collaborator Contribution | Design, fabricate and test new equipment for assessing mTBI patients |
Impact | Yes. Headache Vestibular Opthalomology Cognitive Endorinology Molecular biology (biomarkers of mTBI) Vascular imaging MEG MRI Neurophysiology |
Start Year | 2022 |
Description | Neurology referral guidlines for GPs for Dizziness |
Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | Referral guidlines to enable GPs to refer dizziness cases to the hospital. Included in the website were educational weblinks for the GPs. See URL. |
Year(s) Of Engagement Activity | 2019 |
URL | https://www.healthiernorthwestlondon.nhs.uk/sites/nhsnwlondon/files/documents/dizziness_guidelines_v... |
Description | Patient group presentation |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Patients, carers and/or patient groups |
Results and Impact | I was invited to give an update on my research to members of North London's Headway patient group. This is a group for patients (and carers) who have suffered a head injury. I updated the group on the qualitative research we have conducted. |
Year(s) Of Engagement Activity | 2021 |
Description | Press release concerning a trial that will look at new Parkinson's treatment for frequent falls |
Form Of Engagement Activity | A press release, press conference or response to a media enquiry/interview |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Public/other audiences |
Results and Impact | To make the target audiences aware of our initial funding to improve recruitment rates and additional funding applications (one obtained £540,000; one pending circa £100,000). |
Year(s) Of Engagement Activity | 2019 |
URL | https://www.imperial.ac.uk/news/193546/trial-will-look-parkinsons-treatment-frequent/ |
Description | Talk to 6 form students in a Comprehensive secondary school. |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Schools |
Results and Impact | I enjoy motivating students, particularly those from less privileged backgrounds. I came to the UK from the West Indies aged 17, so I am able to relate to many younger people who are from imigrant families. |
Year(s) Of Engagement Activity | 2020 |
URL | https://www.harriswestminstersixthform.org.uk/38/ambition-perseverance-legacy- |
Description | Talk to therapists on dizziness in mild TBI |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Professional Practitioners |
Results and Impact | Invited to talk on vestibular dysfunction following mild TBI at Imperial College Healthcare NHS Trust |
Year(s) Of Engagement Activity | 2018 |
Description | Teaching therapists at Major Trauma Centres in London |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Professional Practitioners |
Results and Impact | Teaching ward therapists about dizziness following traumatic brain injury - how to assess and treat it. |
Year(s) Of Engagement Activity | 2018,2019,2020 |