Sensory system abnormalities in childhood dystonia / dystonic cerebral palsy - are sensory networks modulated by Deep Brain Stimulation?

Lead Research Organisation: King's College London
Department Name: Clinical Neuroscience

Abstract

Dystonia is a severely disabling and painful motor disorder in which people suffer involuntary muscle contractions causing twisting movements, abnormal postures and painful spasms. It affects at least 70 000 people in the UK (similar to Multiple Sclerosis). There are many causes but we don't yet fully understand what happens within the brain to produce these abnormal movements. Adult-onset dystonia usually involves a single part of the body, whereas childhood-onset dystonia is often widespread and so severe that people find it impossible to control their bodies. This can prevent children with relatively normal intellect from achieving adult independence. The long-term care needs of these individuals are hugely expensive to the National Health Service and society.

Dystonia has no cure but symptoms can be improved by a technique called Deep Brain Stimulation (DBS). This involves using fine wires, called electrodes, to deliver electrical pulses to a specific group of nerve cells deep within the brain, called the Globus Pallidus interna (GPi). The electrodes are implanted in the brain during an operation performed by a neurosurgeon. During the surgery, we can record the activity of nerve cells in the GPi using special recording electrodes.

DBS is more effective in some types of dystonia than others but we do not know why because a) we don't yet know how DBS works and b) we don't yet understand the mechanisms responsible for different types of dystonia, especially dystonia resulting from brain injury during infancy (dystonic cerebral palsy). This gap in our knowledge limits our ability to develop and apply effective therapies.

Most studies investigating the mechanisms of dystonia have been in adults with genetic forms of dystonia. These studies have shown that "inhibition", the mechanism by which the body "damps down" activity within the nervous system, is reduced in people with dystonia. There is also evidence of abnormalities in the way the brain processes sensory information. Thus one possible mechanism of dystonia is that abnormal perception of sensory inputs leads to distorted or excessive movements. However, none of these mechanisms have been investigated in dystonic cerebral palsy.

Studying which mechanisms are common and which differ between different types of dystonia is key to understanding the causes and improving our ability to treat this disabling condition. My own work has identified differences in the activity of GPi nerve cells between different types of dystonia and has shown that the activity of these cells is related to outcome from DBS surgery. I have also found evidence of abnormal sensory pathways in some children with dystonia, particularly in dystonic cerebral palsy. My data suggest that such sensory deficits may be linked to outcome from DBS, but more powerful markers of outcome are still needed. I plan to take this forward by investigating whether measures of sensory processing within the brain are abnormal in different types of dystonia and whether these measures relate to outcome from DBS.

To investigate sensory processing I will use frequency analysis methods to detect changes in EEG (brainwave) activity in relation to a sensory stimulus and a motor task. I will compare these measures in children with different types of dystonia and in children with good and poor outcome following DBS. I will also analyse the activity of GPi cells recorded at the time of DBS surgery and compare these across different types of dystonia. Finally I will assess the pathway linking the GPi and the cortex (the outer layer of the brain) by using the implanted stimulator to evoke activity in the cortex. These data will determine whether sensory processing is abnormal in dystonic cerebral palsy and whether measures of sensory processing relate to outcome from DBS. This has important implications for predicting outcome, selecting the most appropriate candidates for surgery and in counselling patients and families.

Technical Summary

Background: Dystonia can be treated with Deep Brain Stimulation (DBS) of the Globus pallidus interna but outcomes vary widely. My work shows clear differences in neurophysiological parameters between different types of dystonia and suggests these measures may relate to outcome.
Aims/Objectives: To compare changes in sensorimotor cortex EEG activity in relation to a sensory or sensorimotor task in children with different types of dystonia and to investigate whether such changes relate to DBS outcome.
Subjects: 24 children with primary dystonia, 24 with dystonic cerebral palsy and 24 typically developing children.
Methods: Spectral EEG changes will be assessed in relation to a) electrical stimulation of the median nerve as per standard clinical Somatosensory Evoked Potentials, b) a passive wrist flexion/extension task, c) where possible, an active wrist flexion/extension task. Scalp EEG will be recorded using Ag/AgCl electrodes positioned according to the 10-20 system. EEG will be band-pass filtered (1-100Hz), EEG spectral power will be calculated using the Fast Fourier transform or Wavelets, and changes in spectral power, EEG-EEG coherence and EEG-EMG coherence will be measured in four frequency bands (theta 4-7Hz, alpha 8-12Hz, beta 13-30Hz, gamma 31-85Hz). Spectral changes will be compared across aetiological groups and in relation to DBS outcome. In children who have had DBS, neural connections between the Globus Pallidus and sensorimotor cortex will be analysed using Deep Brain Stimulation Evoked Potentials. Firing patterns of pallidal neurons will also be assessed using micro-electrode data recorded from the Globus Pallidus at the time of surgery.
Scientific and medical opportunities: This work has important implications a) for increasing our scientific understanding of the mechanisms of dystonia and b) for clinical decision-making, by using neurophysiological parameters to predict outcome, thus improving patient selection and counselling of families.

Planned Impact

Dystonia is a severely disabling motor disorder. Patients find it impossible to control their bodies due to involuntary muscle contractions, twisting movements, abnormal postures and painful muscle spasms. This project addresses important clinical and scientific questions regarding the underlying mechanisms and the treatment of this group of disorders. The potential impacts of this research are broad, primarily for health, society and the advancement of knowledge but also with benefits for the economy, industry and individuals.

Knowledge
Unfortunately the pathophysiological mechanisms causing different types of dystonia are still not understood. This limits both the development of new therapies and the effective use of current ones, such as Deep Brain Stimulation (DBS). This project will advance fundamental scientific knowledge about the role of abnormal sensory pathways and processing in children with different types of dystonia. This impact will be of benefit to other groups studying motor neuroscience and the mechanisms of neurological disease. By comparing the findings pre- and post-DBS and by relating the findings to outcome I hope to increase understanding of how DBS works and which patients are most likely to benefit.
This knowledge will also have an impact by informing the direction of future studies in this area, both for my own research and that of other groups.

Health - Improving life for Patients
The knowledge gained from this project will have direct application to medical practice, with clear potential to inform clinical decision-making and to guide neuromodulation therapy to benefit patients. Our findings could help to improve the efficacy of DBS by guiding the selection of alternative stimulation targets and may also help to improve the cost-effectiveness of technologies, by enhancing the prediction of benefit from DBS.
The sensory system is also amenable to other, non-invasive therapies, so a broader understanding of how these processes are disrupted in dystonia will facilitate the targeted application of such therapies to individual patients. This knowledge may also guide the development of new therapies to treat patients with movement disorders.

Society and Economy
Dystonia affects approximately 70 000 people in the United Kingdom (probably underestimated) and may arise from various aetiologies, including dystonic-dyskinetic cerebral palsy arising from perinatal Hypoxic Ischaemic Encephalopathy (HIE) due to birth asphyxia. The NHS spends £482 million per year (20% of the obstetric budget) on maternity compensation claims, primarily for payments to cover the lifelong care needs of these individuals. Whilst preventive measures must also be researched, it is vital that we find ways to treat this disabling motor condition. Ameliorating the motor disability will not only relieve suffering for the children themselves but will have economic benefit by reducing their care costs. Improving the effectiveness of existing technologies such as DBS, as outlined above, will contribute to this.

Industry
There are also potential benefits to industry since we anticipate that our findings will increase scientific understanding of how DBS works. This has potential impact for the development of neuromodulation technology, including facilitating the use of real-time feedback of brain activity to neurostimulation devices to improve their performance and enable a more individualized approach to treatment. This in turn will improve the efficacy of DBS, bringing benefit for patients.

People
This fellowship will enhance the development and progression of my career. In the longer term, I hope the outputs of this project will facilitate me developing and educating my own team of researchers.

Publications

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Lumsden DE (2019) "Spastic Dystonia", "Dystonia with Spasticity" or "Dystonia accompanying the Upper Motor Neuron Complex"? A reconciliation of nomenclature is needed. in Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology

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McClelland VM (2017) The neurophysiology of paediatric movement disorders. in Current opinion in pediatrics

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McClelland VM (2019) Disease-specific patterns of basal ganglia neuronal activity in Neurodegeneration with Brain Iron Accumulation type I (NBIA-1). in Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology

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McClelland VM (2020) Abnormal patterns of corticomuscular and intermuscular coherence in childhood dystonia. in Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology

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McClelland VM (2018) Somatosensory Evoked Potentials and Central Motor Conduction Times in children with dystonia and their correlation with outcomes from Deep Brain Stimulation of the Globus pallidus internus. in Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology

 
Description Incorporation of neurophysiology findings into clinical pathway and patient selection and counselling processes for paediatric DBS
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Rosetrees Trust Research Project Grant
Amount £46,989 (GBP)
Funding ID A1598 
Organisation Rosetrees Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 10/2017 
End 09/2020
 
Title Robotic device for stretch evoked potential 
Description Collaboration with human robotics team at Imperial College London to develop a device that can deliver passive movements of the wrist. Not yet published. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2018 
Provided To Others? No  
Impact This tool has enabled me to assessed sensory processing in children with dystonia, without delivering uncomfortable electrical stimuli. 
 
Description Collaboration with Imperial Bioengineering Human Robotics 
Organisation Imperial College London
Country United Kingdom 
Sector Academic/University 
PI Contribution Research ideas and studies in clinical patients
Collaborator Contribution Engineering expertise and provision of equipment for research study. Development of new equipment.
Impact None yet
Start Year 2017
 
Description Collaboration with PET imaging team 
Organisation King's College London
Department Department of Perinatal Imaging and Health
Country United Kingdom 
Sector Academic/University 
PI Contribution I have worked with Professor Alexander Hammers, Head of the PET imaging centre, along with Dr Jean-Pierre Lin (existing collaborating colleague) to develop a new project combining neurophysiology and PET imaging. We have submitted a grant application together. I contributed to the application overall and specifically to the Neurophysiological aspects.
Collaborator Contribution I have worked with Professor Alexander Hammers, Head of the PET imaging centre, along with Dr Jean-Pierre Lin (existing collaborating colleague) to develop a new project combining neurophysiology and PET imaging. We have submitted a grant application together. Professor Hammers contributed to the application overall and specifically to the imaging science aspects.
Impact Multi-disciplinary: Clinical Neurophysiology and Imaging Sciences. No outcomes yet - we have only recently submitted the grant application.
Start Year 2017
 
Description Collaboration with research therapist 
Organisation King's College London
Department King's Centre for Global Health
Country United Kingdom 
Sector Academic/University 
PI Contribution I have worked with Ms Hortensia Gimeno in developing a new project and we have submitted a grant application together. I have contributed specifically regarding the neurophysiological aspects.
Collaborator Contribution I have worked with Ms Hortensia Gimeno in developing a new project and we have submitted a grant application together. She has contributed specifically regarding the therapy aspects, particularly the design of the intervention we will be testing.
Impact This is a multi-disciplinary collaboration involving Clinical Neurophysiology and Occupational Therapy. No outcomes yet as we have only recently submitted the grant application.
Start Year 2016
 
Description Computational Analysis of Cortex-Muscle Interactions 
Organisation Imperial College London
Department Dyson School of Design Engineering
Country United Kingdom 
Sector Academic/University 
PI Contribution Colleagues from these two departments have joined my collaboration with Prof Cvetkovic, Department of Informatics at King's College London. We are writing a grant application together. I have contributed the Neurosciences and Clinical Neurophysiology aspects. This expanded collaboration with colleagues from Imperial College London started after I had been awarded my MRC fellowship, but before it officially commenced. I deferred the start of my fellowship as I had already accepted a 6 month locum consultant post at Great Ormond Street Hospital. However, knowing that I was soon to commence my fellowship made it easier to make plans for this collaboration and to start working on a grant application together.
Collaborator Contribution Colleagues from these two departments have joined my collaboration with Prof Cvetkovic, Department of Informatics at King's College London. We are writing a grant application together. These new colleagues have contributed with regards to the advanced signal processing and computational modelling of motor control.
Impact Multi-disciplinary: Neurosciences, Clinical Neurophysiology, Signal Processing and Computational Modelling. Outputs include the two following publications: 1. Cortico-muscular coherence enhancement via coherent Wavelet enhanced Independent Component Analysis. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference 2017-07 | journal-article DOI: 10.1109/embc.2017.8037435 2. Corticomuscular Coherence with Time Lag with Application to Delay Estimation. IEEE Transactions on Biomedical Engineering 2017-03 | journal-article DOI: 10.1109/TBME.2016.2569492
Start Year 2016
 
Description Computational Analysis of Cortex-Muscle Interactions 
Organisation Imperial College London
Country United Kingdom 
Sector Academic/University 
PI Contribution Colleagues from these two departments have joined my collaboration with Prof Cvetkovic, Department of Informatics at King's College London. We are writing a grant application together. I have contributed the Neurosciences and Clinical Neurophysiology aspects. This expanded collaboration with colleagues from Imperial College London started after I had been awarded my MRC fellowship, but before it officially commenced. I deferred the start of my fellowship as I had already accepted a 6 month locum consultant post at Great Ormond Street Hospital. However, knowing that I was soon to commence my fellowship made it easier to make plans for this collaboration and to start working on a grant application together.
Collaborator Contribution Colleagues from these two departments have joined my collaboration with Prof Cvetkovic, Department of Informatics at King's College London. We are writing a grant application together. These new colleagues have contributed with regards to the advanced signal processing and computational modelling of motor control.
Impact Multi-disciplinary: Neurosciences, Clinical Neurophysiology, Signal Processing and Computational Modelling. Outputs include the two following publications: 1. Cortico-muscular coherence enhancement via coherent Wavelet enhanced Independent Component Analysis. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference 2017-07 | journal-article DOI: 10.1109/embc.2017.8037435 2. Corticomuscular Coherence with Time Lag with Application to Delay Estimation. IEEE Transactions on Biomedical Engineering 2017-03 | journal-article DOI: 10.1109/TBME.2016.2569492
Start Year 2016
 
Description DBSEPs and Bioengineering 
Organisation University of Oxford
Country United Kingdom 
Sector Academic/University 
PI Contribution We are performing Deep Brain Stimulation Evoked Potentials in children with dystonia so we provide the research ideas and clinical patients
Collaborator Contribution Bioengineering and technical expertise
Impact None as yet
Start Year 2018
 
Description Development of neurophysiological research device 
Organisation Great Ormond Street Hospital for Children NHS Foundation Trust
Country United Kingdom 
Sector Hospitals 
PI Contribution Research ideas
Collaborator Contribution Engineering expertise
Impact None yet
Start Year 2018
 
Description Machine Learning 
Organisation University of Oxford
Country United Kingdom 
Sector Academic/University 
PI Contribution Clinical data and research ideas
Collaborator Contribution Machine learning expertise
Impact None as yet
Start Year 2018
 
Description Spectral Analysis of EEG 
Organisation University of Oxford
Country United Kingdom 
Sector Academic/University 
PI Contribution Acquisition of EEG and EMG data in children with dystonia
Collaborator Contribution Advice and training on EEG spectral analysis
Impact None yet
Start Year 2018
 
Description Spike-sorting for intracranial data 
Organisation University of Leicester
Country United Kingdom 
Sector Academic/University 
PI Contribution Research ideas and data
Collaborator Contribution Training and expertise in analysis of single cell and multiple-unit neuronal recordings
Impact None yet
Start Year 2018
 
Description Internal Seminar at Wohl Institute for Clinical Neuroscience 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Part of regular seminar series within our Institute for Clinical Neuroscience. Presented to mixture of post-graduate students and scientists. Interesting questions afterwards. Many of the audience members were basic scientists so they were interested in my work which is very patient-focussed and translational.
Year(s) Of Engagement Activity 2019
 
Description BSCN - London - Abstract presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Oral abstract presentation at National Meeting of British Society for Clinical Neurophysiology. Title "Sensory Evoked Potentials and Central Motor Conduction Times help predict outcomes from Deep Brain Stimulation (DBS) in children with dystonia". Reached a specialist clinical audience and sparked questions and discussion afterwards.
Year(s) Of Engagement Activity 2017
 
Description Biodynamic Symposium - poster presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Poster presentation at a specialist symposium. Poster generated discussion and opportunity to network with academics in this field
Year(s) Of Engagement Activity 2018
 
Description CMDS Education session 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Teaching presentation on how my research relates to the clinical service
Year(s) Of Engagement Activity 2018
 
Description ECCN Budapest - oral presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Oral abstract presentation at the European Congress of Clinical Neurophysiology, Budapest, Sept 2017. Title: "Sensory Evoked Potentials and Central Motor Conduction Times help predict outcomes from Deep Brain Stimulation (DBS) in children with dystonia. This reached a specialist Clinical audience with interest in paediatric neurophysiology. Sparked questions and discussion afterwards from audience and other presenters in the session.
Year(s) Of Engagement Activity 2017
 
Description ECMT Training Course presentation 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Feb 2019: European Continuing Medical Training DBS Expert Forum, London, UK.
This is a course designed to share the experience from our national paediatric DBS referral service with others around the world who are establishing their own paediatric DBS services
Invited to be part of the teaching faculty - gave teaching presentation on role of neurophysiology in paediatric DBS assessment.
"How does neurophysiology improve our understanding of the clinical phenotype and patient selection for DBS in childhood movement disorders?"
Year(s) Of Engagement Activity 2019
 
Description HCARD teaching presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Postgraduate students
Results and Impact Teaching presentation about dystonia and how my collaboration with bioengineering and human robotics group has facilitated my research
Year(s) Of Engagement Activity 2018
 
Description International Congress of Clinical Neurophysiology - platform presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Gave platform presentation of my work at international conference. Sparked interesting discussion afterwards and complements and questions from members of the audience who approached me later in the conference.
Year(s) Of Engagement Activity 2018
 
Description International Congress of Clinical Neurophysiology - poster presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Gave poster presentation of my work at International conference. The poster attracted many viewers and was the most successful poster presentation I have done in terms of the discussion generated and networking opportunities.
Year(s) Of Engagement Activity 2018
 
Description Invited Speaker (MER talk) at European Paediatric Neurology Society - Movement Disorders Symposium, Lyon, France 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited Presentation at Medical/Scientific Conference. Title: "Globus pallidus microelectrode recording during DBS surgery for childhood dystonia - neuronal firing relates to aetiology". This was a special interest group symposium with attendance from worldwide experts in the field. The presentation sparked debate amongst the audience and there were interesting questions afterwards.
Year(s) Of Engagement Activity 2017
 
Description Invited Speaker (SEP talk) at European Paediatric Neurology Society - Movement Disorders Symposium, Lyon, France 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Another invited talk at this specialist symposium. Title: "Can Motor and Sensory Potentials stratify prognosis for DBS for dystonia in children?" I presented to a specialist scientific/medical audience. The talk again sparked discussion amongst the audience and interested questions afterwards, including suggestions for how this work can be applied clinically and suggestions for further research in this field.
Year(s) Of Engagement Activity 2017
 
Description Invited speaker presentations x2 at Specialist Neuromodulation Symposium 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Sept 2019: European Paediatric Neurology Society Neuromodulation Symposium, Athens, Greece.
Invited speaker - gave two presentations at this specialist symposium.
"What can we learn about movement disorders in childhood from somatosensory evoked potentials?"
"Corticomuscular Coherence in typically developing children and children with dystonia"
Sparked questions and discussion afterwards
Year(s) Of Engagement Activity 2019
 
Description National Conference Presentation - British Paediatric Neurology Association Annual Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact I gave two platform presentations of my work at a national UK conference, which is also attended by Paediatric Neurologists from many countries. I was approached by many people afterwards who were interested in my work. Some reported that it had changed their views of the field. In addition I was approached a few weeks later by a senior academic who invited me to write a review article for a journal he edits.
Year(s) Of Engagement Activity 2017
 
Description Poster Presentation at International Conference: 5th International Symposium on Paediatric Movement Disorders 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I presented my poster to a several International experts in this field and engaged in discussion with world -leaders in Deep Brain Stimulation for children, with the potential for future collaboration.
Year(s) Of Engagement Activity 2017
 
Description Poster presentation at International Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact June 2019
Poster presentation at ECCN Warsaw, Poland.
• McClelland, VM. Cvetkovic Z. Lin J-P, Mills KR, Brown P. Abnormal patterns of corticomuscular and intermuscular coherence in acquired and idiopathic/genetic childhood dystonias. (Abstract). Clinical Neurophysiology 2019 130(7): e101-e102
I also had to deliver a brief oral summary of my poster. The doctor assessing this group of posters said she thought it was one of the most interesting and relevant.
Year(s) Of Engagement Activity 2019
 
Description School Presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact Presentation to local school children as part of their Science Week. Presented about the brain and central nervous system and how clinical neurophysiologists record electrical signals from nerve tissue for clinical and research purposes.
Year(s) Of Engagement Activity 2017
 
Description TMS Clinical Practice Session - BPNA London 2018 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This was a clinical practice session, in which I worked with two other experts in the field to present the role of Transcranial Magnetic Stimulation in paediatric neurology, both clinically and in research. We also engaged with the Magstim company who lent us equipment for a demonstration within this workshop. The session reached a broad clinical paediatric neurology audience and sparked questions and positive feedback afterwards.
Year(s) Of Engagement Activity 2018
 
Description Teaching presentation at European Congress of Clinical Neurophysiolgy 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact June 2019: European Congress of Clinical Neurophysiology course for physiologists, Warsaw, Poland.
Invited by Professor Cole to give teaching presentation as part of the physiologists' training course that runs during this conference.
Gave presentation on "A beginner's guide to Transcranial Magnetic Stimulation"
Sparked questions afterwards. Was able to give advice to physiologists looking to use TMS in children.
Year(s) Of Engagement Activity 2019