Why are patients with acute traumatic brain injury not routinely assessed or treated for vestibular dysfunction in the UK? A qualitative study

OBJECTIVES

Vestibular dysfunction is common in patients with acute traumatic brain injury (aTBI). Persisting vestibular symptoms (ie, dizziness and imbalance) are linked to poor physical, psychological and socioeconomic outcomes. However, routine management of vestibular dysfunction in aTBI is not always standard practice. We aimed to identify and explore any healthcare professional barriers or facilitators to managing vestibular dysfunction in aTBI.

DESIGN

A qualitative approach was used. Data were collected using face to face, semi-structured interviews and analysed using the Framework approach.

SETTING

Two major trauma centres in London, UK.

PARTICIPANTS

28 healthcare professionals participated: 11 occupational therapists, 8 physiotherapists and 9 surgical/trauma doctors.

RESULTS

Vestibular assessment and treatment were not routinely undertaken by trauma ward staff. Uncertainty regarding responsibility for vestibular management on the trauma ward was perceived to lead to gaps in patient care. Interestingly, the term dizziness was sometimes perceived as an 'invisible' and vague phenomenon, leading to difficulties identifying or 'proving' dizziness and a tendency for making non-specific diagnoses. Barriers to routine assessment and treatment included limited knowledge and skills, a lack of local or national guidelines, insufficient training and concerns regarding the practical aspects of managing vestibular dysfunction. Of current trauma ward staff, therapists were identified as appropriate healthcare professionals to adopt new behaviours regarding management of a common form of vestibular dysfunction (benign paroxysmal positional vertigo). Strategies to support this behaviour change include heightened clarity around role, implementation of local or national guidelines, improved access to training and multidisciplinary support from experts in vestibular dysfunction.

CONCLUSIONS

This study has highlighted that role and knowledge barriers exist to multidisciplinary management of vestibular dysfunction in aTBI. Trauma ward therapists were identified as the most appropriate healthcare professionals to adopt new behaviours. Several strategies are proposed to facilitate such behaviour change.

TRIAL REGISTRATION NUMBER

ISRCTN91943864.

A demand-capacity mismatch between rehabilitation need and service provision as a result of the COVID-19 pandemic? Early clinical observations from a large teaching hospital in London

In this short report the authors characterise inpatient bed occupancy and predicted rehabilitation need of patients cared for in two acute hospitals of a large London NHS Trust during the first wave of the COVID-19 pandemic, including 394 people with confirmed COVID-19. Data were captured on a single day (17^th April 2020) from the two Trust hospitals to inform discharge planning in line with national COVID-19 Hospital Discharge Service policy guidance. Our data suggests that the proportion of COVID-19 patients predicted to require rehabilitation upon hospital discharge may be greater than the estimates described in the national COVID-19 Hospital Discharge Service policy guidance; posing the question is there a demand–capacity mismatch between rehabilitation need and service provision as a result of the COVID-19 pandemic?

Vestibular agnosia in traumatic brain injury and its link to imbalance

Vestibular dysfunction, causing dizziness and imbalance, is a common yet poorly understood feature in patients with TBI. Damage to the inner ear, nerve, brainstem, cerebellum and cerebral hemispheres may all affect vestibular functioning, hence, a multi-level assessment—from reflex to perception—is required. In a previous report, postural instability was the commonest neurological feature in ambulating acute patients with TBI. During ward assessment, we also frequently observe a loss of vertigo sensation in patients with acute TBI, common inner ear conditions and a related vigorous vestibular-ocular reflex nystagmus, suggesting a ‘vestibular agnosia’. Patients with vestibular agnosia were also more unbalanced; however, the link between vestibular agnosia and imbalance was confounded by the presence of inner ear conditions. We investigated the brain mechanisms of imbalance in acute TBI, its link with vestibular agnosia, and potential clinical impact, by prospective laboratory assessment of vestibular function, from reflex to perception, in patients with preserved peripheral vestibular function. Assessment included: vestibular reflex function, vestibular perception by participants’ report of their passive yaw rotations in the dark, objective balance via posturography, subjective symptoms via questionnaires, and structural neuroimaging. We prospectively screened 918 acute admissions, assessed 146 and recruited 37. Compared to 37 matched controls, patients showed elevated vestibular-perceptual thresholds (patients 12.92°/s versus 3.87°/s) but normal vestibular-ocular reflex thresholds (patients 2.52°/s versus 1.78°/s). Patients with elevated vestibular-perceptual thresholds [3 standard deviations (SD) above controls’ average], were designated as having vestibular agnosia, and displayed worse posturography than non-vestibular-agnosia patients, despite no difference in vestibular symptom scores. Only in patients with impaired postural control (3 SD above controls’ mean), whole brain diffusion tensor voxel-wise analysis showed elevated mean diffusivity (and trend lower fractional anisotropy) in the inferior longitudinal fasciculus in the right temporal lobe that correlated with vestibular agnosia severity. Thus, impaired balance and vestibular agnosia are co-localized to the inferior longitudinal fasciculus in the right temporal lobe. Finally, a clinical audit showed a sevenfold reduction in clinician recognition of a common peripheral vestibular condition (benign paroxysmal positional vertigo) in acute patients with clinically apparent vestibular agnosia. That vestibular agnosia patients show worse balance, but without increased dizziness symptoms, explains why clinicians may miss treatable vestibular diagnoses in these patients. In conclusion, vestibular agnosia mediates imbalance in traumatic brain injury both directly via white matter tract damage in the right temporal lobe, and indirectly via reduced clinical recognition of common, treatable vestibular diagnoses.

A mixed methods randomised feasibility trial investigating the management of benign paroxysmal positional vertigo in acute traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of long-term disability in working age adults. Recent studies show that most acute TBI patients demonstrate vestibular features of dizziness and imbalance, often from combined peripheral and central vestibular dysfunction. Effective treatment for vestibular impairments post-TBI is important given its significant adverse impact upon quality of life and employment prospects. The most frequent peripheral vestibular disorder in acute TBI is benign paroxysmal positional vertigo (BPPV), affecting approximately half of acute cases. Although there is effective treatment for idiopathic BPPV, there are no high-quality clinical data for post-TBI BPPV regarding its prevalence, natural history, which treatment is most effective and when is the best time to treat. In particular, observational studies suggest post-TBI BPPV may be recurrent, indicating that hyperacute treatment of BPPV may be futile. Given the potential hurdles and the lack of accurate post-TBI BPPV data, the current study was designed to provide information regarding the feasibility and optimal design of future large-scale prospective treatment studies that would compare different interventions and their timing for post-TBI BPPV.

METHOD

A multi-centre randomised mixed methods feasibility study design was employed. We aim to recruit approximately 75 acute TBI patients across a range of clinical severities, from three major trauma centres in London. Patients will be randomised to one of three treatment arms: (1) therapist-led manoeuvres, (2) patient-led exercises and (3) advice. Participants will be re-assessed by blinded outcome assessors at 4 and 12 weeks. Acceptability of the intervention will be obtained by patient interviews at the end of their treatment and therapist interviews at the end of the study. Primary outcomes relate to feasibility parameters including recruitment and retention rates, adverse events and intervention fidelity. We will also aim to provide a more accurate estimate of the prevalence of BPPV in TBI cases on the trauma ward.

DISCUSSION

The multi-centre nature of our feasibility study will inform the design of a future prospective treatment trial of BPPV in acute TBI. Important parameters we will obtain from this study, key for designing a future prospective treatment study, include estimating the prevalence of BPPV in TBI patients admitted to UK major trauma wards, and elucidating both patient and care-provider barriers in delivering BPPV treatment.

TRIAL REGISTRATION

ISRCTN, ISRCTN91943864. Registered on 10 February 2020.

The effect of single session bi-cephalic transcranial direct current stimulation on gait performance in sub-acute stroke: A pilot study

PURPOSE

Non-invasive brain stimulation with transcranial direct current stimulation (tDCS) modulates cortical excitability and improves upper limb motor performance when applied to chronic stroke patients. The objective was to evaluate whether tDCS can influence gait function in sub-acute stroke patients.

METHODS

We assessed the effect of single session, bi-cephalic tDCS on gait performance in 14 subacute patients with stroke involving the cerebral hemisphere (2-8 weeks post-stroke) in a double-blinded, sham-controlled study. Patients were randomly allocated to receive either active (n = 7) or sham (n = 7) tDCS. The anodal electrode was placed on the scalp over the ipsilesional lower limb primary motor cortex and the cathode was placed over the contralesional leg motor cortex. Gait performance was measured using the Timed Up and Go test and the Performance Oriented Mobility Assessment before and after active or sham tDCS.

RESULTS

The tDCS group was significantly quicker in the Timed Up and Go test in the tDCS group, compared to the sham group (p = 0.018). The Performance Oriented Mobility Assessment was not different between groups (p = 0.897).

CONCLUSIONS

This is the first study to examine the effects of tDCS on gait in stroke patients in the sub-acute stage. Active tDCS improved gait performance (Timed Up and Go) in stroke patients, despite no changes to limb biomechanics of the hemiparetic side (Performance Oriented Mobility Assessment), as compared to sham stimulation. These results suggest that tDCS could be used as a therapeutic adjunct for gait rehabilitation following stroke.