Title: A feasibility study investigating the clinical effectiveness of interventions for benign paroxysmal positional vertigo in people with acute traumatic brain injury
Funder: Health Education England

Abstract: Title: A feasibility study investigating the clinical effectiveness of interventions for benign paroxysmal positional vertigo in people with acute traumatic brain injury. Background: Traumatic Brain Injury (TBI) is the commonest cause of long-term disability in young, working age adults. Dizziness and imbalance can affect 20-60% of TBI patients, persisting for up to 5 years. Indeed, only a third of dizzy patients are back at work at 6 months post-injury compared to 75% of non-dizzy patients. Additionally, falls affect up to half of community TBI survivors, further compounding physical and psychological morbidity and, mortality. Resulting implications include individual financial difficulties and psychosocial distress, whilst chronic unemployment and long-lasting symptoms results in a wider socio-economic burden and increased healthcare consumption. Clearly, early accurate diagnosis and effective management of these symptoms is required. However, healthcare professionals do not routinely screen for dizziness in acute-TBI. The reasons for this are unclear, but may include insufficient clinician knowledge and skills. An emerging factor in the screening, diagnosis and treatment of dizziness in acute TBI is vestibular agnosia'; a condition identified during pilot research, whereby patients lose their sensation of vertigo despite overt vestibular dysfunction (Seemungal et al. 2004). The neural correlates of vestibular agnosia are the subject of a complementary MRC grant. This presentation is complex, however the clinical implications are clear; patients do not report dizziness symptoms acutely, meaning patients will not be assessed if screening is based on symptoms alone. Pilot data in acute head injury also demonstrated benign paroxysmal positional vertigo (BPPV) was the most frequently diagnosed form of dizziness (45%). This is significant as BPPV can be diagnosed and treated quickly and effectively at the bedside without specialist equipment. To date, there have been no prospective, acute studies assessing the treatment of BPPV in association with clinical outcomes. Therefore, the overarching aim of this study is to investigate the feasibility of treating BPPV in acute TBI, and gather patient-centric outcomes. Through intervening acutely, we hypothesise that we will reduce patients' physical and psychosocial burden, healthcare utilisation and socioeconomic consequences. Aims: To understand why healthcare professionals' do not routinely screen for dizziness in acute TBI To investigate the feasibility of treating BPPV in acute TBI, and the effect on length of stay, return to work and falls. To explore whether acute dizziness treatment is acceptable to TBI patients and carers Design: Study 1: This qualitative study will gather data on healthcare professionals' experiences of, and barriers to, screening, diagnosis and treatment of dizziness in acute TBI patients.Study 2: Sixty participants from St Mary's trauma ward will be recruited. Observational data will be collected regarding the frequency and type of vestibular dysfunction, and the relationship between vestibular agnosia and objective balance measurements. A feasibility study comparing two different BPPV interventions with usual care will fulfil feasibility objectives. Participants will be randomised to: Therapist-led manoeuvres Patient self-treatment Usual care (advice)All participants will be followed up at four and twelve weeks post-discharge. A second qualitative study will determine participants' and carers' views of a dizziness intervention in acute TBI. Potential benefits: Firstly, this study will provide insight into training factors which might limit routine dizziness screening. A corollary may be the design and implementation of an educational intervention, with benefit to other major trauma centres. Secondly, the incidence of vestibular dysfunction in acute TBI patients will be defined, drawing attention to under-appreciated sequelae. Thirdly, if found to be acceptable to patients and carers, it will inform the design of a randomised controlled trial into the effect of treating dizziness in acute TBI, in relation to length of stay, return to work and falls.

Lay abstract: Research background: Head injury is the most common cause of long-term disability in younger, working adults. Dizziness and imbalance affect a large proportion of head injured patients and can persist for many years after the injury. Only one third of patients with dizziness and imbalance are back at work 6 months after their head injury, whereas three quarters of patients without dizziness are back to work after 6 months. Additionally, half of head injury patients living in the community are affected by falls, leading to poorer physical and psychological health and high healthcare costs. Long-lasting dizziness and imbalance and employment difficulties, have large financial consequences for patients, their families, and the whole population. The complex physical and mental health problems, plus the financial and social consequences, mean it is extremely important to investigate ways to enhance early diagnosis and management of dizziness and imbalance after head injury. Ward staff however, do not routinely screen patients for dizziness and imbalance after head injury. We think there may be two reasons for this: Staff knowledge and skills: Ward staff may have insufficient knowledge of dizziness conditions or inadequate skills to diagnose and treat dizziness. Vestibular agnosia: Pilot work conducted on a head injury ward demonstrated that some patients did not report dizziness symptoms, despite obvious signs of inner ear disturbance (i.e. falls, poor balance and disrupted eye movement responses) on clinical tests. This presentation is complex to understand, however, the implications are clear; patients with easy-to-treat inner ear diagnoses do not complain of dizziness, meaning patients will not be assessed if screening is based on symptoms alone. Importantly, our pilot work demonstrated half of head injury patients had Benign Paroxysmal Positional Vertigo' (dizziness caused by dislodged crystals in the inner ear). Currently, no research has assessed the effect of treating this type of dizziness in acute head injury patients. Research aims: Investigate why ward staff do not routinely screen for dizziness. Assess the feasibility of treating dizziness in head injury patients and the effect on length of hospital stay, return to work and number of falls. Ask patients, their carers and clinicians if treating dizziness in the hospital is acceptable. Patient and public involvement (PPI) Discussions with members from a brain injury charity Headway' helped form the research design. Patients and/or carers told us: They were informed their dizziness would get better quickly and on its own. However, most patients reported dizziness for years after their injury. Doctors struggled to understand their dizziness symptoms and In-hospital treatment of dizziness was important; there was a long wait for appointments in an outpatient balance clinic. PPI during the study will be assured by a steering group which will meet regularly to monitor the study. PPI will also be vital for the development of any patient and public facing documents. Research design: Study 1: We will interview healthcare professionals on the head injury ward at St Mary's Hospital, London, to understand why routine dizziness screening does not occur. Discussions will focus partly on healthcare professionals' knowledge, skills and potential training needs. Study 2: We will ask 60 patients on the head injury ward to participate in dizziness tests. We will assess and record the number and type of dizziness and imbalance conditions and ask patients to complete a dizziness questionnaire. From these tests, we will randomly allocate participants who have Benign Paroxysmal Positional Vertigo' (dislodged crystals in the inner ear) into three groups: 1) Therapist-led treatment 2) Patient-led treatment 3) Usual care (i.e. advice). Following discharge, a telephone assessment at 4 weeks will be completed, and an outpatient assessment at 12 weeks. The effect of treatment on hospital length of stay, time taken to return to work and number of falls will be assessed. Patients, their carers and ward staff will be interviewed for their views and opinions of the treatment, and whether they found the in-hospital treatment of dizziness acceptable. Expected long-term benefits of the research: Shorter time to return to work following head injury, Increased staff knowledge and skills in managing dizziness after head injury, Reduced long-term symptoms and healthcare costs, The research will be dissemination via: Articles in scientific journals; presentations at national and international conferences. Work with patients and public (e.g. via Headway) in order to publicise the findings and empower and educate patients and work with local and regional authorities (e.g. NICE and NHS England) to set standards for managing dizziness and imbalance after head injury.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: EAR;NEUROLOGICAL