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Why the Arni way is up

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Dr Tom Balchin’s mission to help UK stroke survivors was forged in tragedy. In late 1996, his twin brother Alex died aged 21 after falling from a building during a night out in London.

Three months later Tom suffered a serious subarachnoid haemorrhage stroke, which he believes may indeed have been triggered by the stress of losing his sibling.

“I wasn’t coping very well before the stroke and there was a lot of grief I just couldn’t get out,” he says.

He was initially paralysed down his left side and weighed just nine stone when he left hospital in a wheelchair six months later. His journey to independence taught him a lot about what really works in rehab; and shaped the ARNI Institute, which has helped thousands of stroke survivors since Tom founded it in 2002.

“I wanted to get out of hospital as soon as I could and I just went for it. I got hardcore about it! At home, I remember hauling myself upstairs on my behind, step by step, to prove that I didn’t need a stairlift.

“I used combinations of all sorts of exercises I found for myself, including piano finger playing exercises – but the best thing in those early days was to try to get back to my DJ decks, put my paretic hand on the platter and try and move it back and forward, beat matching. I even turned the decks backwards initially, before my fingertips were able to grip into the grooves of a record, and made special surfaces for records which assisted my fingers and thumb to move where I wanted them to go.

“The headphone was held on the side of my brain which had suffered the stroke. I progressed to being able to control the cross-fader, equalisers and samplers, take records out of and back into sleeves with my good arm and hand. It was intensive… at least four hours per day, for a number of years. The other big thing was that I was evaluating my performance in relation to my action control each time by recording what I was doing. I made some terrible tapes.

“I would encourage anyone with spasticity in their upper limbs to consider this kind, or any kind, of intensive dosage of fun ‘hobby’- type training. It’s very hard for patients to find the right thing to do, but anything they can do to ramp up the number of hours of rehabilitation, the better.

“Back then there was nobody around to tell you not to do something, which was good, in a way. I had to innovate. Over the last 18 years or so, I’ve seen patients time and time again being told not to move for fear of doing bad movement. But in most areas, particularly lower limb rehab, this is wrong and out-of-date.”

ARNI – or Action for Rehabilitation from Neurological Injury – works with stroke survivors “stuck in limbo” after their therapy programme ends.

Via a network of specialist instructors and therapists across the UK, they learn ARNI’s functional “retraining” strategies aimed at enabling them to take charge of their own recovery.

It offers intensive one-to-one sessions in the home, some group classes and training manuals and DVDs which encourage stroke survivors to continually work on their rehabilitation. Classes are paid for by the client, although often at a reduced rate.

Balchin, however, has always been a volunteer in his own charity and has never taken any payment for his input. The programme is designed to speed clients from the stage where an NHS therapist becomes unavailable, to making recommended activities part of their daily life as they work towards more independence.

Its therapists and professional instructors meet the standards of the Stroke-Specific Education Framework. Clinical Commissioning Groups and charitable and local authorities provide community- based ARNI training for stroke survivors, which has been positively received.

The approach is now the adopted model for combined rehab and exercise after stroke for a number of UK areas.

“My big mission when I launched ARNI in 2002 was to get one ARNI qualified, appropriately insured and DBS-checked trainer within five miles of every stroke survivor who needed help, wherever that was in the country. I now have about 120 trainers on the books and am almost there. We haven’t quite got to everyone yet, but we’re getting there.”

Stroke survivors on the ARNI programme are matched with personal trainers and physical therapists; their focus is on helping people with partial paralysis to make as full a recovery as possible.

Results are achieved through various activities, including education in exercise principles after stroke and the establishment of an independent home-based exercise programme.

ARNI also develops skills in goal setting, functional problem solving and self- monitoring. It is a personalised programme, with substantial one-to-one training to ensure individual tailoring of activities, feedback and progression, and encouragement to work “at the edge of personal capacity”.

The approach has become increasingly well evidenced since 2007. In one small study, reported at the World Stroke Congress, involving 24 stroke survivors at the ARNI stroke gym at Chaul End Centre in Luton in 2011/12, participants reported improved mobility, range of movement, fatigue and confidence. Service audit data reported 24 ambulance call-outs for fallers during the year preceding intervention.

In the year of the intervention there were zero call outs, with an ambulance service saving of £7,200. This particular statistic was mirrored the following year.

Further savings of £5,482 came from the reduction in care packages, nursing input, catheter care, respite care, appliance support and medications.

Another small-scale study in 2014, supported by the NHS and the charity Different Strokes, revealed that all participants showed ARNI-powered improvements over a span of clinical measures.

A number of bigger randomised controlled trials have been undertaken, including one supported by Stroke Association, entitled ‘Retrain’. This was conducted by the University of Exeter and published in 2017.

It involved 45 patients and showed that ARNI is feasible, acceptable and safe. It also showed that key techniques involved in it could successfully support patients with one-sided loss, including those with multiple comorbidities (eg with lower limb amputation).

This year, an upper limb research study is taking place at Brighton and Sussex Medical School, looking at the efficacy of use of ARNI upper limb task training by patients and families in the clinic.

The ARNI programme involves task-specific functional movement training, development of physical management strategies, stroke- specific resistance training with adjuncts such as technology and pharmacological inputs recommended as appropriate. It was borne out of Balchin’s own rehab experience. He credits part of his success to an “innovative” physio who, in the early days after his stroke, taught him the importance of regaining self- reliance as quickly as possible.

Martial arts were also hugely influential. Despite the remnants of partial paralysis on one side, he powered through the coloured belt classes of aikido, karate, taekwondo and hapkido in the years after his stroke.

He also learned Teukgong Moosool, the official martial art of South Korea’s special forces. In 2008, he was awarded the grade of 3rd Dan by Grand Master Lee (8th Dan), Head Grand Master of the International Teukgong Moosool Federation.

Balchin also became a serious power-lifter and strength athlete, regularly working with non-stroke trainees. He added strength training into the mix from the initiation of his project for stroke survivors, at a time when the majority of UK therapists were not introducing it for fear that it would exacerbate tone.

It was difficult to find the evidence for strength training for stroke in the very early days, he says, but eventually did, academically justifying his project and implementing it successfully.

He honed his mental strength and capacity after his stroke too. He went back to university to finish his first degree and then taught for two years in a primary school.

He then went on to complete a masters degree and Phd and spent three years as a research fellow/lecturer in gifted education at Brunel University, London. Following that, he worked as an MA course leader in gifted education at Reading University.

He says: “Through my training, I regained nearly all my functional movement, and continued to perfect it twenty years later using ARNI-developed techniques.

“I still train all the time as it’s the only way to stave off limitations from stroke; and I’m still dealing with drop foot.

“The biggest weapon you already have on your side is definitely neuroplasticity. I learned that from Professor Nick Ward who runs the UK’s first specialist upper limb clinic. A very early supporter of ARNI, he helps me run the ARNI functional rehabilitation course for therapists and trainers.”

In the case of stroke, brain plasticity could allow certain lost functions, such as speech and language, to re-emerge as the result of intensive rehab. The ARNI system contains techniques designed to prime the body for task-related practice.

Often, therapists help stroke survivors to get to their feet and walk again after brain injury and many achieve great successes in the very short time they have to work with them in the acute/chronic stages.

However, ARNI works with many stroke survivors who find it hard to move on from sticks, orthotics and other aids to functional movement. Many feel they could achieve better function in their weaker hand, for example, if given a chance to do so by an ARNI instructor.

The benefits of rigorous training beyond the standard allocation of post-stroke therapy sessions are wide ranging, according to ARNI. They include balance and posture correction, improved timing, better flexibility and greater muscular, tendon and ligament strength.

These in turn can boost self-sufficiency, confidence, self-esteem and productivity in employment or hobbies. In ARNI’s case, clients are encouraged to work “on the edges” of their current ability to stimulate maximum neuroplasticity. Instructors teach progressively more advanced exercises.

A core part of the ARNI approach is to teach clients how to cope with falls; the most dangerous part of the balance problems caused by stroke.

Trainees (many of whom have the functional use of just one arm) learn how to get down to, and up from, the floor without any kind of external support to pull themselves up with.

They also learn other innovative strategies such as turning, step and ramp navigation and emergency action techniques. Balchin also teaches what he calls “gait-tactics”.

Upper limb retraining is a large part of the syllabus, with no coping or compensation allowed for the patients in this area: they are taught creative stretches to access, and then extend time, on discreet and progressive tasks, with spasticity decline being a focus.

“You have to develop strategies that are workable for the individual. You can give them the tools they need but clients need to be able to personalise them. Also, a key to good recoveries that I worked out straight away is that you can’t tell people they can’t do things. That’s absolutely critical.”

Balchin believes the rise of ARNI is timely, given current trends in UK healthcare. He points to the “sad fact” that effective rehab is generally unavailable from the NHS once sufficient movement to simply get around has been achieved.

At the same time, neurophysio and occupational therapy services are stretched, he says, while he believes stroke classes that promote active task-related functional movement and resistance training are non-existent.

“Most physical after-stroke classes that do exist are fitness-focused and many attendees report that these are, in conclusion, unable to provide them with the specific and custom tools they need to rehabilitate functional limitations or effectively cope with the rigours of their daily lives.

“This is especially the case if extra problems persist such as epilepsy, aphasia or fatigue. Most report that they need external help to guide balance control or spasticity decline for example, but that their essential cardio fitness can, in the end, be done better at home.” Meanwhile, global research findings have backed up the ARNI way for years, he believes.

Home visits and outpatient exercise programmes have been shown to improve gait speed. Research into ARNI techniques show that in a number of activities, performance is retained and built upon.

Balchin cites the example of the Dutch researchers Kollen, Kwakkel & Lindeman who, in 2006, reviewed all available published, clinical stroke rehabilitation trials, of which at the time there were 735.

They selected 151 studies including 123 randomised controlled trials and 28 controlled clinical trials. The rest did not meet the inclusion criteria as they lacked quality or statistical validity.

They wrote: “Traditional treatment approaches induce improvements that are confined to impairment level only and do not generalise to a functional improvement level”.

In contrast, they stated that: “More recently developed treatment strategies that incorporate compensation strategies with a strong emphasis on functional training, may hold the key to optimal stroke rehabilitation.”

In summing up their findings, they reported that “intensity and task-specific exercise therapy are important components of such an approach”.

Balchin says: “There is a good range of interventions with strong evidence of both efficacy and effectiveness now. Cochrane reviews have found that electromechanical gait training, treadmill training, circuit training, physical fitness training, repetitive task training, CIMT, mirror therapy and FES are also effective.

“You’ll notice that all of these interventions require that you DO something. So many stroke survivors do what is essentially a homeopathic dose of what is required to recover well.”

The delivery of ARNI’s services usually relies on the goodwill of others. While individuals pay for one-to-one sessions, the session costs are low – around £45 to £55 an hour.

The charity’s overheads are partly covered by physios paying to become qualified trainers and serious rehab training sessions at ARNI’s headquarters in Lingfield, Surrey.

The charity also gives full bursaries to students and runs a trainer sponsorship programme which enables any organisation, family or carer to sponsor an instructor through the ARNI qualification. The course fee is partly paid back by the instructor in the form of free lessons to the survivor. The charity also often gives away helpful material such as copies of The Stroke Survivor Manual and its stroke survivor DVD set.

“It’s a fact that a lot of stroke survivors just don’t know what to do when their clinical physio ends because they haven’t been set up properly to do better. What they probably need is an evidence-based, innovative and personalised programme of training strategies, a low-cost means of trainer or therapy support as they do it and to be guided to access helpful local community services or other specialist services.

“It’s really important that survivors are guided to autonomous retraining efforts if possible, in order that they may fulfil goals and thrive rather than decline, become dependent on others or just re-enter the care pathway.

“This is really hard to achieve, but one by one, over the years, ARNI has helped a vast amount of people. I’m proud of this and of the way that, by its sincere efforts, ARNI has gained the trust and support of professionals in neurorehabilitation over the years.”

Balchin describes the charity as his life’s works and passion. “Stroke has driven me to get better, and it continues to drive me to make the effort to help people affected by stroke to do better,” he says.

Insight

Now is the time to embrace better ways of working

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By Merryn Dowson, assistant psychologist and part of the team behind rehab goal-setting platform Goal Manager

A stitch in time saves nine. Rome wasn’t built in a day. The best things take time.

We are all too aware that some of the most important parts of our lives have been crafted, carved and developed over months and years. Consider your education, for example: you may well have been to primary school, secondary school and then sixth form college. Perhaps you went on to do an undergraduate degree.

You may even have taken another leap and completed a Master’s degree or a Doctorate. This took years. You learned, revised, sat exams, sat resits, applied for places, got results, got rejected, got accepted, and made it here.

One thing is certain: compared to all of this expertise, someone who completed a two-hour online course on the same topic does not come close. We know that putting time and effort into something gives us better results than if we tried a quick approach.

We do not always lead by this example though. Despite the knowledge that great results are only achieved through hard work and perseverance, sometimes we decide just not to bother. Often, a room in our home might look cluttered, worn down and unloved and it could be made to look incredible.

The walls could be painted, clutter cleared, carpet cleaned, furniture patched up, curtains updated, but it is so much effort. We see the effort it would take and keep living with it. It does the job. It’s fine.

We heard this a lot when we began to develop our software. Goal Manager was designed from within a clinical neuropsychology service with young people with acquired brain injury, and we recognised how goal setting was becoming an intimidating concept within our service and our colleagues across the field.

To combat this, we developed an online goal-setting platform which streamlines the key processes of goal setting into one system and allows members of multi- disciplinary teams (MDTs) to collaborate on goal data remotely.

Crucially, it was designed to fill a hole. The more daunting goal setting became, the more it was shied away from, and the guidelines for goal setting that had emerged from the literature were falling to the wayside.

While we designed our platform to save time on completing all of the gold-standard processes of goal setting compared to doing them manually, we found that people had often not been completing them at all. It was all too complicated.

As a result, we recognise that adopting a software solution like Goal Manager can come with its own problems to solve. It requires relearning a lot of
what we know about a concept like goal setting, understanding properly how these key processes work and how they can be applied clinically to benefit clients.

It is only then that you can start to think of ways to make it more efficient. To help with this, our users are offered bespoke demonstrations, guided MDTs through meetings to help with the clinical application of the data, and training on assessments and goal attainment.

This takes time. Our users are often throwing out their previous guide and writing a new one. When surveyed, however, every single one who responded said that it was worth it.

This brings us back to where we started: the best things take time; Rome was not built in a day; a stitch in time saves nine. By taking time to develop an understanding of goal setting and being able to apply it to a software solution, users experience all of the benefits of best-practice goal setting outlined in the literature both for their clients and for their teams.

Clients are motivated, rehabilitation is meaningful, important areas to address are highlighted, MDTs are focussed, clinical practice is evidenced – the list continues. None of this would have been possible without the initial investment of time.

While simple enough to read, this is no doubt overwhelming to apply to your service or practice and, with this in mind, there are some key points to remember. The most significant is that there is no better time than now.

The world is slowly opening its eyes, sitting up in bed and having a good stretch after the darkness of the Covid-19 lockdown. It is not yet certain if we are going back to snooze or if we are leaping out of bed afresh.

What we do know, however, is that we are heading into a brand new day. Even for those of us who continued in practice throughout the pandemic, services have been slightly paused in one way or another, whether that be refraining from home visits or having fewer people in the office.

We are all very aware that we are heading into the “new normal” rather than our old ways. Use this time to bring new and innovative ways of working into your practice. You might completely change your filing system, consider how you approach your waiting lists, or change how you approach MDT meetings.

Whatever you have been wanting to do for you and your service for so long, now is that time.

Perhaps you decide that you are going to welcome change but not all at once. That works too! For users of Goal Manager, we often suggest that starting with one or two clients might feel more manageable than a whole caseload.

This can help get to grips with the new concepts and ways of working without feeling like everything is completely disrupted. This applies elsewhere too. If you are wary of integrating a system into your whole service, start with one corner of it, evaluate, take what you have learned and then look to apply it more widely.

Finally, remember that all time taken to improve and grow impacts more than just what you set out to do. When people lose weight, they rarely conclude
by saying they just lost weight: they often enthuse about how they feel more energised or move easier or feel more positive or experience less anxiety.

This applies to any time you invest in developing your clinical practice or your service.

While time spent learning how to use Goal Manager and establishing it within a caseload is designed to improve goal setting, that investment also leads to improved assessment processes, more effective meetings, improved digital literacy, increased patient involvement and so much more.

The potential is enormous. To motivate you to start the process, look at what you want to achieve and how that might trigger other improvements.

While the world is still trying to drag its head off the pillow to open up the lockdown curtains, look to invest in addressing those needs you have always been aware of but never felt like you could justify the time.

Walk around your “house” and look into each room: is this the best it can be or could I give it a lick of paint?

Is now the time to bring meaningful solutions into my practice? Maybe grab a tester pot and try a new shade on the walls. Sign up for a free trial. Plan to grow and improve. Start building Rome.

To invest in improving your goal setting, visit www.goalmanager.co.uk to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.

 

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Researchers unlock key prognostic tool for brain injured patients

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In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.

The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.

The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.

However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.

When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.

“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.

“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”

But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.

The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.

Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.

“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,”  Brennan says.

To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.

These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.

The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.

Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.

“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.

“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”

“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.

“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”

The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.

“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.

“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.

 

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Insight

Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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