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Submitting institution
Royal Holloway and Bedford New College
Unit of assessment
3 - Allied Health Professions, Dentistry, Nursing and Pharmacy
Summary impact type
Health
Is this case study continued from a case study submitted in 2014?
No

1. Summary of the impact

Macular Degeneration is the leading cause of vision loss in elderly populations in the Global North (World Health Organisation- World report on vision 2019), with wide ranging effects on quality of life. Reading difficulty is one of its most commonly reported consequences. For many, the answer is audio texts, however, for those who wish to continue reading, Professor Walker’s research has enhanced their reading experience. Walker’s research into how people read text presented dynamically, in a horizontally-scrolling format, led to him developing reading aids for people with Macular Degeneration using the scrolling text format. The apps are freely available and have improved reading experiences and extended the reading life of people with Macular Degeneration in the UK and internationally.

2. Underpinning research

Walker’s research at Royal Holloway (since 2011) focussed on how people read text that scrolls horizontally, from right-to-left (like a news ticker, see Figure 1). This work led to him developing the MDevReader ( Macular Degeneration eccentric viewing reader) eBook app for iPads in 2013 that uses the scrolling text format (reference 1).

Embedded image

Fig 1. The MDevReader app (left) for eBooks as used by Dame Judi Dench and EV-platform (right) a web app for presenting current news content, eBooks, and email, developed as reading aids for people with Macular Degeneration.

Macular Degeneration is an irreversible progressive condition that affects around 4.8% of people in the UK aged 65 and over, and also younger working-age people with juvenile genetic forms of the disease. The main characteristic of Macular Degeneration is the gradual loss of central (or foveal) vision that is required for seeing fine details. The loss of central vision results in difficulties in performing everyday tasks, such as recognising another person, watching TV and reading, with profound consequences on quality of life. At the present time, Macular Degeneration cannot be cured, and until recently, the main alternative to reading was to substitute text with audio. Audio is, however, of limited value for elderly people with poor hearing and is also not appropriate for many social situations, or in the workplace. One strategy that enables people to make use of their remaining vision, called ‘ eccentric viewing’, involves the individual making use of their remaining (peripheral) vison by looking away from the visual stimulus of interest. This simple technique can be difficult to use for a task such as reading, but Walker’s research has shown that reading with eccentric viewing is enhanced by using the scrolling text format.

Research in Professor Walker’s laboratory (2012-13) used an eye-tracker to simulate the loss of central vision characteristic of Macular Degeneration in a study of reading with scrolling text. The results showed that people were better able to apply the eccentric viewing strategy when reading, with scrolling lines of text rather than with static text (reference 2). A subsequent study (reference 6), also using the simulated loss of central vision technique, showed that reading with the eccentric viewing technique can be improved simply by increasing the spacing between words. As text can easily be manipulated when presented on electronic devices the use of increased word spacing was incorporated into the MDevReader app.

The MDevReader app was the first app developed by Walker in collaboration with the Macular Society (UK), designed as an eBook reader (released for Apple iPads in 2012 and Android in 2014). An initial study involving participants with Macular Degeneration found that a majority (67%) reported that they found reading was better when reading with the MDevReader app, compared to their normal method of reading (reference 1). A subsequent study funded by the ESRC (ES/L001934/1) showed that reading accuracy was improved when reading scrolling text compared to reading static text (reference 3). Responses to a questionnaire indicated that they also found reading easier with the MDevReader app than with their normal visual aid and the majority (80%) reported that the app would encourage them to read more often (reference 3). The latest research, undertaken as part of the Macular Society’s PhD studentship(2017-2020), has shown that for reading with a central vision loss, comprehension (understanding and reasoning) is greatly enhanced with the scrolling text format (presented at the 20th European Conference on Eye movements, Alicante, Spain 2019; submitted to Journal of Vison).

Professor Walker also performed some of the first detailed experimental studies of eye-movements made when reading scrolling text in typical readers (references 4 and 6). These studies can inform the use, and potential limitations, of this format as a method of presenting text on technological devices with small screen sizes. These studies have shown that the normal pattern of eye movements is altered when reading scrolling text, but basic effects are similar to those observed with static text (reference 4). In a 2018 study performed to examine how well typical readers perform with scrolling text, he showed that comprehension was well preserved (reference 5) demonstrating the usefulness of this method for presenting text on digital displays with small screen sizes.

3. References to the research

The following references to the research were all published in peer-reviewed journals, with high rankings in their fields (source Scimago): British Journal Ophthalmology (9/124), Ophthalmic and Physiological Optics (14/124), Optometry and Vision Science (34/124), Vision Research (25/124), Quarterly Journal of Experimental Psychology (30/154); Journal of Experimental Psychology: HPP (19/154). They were underpinned by grants from ESRC and the Macular Society (see Additional Contextual Data)

  1. Walker, R. (2013). An iPad app as a low-visual aid for people with macular disease. British Journal of Ophthalmology. *2013; 97:*110-112 *doi:10.1136/bjophthalmol-2012-302415 . Available from HEI on request.

  2. Harvey, H., & Walker, R. (2014). Reading with peripheral vision: A comparison of reading dynamic scrolling and static text with a simulated central scotoma. Vision Research, 98, 54-60. doi.org/10.1016/j.visres.2014.03.009.

  3. Walker, R. , Bryan, L., Harvey, H. , Riazi, A., & Anderson, S. J. (2016). The value of Tablets as reading aids for individuals with central visual field loss: An evaluation of eccentric reading with static and scrolling text. Ophthalmic and Physiological Optics, 36(4), 459–464. doi: 10.1111/opo.12296.

  4. Harvey, H., Godwin, H. J., Fitzsimmons, G., Liversedge, S. P., & Walker, R. (2017). Oculomotor and linguistic processing effects in reading dynamic horizontally scrolling text. Journal of Experimental Psychology: Human Perception and Performance, 43(3), 518. doi.org/10.1037/xhp0000329. Available from HEI on Request.

  5. Harvey, H., & Walker, R. (2018). Reading comprehension and its relationship with working memory capacity when reading horizontally scrolling text. Quarterly Journal of Experimental Psychology, 71(9), 1887-1897. doi: 0.1080/17470218.2017.1363258.

  6. Harvey, H., Anderson, S. J., & Walker, R. (2019). Increased Word Spacing Improves Performance for Reading Scrolling Text with Central Vision Loss. Optometry and Vision Science, 96(8), 609-616. doi.org/10.1097/OPX.0000000000001411 .

4. Details of the impact

Professor Walker developed the MDevReader app in collaboration with the Macular Society, the UK’s leading organisation for people with Macular Degeneration (15,000 members). It was launched for Apple iPads in 2012 and extended to include Android devices in 2014. The app presents text as a single horizontal-scrolling line, to support reading using a strategy (‘ eccentric viewing’) which enables people with Macular Degeneration to make the most effective use of their remaining vision. EV News, a web app, provides freely available news and magazine content using the same scrolling text format as released in 2018. These apps were brought together in EV-platform (released January 2020) to combine the features of both apps in one place as well as additional features including for reading emails. The main beneficiaries are individuals with Macular Degeneration although practitioners and therapists working with patients also benefit.  This is achieved by using the app to demonstrate the use of reading strategies and to demonstrate the potential of electronic devices such as tablets as reading aids.

The societal impact of these apps has been to enhance reading experience and extend the reading-life of people with Macular Degeneration. For example, Dame Judi Dench, has described her experience of using the app showing how it can extend reading life: “I suffer from Macular Degeneration, and I find it very very difficult to learn scripts or to read in any way. This is an app [MDevReader] that has been developed by Royal Holloway and it’s enormously beneficial…it really is a huge help” (>6000 views on YouTube by December 31 2020 E1). The Macular Society CEO – Ms. Cathy Yelf noted that: “Robin’s work and that of a PhD student is ‘providing evidence that reading performance [in someone with macular degeneration] improves with scrolling text compared to normal static lines of text” ( E2) . The app is also used by the Society in their ‘Skills for seeing’ program: ‘’Our volunteer trainers use the app to demonstrate the use of the eccentric viewing technique and also as a way of promoting the wider use of technology as a visual aid. Feedback from trainers indicates that the app is useful as a way of demonstrating the eccentric viewing technique and[sic] also helps as a tool for practicing this skill’’ ( E3).

Feedback from users ( E3) has shown that the apps have helped visually-impaired people to read, for example: “ It's a fantastic concept and the app is certainly helping my mother to read again, where before she could not”, and “ For the first time in 17 months, I was able to read more than a very enlarged word”. Mrs C. a volunteer eccentric viewing trainer for the Macular Society, who also has Macular Degeneration says “I am on my third book! That fact alone sums it up really! It is so good to be able to sit and read comfortably, without getting tired” ( E3). Mr W a development manager at the Thomas Pocklington Trust, a UK charity for the visually impaired, provides a case study of how the app can support people, with vision loss, in their home and work environments: “I'm a fan of the app and have used it to read to my children when they were younger. I've recently started using it for work, loading the app with agenda and notes” ( E4). Mr Ward discussed his experience of using the app on the BBC Radio 4 program ‘In Touch’ (21-1-2020).

Since 2014 the MDevReader app and Ev News/Ev Platform webapps show an increasing number of users. Download and usage data ( E5) show that the MDevReader app has 3,976 users (2,666 IOS; 1310 Android) as of November 2020. Analytical data suggests that users are from the UK and Europe (66 %), North America (26 %), Asia (7 %), Latin America and Africa. The MDevReader website has seen 4359 sessions with 2779 unique visitors up to June 2020. Ev News and Ev-platform usage has also increased with 5440 sessions between 2018 and November 2020. In the first two months of the release of Ev-platform, 18 % of users were outside of the UK including the North America, Japan, Greece, and China.

The apps have impacted on professionals (Rehabilitation workers, Optometrists, Eye Clinic Liaison Officers, Orthoptists) in the UK and US as part of their professional practice with individuals with Macular Degeneration. It provides them with a useful (free) tool for demonstrating the use of the eccentric viewing technique in the clinic and the wider role technology can have as a visual aid beyond traditional aids, such as magnifiers. Ev-platform is featured in continuing professional education and training courses for The College of Optometrists (Directorate of Optometric Continuing Education and Training 2020 – E6) as a practical demonstration of how eccentric viewing works and how it supports patients to make the most of their remaining vision. Macular Society volunteers train people with Macular Degeneration, on a one-to-one basis, in how to make the most of their remaining vision in their ‘Skills for seeing’ program. Since 2011, some 315 volunteers have been trained to use and demonstrate the app to people with Macular Degeneration. The c.315 trainers see around 260 people per year and the Macular Society estimate that the app has been used in over 1300 therapy sessions (2011-20) ( E6). Dr Lewerenz, an Ophthalmologist based in the US, uses the app in his clinic and has found it useful for eccentric viewing and also for other visual disorders: “I recommend MDevReader to my patients in two different scenarios: For those who could benefit from eccentric viewing, and those who have visual processing problems or left hemianopia and have a difficult time going from one line of text to the next line. We also have it on an iPad in our clinic and our OTs use it for eccentric viewing training.” ( E7). The app may also have potential for people with dementia as shown by this feedback: “she (elderly mother) doesn't have trouble with her vision, but she gets 'stuck' due to her Dementia bringing on perseveration when she's reading static text. Really easy to set up and Mum finds that she can 'go with the flow' of the scrolling text.” ( E3).

Professor Walker’s research has commercial impact via his collaboration with two independent technology developers. Since 2013 Humboldt Solutions Ltd developed the MDevReader based on Walker’s research. This is now used by them as a case study enabling them to demonstrate their capabilities to other potential clients. Mr Adrian Cox the CEO said: ‘This was Humboldt’s first mobile app for public release…since this initial release, we have gone on to develop mobile applications for several other clients and the MDevReader has been valuable to us as a demonstration of our capabilities’. ( E8). Codica Ltd developed EV News and Ev-platform (in 2018-2020) and have found that these are useful as examples of their social impact work in health and ageing. “ Ev Platform has been a valuable addition to our social impact portfolio and a showcase of our product design capabilities.. Most notably, it has contributed to establishing our relationship with We+Care, a Swiss non-profit association focused on care coordination, where Codica has been a founding member” (testimonial from Mr K. Papagiannopoulos CEO of Codica Ltd E9).

The MDevReader app was selected by Universities UK as one of 20 top examples of innovative university research in 2014 ( E10).

5. Sources to corroborate the impact

E1. Video Recording of Dame Judi Dench speaking about the app EV News https://www.youtube.com/watch?v=8roiil3sEvo

E2. Testimonial from Cathy Yelf of the CEO Macular Society

E3. Feedback from EV trainers and other professionals

E4. Testimonial from Mr J Ward a visually impaired user from the Thomas Pocklington Trust and a transcript of his appearance on BBC radio 4

E5. Usage data is available from Apple iTunes connect for iOS version and from Fabric for the Android version and Google analytics for EV News and Ev-platform

E6. DOCET eLearning CPD for Optometrists and Macular Society Skills for seeing program

E7. Testimonial from Dr David Lewerenz,, Ophthalmologist in Denver Colorado

E8. Testimonials from Adrian Cox, CEO at Humboldt solutions Ltd

E9. Testimonial from Konstantinos Papagiannopoulos, CEO of Codica Ltd

E10. Universities UK ‘Ideas for Life’ Press Release

Submitting institution
Royal Holloway and Bedford New College
Unit of assessment
3 - Allied Health Professions, Dentistry, Nursing and Pharmacy
Summary impact type
Health
Is this case study continued from a case study submitted in 2014?
No

1. Summary of the impact

2,300,000 people worldwide live with multiple sclerosis (MS) and cognitive difficulties profoundly impact their disease management, employment, and quality of life. Langdon led the development of the Brief international Cognitive Assessment for MS (BICAMS) and pioneered its introduction, reducing the cost, time and training required for cognitive assessment in MS, thereby increasing awareness and access to appropriate care. BICAMS has been validated in 24 countries, and globally 11,000 patients are routinely assessed every year on BICAMS. BICAMS has increased the skills of health care professionals in assessing MS cognition, and facilitated cognition as an outcome in major treatment trials.

2. Underpinning research

MS cognitive impairment has been a “hidden symptom”, rarely included in clinical care or drug trials. The resulting disability was often wrongly attributed to physical symptoms. There was no feasible cognitive measure that was psychometrically robust, practical, and validated internationally. Langdon’s research developed a measure that could be completed in 15 minutes, addressing the key MS cognitive deficits (attention and memory). The test requires only papers, pen and stopwatch, it can be administered by most health professionals and was suitable linguistically and culturally for translation globally. This resulted in an international currency for MS cognition, which has facilitated clinical and research work across the world, enhancing awareness, assessment and management.

Langdon secured funding for, and convened, the three BICAMS committee meetings (Toronto 2011, London 2012 and Bordeaux 2012), comprising the 12 leading international MS cognition experts (neurologist and neuropsychologists), which she co-chaired. This was the fundamental driver in developing and publishing the BICAMS battery and international validation recommendations ( R1, R2). This research was used to develop a review process to select scales, from a complex and chaotic literature that could be combined to realise a feasible, valid and international MS cognitive assessment. Based on their combined research and international trial experience, Langdon’s expert committee identified psychometric and pragmatic parameters essential for scale selection. This unique and novel approach took account of both the science (reliability, validity and sensitivity) and the practicalities (ease of administration, patient congeniality, translation stability). 200 key papers were selected by consensus and scales rated on the six parameters. Three scales were identified to assess attention, and verbal and visual memory.

Their resulting recommended battery ( R1) can be completed in 15 minutes, without needing special assessor training. The committee also published an international validation protocol, to guide national validations ( R2). Subsequently, 30 countries have joined the national validation pipeline. 24 have published to date in peer-review clinical neurology journals. Langdon has offered guidance and support as required, recognised in her co-authorship of eight of the validations. These national studies have demonstrated the validity and reliability of BICAMS in different cultures and language groups, and that it has the same sensitivity to cognitive impairment as the lengthy, complex and expensive “gold standard” batteries. BICAMS thus provides a feasible, accurate and quick cognitive assessment for routine clinical use.

Subsequently 100 peer review papers in clinical neurology journals, on 9 of which Langdon is an author, have demonstrated the further validity of BICAMS in relation to physical disability and brain pathology (criterion validity), and everyday functioning including employment (ecological and external validity). These have confirmed Langdon’s original recommendations and supported adoption in clinical practice ( R3, R4).

More recent research ( R6), involving patient partnership and surveys, explored how to enhance the relationship between health professionals and MS patients. Key areas were identified: fostering positive relationships with the patient community; providing patients with up to date and reliable information (mindful of the prevalence of unreliable online information about MS), appropriate for cognitive difficulties; and ensuring patient input to co-produce future patient trials and surveys. Langdon’s research, with funding from Merck KGaA, including sponsored open access for all publications, has helped to pioneer a model for patient involvement in close partnership with health professionals.

3. References to the research

The following articles are all published in highly regarded journals and with established academic publishers, all have been peer reviewed, and include grant funding from multiple sources including pharmaceutical providers.

(R1) Langdon DW, Amato MP, Boringa J, Brochet B, Foley F, Fredrikson S, Hämäläinen P, Hartung HP, Krupp L, Penner IK, Reder AT, Benedict RH. Recommendations for a Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Mult Scler. 2012 Jun;18(6):891-8. Doi: 10.1177/1352458511431076 (560 citations).

(R2) Benedict RH, Amato MP, Boringa J, Brochet B, Foley F, Fredrikson S, Hamalainen P, Hartung H, Krupp L, Penner I, Reder AT, Langdon D. Brief International Cognitive Assessment for MS (BICAMS): international standards for validation. BMC Neurol. 2012 Jul 16;12:55. Doi: 10.1186/1471-2377-12-55 (254 citations).

(R3) Corfield F, Langdon D. A Systematic Review and Meta-Analysis of the Brief Cognitive Assessment for Multiple Sclerosis (BICAMS). Neurol Ther. 2018 Jun 19. Doi: 10.1007/s40120-018-0102-3 (28 citations).

(R4) Smerbeck A, Benedict RHB, Eshaghi A, Vanotti S, Spedo C, Blahova Dusankova J, Sahraian MA, Marques VD, Langdon D. Influence of nationality on the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Clin Neuropsychol. 2018 Jan;32(1):54-62. Doi: 10.1080/13854046.2017.1354071 (15 citations).

(R5) Yeandle D, Rieckmann P, Giovannoni G, Alexandri N and Langdon D Patient Power Revolution in Multiple Sclerosis: Navigating the New Frontier Neurol Therapy. 2018. Dec 7 (2): 179-187. Doi: 10.1007/s40120-018-0118-8 (11 citations, 2,399 downloads - this paper, with an MS patient as first author, reported a live international symposium chaired by Langdon, involving neurologists and patients debating how shared decision-making and patient engagement could improve health care, including cognition).

Pharmaceutical investment

Langdon, DW. EUR13,000 from Bayer Healthcare for development and maintenance of BICAMS.net, December 2010.

Langdon, DW. EUR40,000 from Bayer Healthcare to sponsor BICAMS initiative, largely for funding international committee meetings, November 2011.

Langdon, DW. GBP53,000 from Bayer Healthcare for BICAMS validations. December 2012.

Langdon, DW. IPAD BICAMS. GBP118,960 from Novartis Pharma AG, October 2014.

Langdon, DW. BICAMS UK first adopters. GBP25,114. Novartis UK. October 2015.

4. Details of the impact

MS cognition has been the “dark matter” of the condition, with an inferred ubiquitous, negative impact, but without a tangible presence that could be measured, understood or addressed by health services. Langdon met this challenge by delivering a psychometrically sound and feasible international measurement technology, in collaboration with MS patients, health professionals, MS charities, pharmaceuticals and the global MS community. BICAMS has transformed awareness, assessment and management of MS cognition, thereby transforming the care and quality of life of people living with MS worldwide.

First, the patient community recognises how BICAMS has improved awareness and increased access to care, identifying and validating those ‘missed’ by existing health care. As a leading US-based MS advocate and award-winning author of Facing the Cognitive Challenges of Multiple Sclerosis, Jeffrey Gingold acknowledged, “Her research work is exceptionally relevant and helpful to people with MS. It is hope and validation” adding “The BICAMS project is truly remarkable and is a game-changer for the MS community.” (S4, testimonial 31st October 2019). 2,131 people with MS have participated in published BICAMS validation studies globally and a further 13,102 in other published BICAMS scientific studies, indicating its importance to them. The NMSS (American MS Society) funded a project and publication about MS cognition which recommended BICAMS ( S1, testimonial 28th October 2019).

Second, leading MS charities used BICAMS in their funded trials. MS Societies in the UK and US funded MS-Stat 2 with GBP6,000,000 and the Canadian MS Society funded CogEx with USD5,000,000, together involving over 1,500 patients. Testimonials from other MS patient advocates acknowledge BICAMS’ fundamental contribution to public health improvement and Langdon’s ability to bring together key beneficiaries across charitable, health and care sectors internationally. ( S4, S5, S6). Importantly, they also highlight how Langdon’s research has facilitated change by actively incorporating the views and experiences of MS patients. As MS advocate, David Yeandle noted “The importance of this paper appearing in a peer review clinical neurology journal was that it emphasised that shared decision making and patient engagement were essential for optimum MS patient care” ( S5, testimonial,5th November 2019). This point about Langdon’s research being a catalyst for research network development was emphasised by Sara Joiner, an MS Trust trustee who noted, “Her work on the BICAMS scale has led to the recruitment of 30 countries to the project [i.e. BICAMS], meaning that quick, accurate cognitive assessment is now available to so many more people with MS and so many more MS health professionals are more aware of cognitive issues and able to tackle them” ( S6, testimonial, 4th November 2019). Langdon’s commitment to sharing her research with all possible beneficiaries was acknowledged by another American-based patient advocate, Jeffrey Gingold “I invited her to write the foreword to the second edition of my book “Facing the Cognitive Challenges of Multiple Sclerosis [published by Demos Health]” ( S4, testimonial 31st October 2019).

Third, BICAMS is now recognised and formally adopted in clinical practice around the world. Between 2013 and 2020, 20 peer review papers in international clinical neurology journals, arbiters of clinical practise, recommended BICAMS for routine clinical MS cognition assessment. The American Academy of Neurology (AAN), the world leader in setting standards for clinical care, recommended BICAMS in their Quality Measurement Sets for MS in both 2014 and 2020. The Canadian Guidelines for MS Treatment endorsed BICAMS in 2020. Six leading UK MS clinics have been recruited as BICAMS First Implementers (funded by Novartis UK). Over 10,000 health professionals globally have chosen to attend Langdon’s lectures on BICAMS and MS cognition.

BICAMS is being translated and validated in thirty countries (24 formally published to date) in Asia, the Middle East, Europe, and North and South America. The international MS community has allocated resources equivalent to over GBP3,000,000 to validate BICAMS between 2013 and 2020, signalling the importance with which BICAMS is viewed, for improving MS patient care and health professionals’ MS cognition skills. Cognition management is now possible for 1,000,000 patients in countries with completed national validations (almost half the global MS population of 2,300,000). 188 centres globally have registered with the BICAMS website, which includes access to real time calculation of national norms for individuals. Over 11,000 patients are known to be assessed on BICAMS annually around the world. As Professor Ralph Benedict, Professor of Neurology and Psychiatry, University of Buffalo, New York noted “BICAMS is the core of our clinical test battery…BICAMS is brief and sensitive and enables us to reach a much broader base of patients…” and crucially is more likely to be judged affordable by the US health care industry and patient self-funders ( S2, testimonial 7th June 2019).

Fourth, the pharmaceutical industry has embraced BICAMS, funding Langdon to promote: (1) international validations; (2) software development for IPAD BICAMS; and (3) the UK First Implementer project. In total, Langdon’s initial research generated a total of GBP244,000 pharmaceutical sector investment in further development of BICAMS between 2013 and 2020. The BICAMS battery is being used by global pharmaceuticals such as Merck to measure cognition as a treatment outcome in ongoing trials of new MS therapies (CLARIFY, ENSEMBLE, CASTING, CONSONANCE). Langdon’s consultancy on BICAMS for pharma have generated approximately GBP200,000 income between 2013 and 2020 and this external work has been devoted to ensuring further development and implementation of BICAMS. As Dr Davorka Tomic World-Wide Brand Medical Director, Neuroscience Franchise, Novartis Pharma AG acknowledged “ BICAMS has changed the way that the pharmaceutical industry thinks about MS cognition…Global pharma rarely included recognition as an outcome measure in clinical trials, because it was viewed as too unreliable and difficult to manage… BICAMS has become an international brand with wide global recognition” ( S3, testimonial 13th June 2019).

Fifth, BICAMS has been acknowledged as transforming professional awareness and practice. The feasibility of BICAMS, and validation studies in so many languages, made a raft of MS cognition research projects possible. BICAMS has created a growing cadre of MS neurologists and health professionals around the world with increased awareness, tools, skills and knowledge of MS cognition. This has enhanced their professional development and benefitted MS patients. As Professor Alan Thompson, Dean of UCL’s Faculty of Brain Sciences acknowledged, “ BICAMS has changed the way that the international MS community engages with cognition…I consider the development of BICAMS to be one of the most important advances in the MS world over the last decade, particularly in relation to improving the management of those affected by MS.” ( S1, testimonial 28th October 2019).

5. Sources to corroborate the impact

(S1) Testimonial from Professor Alan Thompson, Dean of Faculty of Brain Sciences, UCL, dated 28th October 2019.

(S2) Testimonial from Professor Ralph Benedict, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, New York, USA, dated 7th June 2019.

(S3) Testimonial from Dr Davorka Tomic, World-Wide Brand Medical Director Neuroscience Franchise Novartis AG, Switzerland, dated 13th June 2019.

(S4) Testimonial from Jeffrey Gingold, US-based MS advocate, author and lawyer, dated 31st October 2019.

(S5) Testimonial from David Yeandle OBE, MS Ambassador and Member of the Council of the Pensions Policy Institute, dated 5th November 2019.

(S6) Testimonial from Sara Joiner, MS Trust trustee and MS patient, dated 4th November 2019.

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