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Brain injuries and the bedroom…

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The neurophysiology of sex 

Sexuality is part of being human. Our sexuality affects how individuals perceive themselves 
and how they interact with those around them. Sexuality is a complex area of functioning encompassing sexual development which begins in utero; sexual awareness which develops through childhood and adolescence; sexual responsiveness and awareness (Bancroft J 2009).

It is a key element in the formation of meaningful relationships in adult life. It is an area of strength but also of vulnerability to internal and external factors such as health, self-esteem, societal and family pressures and values.


At the most basic level, sexuality is the means by which a partner is found for reproduction and the passing on of genetic material and this is evident in the animal kingdom as a whole.

However, for humanity, it is about relationships. Neurological trauma or illness can have a
major impact on sexual responsiveness and the capacity for relationships.
More often than not sexual expression is something that occurs within a relationship.

Part of the normal sexual experience
includes masturbation and fantasy but it is in relationships that sexual expression is generally fulfilled.

Why relationships matter 

The dynamics of a relationship have a profound effect on sexual functioning. Sexual expression begins with desire which is a function of
the brain.

Within the neural pathways there are both inhibitory and excitatory neurotransmitters. Dopamine is excitatory
and Serotonin is inhibitory in the pathways linking desire to arousal of the autonomic and peripheral nervous system.

Desire is influenced by a variety of cognitions and emotions such
as mood – excited, happy, fearful, oppressed memories of previous good sexual experience or memories of painful abusive relationships.

 It will be affected by fatigue which is a very common symptom of neurological disease or trauma. It may be influenced by social context – is this relationship developing in a private setting or is it within a nursing home where privacy is diffcult to establish?


The most recent imaging studies have demonstrated that certain parts of the brain are active in sexual desire, including the anterior cingulate cortex which connects to the amygdala, which in turn has a key role in emotional responsiveness (Zeki A 2007).

The central nervous system, through a complex set of pathways involving the higher levels
of cortical functioning, provides a delicately balanced system to allow sexual expression within relationships.

Any part of the system can be affected by physical, psychological, social and emotional factors.

The brain in turn connects through the spinal cord to the periphery. The sacral segment of the spinal cord is a key area from which nerves travel to the genitalia. The parasympathetic output to the genitalia comes from the sacral cord and the sympathetic nerve supply from the thoracic and upper lumbar cord.

In response to sexual arousal the nervous system connects to the genitalia via the spinal cord leading to a neurovascular response
with the parasympathetic nerves triggering erection in the male and vasocongestion in the female.

The sympathetic system is involved in ejaculation. Any disease or trauma to the nervous system or medications acting on the nervous system can interrupt the pathways. For example, a thoracic spinal cord injury will separate the sacral spinal cord from control by higher centres so that in the male reflex erections may still occur in response to a variety of stimuli including full bladder or irritation to the skin, but psychogenic erections in response to sexual desire may not occur.

What makes a good couple? 

Key factors include mutual attraction, love, having fun together, enjoying sex together, trusting each other, ease of communication
and being special to each other.

As relationships move into longer term commitments, there are additional factors, including shared experiences and future plans, hopes and expectations.

Demands are placed on relationships such as financial commitments, bringing up children, looking after elderly relatives.

Meanwhile, each individual brings into that relationship their own health, beliefs, values
and approaches to managing stress; their past experiences both good and bad, their need for autonomy and their need for intimacy.

Each person has their own self-image and an image of their partner, which can be quite different to how other people see them. Impacting on the relationship are external pressures which can
be social, financial, work and family pressures.

Many factors can challenge the dynamic balance of the relationship and the onset of disease or trauma can have a profound impact.

When everything changes…

The context of most sexual expression is within a relationship. It is also within this context that many people will experience the life-changing impact of chronic disease or acquired disability.

For some couples, problems of adjustment to the changes can be significant and place a strain on the relationship, sometimes leading
to separation. For others, the impact of such stress can enhance their closeness.

Different roles tend to be assumed as a relationship progresses. One of the commonest divisions of roles within a long-term relationship is with 
the arrival of children when, in some cases, one partner assumes the ‘bread-winner’ role and the other home-maker. 

Each partner has an image of self and of their partner, and this includes an awareness of their physical and psychological health. The onset of neurological disease and/or disability can present a great challenge to the stable state of a relationship. This may result in a change of physical appearance and cognitive ability.

The couple, having been partners in a familiar relationship, may find now that there is a carer and a partner who requires care. New roles may be taken on by one partner whilst roles must be relinquished by the other.

The shared hopes and expectations for the future may alter. It is important to note that the greatest impact comes from disorders that alter cognitive and emotional responses – rather than just physical functioning.

Escalating problems 

Most often, the problems are multi-factorial
in origin. For example, there could be loss of sensation because of MS, which alters the sexual experience, together with fatigue causing a change in overall lifestyle; low mood as a response to loss; medication resulting in specific sexual dysfunction, such as delayed orgasm with the selective serotonin reuptake inhibitors (SSRI anti-depressants); social changes resulting from the loss of income; or practical issues at home, such as no longer managing stairs and therefore, sleeping in a separate room from the partner.

Brain injuries can also lead to impaired self-monitoring, which means the individual
may be unable to suppress commenting on things that come to mind no matter how offensive they may be. Self-centredness is also
a common trait, as is a lack of empathy.

The ability to take note of how the other person
is feeling – whether they’ve had a good or a
bad day – without speaking to them, is quite important in relationships.

With acquired brain injury, non-verbal questioning can be lost (Wood R Williams C 2008).
Sexual problems are common post brain
injury and, in one study, 50% of men identified dysfunction (O’Carroll et al. 1991).

In a minority of patients, increased sexual drive and sexual dis-inhibition can be a problem.

This is more likely to occur with damage to the frontal
lobes. Reduced sexual desire and interest
are most common and result from the brain damage itself, the effect on the relationship, fatigue, depression, anxiety, low motivation and, sometimes, low testosterone secondary to damage to the hypothalamic pituitary tract.

The partner’s plight 

A common observation from partners of people with acquired brain injury is ‘this is not the person I married’. Often in relationships, partners face challenges together. In the event of a trauma, the able-bodied partner may face this new challenge alone.

While this is going on they may also feel a
desire to grieve for the old loved one they have lost. But there is no acceptable way for them 
to do this.


They may feel isolated and in a state of social limbo, in which it feels inappropriate to go out and have fun without their partner. Also, friends may say that the patient looks good, but only the partner sees the major behavioural changes that have occurred.
Sometimes we see situations where the relationship had been on the verge of splitting up before the injury or onset of disease.

With the patient, unable to make the decision to end the relationship afterwards, the partner becomes trapped in a loveless or failing relationship
out of guilt.

Rebuilding relationships 

Despite all the pressures trauma and neurological conditions can put on a couple, relationships can be rebuilt. In relationship therapy, we are always honest and explain that things will never get back to how they were.

But, for all the behavioural changes, there
may be factors that the partner still finds very attractive. We encourage couples to find new ways to have fun together and to start getting to know one another from scratch.

Other interventions 

For men, drugs such as phosphodiesterase inhibitors have proved to be useful treatments for erectile dysfunction.
These work on the relaxation of smooth muscle which allows vasocongestion in the genitalia in response to a chemical messenger cyclic GMP. 

However, it is always important to approach treatment of sexual disorders in a holistic manner. It is rarely simply a mechanical problem that can be fixed with a pill.


Therefore, taking a full history and if possible seeing the individual with their partner
allows the psychosocial aspects of the sexual dysfunction to be explored as well as the physical aspects.


Healthcare professionals need to be alert to the stresses and strains that can be experienced in this area of life which generally people view as very private and personal.

The P-LI-SS-IT model (Annon 1976), which
was proposed over 40 years ago, emphasised that the first and most helpful approach to
sex and relationship problems was giving people permission (P) to speak about the issues.

People may drop hints that all is not well in a relationship and it is up to the health professional to pick up on that hint.


Even if you are not certain how to help, acknowledge that there is an issue; allow the individual to talk about it and then, if you feel it is beyond your remit or skill, offer to refer to another agency – perhaps to the GP or to a sex and relationships clinic or to an organisation such as Relate.

The most important response is to say, “this is a valid issue to raise and there is help available”. In the PLISSIT model the next three stages are the provision of Limited Information, Specific Suggestions and Intensive Therapy. Most people will be helped in the first one or two steps of this model.

TEN STEPS: How healthcare professionals should approach their patients’ intimate relationship problems. 

  1. Be honest and realistic with patients and partners. They may never recover their old relationship, but could still build a positive new one.
  2. Consider the difficulties the partner may be going through and how that may be impacting 
on their health. Do they look exhausted? Have they been crying? A doorstep conversation in private might encourage them to open
 Perhaps ask them if they have considered visiting their GP about their own concerns.
  3. Be careful not to overload partners with too many responsibilities, such as helping out with cognitive therapy at home. Although outwardly willing to help, inside they may be feeling drained, isolated and depressed.
  4. Often patients going through rehab can feel their sexual identity is threatened, leading to low self-esteem. Give them time to do the little things they usually would to look their best.
For women, this might
include shaving their legs or putting make-up on; for men it might be having a shave or doing their hair.
  5. Consider implementing some training on sex and relationship problems within your ward, unit, service or centre.
  6. Remember that, ultimately, your primary responsibility is to get the best outcome for the patient – not to influence whether or not their relationship survives.
  7. Get to know the sources of professional help
available in your local area. Relate is a charity offering relationship support across the UK. Some areas are also served by specialist clinical psychology services. Patients should also be encouraged to consider visiting their GP about such matters.
  8. Remember that sex and relationships are very sensitive topics and most people will not be comfortable talking to strangers about them. Create a safe and secure setting to discuss them. Relationship issues should be presented as a normal and important element of the patient’s overall health and wellbeing.
  9. Always acknowledge there is a problem if
the patient or their partner mentions it or even just 
hints at it.
Never ignore the problem and certainly do not make light of it or embarrass or make fun of the patient.
  • If you suspect there are sex and relationship concerns, try asking a non-threatening question. Perhaps as the patient is leaving, ask how things are at home. This gives them an opportunity to get the issue off their chest without bluntly asking them an awkward question.

Barbara Chandler is a consultant in rehabilitation medicine in NHS Highland. Previously she ran a sex and relationships clinic for people with neurological disability in the North of England. She teaches health and social care professionals on sex and relationship issues and has been published extensively on the topic. 

Useful resources: 

Relate: www.relate.org.uk: www.relate.org.uk
The Institute of Psycho-sexual Medicine: www.ipm.org.uk
The College of sex and Relationship Therapists: www.cosrt.org.uk

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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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Stepping up the fight against alcohol-related brain injury

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Alcohol-related brain injury (ARBI) is becoming more widely recognised, but specific rehab services for the condition are surprisingly rare.

With few dedicated units for patients with ARBI, many patients in need of specialist care instead find themselves in a hospital or even an elderly care home.

ARBI is characterised by prolonged cognitive impairment and changes in the brain due to chronic alcohol consumption.

The average age of diagnosis in men is 55, and only 45 for women – following at least five years of excessive alcohol consumption, of around 50 units per week in men and 35 for women.

ARBI is not a degenerative condition, with up to 75 per cent of patients recovering to some degree with the correct support; and the first three months following diagnosis are recognised as key in a person’s recovery. Access to appropriate provision, therefore, is even more crucial at this time.

In February, UK-wide charity Leonard Cheshire opened a residential unit in Northern Ireland to help some of the many patients in need in the country. It is the first facility of its kind on the island of Ireland. 

The 14-bed unit, near Belfast, opened inconveniently – after years of planning – just as the COVID-19 crisis was emerging.

Its work goes on, however, with the centre taking patients from across the country, though initially from the capital and surrounding areas.

The residential centre aims to support residents over a two to three-year period, although that can be shorter for some patients. It helps them to live independently, by building the life skills and confidence to do so. 

Naomi Brown, clinical lead at the centre, joined Leonard Cheshire late last year to oversee the opening of the facility, following an extensive career in brain injury work and in being part of multidisciplinary teams.  

She says: “The background here in Northern Ireland is that the acquired brain injury (ABI) service is really well structured and established but for ARBI, often the person wouldn’t meet the criteria for addiction services, but their needs would not be such that they needed to be admitted to hospital, or even fulfil the criteria for ABI services, so they would fall through the cracks.

“The provision they receive would often come from the care sector, but to end up in a care home at what could be a very young age is not appropriate either.

“There is a real lack of options. Their care managers recognise they aren’t in the appropriate setting for them, but through a lack of alternatives, it is very difficult.

“A lot of symptoms are very similar to those under the influence of alcohol, difficulty with balance and memory for example, which can make ARBI difficult to diagnose.

“Often it can be something like liver failure that gets them into hospital, but then it becomes obvious there are cognitive issues there too.

“Our centre only has 14 beds, which we don’t pretend is going to answer the scale of the problem, but the decision to restrict it to that number is that we don’t want quantity over quality. To try and accommodate huge numbers would risk the patient-centred approach that we are really proud of, so we wanted to keep it on a small scale.

“But there are 14 places here at any one time for people to get access to the specialist rehabilitation they need, so we are really pleased to be able to offer this.”

With the centre’s goal being the independent living of its patients, a resident-led rehab plan is created for each individual, based around their individual goals and aspirations.

It is delivered by Leonard Cheshire’s team of rehab assistants, supported by clinicians, occupational therapists, physiotherapists, speech and language therapists and neuropsychologists who come in to hold sessions with the residents, and overseen by Naomi. 

“From the minute someone is admitted to us, we are already planning for their discharge, even though that may be a long time and a lot of work away.

“From the very start, it’s about the individual, it’s absolutely not a generic approach, even though the ultimate outcome for everyone may be the same. Most people who move in do want to live independently, so if that’s their goal and we will do all we can to help them achieve that, with a plan individualised for them. 

“Some people will come to us and we realise they won’t be here very long as they do very well very quickly, but for others, they are going to be with us for two or three years.

“Some people arrive and love it here and say they don’t want to leave, which is a great reflection on the work we do and the centre we’ve created, but the ambition is that the point will come where they realise they don’t need us anymore.

“Through the work we do and our interventions, we can make very good progress. We’ve had some people here already who have been in quite an acute state but the progress they make brings joy into my heart.”

One such patient is David* who, despite only being with the centre for a matter of weeks, has made significant progress in his recovery.

Prior to moving to Leonard Cheshire, he lived in a nursing home for two years.

Before his arrival, Naomi remembers he had low mood, minimal spontaneous conversation and spent long periods of time in his bed sleeping.

He had no clear weekly routine and lacked any scheduled therapeutic or recreational activities.

Naomi says: “David initially required a significant amount of support to initiate activities, engage with others or even leave his room. He has slowly adjusted to the active therapeutic programme in the unit and his mood has improved significantly.

“His mobility and exercise tolerance has greatly increased, he participates in group activities, is now more spontaneous in conversation and has developed facial expressions. David has been able to self-identify rehabilitation goals and discovered a new love for playing the drums and guitar. 

“He is in the very early stages of his rehabilitation but having spent three months in the ARBI unit, the change is his quality of life is already dramatic.

“He engages in an individual, weekly timetable which includes activities of daily living, physical, cognitive and social activities, and is reportedly very happy in his current placement. Once the COVID-19 restrictions are lifted, we very much hope to begin reintegrating David to the local community and making future plans for his discharge.”

David’s experience is one which the unit is keen to replicate, by engaging patients from the earliest stages of their arrival at Leonard Cheshire in building a new and healthier daily routine.

“We are always keen to introduce routine, as that is so important in the longer-term. Where some people have maybe traditionally watched TV all night then get up into the afternoon, we try to create a new routine with lots of support services available in the morning. A healthy routine is what we want them to have when they go back home,” says Naomi.  

“We encourage people to do things for themselves – to get up, make yourself breakfast, maybe do some gardening or help with the cleaning, all things which promote the ability to do things independently.

“If they put the washer on, they’ll need to go back to it when it’s finished. We have rehab assistants on-hand to support them, but we do actively encourage independence.”

Everyone has an individual timetable for the week based on their own interests, combined with their clinical requirements, which centres on promoting reintegration into the community.

“It’s very individualised, so if someone wants to do an online course or learn how to cook for themselves, or learn a musical instrument, we’ll focus on that. We have a fantastic team here who will turn their hand to anything for the benefit of our residents,” says Naomi.

“As well as activities in the centre, we do a lot in the community, or rather we did before COVID-19, but that will resume when it’s safe to do so. We did sports activities, yoga classes, bowling, it’s not just your classic physio. We want people to be engaged and comfortable with the world outside. 

“We will always ensure residents have support once they leave us, and are setting that up long before they go.

“If there was someone who was with us who wasn’t from Belfast, we would use resources we knew were transferable to where they lived, so they didn’t leave us and not know how to access support.

“We build up these links with community services in the relevant discharge areas, so ideally the person will already be confident at being independent and will have the added assurance of knowing they continue to be supported.”

The Leonard Cheshire centre’s launch came amid changes to Northern Ireland’s legislative backdrop with the implementation of the Mental Capacity Act (NI) 2016. This has new deprivation of liberty regulations, a significant new introduction for the country and its approach to capacity and consent.

Naomi says: “When planning for the opening of a new centre, a global pandemic wasn’t on the radar, and for it also to coincide with the new mental capacity legislation meant it was a really busy time for us in the early stages, the COVID-19 aspect of which we could not have foreseen. 

“The pandemic did present challenges for our residents, many have a certain level of confusion so it’s difficult for them to always remember that they can’t be close to someone else, they have to regularly wash their hands. There is a lot of prompting which leads to a certain amount of frustration. While they are watching these things on TV about how COVID is affecting the world, it’s hard to relate that to everyday life.”

New referrals continue to arrive during the pandemic, from both hospital discharge and moving from a care home environment, although happily the Leonard Cheshire unit has remained COVID-19 free.

“We were keen to admit new residents and take referrals from hospitals and care homes, subject to extra measures being in place to protect ourselves and our residents.

“We wanted to continue to support hospitals and free up beds, but also to offer the appropriate care to people whose specific needs through their ARBI diagnosis meant they would be better in our centre than a hospital environment or care home.

“This has certainly been a challenging period in which to start our ARBI unit, but we have come through it well together so far and we look forward to continuing to develop ourselves as we come out of the pandemic and go into the future.”

*Name changed for anonymity.

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Neurobehavioural rehab in aggression management after TBI

Changes in personality following TBIs are often more problematic than neurocognitive, functional deficits or even physical disabilities. Dr Grzegorz Grzegorzak, consultant neuropsychiatrist at St Peter’s Hospital, South Wales, explains why taking a neurobehavioural approach to treating TBI can be highly effective.

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Personality changes are sometimes referred to as neurobehavioural disability (ND), especially when associated with social difficulties.

The concept of ND involves impairments of numerous aspects of functioning including the abilities to self- monitor and self-regulate, to control frustration, anger and aggression, to tolerate delay in gratification, and to self-motivate.

These impairments can lead to a sense of being overwhelmed when facing situations requiring control and management of internal impulses or coping with social situations or tasks.

Impulsivity, disinhibition and aggression all have significant potential to interfere with rehabilitation efforts, jeopardize recovery and become a major obstacle to successful functioning in social roles.

Research estimates the prevalence of aggression in survivors of TBI as being as high as 33.7 per cent.

Addressing aggression as soon as it arises is critical to the individual’s recovery.

Sometimes aggressive behaviour is so intense and frequent that its management takes priority over all other aspects of care and rehabilitation.

Neurobehavioural rehabilitation (NR) was introduced in the late 1970‘s as an attempt to improve functional abilities of TBI patients.

NR stems from recognising that people who survive TBI can still learn new skills to self-regulate and to modify their behaviour.

The basis of NR is embedded in learning theory and thus the success of NR is reliant on the patient’s ability to make use of new information and experiences.

Therefore, NR is only suitable for the post-acute phase of recovery from TBI, and in fact is intended as a medium to long term rehabilitation programme.

​NR interventions are composed of comprehensive and multidisciplinary efforts to create a user-friendly, supportive and encouraging social environment which facilitates therapeutic interactions and activities.

Specific goals and detailed routines are constructed for each patient individually, based on structured collection of data informed by behavioural analysis.

The process of designing and implementing the interventions puts emphasis on personal autonomy.

Clinical formulation is preferred over medical diagnosis. The attitude of the MDT should always be positive, embracing a strong belief in the patient’s ability to achieve their goals, improve and recover.

Carefully managed feedback and positive reinforcement are an essential part of NR.

Consistent interactions with every member of the team are of utmost importance, given that neurobehavioural intervention should not be limited to scheduled activities but in fact incorporated in every interaction.

Over the last forty years the model has been implemented by many neurorehabilitation services worldwide.

Several case studies describing recovery pathways through NR paint a very positive picture, and our own experience at St Peter’s of adopting a neurobehavioural approach has demonstrated it can produce real and measurable outcomes for both our patients andtheir families.

Case Study: Mehmet

On admission to St Peter’s Hospital, Mehmet presented with extreme challenging behaviours including serious assaults on staff, destruction of environment, verbal abuse and shouting.

Mehmet has frontal lobe dysfunction as a result of a head injury he sustained. For the previous 18 months he had been in a general hospital.

At St Peter’s a bespoke positive behaviour support plan and activity plan were developed with Mehmet’s input and reflecting his cultural needs which, under the supervision of his MDT, promoted positive changes to his social interactions, routines and activities.

Over nine months Mehmet’s challenging behaviours reduced significantly and he now enjoys a wide range of activities including regular community visits and has strengthened his relationship with his family.

Dr Grzegorz Grzegorzak is one of the consultant neuropsychiatrists at St Peter’s Hospital a specialist 39-bed Neuropsychiatric facility in Newport, South Wales run by the Ludlow Street Healthcare Group. www.saintpetershospital.co.uk

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