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“It’s a really, really lonely place to be…”

Up to a third of women, and one in four men, will experience violence at the hands of a partner at some point in their lives. A black eye may be hard to hide, but a traumatic brain injury could remain undetected indefinitely, as Sarah Sinclair reports.

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Paula Walters was strangled by her boyfriend in 2006.

“I remember him putting his hands around my throat and thinking, ‘I’m going to die’.”

For years afterwards she kept forgetting things, struggling to concentrate and losing control of her emotions.

At her lowest point, she even tried to take her own life. What Paula didn’t know, was that her symptoms were not because she was “crazy” or “stupid”.

They were the result of a brain injury sustained in the strangulation.

Paula survived, thanks to a neighbour who found her severely beaten and took her to hospital. But neither she nor the medics thought to consider the possibility of a brain injury at the time.

It wasn’t until an MRI scan after a car crash in 2017 revealed the extent of the problem, that the connection was made.

Even now, Paula battles with the symptoms caused by the damage done that night. “It’s a really, really lonely place to be,” she says.

But Paula is not alone. In the first community- based study of its kind, researchers in Ohio found that 81 per cent of domestic violence survivors reported being hit on the head.

More than 50 per cent were hit so repeatedly that they couldn’t remember exactly how many times.

Meanwhile, 83 per cent said they had been choked or strangled.

Many are likely to have experienced both repetitive head injuries and strangulation, a deadly combination that could lead to memory loss, difficulty understanding, loss of motivation, anxiety and problems with vision and hearing.

The research indicates that high numbers of domestic violence survivors are living with undiagnosed, unrecognised brain injuries.

And no one yet knows what this could mean for them in the long term.

“Although we know it’s very common that domestic violence survivors experience blows to the head, neck and face, we were not expecting to see the numbers that we did,” says Julianna Nemeth, assistant professor of health behaviour and health promotion at Ohio State University, and lead researcher on the study.

“It’s not just that most survivors accessing services have had exposures that can lead to brain injury, but the number of times they reported it.”

While previous research has linked brain injury to domestic violence, this is the first study to gather such detailed information from the field.

Researchers interviewed female survivors not only from shelters but those accessing a wide range of community services.

Like Paula, many in the study had been experiencing lasting physical and mental health problems as a result of their experience, but had never considered that it could be a brain injury.

Instead they were blaming the abuse, and in many cases, themselves.

“People that we’ve talked to struggle with ongoing mental health issues, suicide ideation, substance use and physical health issues, such as concentration and issues with vision, hearing and balance,” says Nemeth.

“Many survivors were ascribing those symptoms to the abuse or trauma, but not recognising that it could be a brain injury, and not because they are crazy, because their abuser has told them that.

“Just putting symptoms in front of people, and providing the information that these symptoms have to do with a brain injury, gave some survivors a sense of relief.”

Dr Eve Valera an assistant professor in psychiatry at Harvard Medical School, published one of the first studies examining the prevalence of intimate partner violence (IPV) related to traumatic brain injury (TBI) in 2003.

She first became interested in the link when working in a women’s shelter while at university, but at that point there wasn’t a single piece of literature on the subject.

Valera interviewed 99 women, from shelters and the community, and found that around three quarters had sustained at least one mild TBI from their partners, and half had sustained repetitive brain injuries.

The number of brain injuries and severity was also negatively associated with measures of memory, learning, and cognitive flexibility in the women, and these women were much more likely to experience higher rates of depression, anxiety, post traumatic stress disorder (PTSD) and general distress.

“One in three women will experience at least some physical or sexual IPV after the age of 15, and if you look at the numbers that I have, you’re talking about millions of women walking around with undiagnosed, unrecognised repetitive head injuries,” she says.

“These are our daughters, our mothers, our friends, our colleagues, our partners. Everybody knows somebody who has experienced this, it’s virtually impossible not to – even if they may not tell you.”

Valera is now working on a larger study, partly replicating those which have examined concussions in athletes, in order to explore the potential long-term consequences of these injuries for women, and how they might contribute to ageing and the development of neurodegenerative diseases, as seen
in those suffering from chronic traumatic encephalopathy (CTE).

She hopes to bridge the gap between the lack of research on the topic compared with that on concussion in men.

“It’s an international public health epidemic,” she says.

“If you think of the numbers, it’s far more than athletes, far more than in the military. We have all these resources and studies on male athletes and there’s nothing like that with respect to women experiencing IPV.

“We’ve not even scratched the surface, but we do know enough to know that this is dangerous and we need to find out exactly how it’s affecting women in the long term.”

Valera has seen women in their 40s and 50s with histories of repetitive head injuries, who are now struggling to remember how to spell certain words, or help their children with their homework.

“It could be that huge swathes of the population worldwide have been negatively affected in their older years because they sustained years of abuse to the head,” she adds.

But while the long-term impact remains uncertain for now, the immediate dangers are far more clear-cut.

“People with concussions can’t process information as well, and the idea that they can navigate a potentially dangerous situation drops significantly if you’re dealing with a concussion on top of everything,” says Valera.

The complexity of their situations also means that someone sustaining a concussion as a result of IPV, is less likely to make a good recovery.

According to Valera, not recognising or addressing the potential brain injury or concussion means they are unlikely to seek immediate medical care or take a break from their daily activities, both of which are vital for making a full recovery.

Other factors such as being under acute stress, injuries elsewhere on the body and sustaining repeated concussions with relative frequency without giving injuries time to heal, are not conducive to optimum recovery.

“If they do go to the ER, it’s likely for a broken bone or blood coming from somewhere.

“There’s a disjoint between what people are learning in sports or military data, where we see most repetitive head injury studies, and what a woman may think is going on with her.”

The symptoms are not being recognised by those who are in a position to help survivors either.

Data suggests that frontline staff anticipate the number of women with a concussion coming into their care as far lower than the number actually is, and many don’t feel comfortable addressing brain injury with their clients.

“We really need to start understanding this better and getting this information out there to women, and all the different stakeholders who interact with these women.

“If you don’t realise they’ve got a brain injury you’re going to see them in a very different light.

“We need to be approaching women that have been in this situation with the idea that they may have sustained a concussion and factor that into how we care for them.”

The Ohio study interviewed 62 staff members from five agencies across the state and, according to researchers, professionals such as advocates, healthcare providers and law enforcement personnel are not considering that the individual they are dealing with could be behaving a certain way because they are suffering from a brain injury.

“Advocates absolutely want to help the survivors that are coming into their services, but we haven’t made the link yet as a service community between the potential for brain injury and the symptoms we’re seeing in front of us,” says Nemeth.

“We assume that the symptoms we see are because of psychological trauma or potentially mental health or other substance use issues.”

In direct response to the study’s findings, the Ohio Domestic Violence Network has developed the CARE (Connect, Acknowledge, Respond and Evaluate) model, an intervention tool which provides free resources to survivors and service providers to help them identify when someone may have a brain injury and how to respond appropriately to get them the care they need.

The next steps involve developing protocols for all services that come into contact with survivors, to ensure that brain injury is always put on the table as a possibility.

“We need to rule out brain injury instead of ruling it in,” adds Nemeth.

Elsewhere in the US, PINK Concussions, the first ever non-profit organisation for women and girls with brain injuries, is also working with women’s shelters to try to increase awareness among frontline staff.

Founder Katherine Price Snedaker (pictured above) says: “The shelters that we’ve spoken to have been overwhelmed, but what we say is that we don’t need you to diagnose brain injury, we just need you to be aware of it in the same way that we ask sports coaches and parents to be aware of brain injuries.

“I don’t think it’s anything that workers aren’t already dealing with. It’s the reason clients aren’t showing up to appointments on time, that they are cranky or irritable, or they don’t have all the details.

“You may see them as non-functioning and irritable people, but if you see them as someone with a brain injury that might allow you more patience and understanding.”

A brain injury could also be the reason that a survivors’ story is inconsistent, or that they may appear to be under the influence of drugs or alcohol.

This is something which Valera tries to convey to police officers dealing with domestic disputes.

“How someone looks after they’ve sustained a brain injury is a lot like someone who’s intoxicated.

“They may be dizzy, disorientated, vomiting or seem confused and may not remember.

“Yes, often there are drugs and alcohol involved, but that doesn’t mean it’s the culprit for what you’re seeing there.”

It’s like a lightbulb moment, Valera says, when people realise what is really going on.

But how has something so obvious gone under the radar for so long?

A general lack of understanding of IPV, combined with the stigma that survivors face, means it is often easier for everyone to keep the problem hidden.

“IPV is so stigmatising that individuals don’t want to admit to it,” says Valera. “There’s so much victim-blaming and misogyny involved, that it’s not easy to own it and say ‘that happened to me’.”

Especially as so often when a woman does speak out, she is faced with the question: Why doesn’t she just leave?

Approximately three quarters of intimate partner murders occur while a woman is attempting to leave, or after they have left.

“It’s not a silly belief that a woman may actually be killed for leaving,” says Valera.

And it’s even more difficult to speak up for those women who are further marginalised in society.

“Women are already fighting the stigma of domestic violence and trauma, and brain injury is an invisible illness, so you have invisible people with invisible injuries,” says Price Snedaker.

“And if they are a woman of colour or there’s a language barrier – all these barriers stack up. We have very few women of colour that come forward. That’s a group that we really need to reach out to more.”

IPV is a topic which people not only don’t understand, but don’t want to understand, she says.

“No one likes to think about it and people don’t necessarily think women are worth it.

“People have an impression that it’s just a problem for other people – those in the ghettos, the drug addicts and the poor people – but it absolutely diversifies all socioeconomic classes.”

Paula Walters actually worked with trauma victims in the same hospital where she was treated, yet the true extent of her injuries still went unrecognised.

“As much as I know about trauma, I totally missed the strangulation part of the brain and the effects that it has had on my body,” she says.

“My friends and family have watched me try to end my own life. That all could have been avoided if the right people had had the right knowledge.”

In order to make it part of the public conversation we need to get comfortable being uncomfortable, says Valera.

“[Women] are being dragged down the street, thrown out of cars, having refrigerators thrown on them, their head stamped on with work boots, smashed against cement floors, or hit with a baseball bat.

“We need to start talking about IPV as if it’s not this horrible disease or crime. It’s something that is happening to women all over the place.

“We can’t just keep looking the other way or saying it’s their fault.”


Why men injured in domestic violence must be encouraged to speak out too

The studies cited in our domestic violence report are focused entirely on female victims of intimate partner violence.

However, men, of course, may also suffer brain injury at the hands of their partner or a family member at home.

The latest figures from the Crime Survey for England and Wales for the year March 2018, show an estimated two million adults aged 16 to 59 years reported domestic abuse during the period.

Of those, 695,000 were men. The real figure for both genders is thought to be much higher. Stigma, fear of retaliation and lack of trust in the police are among the deterrents to reporting such incidents, say researchers at University of South Wales (USW) who run the Compass programme, which helps men to consider themselves as victims, challenging gender stereotypes.

The US body, the National Coalition Against Domestic Violence (NCADV), meanwhile, estimates that one in four men have experienced some form of physical violence by an intimate partner, compared to one in three women.

This gap widens, however, when the severity of the attacks is measured. While one in seven women have been injured by an intimate partner, this falls to one in 25 among men, NCADV says.

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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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