TBI is not a single event, but can be a chronic and often progressive disease with long-term consequences.

Even after an ostensibly good recovery, patients might have to live with a continuing process of coping and adaptation.

TBI represents 30-40 per cent of all injury related deaths and neurological injury is projected to remain the most common cause of disability from neurological disease up to 2030 – two to three times higher than the contribution from Alzheimer’s or cerebrovascular disorders.

A report by the Centre for Mental Health – Traumatic brain injury and offending.  An economic analysis – states that approximately 1.3 million people in the UK are living with head injury-related disabilities, with these injuries causing around 160,000 hospital admissions each year.

TBI also has a marked impact on the economy, at a cost of £15bn a year.  This figure comprises lost work contributions, premature death and health and social care costs.

This £15bn does not, however, include the human cost of head injury to the injured and their families’ wellbeing and quality of life, which is clearly the biggest cost. The impact of a TBI on an individual may be wide-ranging with not only a reduction in cognitive abilities and executive function, but also in mental health difficulties, problems in psychosocial functioning and a reduction in self-esteem and self-awareness.

Walking to Latrigg with Calvert Trust Staff.

The results of a study on longer-term outcomes (Hoofien et al, 2001) reveal relatively high rates of depression, psychomotor slowness, loneliness and the family’s sense of burden amongst people with TBI. Another study of adolescent and young adult inpatients, evaluating cognitive, behavioural, depressive and self-awareness disorders (Viguier et al, 2001) highlighted a discrepancy between patient and clinician’s evaluations suggesting a lack of self-awareness of behavioural and cognitive disorders in TBI patients.

It was mooted that correlations of depressive mood with anxiety and cognitive complaints seemed compatible with some degree of lack of self-awareness of cognitive and behavioural difficulties in the TBI  patient group.

A further study on identity, grief and self-awareness after TBI (Carroll et al, 2011) revealed that 90 per cent of participants suffered from low self-esteem at levels deemed clinically significant.

TBI is also a huge hidden disability within prison populations, according to the University of Salford. Prisoners who have had head injuries are more likely to experience a variety of mental health problems including severe depression and anxiety, substance use disorders, anger and suicidal thoughts.

Physical exercise has the potential not only to improve physical health but also to have a positive effect on mental alertness and mood in the general population. Exercise can result in an increase in self-esteem and self-worth in all age groups from children to older adults (Baumeister et al, 2003).

Studies on the benefits of outdoor activity in addressing problems associated with TBI point to improvements in self-esteem, self confidence, increased control, memory  and planning.

A one-year outcome study of a three day outward bound experience (Lemmon et al, 1996) recorded a range of positive outcomes. At the one-year evaluation, 83 per cent of the participants ranked themselves above their pre-course rating in an understanding of their strengths and limitations.

Other positive changes over the same time span included: ability to rely on others (50 per cent), higher self-esteem (58 per cent) and improvement in problem solving (50 per cent).

It was commented that the outdoor challenge course allowed therapists to help the participants recognise and acknowledge their thoughts, feelings and behaviours during the course and that, one year later, the participants were calling on this understanding to improve their daily functioning.

Another UK pilot programme (Walker et al, 2005) incorporated a context-sensitive approach to cognitive rehabilitation with a focus on goal planning with goal attainment as an outcome measure.

The results revealed a high level of achievement (over 80 per cent) on selected, identified, specific and mainly practical goals. In discussing the results, the authors considered that the strength of the project appeared to lie partly in the motivation provided by the outdoor activity course; which appeared to later encourage participants to work towards broader goals.

An Australian study (Thomas, 2009) was similarly positive. Participants attended a standard nine-day outward bound course adapted to meet the needs of the participants. Fortnightly meetings over a period of three months were then facilitated by rehabilitation staff who had also attended the course.

The focus of these meetings was on “restructuring” tasks including achievement of individual goals, problem solving, further life planning and social skills development.

A comparison group matched as far as possible to the experimental group who did not attend the course was also evaluated using quality of life analysis. The findings were as follows:

1.  Understanding: Participants reported that they gained insight into personal strengths, limitations and unexpected capabilities as a result of engaging in the programme’s activities.

2.  Re-integrating identity: Participants identified increases in self-confidence and competence and this had a positive impact on their sense of identity.  Several participants noted that they felt they had more control and responsibility for the direction of their life.

3.  Acceptance: Participants stated that the  outdoor activity course had helped in the processing of their acceptance of the impact of their injuries on their lives.

4.  Restructuring: Participants who attended most of the follow-up groups were seen to report most improvements as shown by Quality of Life Inventory (QOLI) evaluation. This may be the result of the follow up group providing time for reflection, to set and refine personal goals as well as group encouragement and support.

The Lake District Calvert Trust ABI Rehabilitation Programme

TBI can have profound long-term consequences, not only to individuals, but to their families, carers and society as a whole.

The impact of a TBI on an individual is immediate but TBI survivors may also have to live with a continuing and developing need of coping and adapting (Maas et al, 2017). It has been shown that post-TBI, an individual may have to cope with a reduction in cognitive abilities, a reduced ability to plan and make decisions, mental health difficulties such as depression, and psychosocial problems with a lack of self awareness, self esteem, self control, apathy or aggressive behaviour (Levin et al, 1991).

Physical exercise is known to improve physical health and also to have a positive effect on mental alertness and mood in the general population. The pathology associated with TBI can be characterised by a reduced capacity of neurons to metabolise energy and sustain synaptic function which often results visibly in emotional and cognitive problems (Wu et  al 2011).

The anti-neurogenerative effects of exercise are beneficial to neurocognitive functioning and neuroplasticity, while the detrimental effects of TBI on the vasculature may be reduced by carefully selected exercise/activity programmes.

It has been suggested that the concept of exercise providing a “scaffolding” may aid the understanding of the benefits of exercise to the injured brain.

It is thought that physical exercise reinforces the adaptive processes of the brain post-TBI, facilitating the development of existing networks and helping to compensate for those lost through damage (Archer, 2011).

The Lake District Calvert Trust (LDCT), which has provided outdoor activity for people with disability over the last 40 years, has developed a proposed post-acute ABI rehabilitation programme which will support brain injury survivors in a new  residential centre.

It was developed with the support of clinicians and academics and the limited, but positive,initial results of research of outdoor activity in rehabilitation following TBI.

The rehabilitation programme, delivered by a team of clinicians and specialists in outdoor activity, will be tailored to each individual participant’s needs, with the aim of providing the tools needed for people to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels.

Experiential learning and rehabilitation through outdoor activity is therefore not simply about the specific skills learned or the satisfaction of completing a challenge, there are also improvements in self-esteem, self awareness and self-confidence, lifting of mood and clinical depression, as well as cognitive improvements. Importantly, learning can then be internalised, and transferred and applied to daily life.

The LDCT ABI Rehabilitation Programme acknowledges and supports the recommendation of The Lancet Neurology Commission Report in 2017:

“There is a clear need for studies to inform guidelines on rehabilitation approaches and optimum timing of rehabilitation in TBI. Such guidance would need to take into account the growing evidence that the diversity of disability after TBI is best addressed through a holistic approach to rehabilitation delivered by a multidisciplinary team.”

The LDCT will be carried out at PHD level in conjunction with  Newcastle University.