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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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Insight

Taking time to look back – so the way ahead is clearer

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Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.

Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.

It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.

But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.

It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.

The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.

Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.

The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.

“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.

“If we have an incident with a patient, we discuss it in the session” she says.

Sessions are led by the management team, with added input from psychology teams on each ward.

They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.

They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.

While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.

In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”

Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.

“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.

“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.

“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.

“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”

Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.

“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”

In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.

She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.

The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.

The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.

Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.

Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.

Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.

Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.

For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological

Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/

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Robots and resilience at Askham Rehab

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NR Times reports on a new rehabilitation approach taking place in Cambridgeshire.

Despite a year of relentless change and upheaval for all involved in neuro-rehab, one provider in Cambridgeshire has been able to keep its ongoing development on track.

Askham Rehab, part of the Askham Village Community, is a recently-launched specialist rehabilitation service incorporating the latest in rehab robotics and sensor assisted technology.

While the firm has invested in state-of-the-art technology to do the heavy lifting, however, its rehab services remain person-centred, as director Aliyyah-Begum Nasser explains.

“We’re a specialist rehab centre in essence, and so, although the robotic technology helps us to get the most out of our patients and staff, we are very much family-focused.

The equipment is obviously fantastic but we know from experience that a person’s mindset, and their ability to sustain whatever improvements they make, comes down to the people who are supporting them – their family members.

“We’ve been on some real journeys with many of our family members who just didn’t understand the impact of a brain injury in terms of how it can impact behaviour or what it can do for cognition.

“Once they understand that, suddenly they become a lot more compassionate, and a lot more supportive; they become part of the recovery process, rather than being a frustrated observer.”

With recognition of the family’s paramount importance to recovery, Askham Rehab does everything within its power to harness this force – including by enabling families to stay together in specially-designed apartments on site.

Aliyyah-Begum says: “The flats are fully adapted, with cantilever cupboards, height-adjustable sinks in the bathroom and full wet room with turning spaces.

“We have the patients themselves participating in rehab, specifically to their programme, but relatives are also there from the beginning, seeing the improvement and being part of our process from the outset.

“We think of the centre as more of a rehab environment; it’s not a just care home with therapy as an added extra.

“So from the minute our patients wake up to the minute they go to bed, everything is based around their recovery goals, and everyone is working together towards achieving them.”

And robotics are an important tool in pursuing these goals through patient exercise. They help therapists to achieve the repetitions and intensity needed to progress their clients, as Aliyyah-Begum explains.

“The point of the robotics is that they respond to the patient. For example, if you set the machine on a left lower limb, but it senses that there is more pressure being exerted through the right limb than the left, it will automatically respond to make sure the patient is moving the correct part of their body.”

The centre’s head of rehab and nursing, Priscilla Masvipurwa, says: “This is a real a game changer in our approach to rehabilitation.

“Robotics help to bridge the gap, increasing the frequency and repetitiveness of treatment, something that’s an essential part of the process.

“We anticipate that this will enable us to support our patients in reaching their goals in a more efficient and sustainable way.

“The centre has so far invested in four items from robotic rehabilitation firm Tyromotion, but is looking to add more over time, as the benefit to both staff and patients becomes ever more evident.

Aliyyah-Begum says: “It’s really important to the team at the centre that the robotics aren’t just seen as an add on.

“There is a lot of nervousness about robots replacing therapists, but our service is still very much therapy-led.

“What this means in practice is that, where a resident would previously have had maybe an hour of therapy time in an afternoon, now you have an hour of therapy time, and then you can carry on exercising if you want to, or carry on playing games with other residents.

“For example, one of our machines, the Myro, enables patients to play games like bat and ball, or perform virtual tasks like sweeping leaves.

“However, because it is all sensor-assisted, if it senses that the patient needs to work a certain hand, it will alter what it is asking them to do accordingly, while they won’t even necessarily feel they’re having therapy – it’s all part of the game, and part of their socialising with other residents.”

Askham Rehab forms part of the Askham Village Community, on the edge of Doddington village, in Cambridgeshire.

It provides specialist care for people of all ages, offering day visits, respite care and continuing long-term support, both on-site or at home.

The site consists of five homes, three of which are specialist neurological facilities. In total, the neuro-rehab team can look after up to 52 patients at any one time, with 120 staff made up of rehab professionals and specialists.

The team comprises carers nurses, physiotherapists, occupational therapists, speech and language therapists and psychologists.

Aliyyah- Begum believes that the introduction of the robotic rehab services, combined with the patient-led therapy the group has been offering for 30 years, can only enhance the centre’s outcomes.

She adds: “We know that there is an increasing number of care homes that offer specialist therapy, but the difference with Askham Rehab is that we have embedded it into the whole culture of our setting – and the outcomes really speak for themselves.

“We often discharge people earlier than planned, and that’s a testament to the fact that the patients are really working hard with the team throughout their stay with us to achieve their goals – and that is the key.”

For more information about Askham Rehab, visit www.askhamrehab.com

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Astrocytes identified as master ‘conductors’ of the brain

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In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.

Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.

When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.

Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.

“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.

Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.

However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.

“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”

Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.

Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.

Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.

“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”

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