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“Blows to the head, thrown from moving cars, strangled – it’s depressingly common”

A neuroscientist and a women’s shelter are working together to save domestic violence survivors through brain injury research. And it all started on Tinder…

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It started, as with many modern love stories, with a swipe.

In 2015, Paul van Donkelaar, a recently divorced neuroscience professor, met Karen Mason, a woman working with survivors of intimate partner violence.

They started dating and fell in love. To begin with, they were just another couple who happened to have found their happily ever after through online dating. But it soon became clear that there were bigger forces at play.

“We’re definitely unique,” says Karen, who is executive director of Kelowna Women’s Shelter in British Columbia, Canada.

“The fact that the universe decided to put Paul and I together, when I am the executive director of an organisation that provides shelter to women fleeing violence, and he’s a neuroscientist with an expertise in concussion. There’s clearly some universal plan afoot.”

Not long after they began dating she came across an article highlighting an epidemic of traumatic brain injury (TBI) among survivors of intimate partner violence (IPV).

As a professor of neuroscience at the University of British Columbia in Canada, Paul has been researching brain injury in the context of sports concussion for more than 20 years.

But while much has been done to explore the impact of head injuries on athletes, the studies on IPV are still relatively scarce. He started to question why more work wasn’t being done.

“I didn’t have a good answer,” he admits.

One in three women, and one in four men, will experience some form of IPV in their lifetime, according to the US-based National Coalition Against Domestic Violence (NCADV).

In Canada, statistics show that 207,000 women will experience a severe violent episode at the hands of a partner each year.

Of those women who seek help, either from medical professionals, A&E departments or women’s shelters, as many as 90 per cent report symptoms consistent with concussion.

“For every man who suffers a concussion playing the sport they love, 7,000 women suffer the same injury at the hands of the man they love,” Karen announced in her and Paul’s 2017 TEDxTalk ‘Ahead of the Game’.

“I realised that this was something that was probably going on with most of our clients and I insisted that we needed to do something about it,” she says now.

“We know that most physical violence within relationships is based on blows to the head and neck and there’s also the strangulation aspect.

“Most women experience physical blows to the face, head and neck, and strangulation, so brain injury is a natural implication of that.

“The stories we hear are extreme. One woman has spoken about the number of times she was thrown out of a moving car, and the occasions on which he repeatedly smashed her head against the floor.

“It is distressingly common.”

With their individual expertise, Karen and Paul were well placed to make a real difference to these women. In 2016, they launched their project Supporting Survivors of Abuse and Brain Injury through Research (SOAR) – a collaboration between the University of British Columbia and Kelowna Women’s Shelter.

In June 2019, they received a US$1m grant from the Canadian government’s department for Women and Gender Equality, to continue the research for another five years.

The study takes several approaches, both scientific and community-based, to improve the quality of life for survivors of IPV.

“We’re in a position to create some promising practices that may change the way that women’s shelters interact with their clients, the referral network and the way healthcare systems and community-based supporters accommodate and support women who have experienced IPV,” says Paul.

The fact that the government has supported the project so substantially is noteworthy in itself, and shows a recognition and understanding of the desperate need for this research.

“It’s groundbreaking. It’s very important to have direct funding supporting research around this topic, because it could have a huge impact on the quality of life of participants themselves, and in the way practices are done,” Paul adds.

“The goal of this specific funding is to create a blueprint that can be used across Canada, both within the healthcare system, and within community organisations that support women of IPV.

“That’s our ultimate goal.”

Paul van Donkelaar and Karen Mason.

Recruiting participants from the Kelowna Women’s Shelter, Paul and his team are measuring physiological changes such as blood flow, to better understand the characteristics of brain injury in survivors.

They are also carrying out assessments for psychological comorbidities such as posttraumatic stress disorder (PTSD), anxiety and substance abuse.

He is using assessments which have proved to be successful over many years of studying concussion in athletes.

Sports related concussions and the link between contact sports and CTE are a growing concern for athletes.

The Centre for Disease Control (CDC) now estimates up to 3.8 million sports related concussions occur every year in the US and more than 100 NFL players have been diagnosed with CTE at the VA-BU-CLF Brain Bank in Boston.

While studying the effect of repetitive impacts to the head in contact and non-contact sports, Paul’s research was among the first to show that certain markers of nerve cell injury were elevated following multiple hits, and that these could be linked to a higher number of concussion-like symptoms such as headaches, dizziness and confusion.

Concussions sustained through IPV, however, are more complex to dissect.

“It’s clear that people who have experienced IPV are very likely to have a brain injury as a result of that, but it’s not like in a sports concussion situation where it happens at a sporting event, there are lots of witnesses and you can very quickly do an assessment and determine that a concussion has taken place,” says Paul.

“In the IPV population quite often it’s months to years before they seek help and so the injuries tend to be remote in time and tend to interact with some of the comorbidities.

“It’s really important to disentangle all of those factors and get a good sense of how much of the challenges they are currently facing are due to the head impacts they have received as a result of their experience.”

The information will then be used to develop tools and training resources for frontline staff and services who come directly into contact with survivors of IPV, to help them provide more effective support.

Frontline workers will also be trained in how to spot the signs and symptoms that someone is suffering from a brain injury, to help them flag up vulnerable women.

Women who may come across as “difficult”, suffer from behavioural issues, memory loss, or struggle to complete basic tasks that would allow them to move forward into a life free from abuse, are actually most likely displaying symptoms of an undiagnosed brain injury.

“For gender-based violence research, this is so critical as it is not something that we have ever taken into account before,” says Karen.

“For those of us who work in the industry, it’s going to play a huge role in creating new support systems when we’re trying to help women be healthy and better.

“If you’re coming to this without any previous knowledge that perhaps there are other factors at play such as a brain injury, your level of empathy and patience, and ability to support that woman is severely diminished.

“We should be approaching every woman we serve based on an understanding that she probably has suffered at least one, if not more, brain injuries.”

This could be as simple as making small adjustments such as interviewing a client in a calming, dimly lit, environment away from other activity, as opposed to a brightly lit, noisy room.

“A simple step like that is very specifically directed at supporting someone who has a brain injury, and is something that frontline workers and shelters could be doing right now,” says Karen.

Their long-term goal is to create a community-based support referral network, bringing various support systems together, from medical care to occupational therapy and speech pathology, so that survivors who may have sustained a brain injury have access to a wealth of support on hand.

Paul is also developing a Concussion Awareness Training Tool (CATT), a web-based utility, originally designed for use in sports concussion.

It has proved hugely successful for educating and increasing awareness of concussion and TBI in the sports industry, and it is hoped it can do the same for those working with survivors of IPV.

“The idea is to create a new module of the CATT online, specifically for those working in the IPV sector, with the goal of increasing awareness of TBI in the population and then disseminating that as widely as possible,” he says.

“We hope to have that up and running and in place by next year.”

In the meantime, SOAR is already beginning to see results on the ground, with Kelowna Women’s Shelter leading the way.

“It’s the thing that is in mind for staff whenever they do an intake with a new client, or whenever they are dealing with a particularly challenging client,” says Karen.

“Five years ago that wasn’t the case, so we’re definitely seeing change.

“I know other shelters are now thinking about brain injury and I’ve had executive directors from other shelters tell me that it has changed the way they approach their clients.”

But it’s the survivors of IPV themselves who have seen most of the impact.

The fact that someone wants to listen and acknowledge their experience has given them a sense of empowerment.

“For women experiencing IPV this is their normal,” Karen explains.

“It might be normal to wake up and be dizzy because of the physical fight they had with their partner last night, or forget things all the time and he tells her she is just stupid.

“She internalises all those messages and it might never cross her mind that she actually has a physical condition that is a direct result of how her partner treats her.

“We’ve had women go through this process and almost have a sense of empowerment at the end, because they feel like they have a label for this, that it’s not their fault, and maybe there are things that can be done to help them.”

And ultimately, that is what the project is all about.

“The reality is, women make up more than half the population, and at least a third of them, statistically, will be in this situation.

“Many, if not most of them, will see some sort of impact to the head and possibly a brain injury,” says Karen.

“Brain injury can be a hidden injury and IPV is also often an invisible problem.

“In 2019, we’re still dealing with some of that shame and stigma, it’s still an issue that many people prefer to pretend doesn’t happen.”

Paul and Karen are not those people.

They are committed to increasing research into the impact of concussion beyond what might be seen in athletes, says Paul: “We know helping them achieve a healthy life, free from abuse, is good for all of us.”

It’s a good job then, that they both swiped right.

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Study reveals if body weight could increase the risk of stroke

Could body extra body weight have an effect on the brain? A new study investigates if it could have an increased risk of stroke or diabetes

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A blue measuring tape to mark a study on the effects of body weight on stroke and dementia

A new Australian study using UK data has shown that extra body fat could lead to brain atrophy which increases the risk of dementia and stroke.

Researchers found that increased body fat could lead to increased atrophy of grey matter and consequently the higher risk of declining brain health. They compiled the data from 336, 309 UK Biobank participants.

Stroke studies

The team analysed the genetic data of the participants within three metabolically different obesity types – unfavourable, neutral and favourable. This established if some bodyweight groups were more at risk than others.

The unfavourable and neutral adiposity subtypes were associated with lower grey matter volume. Metabolically favourable adiposity was tentatively associated with a higher grey matter volume.

The study was published in the journal Neurobiology of Ageing.

Read More: Investing in the future of rehab robotics

Results on body weight

The study did not find any conclusive evidence to link a specific obesity subtype with dementia or stroke. It did suggest that the possible role of inflammation and metabolic abnormalities and how they contribute to obesity and grey matter volume reduction.

The researchers highlighted that maintaining a healthy weight is key for public health. They stressed that there is a need to examine the type of obesity when assessing the impact on health.

Read more: Osteoarthritis: breaking the cycle

Further investigation

Dr. Anwar Mulugeta, a researcher in the Australian Centre for Precision Health at the University of South Australia said: “While the disease burden of obesity has increased over the past five decades, the complex nature of the disease means that not all obese individuals are metabolically unhealthy, which makes it difficult to pinpoint who is at risk of associated diseases, and who is not.”

He added: “Generally, the three obesity subtypes have a characteristic of higher body mass index, yet, each type varies in terms of body fat and visceral fat distribution, with a different risk of cardiometabolic diseases. We found that people with higher levels of obesity especially those with metabolically unfavourable and neutral adiposity subtypes had much lower levels of grey brain matter, indicating that these people may have compromised brain function which needed further investigation.”

Read more: New report reveals a higher number of people with a brain injury in the criminal justice system

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Police must be monitored for brain injury, argue researchers

Twenty-one police officers out of the 54 who took part in their study, all from the same police constabulary, reported having a traumatic brain injury (TBI).

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“Most of the head injuries were from general life experience, such as contact or extreme sports, and some officers were ex-armed forces,” says Huw Williams, associate professor of clinical neuropsychology at the University of Exeter.

Those with TBI were more likely to have experienced post‐concussion symptoms, which was associated with greater severity of PTSD, depression and drinking to cope.

The research supports findings that head injury can compound PTSD, which almost one in five officers have, and exacerbate drinking as a coping strategy.

The study is the first of its kind, and came about when researchers saw there was no data on the relationship between brain injury in police officers and their mental health.

“We did a brief scoping exercise of the literature, and were fascinated to see there was no research on brain injury in police officers, particularly in connection with brain injury and adverse mental health,” says Nick Smith, graduate research assistant at the University of Exeter.

Williams and Smith were surprised how many officers reported having a brain injury, although they expected there to be a relationship between TBI and adverse mental health.

We found that, when officers have a mild brain injury, where they were assaulted or in a car accident, they could have PTSD. When they have this with head injury it can be long lasting, and they can exacerbate each other,” says Williams.

“Despite being a relatively small group, the findings were robust enough to say head injury, in the mix with PTSD, depression and drinking to cope, might lead to negative long-term outcomes,” says Williams.

The findings, the researchers argue, highlights a need to tackle TBI and the consequences of post-concussion syndrome, which can cause irritably, poor concentration and memory issues.

The paper states that exploring TBI in the police could, identify a major factor contributing towards ongoing mental health difficulties in a population where, based on previous research, the implications of TBI should not be overlooked.’

“If it’s not properly treated, it could lead to greater absence from work, so it’s reasonable for police forces to pick up on these issues to mitigate risk of long term sickness,” says Williams.

“Otherwise, I can see it snowballing – chronic stresses increase over time and the weight of negative experiences become harder to carry.

“This leads us to think we need a better system in place to identify TBI, an alert system to allow people come back into operations or situations in a way that’s healthy so they’re not exposed to more risk,” Williams says.

In sports, for example, the protocol following a concussion is much clearer, Williams says, and helps to lower a player’s risk of having a second concussion while recovering from the first.

“England Rugby does a great job with concussion management protocols, they identify the problem then do something about it, ensuring people are in the right mindset to be doing a very demanding job,” Williams says.

Increased awareness of TBI in the police would be a natural progression from being aware of prisoners with TBIs, says Williams.

“I’ve worked in prisons looking at how common head injury is in people who end up in prison, and various police forces became interested in working with us in a trauma-informed manner, taking on a more broad view of the vulnerabilities of people they’re working with.

“But working from this perspective involves understanding trauma of people who provide services as well,” he says. “Sixty, 70 percent of the time, police are trying to manage and look after vulnerable people. It’s important to recognise how they can become vulnerable themselves.”

There needs to be a system and trauma-informed principles in place for police officers to manage their own vulnerability, Williams says – and he’s hopeful this will happen in the future.

“Initial conversations with forces indicate a healthy attitude towards trying to improve how can improve psychological wellbeing,” he says.

But this isn’t just up to forces themselves. It’s also important, Smith adds, to lessen divide between police and public.

“Police need help like us – it’s important to understand how trauma might affect them.”

Williams says police are often portrayed negatively in the media, and it’s important that the public is aware of why they make the decisions they make and the laws they have that could lead to them suffering trauma. 

PTSD, he says, is more likely to occur when officers don’t feel like society is backing them and the public doesn’t understand why they do what they do.

“It’s important for police to be understood as operating as people for people,” Williams says.

This will also require efforts from across probation, healthcare and education, Williams says, to better understand people from different backgrounds and how to build up empathy across society and reduce violence, as well as educating on the importance of identifying brain injuries when they occur.

Ultimately, Williams is hopeful that police forces want to give officers better protection from the consequences of TBI.

“Police officers need to think about myriad factors at same time, and we want them to be optimum capacity to do that,” Williams says.

This study was a pilot, and Smith hopes to do a much larger study in other police forces across the UK that controls for PTSD and depression to see if increases in post-concussion syndrome are due to head injury and not any other factors.

The first step, Smith says, is finding out the rate of TBI in the police force, then developing a tool to measure and monitor brain injury over time. The research, he says, will be done to help rehabilitate people with TBI, with the aim to help police understand the people they’re meeting, and vice versa.

Williams argues that this work is very relevant to public protection, and it’s important it continues.

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How two community services are making tentative steps to normality

As pandemic restrictions lift, brain injury services are starting to come back out of hibernation. Jessica Brown speaks to two Headway groups across the country to see how they’re resuming support offline.

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In Portsmouth, the local Headway has had a difficult time in recent months. Two service users have died from Covid-19, and another has been sectioned and taken to a secure facility after their mental health took a downturn.

There’s been a huge spike in mental health problems, and a few service users, who wouldn’t have done so under normal circumstances, have got in trouble with the police.

Most service users are gradually building their contact with the outside world again, with Headway’s help.

When lockdown began in March, service manager Deborah Robinson decided the best course of action was to identify the most vulnerable users and make sure she and her team maintained regular contact with them. The next challenge was gradually exposing them to more contact as restrictions began to ease.

“We regard it as a graduation – first is phone contact, then sitting in the garden with them, then inviting them on a walk once they’ve got confident enough to come out of their homes with us, then eventually we’ll suggest they come to a session with the group,” she says.

“Some people are too frail or anxious, so they won’t come out,” she says, “So we’ll have to carry on popping in to see them.”

This approach has proven particularly helpful in some ways, Robinson says. Before the virus, staff members hoped service users would speak up in sessions when they had a problem, but visiting people at home has allowed staff and volunteers to pick up on issues faster and get to know them better.

“One staff member met a service user in his garden, and noticed that the recycling bin was overflowing with alcohol. We knew he’d been a drinker in the past, so the staff member talked to him about his drinking, teasing information out,” Robinson says.

“He said he was drinking a lot, so we’ve been able to put in place goals to help him cut down on his drinking and put him in touch with AA, as well as various other things to help with a problem that reared its head in lockdown.”

Employees and volunteers, she adds, are also getting better at texting group members and touching base.

“It’s a mix of phoning people regularly and picking up the ones where there are issues. We’re getting more adept at that because it wasn’t something we did, and we’ve also picked up almost everyone’s carers because we’ve been talking to them to hear their concerns, too.”

Forty miles west in Salisbury, Headway arranged Zoom groups every week, but recognised that this option wasn’t suited to everyone.

“We were conscious to get actual face-to-face contact again, so as the guidelines have changed, we’ve thought about how we can work with that,” says Sarah Allen, service manager.

In recent weeks, online groups have continued, but staff members have started arranging small group meet-ups in various locations, including the outdoor café at Salisbury Museum, which Allen says provided a good learning opportunity.

One of Robinson’s major concerns in Portsmouth is how service users will react when they see other people not wearing masks or standing too close, and are told they have to adhere to guidelines themselves.

Allen, however, hopes meeting up in public places will help service users slowly accustom to these new ways of life.

“Some people coming to the groups haven’t been outside during the pandemic because all their activities have stopped, so it’s really important to model social distancing and hygiene behaviours,” Allen says.

“Somewhere like an outdoor café has been really useful because it’s about giving group members social contact in a setting where they can see people all around them modelling social distancing, staff wearing face masks and putting on hand sanitiser,” she says. “Then, when group members do go out and about more, it’ll be more familiar for them.”

In recent weeks, groups in Salisbury have also met up in a park, where they were able to socially distance.

Allen says coming out of lockdown and resuming services has been a learning curve for her, and she is realising that it’s sometimes more beneficial to have smaller groups than the maximum allowed by government guidelines. 

She knows she will have to continue to adapt in unknown ways as government guidelines change.

But the future remains uncertain. Headway Salisbury doesn’t have its own centre, so rents community rooms to host sessions instead – and none have reopened yet. Allen plans on continuing outdoor activities for as long as possible, but is uncertain of what will happen as temperatures cool.

“Going into autumn and winter poses a new challenge,” she says. “I’m not sure how we’re going to meet if the government guidelines if the maximum number of people who can meet indoors stays the same,” she says.

Meanwhile in Portsmouth, premises have been locked up for the duration of lockdown. Robinson has seen an increase in demand for services, so as things resume back to pre-Covid 19, she says here’s a lot of thinking to be done about how the service is going to expand to accommodate increased need. She anticipates the service will need to expand by a third.

Both Portsmouth and Salisbury Headway services adapted quickly when the lockdown came in March. Adapting back to how things were before looks like it will be a longer, more difficult path – but while Allen and Robinson have faced slightly different challenges over the last few months, there’s no doubt they’ve both found silver linings in the challenges thrown at them so far.

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