We wish to thank Dr John Corrigan for the invitation to orchestrate this topical issue on brain injury (BI) resulting from intimate partner violence (IPV). The articles in this issue address a long-neglected gap in research, education, and practice in both the IPV and BI literature. We include articles on traumatic brain injury (TBI) caused by external forces to the head and also potential hypoxic-ischemic brain injuries (HIBIs) from strangulation assaults. With 1 in 3 women globally reporting physical or sexual IPV, and up to 92% of blows being to the head, face, or neck,1 it is imperative that practitioners, decision/policy makers, and affected women be aware of this co-occurrence of IPV and BI and have access to necessary supports. IPV has been called the “shadow” or “parallel pandemic” to COVID-19, with BIs from IPV being recognized as a significantly increased concern now and for the foreseeable future.2,3 Furthermore, addressing violence and abuse among women with TBI has been identified as a research and practice priority including among women with lived experience of TBI and IPV.4,5 As such, the importance of the articles in this issue of the Journal of Head Trauma Rehabilitation (JHTR) should be particularly apparent as they highlight a range of topics pertaining to IPV-related BI, including prevalence data, clinical characteristics, and correlates, promising/tailored interventions as well as health systems data with national policy relevance.
UNDERSTANDING CHARACTERISTICS AND OUTCOMES OF NONFATAL STRANGULATION
This issue describes characteristics and correlates of nonfatal strangulation. We start with this to stress the importance of recognizing the potential of acquired BIs, or HIBIs, occurring from a strangulation assault. First, Bergin and colleagues6 recount information from women presenting for care to a community-based emergency department. Victims of nonfatal strangulation most commonly reported not only symptoms of neck pain and headaches but also signs of more severe injury such as loss of consciousness, dysphagia, and dysphonia. In addition, Valera and colleagues7 provide the first report of assessment of strangulation-related alterations in consciousness and relate them to objective measures of cognitive and psychological functioning. The data show relationships between a history of strangulation-related alterations in consciousness and working memory, long-term memory, depression, and posttraumatic stress symptoms.7
INCREASING OUR UNDERSTANDING OF NEUROBEHAVIORAL SYMPTOMS IN BOTH SURVIVORS AND PERPETRATORS
To further understand symptoms of women from a lifetime of trauma perspective, Saadi and colleagues8 examined the relations between child abuse and an IPV-related BI score reflecting neurobehavioral outcomes. They show that childhood trauma is positively associated with emotional and somatic neurobehavioral symptoms independent of BI; furthermore, they found that BI is positively associated with cognitive neurobehavioral symptoms in women who had experienced IPV-related BI. These data underscore the need to consider neurobehavioral symptoms in the context of the entire life experience of women rather than isolated to outcomes of BIs. Examining perpetrators of IPV, Portnoy and colleagues9 found that persistent postconcussive symptoms significantly predicted IPV perpetration after controlling for other common predictors. These data highlight the importance of evaluating and addressing postconcussive symptoms to decrease the risk of IPV perpetration.
UNDERSTANDING NEUROIMAGING CORRELATES OF IPV-RELATED BI
Adding to the growing number of IPV-related neuroimaging articles,10–12 Likitlersuang and colleagues13 conducted a pilot study that included groups of women who have sustained either IPV-related or other trauma-related TBI. Their data suggest that there may be effects on cortical thickness depending on whether TBIs were from IPV or other types of trauma.
PREVALENCE OF IPV-RELATED BI
Offering a global perspective, this issue presents novel contributions concerning the prevalence of IPV-related BI in 3 countries. Manoranjan and colleagues14 report a high suspicion of lifetime IPV-related TBI among 29% of adult women presenting to an Acquired Brain Injury Clinic in Ontario, Canada, with confirmed or suspected concussion. Gabbe and colleagues15 compared outcomes of major trauma patients with IPV-related BI with other interpersonal violence–related BI captured by a population-based statewide trauma registry in Australia. The findings reveal a higher proportion of IPV-related major traumas in women, with more severe and poorer long-term outcomes, including employment, than in persons affected by other types of violence.15 Finally, Saleem and colleagues16 report on IPV-related TBI from a New York Community Justice Center. Although all women who reported IPV had sustained a partner-related BI, only 40% of these women screened positive on a common BI screener (the HELPS). The authors noted that refugee status was associated with the number of IPV-related BIs, highlighting the importance of carefully assessing for BIs in this population.
ADDRESSING THE IMPACT OF IPV ON BOTH SERVICE USERS AND PROVIDERS DURING COVID-19
Two studies addressed the impact on service users and providers of IPV during the COVID-19 pandemic—one study from the perspective of survivors, executive directors/managers, frontline workers, and employer/union representatives,17 and the other from an emergency summit that involved a diverse set of stakeholders from a national IPV-TBI Knowledge to Practice Network.18 These studies report increased rates and severity of IPV, increased risks and complex challenges to mental health for service providers, as well as impact on employment for survivors. Key priorities identified include flexibility and adaptability of services through the use of technology; increased outreach; trauma-informed, anti-racist, equitable systems of care; the need for cross-pollination of knowledge between disciplines; and integrated and coordinated care at the system level. IPV-TBI resource materials from the summit are available in the Abused and Brain Injured Toolkit (www.abitoolkit.ca).19
PROMISING NEW DEVELOPMENTS IN PROGRAMMING AND KNOWLEDGE TRANSFER
Finally and critically, this issue highlights the impact of a promising health advocacy intervention, CARE (Connect, Acknowledge, Respond, and Evaluate),20 revealing improvements in agencies' and advocates' provision of instructional and functional social support to survivors of IPV-related BI. Survivors increased their knowledge, personal validation, and agency. These tools can be downloaded from the Centre for Partner Inflicted Brain Injury website (www.odvn.org/brain-injury). Also, a letter by Katherine Snedaker21 of Pink Concussion (www.pinkconsussions.com) provides information about the Partner Inflicted Brain Injury (PIBI) task force created in 2018. The task force meets monthly and serves as a focal point for professional education and networking that has led to collaborative research and knowledge transfer activities.21
We are very excited about this issue and extend sincere gratitude to all the contributors, the JHTR editorial board, and the reviewers for making this possible. The articles are highly relevant to the rehabilitation field as persons with disabilities, including persons with BI, are at risk of IPV and victimization. Women, in particular, have reported susceptibility to violence and abuse22 and, unfortunately, are often overlooked in the context of recognizing BI in IPV survivors. We are optimistic that the articles in this issue will further the field and prepare the way for additional research that will expand knowledge of IPV-related BI to other marginalized groups (eg, transgender women) yet to be examined.
Angela Colantonio, PhD, OT Reg. (Ont.)
Canada Research Chair in Traumatic Brain Injury
in Underserved Populations
Professor and Director
Rehabilitation Sciences Institute
Department of Occupational Science and Occupational
Temerty Faculty of Medicine
Dalla Lana School of Public Health
University of Toronto
Toronto, Ontario, Canada
Senior Scientist and Team Leader
Acquired Brain Injury & Society Team
KITE-Toronto Rehabilitation Institute-University Health
Toronto, Ontario, Canada
Eve M. Valera, PhD
Associate Professor in Psychiatry
Psychiatric Neuroscience Division
Department of Psychiatry
Harvard Medical School
Massachusetts General Hospital
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2. Valera EM. When pandemics clash: gendered violence-related traumatic brain injuries in women since COVID-19. EClinicalMedicine. 2020;24:100423. doi:10.1016/j.eclinm.2020.100423
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