Intimate partner violence (IPV) is remarkably prevalent (for women, lifetime prevalence has been reported as high as 1 in 3, and 12-month prevalence has been reported as high as 1 in 10) [1], leading to a variety of negative physical and mental health outcomes, including posttraumatic stress disorder (PTSD), anxiety, and depression [2]. Brain injury (BI) resulting from violent blows to the head, face, and neck or episodes of strangulation is increasingly recognized as part of the IPV experience [3-5]. The prevalence of IPV-caused BI (IPV-BI) is estimated at >70% [6,7]. Furthermore, strangulation is a common mechanism of injury in IPV [8] and often indicates an increase in the severity of BI. As such, nonfatal strangulation (NFS) is an important risk factor for negative health outcomes in people who experience IPV [9]. NFS is commonly a repetitive rather than an isolated event, and is used to exert control by inducing feelings of pain and helplessness [10]. NFS can lead to BI by one or more of the following mechanisms: (1) anoxic or hypoxic BI due to compression of the trachea; (2) ischemic BI due to occlusion of arterial blood flow; (3) hypoxic-ischemic BI due to the combined compression of the trachea and the carotid arteries or due to the triggering of carotid sinus reflex leading to dysrhythmia or cardiac arrest, which subsequently could cause BI; and (4) pressure-related BI due to the occlusion of the jugular veins leading to venous congestion, increased intracranial pressure, blocking of the removal of metabolic byproducts, and pinpoint hemorrhage [7,11,12].

Survivors of IPV-BI demonstrate cognitive impairments (eg, deficits in memory, attention, reasoning, planning, and executive functioning) [13], psychological or emotional disturbances (eg, depression, anxiety, fatigue, and PTSD) [5,13], and sensorimotor problems (eg, paralysis or paresis of facial or extremity muscles, numbness, loss of sensation, muscle spasms, facial droop, and unilateral weakness) [14], which ultimately impacts the quality of life (QoL). Therefore, therapeutic treatment for survivors of IPV-BI is crucial, and any physical or cognitive impairment in these survivors requires therapeutic interventions similar to those for BIs from other injury mechanisms (eg, sport-related concussion and car accidents). Effective therapeutic interventions would not only improve the QoL of survivors of IPV-BI but also have the potential to prevent longer-term neurodegeneration if early detection is possible and timely treatment is provided [15].

In the case of BI from other causes, individuals often access rehabilitative resources through the health care system [16]. Given the goals of care outlined by the Canadian Medical Association, resources are positioned to assess and treat both short- and long-term effects of BI, with the overarching goal of complete recovery. Rehabilitation is individualized and may include a range of services spanning emergency care to physical or occupational therapy [17]; however, differential access is common. Women who have experienced IPV-BI are chronically underserved [4,7,18]. This is in part due to the failed recognition of IPV and an inability to link IPV and BI within the more comprehension health care system. The complexities surrounding IPV, such as safety, stigma, and child custody concerns, discourage survivors from accessing primary health care. If survivors do access primary health care, they may not feel comfortable or see marked benefit in disclosing the cause of their injuries [19]. Disclosure of IPV in health care settings is further influenced by negative health care provider attitudes, survivors’ perception of safety, and concerns about the consequences of disclosing. Importantly, help-seeking behaviors are intersectional and may also be influenced by race, ethnicity, gender identity, or sexual orientation [20]. As a result of these factors, evidence-based therapeutic interventions to improve the QoL of survivors of IPV-BI are still lacking. Therefore, in collaboration with ABI Wellness, our team has developed a rehabilitation program termed the “community support network” (CSN) rehabilitation intervention specific to IPV-BI. Traditionally, health care and community supports that offer services for those who have experienced IPV typically do not take IPV-BI into account. Recent Canadian research by Nicol et al [21] found that 75% of the women’s shelter workers in a national sample reported they did not screen for BI following IPV [21]. The challenge in assessing IPV-BI is further complicated by the increased risk of psychopathological comorbidities such as PTSD, depression, anxiety, and substance use that can mask or exacerbate BI symptoms. Cumulatively, the need for a rehabilitation intervention spanning primary health care to independent activities of daily living is evident. Therefore, by definition, the support provided to survivors must be multifaceted, multidisciplinary, integrated, trauma- and violence-informed, and culturally safe.

Following BI, the recovery trajectory is strongly affected by the severity of the injury. In mild cases, 80% of individuals with a concussion or mild BI make a complete recovery. However, a portion of individuals experience persistent symptoms, cognitive impairments (eg, deficits in executive function and working memory, reduced processing speed and attention, difficulty in focusing, and difficulty with word recall), and reduced QoL for months to years after the injury. We propose that this gap in recovery is related to higher-order cognitive functions and, by targeting these core functions through rehabilitation and regaining function through the CSN rehabilitation intervention, individuals can return to a complete and meaningful life after the injury.

With all this in mind, this study protocol aims to evaluate a community-based, neurorehabilitative intervention to improve outcomes for survivors of IPV and IPV-BI.

The primary objectives of this study protocol are as follows:

The secondary objectives of this study protocol are as follows:

This study will follow a pre- and postexperimental study design. Subsequently, a comparative study will be conducted by recruiting a control group receiving usual care.

Self-identified women (aged 18 to 50 years) who are survivors of IPV (disclosed) and IPV-BI (Brain Injury Severity Assessment [BISA] score ≥1) [5] will be eligible for recruitment to this study. Although IPV is not exclusive to women, this protocol study will only examine women. This approach was selected for two primary reasons: (1) the prevalence of reported IPV is higher in women compared to men [1] and (2) the infrastructure currently available for women who experience IPV is adequate to support recruitment into the intervention. The realities of recruiting self-identified women for a study of this nature are both impactful, from a survivor standpoint, and achievable, from a CSN approach.

Exclusion criteria will include current pregnancy; any diagnosed neurological disorder known to affect cerebrovascular, neurocognitive, or sensorimotor function (eg, stroke, Parkinson disease, Alzheimer disease, cerebral palsy, multiple sclerosis, migraine, or seizures); and taking medication that might alter blood pressure. Participants will be tested in the early follicular phase or, if they are on combined hormonal contraception, at the end of the week they have stopped this contraception.

Recruitment will occur through partnerships with the Nanaimo Brain Injury Society (Nanaimo, British Columbia), the Central Okanagan Elizabeth Fry Society (Kelowna, British Columbia), William and Associates Counselling Services (Kelowna, British Columbia), and Connect Counselling and Therapy (Kelowna, British Columbia). Potential participants will be made aware of the project through promotional media and by direct staff referral within partner organizations. Potential participants will be screened by the research coordinator for eligibility using the adapted HELPS BI assessment tool [22].

The study has been reviewed and approved (H20-02412) by the behavioral ethics board at the University of British Columbia, Okanagan.

Participants who agree to take part in the study will be asked to provide informed consent and will be reminded that they can withdraw from the study at any time.

The identity of participants will be kept secure by storing consent forms and any other documents that could be used to determine the participants in a locked filing cabinet in the office of the senior author (PvD). Data will be deidentified and anonymized using codes so that participant information will remain confidential.

Participants will be compensated a total of CAD $550 (US $405.45) across the different components of the project for contributing their time and effort.

The CSN intervention is an evidence-based, multipillar, interdisciplinary rehabilitation program grounded in the ABI Wellness Brain Enhance And Recovery System (BEARS) program platform, with additional components incorporated to support the unique needs of survivors of IPV-BI.

To generate and design a study with adequate power, we estimated the required sample size based on previous data from our laboratory in both healthy participants and those with IPV-BI [34,35]. Power calculations are based on the desired end point to detect a change in each of the assessments across testing times. Therefore, assuming our published SDs for these measures and considering the potential for increased variability in this study population, a total sample size of 100 participants would provide a >90% probability that the study will detect a significant change score at a 2-sided 5% significance level.

The objective of this project is to evaluate the efficacy of a CSN intervention for women who have experienced IPV-BI. This will be accomplished by quantitatively measuring resiliency, QoL, and neurocognition before and immediately after the intervention. A follow-up assessment will occur 3 months after the completion of the intervention to evaluate the maintenance of any gains in function. The mean (or median) for each assessment will be compared across testing times using 1-way ANOVAs. Relationships between BISA scores and the change scores for each assessment will be evaluated using regression analysis. Furthermore, the outcome of the intervention will be compared among various subgroups based on the findings of various mental health screening tools (eg, participants with PTSD vs participants without PTSD), substance use, and adverse childhood experience (eg, participants with adverse childhood experience vs participants without such experience). Various demographics and mental health screening assessments will be used to control for nonspecific effects of IPV. In addition, we will have opportunities to better characterize IPV-BI based on the BI load from the BISA tool, findings of various mental health screening tools, and cognitive findings using the Creyos assessment and task-switching paradigm. The α value will be set a priori at P<.05. All data will be analyzed using SPSS (IBM Corp).

We will take appropriate precautions to minimize potential risks associated with the proposed study. The participants are not expected to encounter any substantial physical or mental risks as a result of this study. The BISA and other psychosocial assessments will be conducted by a trained research coordinator who has substantial career experience directly supporting survivors of IPV, previously at a women’s shelter and currently at a community agency as a victim support worker. She is well-versed in trauma- and violence-informed practice and will take all the necessary steps to protect participant safety and well-being. In addition, the assessments will be conducted at the community agency with which the participants are already familiar and where trauma support services are in place and readily available should they be required. We will also develop a series of participant safety protocols that outline how the research coordinator will identify suicidal ideation and risk factors for suicide, participant safety, and child safety and what actions she will take if required. All participants will be undergoing clinical counseling as part of the study and may have received professional support resulting from their trauma and abuse. Nonetheless, completing the testing involved in this study may trigger painful memories and create a triggering state. If the participant expresses any concerns during the data collection that suggest the need for immediate attention, they will be counseled by the research coordinator or participant navigator, both of whom will have strong professional backgrounds supporting survivors of gender-based violence. The assessment and intervention administration will be based on the trauma-informed approach (TIA). Research team members will be trained to follow TIA. All interviews and mental health screening instruments will be completed with each participant privately. The mental health screening process will be conducted by the research coordinator who will have to complete specific training and practice with all instruments and interview schedules.

To the best of our knowledge, this will be the first study to systematically investigate the efficacy of an evidence-based, multipillar, interdisciplinary rehabilitation program in improving resiliency, QoL, and neurocognitive functions in women who have experienced IPV-BI. All components of the CSN program are evidence based and have shown a positive impact on QoL in people with TBI and those with various other forms of BIs [26-29,31]. This intervention also aims to take advantage of the neuroplastic benefits of its various components [24,25,29]. In addition, this intervention will be administered based on TIA that addresses traumatic experiences with the goal of reducing symptoms and optimizing therapeutic outcomes [30]. Therefore, we anticipate improvement in resiliency, QoL, and neurocognitive functions with the CSN intervention in women who have experienced IPV-BI. Moreover, we expect that the CSN intervention will be feasible in terms of recruitment, adherence, and retention because it has been successfully implemented to address physical and cognitive impairments in individuals with BI from various causes. Furthermore, the CSN is IPV-BI specific in that it is structured with the addition of TIA, counseling, a participant navigator, and peer support.

This efficacy and feasibility study will help to address the current gap in the intervention study aimed at improving resiliency, QoL, and neurocognitive functions in women who have experienced IPV-BI. Successful implementation will help to support future full-scale comparative studies and randomized controlled trials.

The proposed study will not be without limitations. The lack of a comparative control group will be a limitation. Having a comparable control group to an IPV-BI intervention group is a substantial challenge. Furthermore, an IPV-BI–specific gold standard rehabilitation intervention is not available, which makes a comparative study with a control group even more challenging. However, the addition of an appropriate control group would obviously strengthen the outcome of the CSN intervention; therefore, it is a recommendation for future studies. Having limited recruitment sites within a specific geographical region could limit the pool of participants and the generalizability of the findings of this study.

This will be the first intervention study of its kind to examine the impact of a rehabilitation intervention on resiliency, QoL, and neurocognitive function in women who have experienced IPV-BI. If this intervention is successfully implemented and its effectiveness is demonstrated, the findings will not only benefit individual participants and their families but could also have far-reaching implications for policy makers, service seekers, and service providers.