JOINING FORCES

Joining Families

Volume 18, Issue 5 • Winter 2020

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

Traumatic Brain Injury and Intimate Partner Violence:
Awareness, Recognition, and Rehabilitation
Interview with Angela Colantonio, PhD, OT Reg. (Ont.), FCAHS, FACRM andHalina Haag, MSW, RSW, PhD(c)Angela Colantonio, PhD

Dr. Colantonio is a Professor of Occupational
Science and Occupational Therapy and Rehabilitation Sciences at the University of Toronto
where she holds a Canada Research Chairon Traumatic Brain Injury in Underserved
Populations. She is also a Senior Scientist at
the KITE-Toronto Rehabilitation InstituteUniversity Health Network, where she leads
the Acquired Brain Injury and Society team.

In This Issue

The focus of this issue is traumatic brain injury (TBI) in the context of
intimate partner violence (IPV). Why is this interrelation important? TBI isa frequent result of IPV due to blows to the face and head, being thrown
about against a wall or floor, and non-fatal strangulation. The outcome isparticularly severe when TBI occurs repeatedly. Our interview is with Dr.
Angela Colantonio, the Director of the Rehabilitation Sciences Institute at the
University of Toronto, and Halina Haag, of the Wilfrid Laurier University inWaterloo, Ontario. The interview focuses on TBI and its impacts on mental
health, return to work, and social integration of women survivors of IPV withbrain injury. A separate article explains the gendered experience of TBI, andanother gives basic information on the physical, psychological, and social
impacts of TBI. Our statistics article focuses on odds ratios and confidence
limits, measures that are often encountered in comparisons of populations,particularly regarding risks. Finally, we have identified websites of interest
with resources for those who have sustained TBI and for their caregivers.
CONTENTS
Traumatic Brain Injury and Intimate Partner Violence: Awareness,
Recognition, and Rehabilitation.....................................................................1
Building Bridges to Research: Odds Ratios and Confidence Intervals............6
What is a Traumatic Brain Injury?..................................................................7
Sex and Gender in Traumatic Brain Injury....................................................10
Websites of Interest.....................................................................................12

Dr. Colantonio leads an internationally recognized program of research on acquired brain
injury with diverse foci on women, sex andgender, work-related traumatic brain injury,
and under-served populations. She is a Fellow of
the Canadian Academy of Health Sciences, theAmerican Congress of Rehabilitation Medicine
and the American College of Epidemiology. She
was the 2020 recipient of the Brain Injury Association of America William Fields CavenessAward, which recognizes research that has madeoutstanding contributions to bettering the lives ofpeople with brain injury.

Halina Haag, PhD(c)Halina (Lin) Haag
is a Contract Faculty Member and
PhD candidate inSocial Work at Wilfrid Laurier University in Ontario,
Canada. Her work
focuses on the gendered experienceof traumatic brain
injury and the impact on mental health, return
to work, and social integration encounteredby brain injured women survivors of intimate
partner violence. Lin is committed to improving outcomes through direct practice, innovative
research, and professional education, believingthat increased knowledge and understanding is
key. As someone with lived experience of TBI, she
has been a guest speaker addressing issues of disContinued on page 2

Interview with Angela
Colantonio and HalinaHaag, from page 1

ability, brain injury, and marginalization for avariety of international academic, professional,
and community-based organizations.


A key message fromsurvivors is thatpeople need to ask
more. There is still astigma, there is still asilencing around IPV
and around TBI.

Dr. Whalen: How did you become interested
in interpersonal violence-related brain injury?
Dr. Colantonio: Early in my career I noticed
the gap in terms of brain injury and intimate
partner violence (IPV). Our lab at the theUniversity of Toronto has had a long-standing
focus on marginalized and underrepresented
populations and addressing sex and genderwith respect to traumatic brain injury (TBI).
We have looked at the prevalence and extent ofbrain injury in persons in marginalized groups
such as the homeless, those in the justicesystem, and persons injured due to violence.
These are often overlapping populations.
We produced the first papers in Canada
on brain injury and IPV looking at the gaps inknowledge regarding brain injury and frontline providers. We have addressed assault as amechanism of injury looking at how intentional injury might differ from other mechanisms
of injury in TBI. Also, we led the first international workshop on women and brain injury incollaboration with the American Congress of
Rehabilitation Medicine.

JOINING FORCES
Joining Families
Joining Forces Joining
Families is a publication of
the Center for the Study ofTraumatic Stress (CSTS) andthe U.S. Army Installation
Management Command.
The CSTS is part of the
Department of Psychiatry,
Uniformed Services
University (USU), Bethesda,
MD 20814. The USU is the
US national federal military
medical school.

EditorRonald J. Whalen, PhD, LMSW
Research Assistant Professor
Department of Psychiatry, USU
e-mail to ronald.whalen.ctr@usuhs.edu(301) 319-8003
Editorial Consultants
Joshua C. Morganstein, MD
Captain, US Public Health Service
Assistant Director, CSTS
Associate Professor and Assistant Chair
Department of Psychiatry, USU
James E. McCarroll, PhD, MPH
Research Professor
Department of Psychiatry, USU
Assistants to the Editors
Alexandra Burris, BA
Britany Mullins-Husain, BA

2 • Joining Forces/Joining Families

We received funding from the Federal
Department of Justice to help with the development of our web-based toolkit (Abused & Brain
Injured) to draw attention to the intersection
between IPV and brain injury. It is evolving
to provide information, resources, researchand practice recommendations for providing trauma-informed service delivery (www.
abitoolkit.ca).
We received a large grant funded by the
Ontario Ministry of Health and Long-TermCare focused on the integration of TBI, mental
health, and addiction, again, working collaboratively with major stakeholders aroundthese topics. It aimed to address brain injury inunderserved populations such as homeless andpersons in the justice system, and to include
intimate partner violence (IPV) because there
is so much overlap in these underrepresented
populations. I should say too that I have been
recently awarded a Canada Research Chair inTraumatic Brain Injury in Underserved Populations. The first term is seven years and includes
a focus on IPV. We were fortunate to have
Halina Haag, who has training in social work,
join our lab and take on a leadership role in thiswork as a doctoral candidate.
Halina Haag: I came to work with Angela
as I was drawn by her research interests andthe opportunity to work with her in an interdisciplinary collaborative group. I had worked
alongside of social workers who perform a lotof the frontline work in the IPV context and I
knew that there is little conversation about TBI.
I just thought, “This is something that reallyneeds more attention.” I felt very passionate
about committing to this work.
Dr. Whalen: You touched upon critical gaps
in TBI research. Would you elaborate on that
topic?
Dr. Colantonio: I believe this field is in its
infancy. There is a huge information gap. We
do not have good prevalence numbers. Having national estimates that cover the full rangeof brain injury is very important. In addition,much of the data on TBI research on womenwith an IPV is based on a range of different
types of samples and some studies that include
shelter populations have found that the prevalence of TBI is high. The World Health Organization indicates that one out of three womenare affected by IPV in their lifetime
Continued on p. 3
Winter 2020

Interview with Angela
Colantonio and HalinaHaag, from page 2

Information has
a huge impact on
the experience of asurvivor. Literaturesuggests that sharedexperience, theunderstanding ofwhat is happening to
yourself in relation towhat has happened
or is happening withothers, is helpful.

http://www.CSTSonline.org(https://www.who.int/news-room/fact-sheets/
detail/violence-against-women). The mostcommon sites of injury are the head, face, andneck, but our research shows that there has
been minimal training in this area for frontline
providers.
Some TBI screening instruments, like the
HELPS (Picard, Scarisbrick, & Paluck R, 1991),
have been published, but I do not believe there
is one that has been validated to address IPVin this context. There need to be protocols forthe screening. There are risks associated withbeing a brain injury survivor. It is importantto remember to do no harm in the process of
screening.
Halina Haag: A lot of people say “screening,
screening, screening,” but not how to do it in amanner that respects the dignity and the choiceof the person. That needs to be worked out as
well.
Dr. Colantonio: Another side to screeningis the context where this may take place. One
needs to make sure that your facility is accessible to people who may have some of theconsequences of a brain injury. The facility
needs to consider having a setting that canminimize distractions and sound, if needed.
Some of these individuals also have sensitivity to light. They may need written instructions and reminders for appointments. Thereis also some good evidence for the success ofcommunication partner training relevant topersons with TBI leading to positive changes
in communication outcomes with community
members like police (Togher, McDonald, Code,& Grant; Wiseman-Hakes et al., 2020). Training communication partners has the potential
to improve conversation outcomes for persons
with TBI and provide more accessible environments. These could be implemented universally
so nobody has to self-identify as brain-injured
or as a victim of IPV because the communication processes and strategies are incorporated
into your everyday structure.
Women want information on the effects
of TBI, to put a label on what they are feeling.
They want to know that there is something
biologically wrong and that it is not an issue ofmotivation or personal failings. There is something biological that might explain why things
like appointments might be missed.
Halina Haag: Information has a huge impact on the experience of a survivor. Literaturesuggests that shared experience, the understanding of what is happening to yourself in
relation to what has happened or is happening

with others, is helpful. “I am not just losing
my mind. There is a physiological underlying
condition that has created this in me.” That is
a very common refrain from survivors of TBI.
I have no reason to believe that this does not
apply to the IPV context as well and, in many
ways, is amplified, because they are getting
messages of “You’re stupid. You’re useless.
You’re not valuable as a human being. You can’teven make appointments. You cannot do yourhomework.” They hear this from an abuser, butalso frequently in their interactions with support structures. There is a disconnect between
the understanding of a frontline worker and the
behavior of a survivor. We are working hard tofind the balance. How do we provide this forsurvivors and empower them through knowledge and understanding without putting themat further risk and, as Angela says, how do we
do no harm?
Dr. Whalen: There are certainly risks
associated with screening, but there are alsorisks for TBI not being identified and going
untreated. What do frontline workers need toknow about TBI?
Dr. Colantonio: Frontline workers absolutely
need to know about brain injury. In the toolkit
we have red flags that are pretty well-known
and are part of standard concussion evaluation.
Some examples are: headaches that worsen,neck pain, looking very drowsy, repeated vomiting, inability to recognize people or places,
increasing confusion, weakness or numbness inarms or legs, unusual behavior change, increasing irritability, and loss of consciousness. You
want people to know about these red flags andto know to call for immediate help.
Halina Haag: One of the challenges is thatso many of the symptoms that Angela wasdescribing can be misinterpreted as somethingelse, as substance use or defiance, and may often
be overlooked. There are layers of challenges inthe sense that people will look at behaviors andattribute them to something completely different because there is a lack of recognition of thesymptoms of TBI. When we look at a football
player who doesn’t get up right away and shakes
his head a little bit, there is an immediate response of “Are we dealing with a concussion?”
There are protocols in place for that. But we arestill not thinking about underlying trauma to
the brain when looking at women, even when
Continued on p.4
Joining Forces/Joining Families • 3

Interview with Angela
Colantonio and HalinaHaag, from page 3

I think we needto step aside,at least for the
moment, from theidea of diagnosis
for treatment andmove towards
a model ofidentification orawareness foraccommodationand support.

there are physical signs of extreme violence tothe head, face or neck.
For some women with TBI, it is extremely
important that they receive immediate medicalcare. There can be significant medical implications when there are hits to the head, face, andneck. If you are looking at repeated exposure
within a short period of time you could have“second impact syndrome”. A minimal amountof basic information handed out to the frontline worker can aid them in making thosecritical observations and decisions. Then, how
do we refer women out into our communities
in such a way that they are safely able to accesssupport?
I think we need to step aside, at least for the
moment, from the idea of diagnosis for treatment and move towards a model of identification or awareness for accommodation and support. We do not need to put another label onsomebody that potentially puts them at higher
risk. We need to become aware of what we areseeing from a survivor’s behavior compared towhat we expect to see, and is there a disconnect between the two? There are low cost, easyto-implement solutions that organizations can
put in place. It is about letting them know what
to look for. The tools that Angela mentioned
are very helpful for the people who are talking to the survivors: “What do I need to know
to make this assessment?” Are they looking at
someone who has a chronic ongoing situation
where they need some extra support in termsof memory tasks and organizational capacity
and safety planning?
Dr. Colantonio: We have spoken about
people in the justice system being a marginalized group. Rates of abuse are high prior to incarceration and often there are early life experiences of physical and sexual abuse, particularly
for women. These settings are overwhelmingly
focused on mental health and addiction,
but TBI could be a factor in the treatment ofvictims in terms of consequences of a brain
injury like impulsivity. Having an awareness ofsome underlying causes of these problems canenhance a more effective treatment response.
Halina Haag: I want to highlight someof the implications of marginalization in thegroups we have described and to note that
their experiences are different and complex.
Intimate partner violence happens across a
broad cross-section, but the more you layer
marginalization on top of that, the harder it
is for women to overcome their situation andescape. While it is massively overrepresented

4 • Joining Forces/Joining Families

in women, it is important to remember that IPVwith TBI does happen to all genders. TBI canalso be a precursor to marginalizing conditions
such as being homeless or incarcerated. Being exposed to IPV is much more likely for people whohave a TBI. So, I think you have a bit of a chicken
and an egg situation.
When someone sustains a TBI, often throughsome perfectly innocuous event, their judgment
and decision-making may be impaired. They may
experience substance use or other challenges
and end up in the criminal justice system where
they can experience more violence and there isa greater likelihood of further injury. It is really
important to look at lifetime history of TBI andhow that increases the risk of negative outcomes.
Dr. Colantonio: As written by Wayne Gordon,
a leader in the field in New York (https://www.
brainline.org/article/tbi-research-review-unidentified-brain-injury), we are trying to prevent social
failure through providing some support and rehabilitation after brain injury so we do not havesome of these negative consequences.
Dr. Whalen: If we assume that the mental healthparadigm will continue to dominate the field,say focusing on PTSD or depression, how would
you recommend helping clinicians to prioritize
treatment?
Dr. Colantonio: There has to be a tailoredapproach to the individual. We have guidelinesthat are comprehensive in terms of what should
be examined. With brain injuries, one of thechallenges is that no two brain injuries are alike.
PTSD is an overlapping condition with brain
injury, but some of the symptoms are different.
These are important considerations in assessing
PTSD.
Halina Haag: A lot of what we have called
PTSD historically, may have a lot more to dowith TBI than we previously understood. Equally, for what we think about in terms of mental
health treatment for depression and anxiety.
These conditions are very often-seen with TBI.
Knowing that there is an underlying brain injury
component can change how you want to intervene for the depression or anxiety.
Dr. Colantonio: It is important to have anappreciation for what all rehabilitation professionals can provide in terms of care and to keepa broad focus on that. Supporting survivors toengage in or return to employment through vocational rehabilitation and/or occupational therapy for instance, can be very empowering. Other
Continued on p. 5
Winter 2020

Interview with Angela
Colantonio and HalinaHaag, from page 4

Another area ofinterest is thatof sleep and TBI.
The importance ofsleep to recovery
has been very
underappreciated.

http://www.CSTSonline.org

providers of rehabilitation are speech-language
pathologists who can address problems related
to speech and social communication. Physicaltherapists can assist with therapeutic physicalactivity and psychologists and other providers can offer cognitive behavioral therapy andmindfulness-based approaches, for example.
Another area of interest is that of sleep
and TBI. The importance of sleep to recovery
has been very underappreciated. As part of a
doctoral thesis, one of my students showed thatwhen sleep was treated and targeted, persons
with TBI show significant improvements ina variety of the outcomes. Some people havesuffered with trauma-related sleep disorders fora very long time that were not being addressed.
Again, some of the symptoms related to anxiety
and depression may have been due to an underlying sleep disorder.
We should also note that perpetrators havebeen found to have a higher than expected
lifetime brain injury. A lot of programs do notaddress the perpetrator side, but it is an important consideration. The problem may be bigger
than just the woman being affected. We know,for example, that TBI can be associated with
impulse control.
Halina Haag: Much of our work is about
education, whether it is somebody who isthrowing the punch or somebody who isreceiving it. We are giving those who support
these populations tools for their toolbox. It is
not about telling them how to do their job. It
is not about giving them another checklist thatthey need to go through at a very specific timeand make a diagnosis. It is about an awarenessand a sensitivity to issues that are prevalent on
both sides of the fence, victim and perpetrator.
One of the things that we can do is to try
not to be the ones who are leading the agenda.
Rather, we can continually go back to ourcommunity partners and to our network toseek guidance. Over the past five years, wehave built our Knowledge to Practice Network(K2P Network) with a significant number ofmembers who have joined for the purpose ofdisseminating information and contributing
to the work we are doing (Haag et al., 2019).
If we need research partners or we are looking
for stakeholders for a project, we go to the K2P
Network. Before we sit down and start thinking up the next research project and looking
for funding, I usually put in a couple of phone
calls and say, “What are you experiencing?
What are you seeing on the front lines? Whatdo you think is the next step?” The people whohave the best sense of what is happening are thepeople who are living with it every day, either
in terms of a survivor perspective or a service
provider. We have had contacts from police
forces, nurses who are in emergency rooms,
and shelter organizations in direct IPV service.
Dr. Whalen: There are other risks associatedwith a brain injury. Could this information be
used by an abuser to get custody of children or
to work against the person affected? Is there
evidence that this kind of information has
been used for custody battles or other legal
proceedings?
Halina Haag: In terms of evidence, at thispoint it is largely anecdotal. We hear concerns
from frontline workers, people in the IPV sector with legal backgrounds and from survivors
themselves regarding their concerns and experiences. We do not have specific data on therelationship between a diagnosis in this context
and outcome in a legal context because the field
is in its infancy. But, we have raised the issue ofrisk and the need for consideration of whether
we are potentially putting women at further
risk of harm and for what gain in terms of what
services are there to support them.
Dr. Whalen: What are some additional the
topics on TBI and IPV that we should be talking
about?
Dr. Colantonio. We have addressed how
brain injury might be different in terms of sex
and gender. We found that among ninety thousand concussions presenting in an emergency
room, women are more likely to have comorbidneck injuries likely due to weaker neck musculature. This held true for a range of mechanisms of injury such as motor vehicle collisions,sports, as well as assault-related injury. It is
important to create that awareness among practitioners. Also, from the sports injury literature,
it seems to support that girls and women canhave a longer recovery time after concussion.
Halina Haag: I would like to give you a final
perspective from survivors. A key message
from survivors is that people need to ask more.
What we are hearing from survivors is that they
are not being asked about IPV and TBI. Thereis still a stigma, there is still a silencing around
IPV and around TBI.
Dr. Colantonio: Finally, some of our education materials are not meant for indigenous andContinued on p. 6
Joining Forces/Joining Families • 5

BUILDING BRIDGES TO RESEARCH

Odds Ratios and Confidence Intervals
By James E. McCarroll, PhD, Ronald J. Whalen, PhD, Joshua C. Morganstein, MD,
and Robert J. Ursano, MD

Multiple injuries were
almost three times as
likely to be reported
by abused womencompared to nonabused women.

Interview with Angela
Colantonio and HalinaHaag, from page 5

What are the odds of…? This is a question
we often ask ourselves, whether we are playing the game tables in Las Vegas or making
some other important decision. In behavioral
research, this question is often about whether
there is a significant difference between two
groups and, if so, how much of a difference.
For example, the odds of a smoker developing lung cancer compared to a non-smoker ismuch greater for those who smoke cigarettes
compared to those who do not smoke cigarettes.
An odds ratio can be a useful comparisonof events in family violence. For example,
differences between the reports of abused andnon-abused women were compared in a studyof 380 who reported a history of abuse and 358
reported never being abused. When the reports
of injuries by abused women were compared
to injuries reported by women who were notabused, multiple injuries were almost threetimes as likely to be reported by those whoreported abuse (Anderson, Stockman, Sabri,
Campbell, & Campbell, 2015). This result was
based on the odds ratio of 2.75 with the 95%
confidence interval (CI) of 1.58-3.57. A 95%
CI means that there is 95% confidence that theinterval defines a range of values that contains

the odds ratio and the values are not due tochance. The range of the CI shows that there
was a statistically significant difference between
the two groups because the values of the lower(1.58) and upper boundaries (3.57) of the CI
do not include 1.0. The interpretation of theboundaries of the CI indicate that the odds ratio
could be from 58% higher (1.58) to as much as257% greater (3.57) when abused women werecompared to non-abused women.
The important points to remember fromthis example are (1) that an odds ratio greaterthan 1.0 indicates that the exposed group(abused women) has a higher likelihood of injuries than the comparison group (non-abused
women); (2) the confidence interval does notinclude the value of 1.0 indicating that thedifference in the two groups is significant; and(3) there is 95% certainty that these values areaccurate.

black women. They may need a completely different approach and more research needs to be
done. In addition, the leadership should comefrom those underrepresented groups.
Halina Haag: One solution is not going to
fit everybody and it needs to come from thecommunities that are experiencing them. We
can support that, but I do not think we can be
the driving force.
Dr. Colantonio: I also want to say that thiswork that we have described is not about one
person. It is many people. We have many terrific collaborators, trainees, people like Halina,
and supporters. We try to incorporate the enduser perspective in the work that we do. So, a
lot of recognition goes to everyone who has
contributed to our research program.

References

Dr. Whalen: Thank you both.
6 • Joining Forces/Joining Families

Reference

Anderson, J. C., Stockman, J. K., Sabri, B., Campbell, D. W., & Campbell, J. C. (2015). Injury
outcomes in African American and African
Caribbean women: the role of intimate partner
violence. Journal of Emergency Nursing, 41(1),36-42.

Haag, H. L., Sokoloff, S., MacGregor, N., Broekstra, S., Cullen, N., & Colantonio, A. (2019).
Battered and brain injured: Assessing knowledge of traumatic brain injury among intimate
partner violence service providers. Journal of
Women’s Health (Larchmt), 28(7), 990-996.
Picard M., Scarisbrick D., & Paluck R.
(1991). HELPS Brain Injury Screening Tool.
International Center for the Disabled, TBINET, United States Department of Education, Rehabilitation Services Administration,
Washington, DC.
Togher, L., McDonald, S., Code, C., & Grant, S.
Training communication partners of people
with traumatic brain injury: a randomized
controlled trial. Aphasiology, 18, 313-335.

Continued on page 11

Winter 2020

What is a Traumatic Brain Injury?
By James E. McCarroll, PhD, Ronald J. Whalen, PhD, Joshua C. Morganstein, MD,
and Robert J. Ursano, MD

Recovery from TBI is
influenced by severityof injury, age, gender,prior concussion,
health history, andthe presence ofcomorbidities andvulnerabilities.

http://www.CSTSonline.org

A traumatic brain injury (TBI) is one of
two types of acquired brain injury (ABI). Thatis, an injury to the brain that has occurred after
birth. ABI can be non-traumatic or traumatic.
Non-traumatic brain injury can occur in a variety of ways such as from a stroke, tumor, or a
cardiac arrest that deprives the brain of oxygen
and results in brain damage. TBI occurs whena force to the head or body alters brain function. TBI can be focal or diffuse, intentional orunintentional.
Focal injuries occur from blows to the faceor head that produce contusions, lacerations,and hemorrhage. In such incidents, there canalso be a rapid acceleration and decelerationof the brain resulting in injury. Diffuse injuries
can occur even when there may not be a directblow to the head, but from being shaken or
thrown about (McKee & Daneshvar, 2015).
TBI can also occur from penetrating injuries
such as gunshot wounds to the head. External
forces resulting in TBI can also damage thespinal cord and neck (Pacheco, Mollayeva, Jacob, Colantonio, & Mollayeva, 2019). Females
are at higher risk for concurrent neck injury
compared to males likely due to necks that are
weaker and have distinct anatomical features(Catenaccio et al., 2017; Sutton et al., 2019;
Vasavada, Danaraj, & Siegmund, 2008).
In 2013, TBI accounted for 2.8 million
emergency department (ED) visits, hospitalizations, and deaths in the U.S. TBI is undercounted when there is no hospital or othermedical evaluation or treatment, when more
severe injuries take priority in the ED, andcomorbidities may mask or mimic, the effects
of TBI. Definitions and criteria for diagnosis vary; there are no standardized processes
for evaluating patients (McCrea, Nelson, &Guskiewicz, 2017). Additionally, refusal orinability to seek medical care and the lack ofrecognition of the signs and symptoms of TBI
by both victims and providers may contributeto underdiagnoses. Approximately 87% of TBIs
are mild (mTBI) and represent persons who
were treated in and released from EDs (Centers
for Disease Control and Prevention, 2015).
The terms mTBI and acute concussion are
sometimes considered interchangeable, yet thedefinitions of both vary (McCrea et al., 2017).
Central to the definition of mTBI/concussionis the rapid onset of impairment of neurologic
function that can resolve in a short time frame— hours to weeks. Subconcussion, anotherform of mTBI, can occur when there is noclinical sign of a concussion and symptoms areminimal or non-existent. Subconcussion can beharmful when it is repeated causing long-term
diverse and non-specific changes in cognition,mood, behavior, and motor functioning (Bailes,
Petraglia, Omalu, Nauman, & Talavage, 2013;
Mariani, Alosco, Mez, & Stern, 2020).
Clinical diagnosis of mTBI is based on the
combination of injury mechanism and acute
symptoms and signs. It can occur without lossof consciousness or measurable posttraumatic
amnesia. There are varied injury characteristics
that are physical (e.g., headache), cognitive(e.g., difficulty concentrating), emotional (e.g.,
irritable), and sleep disturbances (e.g., drowsiness). Some symptoms are nonspecific and canoccur in the context of other health conditions(e.g., mood disorders, learning disabilities,
other developmental cognitive disorders). The
rate of recovery is influenced by severity of
injury, age, gender, prior concussion, healthhistory, and the presence of comorbidities andvulnerabilities. Many assessment tools havebeen developed including checklists, CTs and
MRIs, and neuropsychological tests. However,there is much to be learned about the neuropathological and metabolic changes that occurin brain injury and how such changes affect recovery (Povlishock & Katz, 2006). In addition,
recovery is affected by a variety of biological,
psychological, and social factors and symptoms
may not resolve in the anticipated time (Hou etal., 2012). This failure to meet expectations ofrecovery is not uncommon. The failure to meet
expectations of recovery may be internalizedby patients as a personal failure, particularly ininstances of repetitive head trauma. In a studyof 131 patients with mild concussion, 14.5%
still had symptoms that did not resolve in one
year (Rutherford, Merrett, & McDonald, 1979).
Recovery is tailored to the patient’s individual
needs and progress (McCrea et al., 2017).
mTBI is not only a common concern in contact sports, but also a frequent result of intimate
partner violence (IPV). There has been more
research on mTBI in male athletes than on
Continued on page 8
Joining Forces/Joining Families • 7

What is TBI?, from page 7

A wide variety of
research shows
multiple effects of
mTBI in contexts of
IPV. A clinical studyof 99 women residing
in a shelter andcommunity womenfound that almost
75% had experienced
a TBI from an intimate
partner and nearly half
had been repeatedly
victimized.

female victims of IPV even though the population of abused women with mTBI affects millions of women worldwide (Colantonio, 2020).
IPV victims may not seek medical care due tostigmatization of admitting family violence orfear of retaliation by the abuser or their family(St Ivany et al., 2018). Despite the frequency of
IPV-related TBIs, many health care providers
are often unaware of the prevalence of TBI in
IPV and many lack the understanding of how
to respond to it (Haag et al., 2019).
A wide variety of research shows multiple
effects of mTBI in contexts of IPV. A clinicalstudy of 99 women residing in a shelter andcommunity women found that almost 75% had
experienced a TBI from an intimate partnerand nearly half had been repeatedly victimized(Valera & Berenbaum, 2003; Valera, Campbell,
Gill, & Iverson, 2019). Women veterans also
have been found to have a high level of IPVrelated mTBI. Of 176 women veterans, 18.8%
met the VA criteria for an IPV-related TBI
history (Iverson & Pogoda, 2015). Similarly, of
224 who completed a web-based survey, 12.5%
reported an IPV-related TBI history with current symptoms and 15.6% reported no symptoms (Iverson, Dardis, & Pogoda, 2017). The
women with symptoms were almost six times
more likely than women without symptoms
to also report probable PTSD. A longitudinal
study of 13 women veterans who reported
persistent TBI symptoms (problems withmemory, balance, dizziness, sensitivity to light,
irritability, headaches, and sleep) that began or
became worse immediately after the TBI werecompared to 20 women without persistent
symptoms. Follow-up at 18 months of thosewith persistent symptoms found significantly
worse outcomes including insomnia, depression, and deteriorating physical health (Iverson, Dardis, Grillo, Galovski, & Pogoda, 2019).
These studies show a high prevalence of TBI in
which victims have a wide variety of acute andchronic symptoms and poor outcomes when it
occurs in incidents of IPV.
In strangulation, several mechanisms can
produce brain injury as well as immediate
death: pressure of the carotid arteries preventing blood flow to the brain; pressure on thejugular veins preventing venous blood returnfrom the brain and resulting in blood being
backed up in the brain causing unconsciousness and depressed respiration; and pressure
obstruction of the larynx cutting off air flow
to the lungs and producing asphyxia (Hawley,
McClane, & Strack, 2001). Non-fatal strangula-

8 • Joining Forces/Joining Families

tion can cause brain injury through hypoxia or
anoxia of the brain as well as injury to the neckand cervical spine (Sutton et al., 2019). Females
are the predominant victims of non-fatal strangulation. In 586 ED and acute care visits for assault
by strangulation, 70% were females and 58.7%
were between the ages of 20-39 years (Jacob etal., 2020). In addition to the multiple physicalinjuries from non-fatal strangulation there areoften multiple acute and long-term psychologicalsymptoms including anxiety, depression, suicidal
ideation, PTSD, nightmares and insomnia. Nonfatal strangulation is also under-reported. Focus
groups and interviews of 17 women who had survived intimate partner strangulation found that
15 of the 17 had been strangled multiple times.
Fewer than half had sought medical care andonly one quarter of those disclosed strangulation(Joshi, Thomas, & Sorenson, 2012). Such lack ofdisclosure may be decreased when clinicians ask
specific questions about strangulation and examining the victim’s neck.
Much more needs to be learned about theeffects of TBI (including mTBI and concussion)in the context of IPV such as how it relates tosex and gender (Colantonio, 2016; Colantonio,
Harris, Ratcliff, Chase, & Ellis, 2010). Additional
needs are for more neurorehabilitation as well as
strategies that address victims’ physical and social
environments.
A further suggestion for improving practiceand research is the need for increased education
about the relationship of TBI to IPV among theservice sectors for women’s health, including
frontline workers, legal officers and the courts,
and the general public. Interventions are needed
to provide and improve services for TBI victims
such as shelters, rehabilitation for returning towork, parenting, reducing barriers to successful participation in legal and child protection
systems, and procedures to promote long-term
health (Haag et al., 2019). Underlying all these is
the need for research.

References

Bailes, J. E., Petraglia, A. L., Omalu, B. I., Nauman,
E., & Talavage, T. (2013). Role of subconcussion
in repetitive mild traumatic brain injury. Journalof Neurosurgery, 119(5), 1235-1245.
Catenaccio, E., Mu, W., Kaplan, A., Fleysher, R.,
Kim, N., Bachrach, T., … Lipton, M. L. (2017).
Characterization of neck strength in healthy
young adults. PM&R, 9(9), 884-891.
Centers for Disease Control and Prevention.
(2015). Report to Congress on Traumatic Brain
Injury in the United States: Epidemiology and ReWinter 2020

What is TBI?, from page 8

habilitation. In (pp. 72). Atlanta, GA: National
Center for Injury Prevention and Control,
Division of Unintentional Injury Prevention.
Colantonio, A. (2016). Sex, gender, and traumatic brain injury: A commentary. Archivesof Physical Medicine and Rehabilitation, 97(2Suppl), S1-4.
Colantonio, A. (2020). Beyond football: Intimate
partner violence and concussion/brain injury.
Canadian Psychology/Psychologie canadienne,
61(2), 163-166.
Colantonio, A., Harris, J. E., Ratcliff, G., Chase,S., & Ellis, K. (2010). Gender differences inself reported long term outcomes following
moderate to severe traumatic brain injury.
BMC Neurology, 10, 102.
Haag, H. L., Sokoloff, S., MacGregor, N.,
Broekstra, S., Cullen, N., & Colantonio, A.
(2019). Battered and brain injured: Assessing
knowledge of traumatic brain injury among
intimate partner violence service providers.
Journal of Women’s Health (Larchmt), 28(7),990-996.
Hawley, D. A., McClane, G. E., & Strack, G. B.
(2001). A review of 300 attempted strangulation cases Part III: Injuries in fatal cases. Journal of Emergency Medicine, 21(3), 317-322.
Hou, R., Moss-Morris, R., Peveler, R., Mogg,
K., Bradley, B. P., & Belli, A. (2012). Whena minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild
traumatic brain injury. Journal of Neurology,
Neurosurgery and Psychiatry, 83(2), 217-223.

Mariani, M., Alosco, M. L., Mez, J., & Stern, R. A.
(2020). Clinical presentation of chronic traumatic encephalopathy. Seminars in Neurology.
doi:10.1055/s-0040-1713624
McCrea, M. A., Nelson, L. D., & Guskiewicz, K.
(2017). Diagnosis and management of acuteconcussion. Physical Medicine and Rehabilitation Clinics of North America, 28(2), 271-286.
McKee, A. C., & Daneshvar, D. H. (2015). Neuropathology of Traumatic Brain Injury. In J.
Grafman & A. M. Salazar (Eds.), Handbook ofClinical Neurology (Vol. 127). Waltham, MA:
Elsevier B. V.
Pacheco, N., Mollayeva, S., Jacob, B., Colantonio,
A., & Mollayeva, T. (2019). Interventions andcognitive functioning in adults with traumatic
spinal cord injuries: a systematic review andmeta-analysis. Disability and Rehabilitation,
1-17.
Rutherford, W. H., Merrett, J. D., & McDonald,
J. R. (1979). Symptoms at one year following
concussion from minor head injuries. Injury,
10, 226-230.
St Ivany, A., Bullock, L., Schminkey, D., Wells, K.,
Sharps, P., & Kools, S. (2018). Living in fearand prioritizing safety: Exploring women’s
lives after traumatic brain injury from intimate
partner violence. Qualitative Health Research,
28(11), 1708-1718.

Iverson, K. M., Dardis, C. M., Grillo, A. R., Galovski, T. E., & Pogoda, T. K. (2019). Associations between traumatic brain injury from
intimate partner violence and future psychosocial health risks in women. Comprehensive
Psychiatry, 92, 13-21.

Sutton, M., Chan, V., Escobar, M., Mollayeva, T.,
Hu, Z., & Colantonio, A. (2019). Neck injury
comorbidity in concussion-related emergency
department visits: A population-based study ofsex differences across the life span. Journal of
Women’s Health (Larchmt), 28(4), 473-482.

Iverson, K. M., Dardis, C. M., & Pogoda, T. K.
(2017). Traumatic brain injury and PTSD
symptoms as a consequence of intimate
partner violence. Comprehensive Psychiatry,74, 80-87.

Valera, E. M., & Berenbaum, H. (2003). Brain injury in battered women. Journal of Consulting
and Clinical Psychology, 71(4), 797-804.

Iverson, K. M., & Pogoda, T. K. (2015). Traumatic brain injury among women veterans.
Medical Care, 53(4), S112-S119.
Jacob, B., Cullen, N., Haag, H. L., Chan, V.,
Stock, D., & Colantonio, A. (2020). Assault by
strangulation: sex differences in patient profileand subsequent readmissions. Canadian Journal of Public Health, 111(4), 492-501.

http://www.CSTSonline.org

Joshi, M., Thomas, K. A., & Sorenson, S. B.
(2012). “I didn’t know I could turn colors”:
Health problems and health care experiencesof women strangled by an intimate partner.
Social Work in Health Care, 51(9), 798-814.

Valera, E. M., Campbell, J., Gill, J., & Iverson,
K. M. (2019). Correlates of brain injuries inwomen subjected to intimate partner violence:
Identifying the dangers and raising awareness.
Journal of Aggression, Maltreatment & Trauma,
28(6), 695-713.
Vasavada, A. N., Danaraj, J., & Siegmund, G. P.
(2008). Head and neck anthropometry, vertebral geometry and neck strength in heightmatched men and women. Journal of Biomechanics, 41(1), 114-121.

Joining Forces/Joining Families • 9

Sex and Gender in Traumatic Brain Injury
By James E. McCarroll, PhD, Ronald J. Whalen, PhD, Joshua C. Morganstein, MD,
and Robert J. Ursano, MD

Males and females
have differencesin head andneck geometry,neck strength,and vertebrae.
Females’ necks are
significantly weakerin flexion (32%) andextension (20%)
than males’ necks
making females more
prone to concussion,
whiplash, and neckpain.

Traumatic brain injury (TBI) is defined as
an alteration in brain function or other evidence of brain pathology, caused by an external
force (Menon, Schwab, Wright, & Maas, 2010)
such as direct blows to the head, neck, and face
(Haag et al., 2019). Brain injury can also occur
by strangulation resulting in decreased oxygen
supply to the brain causing hypoxic or ischemic injury and death (Hlavaty & Sung, 2017;
Mcquown et al., 2016).
Research on TBI in Dr. Colantonio’s lab(University of Toronto and Toronto Rehabilitation Institute) has emphasized the roles of both
sex and gender, complex and often misunderstood terms. Sex and gender are often usedinterchangeably, but there are marked differences that should be accounted for in research(Mollayeva, Mollayeva, & Colantonio, 2018).
Sex refers to biological attributes of humans
and animals, including physical features,chromosomes, gene expression, hormones
and anatomy whereas gender refers to sociallyconstructed roles, behaviors, expressions andidentities of people, which are culturally- andhistorically-based, and constantly changing.
Gender can refer to the socially prescribed
dimensions of “masculinity” and “femininity”
for example [author’s quotes]. Colantonio recommends referring to sex/gender as a meansof including the complexity of both when theseconcepts are hard to disentangle rather thanrelying solely on the terms sex and genderseparately (Colantonio, 2016, 2020). However,these differentiations are overlapping and theinteractions are influenced by other factors
such as income, education, social environments, health practices, and culture (Mollayeva, El-Khechen-Richandi, & Colantonio, 2018).
[Also see Government of Canada https://cihrirsc.gc.ca/e/48642.html]
How does use of the sex/gender framework
affect outcomes in rehabilitation research? This
question is difficult to answer in that researchstudies of rehabilitation in general often either
have not included females or the results are notstratified by sex (Mollayeva, Mollayeva, et al.,2018). A review of more than 200 studies ofmild traumatic brain injury (mTBI) outcomesin children and adults, found that only 7% ofthem stratified their data by sex (Cancelliere,10 • Joining Forces/Joining Families

Donovan, & Cassidy, 2016). Examples of gendernorms and role expectations have been reported in sports injuries. Men were found to haveless knowledge about TBI and were less likely toseek medical care and outpatient rehabilitation
care. Women were more likely to seek healthcare and treatment and were less likely to leave
hospital care against medical advice.
The origins and effects of traumatic brain
injury (TBI) differ for men and women. For
men, different severity levels of TBI can befound in sports injuries, in high risk occupations (e.g., those that are physically demanding) and military service (Colantonio, 2016).
Women are more likely than men to suffer TBI
from intimate partner violence (IPV), and in
occupations typically held by women such as
health care. mTBI in sports is more frequent
among women than men in both soccer andbasketball injuries resulting in concussion (Gizaet al., 2013). Physical damage to females can beworse than that for males based on differencesin skeletal structures and musculature. Males
and females have differences in head and neckgeometry, neck strength, and vertebrae. Females’ necks are significantly weaker in flexion(32%) and extension (20%) than males’ making
females more prone to concussion, whiplash,and neck pain (Sutton et al., 2019; Vasavada,
Danaraj, & Siegmund, 2008).
Sex/gender effects are highly prevalent in
IPV and TBI. Service providers of IPV support often have little awareness, knowledge, or
understanding of TBI among women exposed
to IPV. In addition, frontline workers andsurvivors themselves have been found to notrecognize symptoms of TBI. These are significant practice deficits that require increased
education about the effects of sex and genderon health and well-being as well as research tobenefit survivors (Haag et al., 2019).
TBI is a major and escalating public healthconcern that has resulted in increased funding
and legislation. However, research on differences in TBI by sex/gender is limited at the present
time. Animal models, preclinical, and clinicalstudies have explored the role of vulnerability,
nature and presentation of injury, responses totreatment, and outcome, all of which can varyContinued on p. 11
Winter 2020

Sex and Gender in TBI,
from page 10

Research on TBI
requires attempts
to resolve many
controversies. Amongthese are the effectof sex hormones on
TBI outcome, whether
men or women havegreater impairment
and disability after
TBI, vulnerability
due to personal,
environmental,
and injury-related
factors, and negative
stereotyping or
stigmatization in
women’s health.

by the interaction of sex and gender (Mollayeva, Mollayeva, et al., 2018).
Research on TBI requires attempts toresolve many controversies. Among these are
the effect of sex hormones on TBI outcome,whether men or women have greater impairment and disability after TBI, vulnerability
due to personal, environmental, and injuryrelated factors, and negative stereotyping
or stigmatization in women’s health. The
multitude of interacting processes affecting
survival of TBI, including TBI from IPV, require the consideration of sex- linked factors
at the biological level, and gender-linked factors including, and not limited to, health careutilization and interpersonal relationships(Mollayeva, Mollayeva, et al., 2018).

References

Cancelliere, C., Donovan, J., & Cassidy, J. D.
(2016). Is sex an indicator of prognosis after
mild traumatic brain injury. Archives ofPhysical Medicine and Rehabilitation, 97(2Suppl), S5-18.
Colantonio, A. (2016). Sex, gender, and traumatic brain injury: A commentary. Archivesof Physical Medicine and Rehabilitation, 97(2Suppl), S1-4.
Colantonio, A. (2020). Beyond football: Intimate partner violence and concussion/brain
injury. Canadian Psychology/Psychologie
canadienne, 61(2), 163-166.
Giza, C. C., Kutcher, J. S., Ashwal, S., Barth, J.,
Gethius, T. S. D., Gioia, G. A., . . . Zafonte,
R. (2013). Summary of evidence-based
guideline update: evaluation and management of concussion in sports. Neurology, 80,
2250-2257.

Hlavaty, L., & Sung, L. (2017). Strangulation andits role in multiple causes of death. American
Journal of Forensic Medicine and Pathology,
38(4), 283-288.
Mcquown, C., Frey, J., Steer, S., Fletcher, G. E.,
Kinkopf, B., Fakler, M., & Prulhiere, V. (2016).
Prevalence of strangulation in survivors of
sexual assault and domestic violence. American Journal of Emergency Medicine, 34(7),1281-1285.
Menon, D. K., Schwab, K., Wright, D. W., & Maas,
A. I. R. (2010). Position statement: definitionof traumatic brain injury. Archives of Physical
Medicine and Rehabilitation, 91(11), 16371640.
Mollayeva, T., El-Khechen-Richandi, G., &Colantonio, A. (2018). Sex & gender considerations in concussion research. Concussion,
3(1), CNC51.
Mollayeva, T., Mollayeva, S., & Colantonio, A.
(2018). Traumatic brain injury: sex, genderand vulnerabilities. Nature Reviews Neurology,
14(December), 711-722.
Sutton, M., Chan, V., Escobar, M., Mollayeva, T.,
Hu, Z., & Colantonio, A. (2019). Neck injury
comorbidity in concussion-related emergency
department visits: A population-based studyof sex differences across the life span. Journalof Women’s Health (Larchmt), 28(4), 473-482.
Vasavada, A. N., Danaraj, J., & Siegmund, G. P.
(2008). Head and neck anthropometry, vertebral geometry and neck strength in heightmatched men and women. Journal of Biomechanics, 41(1), 114-121.

Haag, H. L., Sokoloff, S., MacGregor, N., Broekstra, S., Cullen, N., & Colantonio, A. (2019).
Battered and brain injured: Assessing
knowledge of traumatic brain injury among
intimate partner violence service providers. Journal of Women’s Health (Larchmt).
doi:10.1089/jwh.2018.7299

Interview with Angela
Colantonio and HalinaHaag, from page 6

http://www.CSTSonline.org

Wiseman-Hakes, C., Ryu, H., Lightfoot, D.,
Kukreja, G., Colantonio, A., & Matheson, F.
I. (2020). Examining the efficacy of communication partner training for improving
communication interactions and outcomesfor individuals with traumatic brain injury:
A systematic review. Archives of Rehabilitation Research and Clinical Translation, 2(1),doi:10.1016/j.arrct.2019.100036.

Joining Forces/Joining Families • 11

Websites of Interest
As noted in the interview with Dr. Colantonio andHalina Haag, the Acquired Brain Injury ResearchLaboratory, University of Toronto (https://abiresearch.utoronto.ca/research/tbi-intimatepartner-violence/), received funding for thedevelopment of an educational toolkit for frontline
workers serving women survivors of intimate
partner violence (IPV) as well as survivors and theirfamilies and friends (see www.abitoolkit.ca). This
website provides a variety of resources including adescription of brain injury, care guidelines, service
provision, and many others.
Dr. Colantonio is the Primary Investigator on a
project sponsored by the Ontario Neurotrauma
Foundation (onf.org) to provide information
about the intersection between TBI and IPV, andits implications for women’s mental health andemployment, in order to develop and implement
knowledge materials that are intended to support
women survivors of IPV. (Search “Supporting
Employment in Brain Injured Women Survivors ofIntimate Partner Violence” at onf.org to learn theobjectives of this project)
In the U.S., the Department Defense has many
resources for evaluation and management of
traumatic brain injuries (TBI) including militaryacute concussions (https://health.mil/SearchResults?query=traumatic%20brain%20injury%20
center%20of%20excellence&refSrc=1).
This website has basic information on brain injury,
current statistics on worldwide TBI, current research,and stories by caregivers in supporting recovery.
VA’s Polytrauma System of Care (PSC) (https://www.polytrauma.va.gov/index.asp) is an integrated
network of specialized rehabilitation programs
dedicated to serving Veterans and Service Memberswith both combat and civilian related traumaticbrain injury (TBI) and polytrauma. Services available
through PCS include: interdisciplinary evaluation andtreatment, development of a comprehensive plan ofcare, case management, patient and family educationand training, psychosocial support, and applicationof advanced rehabilitation treatments and prosthetic
technologies.

12 • Joining Forces/Joining Families

Winter 2020