Community Support Network Rehabilitation Intervention Improves Cognitive Functions in Women Who Experienced Intimate Partner Violence-Caused Brain Injury: A Preliminary Study

Abstract

Background:

Survivors of intimate partner violence (IPV)-caused brain injury (BI) demonstrate cognitive impairments, which ultimately impact quality of life (QoL). Therefore, therapeutic interventions for IPV-BI are required, similar to those for BI from other causes.

Objective:

To examine the potential feasibility and signs of effectiveness of the community support network (CSN) rehabilitation intervention for promoting recovery of cognitive functions in survivors of IPV-BI.

Methods:

Women with a mean age of 42.87 years who experienced IPV-BI were recruited from women’s shelters and gender-based violence community organizations. The CSN was administered remotely. Each session lasted for about 2.5 hours for 2 days/week for 3 months (compressed) or for 1 day/week for 6 months (expanded) protocol. The program also included biweekly counseling and monthly peer support. Cognitive functions were assessed before and after the intervention, and at 3/6 months follow up using the Creyos, and Brainex symbol relation assessments (BSRA). The traumatic BI-QoL and the Brain Injury Severity Assessment (BISA) were used to assess QoL and probable IPV-BI, respectively.

Results:

The results showed an adequate (89%) proportion of recruitment and excellent (100%) adherence to the intervention. Furthermore, we found a statistically significant difference in the average score between pre- and post-intervention on the BSRA (Z = 2.39, p = 0.016, effect size: 0.84). Both the Creyos assessment and TBI-QoL showed an improved trend following the intervention.

Conclusion:

The CSN was feasibly implemented in survivors of IPV-BI. The preliminary findings were promising in improving cognitive functions. However, larger-scale studies are necessary to establish the effectiveness of the intervention.

Keywords

brain injury cognitive impairments cognitive recovery intimate partner violence quality of life rehabilitation

Introduction

As many as 92% of survivors of physical intimate partner violence (IPV) may also experience brain injury (BI)^1,2 as a result of blows to the head, face, and neck and/or nonfatal strangulation (NFS).^1,3,4 Survivors who have experienced IPV-BI demonstrate cognitive impairments (e.g., deficits in memory, attention, reasoning, planning, and executive functioning),^5,6 psychological or emotional disturbances (such as depression, anxiety, fatigue, and post-traumatic stress disorders [PTSDs]),^4,5 and/or sensorimotor problems (such as balance issues, loss of sensation, facial droop, and unilateral weakness),⁷ which ultimately impact quality of life (QoL).⁸ Furthermore, survivors of IPV-BI are unique in that they have experienced both IPV and BI.⁹ Both traumas have simultaneous and overlapping impacts on QoL. Therefore, IPV-BI–specific rehabilitation intervention is necessary for survivors of IPV, in order to improve QoL, and to minimize longer-term neurodegeneration.¹⁰ However, there is a general lack of such treatments designed specifically for survivors of IPV-BI. This gap indicates a crucial need to address the consequences of IPV-BI in this population.

Historically, health care and community assistance that provide services for individuals who have undergone IPV generally do not take IPV-BI into account. Additionally, the heightened risk of psychopathological comorbidities in IPV like PTSD, depression, anxiety, and substance use may conceal and/or worsen BI symptoms. Therefore, the supports offered to survivors should be diverse, cross-disciplinary, cohesive, informed by trauma and violence, and culturally aware. To meet this need, a community support network (CSN) rehabilitation intervention was developed to tackle cognitive-motor issues resulting from IPV-BI, aiming to enhance QoL. The CSN is based on the ABI Wellness “Brain Enhance And Recovery System” (BEARS) program framework,¹¹ along with added elements such as counseling, peer support, a participants navigator, and a trauma-informed strategy to address the specific needs of IPV-BI survivors. The BEARS program is a multidisciplinary, evidence-driven rehabilitation approach that incorporates several elements, including aerobic exercises, cognitive training, and mindfulness meditation.¹² The BEARS programs have been successfully implemented in people with motor-cognitive deficits after BI from various causes.^11,13 Findings from an initial study offer proof of functional network reorganization corresponding to cognitive enhancements post-cognitive rehabilitation in individuals with BI.¹³ A brief overview of the CSN program is included in the intervention section of this article, with additional information available in the published protocol paper.¹²

The first objective of this study was, therefore, to examine the potential feasibility of the CSN rehabilitation intervention in survivors of IPV-BI. The second objective was to evaluate the potential efficacy of the CSN intervention in survivors of IPV-BI. We hypothesized that the CSN rehabilitation intervention could be effectively implemented in survivors of IPV-BI and that it would enhance cognitive functions in these individuals, consequently leading to improved QoL.

Materials and Methods

Approval to conduct this study was received from the University of British Columbia clinical research ethics board, and all participants provided written, informed consent prior to participation in this study.

Details on the methodology of this study are available in a protocol paper at https://www.researchprotocols.org/2024/1/e54605/.12 Therefore, the methods section in this article is brief.

Design

We used a pre–post-quantitative design because it is a common and convenient study design for pilot intervention studies.^14,15 Although we did gather anecdotal feedback from the participants, we were hesitant to label the design “a mixed method approach” due to the absence of formal qualitative methods (e.g., focused interviews and thematic analysis). The feedback collected from the participants was informal in nature. In particular, we were interested in their perception of the different components of the intervention with a view of potentially improving on things that may have been negative in some way. For this reason, the quotes presented in the article were provided without formal qualitative analysis as a way of providing the reader with some insight into how the participants felt about taking part in the intervention. Therefore, in the relevant sections of the study design, data analysis plan, and results, we focus on the quantitative data from the outcome measures and complement this with the anecdotal feedback provided by the participants.

Participants and recruitment

Women aged 18–60 years who had experienced physical IPV (either head impacts due to direct hits to the head, face, and neck and/or strangulation) were screened for this study. We chose women with physical IPV because physical violence is associated with probable BI.^16–18 The Brain Injury Severity Assessment (BISA) interview⁴ was used to screen for a probable IPV-BI. A BISA score ≥1 indicates an occurrence of at least one episode of IPV-BI.⁴ Therefore, women who scored ≥1 on BISA were eligible for this study. Women with any diagnosed neurological disorder known to affect cerebrovascular, neurocognitive, and/or sensorimotor function (e.g., stroke, Parkinson’s, Alzheimer’s, cerebral palsy, multiple sclerosis, migraine, and seizures) were excluded. Eligible participants were recruited from different community-based, women-serving organizations.¹²

Intervention

Participants received the CSN rehabilitation intervention^11,12 remotely on the university-licensed Zoom app. As presented in Figure 1, the components of the CSN rehabilitation intervention included aerobic exercises, cognitive training, and mindful medication (which were three pillars of the BEARS programs) as well as counseling, inclusion of a navigator, and peer support (which were additional to the BEARS components) all while incorporating a trauma-informed approach (TIA). The aerobic exercise was tailored to the participants’ choices and included, but was not limited to, running, jogging, walking, rope jumping, swimming, stationary or recumbent bicycling, Zumba or dancing, using a treadmill or rowing machine, or elliptical exercises. These exercises were introduced during the sessions and assigned as therapeutic tasks. The cognitive training program was the Brainex symbol relations task, which is a computer-based cognitive exercise consisting of a sustained visual-spatial processing or relational reasoning task of progressively increasing difficulty. It required participants to use relational reasoning on an analog clock to conceptually and automatically process relationships that increase in complexity. Participants also attended mindfulness meditation in a guided meditation block that focused on education related to various types of meditation and development of familiarity and skill to foster independent practice.

FIG. 1.

The community support network (CSN) rehabilitation intervention. The intervention was grounded in the ABI Wellness “Brain Enhance And Recovery System” (BEARS) program platform (first arm in the figure), with SOAR’s (Supporting Survivors of Abuse and Brain Injury through Research) additional components incorporated to support the unique needs of survivors of IPV-BI (second arm in the figure). IPV-BI, intimate partner violence-caused brain injury.

Since women who faced IPV and IPV-BI frequently encounter numerous additional difficulties, it was crucial for them to have someone to relate to, alongside the BI specialists providing the rehabilitation program. Therefore, targeted counseling of 60 minutes biweekly (once every 2 weeks) was provided by clinical counselors. Participants saw master’s level educated clinical counsellors with specialized backgrounds in trauma and IPV. Counsellors applied mainly the cognitive behavioral therapy modality of support. The sessions were participant-driven and addressed whatever issues were of most concern to participants at the time, and were not necessarily solely focused on issues directly related to IPV-BI or trauma from IPV. In addition, a navigator supported participants to provide trauma- and violence-informed advocacy and program or systems navigation support to the participants, as well as referrals to other community agencies or services as needed. The participant navigator engaged and assisted via phone or video call. The participant navigator also facilitated a monthly (once a month) peer support group discussion, which included personal development presentations on topics, including navigating life after BI, healthy nutrition, and lifestyle, etc.

Finally, across all the different components of the CSN, a TIA was implemented. A more detailed description of the intervention can be found in Textboxes 1 and 2 of the protocol paper.¹² Survivors participated in the program for either 3 (compressed protocol: 2 days/week) or 6 months (expanded protocol: 1 day/week) based on their preference. These two protocols were developed based on participant feedback in terms of feasibility and time commitment. However, the total dose of the intervention (approximately 60 hours in total) remained the same across the two (compressed and expanded) protocols. The cohorts with compressed and expanded protocols had follow-up assessment at 3 and 6 months, respectively. Each intervention session lasted for about 2.5 hours. Any missed session(s) were subsequently completed at a later date within the 3-month (compressed protocol) or 6-month (expanded protocol) time period.¹²

Measures

Demographics, brain injury, and mental health screening tools

Participants’ demographic information such as age, ethnicity, education, and income was collected using a screening questionnaire. The original BISA interview tool, which was designed particularly to screen BI due to IPV, was used to screen probable BI in this study.⁴ It is a semi-structured interview containing a series of questions regarding loss of consciousness, dizziness, memory loss, feeling stunned or disoriented, seeing stars or spots following potential traumas to the brain. It consists of three subscales: (1) frequency—an estimate of the number of previous episodes resulting in signs or symptoms of BI (0–4 scale), (2) recency—the time since the most recent event resulting in signs or symptoms of BI (0–3 scale), and (3) severity—whether an episode ever resulted in a loss of consciousness and/or a period of post-traumatic amnesia (0–1 scale). The BISA provides a summary score ranging from 0 to 8. The score 0 indicates no BI, whereas 1–8 indicates an occurrence of probable BI. The higher the score, the higher the amount of exposure to potential BI.^4,12

The Generalized Anxiety Disorder Scale (GAD-7),¹⁹ Patient Health Questionnaire (PHQ-9),²⁰ PTSD Checklist for DSM-5 (PCL-5),²¹ Somatic Symptom Severity Scale (PHQ-15),²² Alcohol Use Disorders Identification Test (AUDIT),²³ and the Brief Irritability Test (BIT)²⁴ were used to measure anxiety, depression, PTSD, somatic symptoms, alcohol consumption, and level of irritability, respectively. These psychopathological measures were measured once during the pre-intervention session and acted as control measures (i.e., to account for any modulating effect of the psychopathological factors on the main outcome measures). Further details on these measurement tools can be found in the protocol paper.¹²

Outcome measures

Creyos assessment for neurocognition

The Creyos tasks were used to assess neurocognitive functions.¹² The assessment includes 12 neurocognitive tasks under four domains, short-term memory, reasoning, concentration, and verbal ability.²⁵ The Creyos system provides a numerical value at the end of the test. These tests have been shown to be valid and reliable.¹² The tests were administered through the web application using a desktop or laptop. Task results (numerical value on each test) were stored securely in the cloud and could easily be downloaded for offline analyses.^12,25

In addition, we were able to access a large age-specific dataset of women who had not experienced IPV-BI from Creyos. We calculated an individual mean score (with 1.5 standard deviation [SD])²⁶ matching the age and sex of each survivor of IPV-BI. The objective of this calculation was to compare the Creyos data of IPV-BI individuals with that of women who had not experienced IPV-BI as matched controls.

Brainex symbol relations assessment

The Clock test in the Brainex symbol relations assessment is a computer-based, cognitive exercise consisting of a sustained visual-spatial processing or relational reasoning task of progressively increasing difficulty. In this test, participants were involved in tasks that enabled an individual to reason using logic, and to connect and process complex relationships and concepts. The test was made up of multiple levels indicated by hour exact, hour between, minute exact, minute between, two hand, three hand, four hand, and six hand levels. Progression through the Clocks test from one level to another was determined by the participant’s performance at each level. Before starting each level of the test, the assessor ensured the participant understood how to read the clock. The instructions were repeated if required. Participants sat in front of the computer and read the clock. The assessor typed the answers for the participants in the given text box. The test was continued until either the participant attained a score of 50% or lower on a level, or the last level of the test was completed. At the end of the test, the assessor evaluated the quality of the assessment by completing a checklist of behaviors that might have taken place during the test (e.g., any distraction). Once all this information were entered, the Brainex system provided a score on the cognitive capacity of each participant.^11,12

Traumatic brain injury quality of life

This 20-item questionnaire measures the QoL of individuals who experienced BI across four domains, physical health, emotional health, cognitive health, and social participation.^12,27 A summary score of the TBI-QoL was available for analysis. This assessment tool was incorporated within the CSN rehabilitation intervention. Therefore, TBI-QoL data were available to analyze only pre- versus immediate post-treatment analysis (no data on follow up were available).¹²

Feasibility measures

Recruitment was measured as the proportion of individuals enrolled compared with those who were approached and eligible but did not enroll. Each participant attended either two sessions per week for 3 months (compressed protocol) or one session per week for 6 months (expanded protocol) to complete a total of 24 sessions. The proportion of the attended sessions by the participants to the total number of predefined sessions was calculated to assess an adherence. Retention was evaluated by the proportion of participants with complete datasets on primary outcome measures at pre- and post-intervention time points.^12,28,29

Feedback and anecdotal information

In order to assess how participants felt about the intervention and its potential efficacy, informal feedback and anecdotal information were gathered during program sessions and in interactions with the group facilitator and the participant navigator.

Procedure

Each eligible participant underwent three assessments, before the intervention, immediately after completion of the intervention, and at follow up.¹² The research coordinator, program facilitator, and navigator underwent introductory training in IPV and trauma-informed practice. Additionally, the research coordinator received formal training in the administration of the various assessment tools. A facilitator (who was different from the research coordinator) administered either 3 months (compressed) or 6 months (expanded) of the CSN rehabilitation intervention based on participants’ preference.¹² The intervention was conducted remotely (which was also based on participants’ preference) using a university-licensed Zoom app. The CSN facilitators took formal training on the BEARS program from ABI Wellness and were certified for its administration. All assessments and the CSN facilitation were conducted using a TIA.¹² The team met every other week, or more frequently as needed, to track the program and participant progress and address questions or issues that arose. After completing the intervention, and until the follow-up interview (compressed protocol: 3 months, expanded protocol: 6 months), participants maintained a logbook to document their physical activities.¹² Additionally, feedback from participants was gathered during program sessions and in interactions with the group facilitator.

Statistical analysis

Descriptive statistics were conducted to analyze the demographic and clinical characteristics of the cohort. To achieve the first objective, recruitment, compliance, and retention were assessed. Recruitment was evaluated as the proportion of individuals who enrolled compared with those who were contacted and qualified but decided against enrollment. The proportion of weekly sessions attended by the participants was calculated to assess adherence. Retention was evaluated by the proportion of participants who had complete datasets on primary outcome measures both prior to and following the intervention.

Because of the limited sample size, nonparametric tests were performed to achieve the study’s second objective. Mann–Whitney U tests were performed to evaluate neurocognitive function in the IPV-BI group against matched controls from the Creyos dataset. Wilcoxon Signed-rank tests were conducted to compare before and after treatment within the IPV-BI group. Kruskal-Wallis tests were performed to compare data of the IPV-BI group across three time points, pre- (before intervention), post 1 (immediately after intervention), and post 2 (at follow up). Follow-up post hoc comparisons were conducted to compare data among each group. Since the sample size was small, we could not conduct complex inferential tests such as covariate analysis (for exploring any influence of any covariates such as the psychopathological measures), multiple linear regression (to model the linear relationship between an exposure variable and outcome variables in order to predict an outcome), etc. We rather conducted simple within-group comparisons on the outcome variables. Effect size (ES) for Cohen’s d was calculated to determine whether the effects were small (0.2), medium (0.5), or large (0.8).³⁰ Significance was set at p < 0.05. All statistical analyses were performed using SPSS Statistics version 30.0 (IBM Corp, Armonk, NY), and GraphPad-Prism software, version 10.4.0 (Dotmatics, Boston, MA).

Results

Demographic and clinical characteristics

Eight participants (four each in the compressed and expanded protocols) completed the study. The mean age of the participants in the study sample was 42.87 years (SD: 8.66, range: 30–60 years). Six of the participants (75%) were Caucasian. Half of the cohort had some post-secondary education (n = 4, 50%). Regarding the exposure to IPV-BI, the majority of participants (62.5%) had medium BISA scores (BISA = 3–5), a few of them (37.5%) had low BISA scores (BISA = 1–3), and none of them had high BISA scores (BISA ≥ 6). Other descriptive information including the psychopathological data are presented in Table 1. The two cohorts—one completing the compressed protocol and the other completing the expanded protocol—were not statistically different (p > 0.05) in their demographics (age, ethnicity, and education), IPV-BI assessment (BISA score), and psychopathological (ACE, GAD-7, PHQ-9, AUDIT, PHQ-15, PCL-5, and BIT) characteristics.

Table 1.

Demographic and Clinical Characteristics of the Participants (N = 8)

Characteristics	Mean ± SD	Number (%)
Age (year)	42.87 ± 8.66	—
Ethnicity
Caucasian		6 (75.00)
Asian		2 (25.00)
Education
Some post-secondary but not degree		4 (50.00)
Less than high school		1 (12.50)
Bachelor degree		1 (12.50)
Not disclosed		2 (25.00)
BISA
Frequency	2.50 (1.20)
Recency	0.13 (0.35)
Severity	0.38 (0.52)
Total	3.00 (1.31)
Strangulation
Yes		5 (62.5)
No		3 (37.5)
Non-IPV-caused BI
Yes		7 (87.50)
No		1 (12.50)
GAD-7	10.13 (6.90)
PHQ-9	13.86 (8.13)
AUDIT	1.87 (4.52)
PHQ-15	13.38 (7.44)
PCL-5	40.25 (25.99)
BIT	14.38 (7.96)

IPV, intimate partner violence; IPV-BI, intimate partner violence-caused brain injury; BISA, Brain Injury Severity Assessment; GAD-7, Generalized Anxiety Disorder Scale; PHQ, Patient Health Questionnaire; PCL-5, PTSD Checklist for DSM-5; PTSD, post-traumatic stress disorder; AUDIT, Alcohol Use Disorders Identification Test; BIT, Brief Irritability Test; SD, standard deviation.

Feasibility of the CSN

As part of the first objective, feasibility measures were analyzed descriptively. The proportion of individuals enrolled (N = 8, 89%) compared with those who were approached and eligible but did not enroll (n = 1, 11%, reason: medical issue) was high indicating an adequate proportion of recruitment. On average, seven sessions during the whole course of the intervention were missed by different participants. These were completed as make-up sessions within the intervention timeframe such that all participants completed the predefined dose of the intervention. Thus, an excellent (100%) adherence to the intervention was achieved. Every participant had an excellent level of engagement (score >90 out of 100) on the overall engagement scale (which was calculated based on participants’ attendance, compliance to the prescribed duration of activity, and goals met). Furthermore, all participants completed the structured protocol including the follow-up assessments which indicated 100% retention as well.

Recovery of short-term memory function

As part of the second objective, short-term memory function was compared between two groups. Given we collected data on all 12 neurocognitive functions using the Creyos platform, results revealed significantly lower scores particularly on the short-term memory functions in women with IPV-BI compared with age-matched women who had not experienced IPV-BI. As shown in Figure 2, women with IPV-BI scored lower for spatial span (p < 0.001, ES = 0.83), paired associates (p < 0.001, ES = 0.86), token search (p = 0.009, ES = 0.65), and number ladder (p < 0.001, ES = 0.86) tests. These tasks were used to measure short-term memory.

FIG. 2.

Comparison of Creyos assessment data between women who have not experienced IPV-BI and women with IPV-BI. Four tasks assessing short-term memory included: (A) spatial span, (B) paired associates, (C) token search, and (D) number ladder. Raw scores on the Creyos memory tasks (Y-axis) were plotted for the different groups (X-axis). Each point in the figure indicates an individual participant. Mean and standard deviation are presented for central tendency measures. IPV-BI, intimate partner violence-caused brain injury.

Neurocognitive function was also measured using the Brainex symbol relations assessment. Since the Brainex symbol relations assessment tool was incorporated within the CSN intervention, this tool was used to assess women only before and immediately after the intervention. The results (Fig. 3A) also revealed a statistically significant improvement in the average score between pre- and post-intervention for this assessment (Z = 2.39, p = 0.016, ES = 0.84). Similarly, the Creyos platform was used to assess participants’ neurocognitive functions comparing the total score at three time points (before intervention, immediate post-intervention, and follow up). As shown in Figure 3B, C, the results revealed an improved trend on the “spatial span” and “paired associates” tasks after the intervention. However, the results were not statistically significant (p > 0.05).

FIG. 3.

Assessment of neurocognitive functions. (A) Brainex symbol relations assessment: before (pre) and after (post 1) the intervention; (B) “spatial span” task: before (pre), after the intervention (post 1), and at follow up (post 2); and (C) “paired associates” task: before (pre), after the intervention (post 1), and at follow up (post 2). Raw scores on the Y-axis were plotted against pre–post data on the X-axis. Each point in the figure indicates individual score. Mean and standard deviation are presented for central tendency measures.

Improvement in QoL

In relation to the second objective, the QoL was assessed. Participants with IPV-BI demonstrated some improvement in their QoL, although data did not show significant results (p > 0.05), which was likely due to the small sample size. Wilcoxon Signed rank test revealed pre–post differences with borderline significance for TBI global (p = 0.062) and TBI cognitive (p = 0.086) domains, and a trend toward improvement in all other TBI-QoL domains as well as TBI total score (Fig. 4).

FIG. 4.

Comparison of raw scores before (pre) and after (post) intervention for different traumatic brain injury–quality of life (TBI-QoL) domains. Raw scores on the TBI-QoL (Y-axis) were plotted against pre–post data (X-axis). TBI-QoL included: (A) TBI global, (B) TBI physical, (C) TBI cognitive, (D) TBI emotional, (E) TBI social, and (F) TBI total. Each point in the figure indicates an individual participant. Mean (standard deviation) is presented for central tendency measures.

Informal feedback from participants

In relation to both first and second objectives, we also gathered anecdotal responses regarding the intervention from the participants. Overall, participants provided positive anecdotal feedback on the intervention. Of the CSN overall, one participant said, “It shifted my thinking that now I can trust my brain and I have accepted that my brain can perform well and my injury can be improved.” Another reflected, “I am very excited because I am re-joining my work this week. I hope my brain will work smoothly like before the incident.” When asked what improvements, if any, she’d noticed since participating in the CSN, another participant said, “Mental capacity, memory, overall wellbeing, and self-confidence.” With respect to the peer support group component, one participant said, “It helped me process stuff without having to say the same thing over and over out loud.” Finally, inclusion of a navigator led one participant to mention that “I felt supported having the navigator, it helped a lot with problem solving and arrangement.”

Discussion

There were two major findings in relation to the first and second objectives of this study: (1) The CSN rehabilitation intervention was feasibly implemented in women survivors of IPV-BI; (2) the CSN rehabilitation intervention showed it has potential to improve short-term memory function in survivors of IPV-BI. Additionally, as a post hoc secondary objective, we found that the survivors of IPV-BI who participated in this study demonstrated lower scores on various cognitive assessments compared with age-matched women who had not experienced IPV-BI.

Feasibility of the CSN

The possible feasibility of the CSN intervention was assessed using a pre–post design. The initial goal was accomplished by demonstrating the appropriateness of the intervention in survivors of IPV-BI. The descriptive data (recruitment, adherence, engagement, and retention) along with informal anecdotal feedback indicated that the intervention was appropriate. Administration of a multi-pillar, multidisciplinary rehabilitation intervention is a huge challenge. However, various key components integrated within the intervention such as composition of the intervention, individually tailored training program, possibility of selection of exercise parameters based on participants’ own performance level, engagement-focused, flexibility with schedules, integration of a monthly peer support group, and inclusion of a program navigator, all might have played a significant role in having successful implementation and positive outcome of the intervention in this population.

Recovery of short-term memory function, and improvement in QoL

This preliminary research showed indications of the effectiveness of the CSN intervention in enhancing cognitive function, especially short-term memory, in survivors of IPV-BI who scored lower than women without IPV-BI. The symbol-relation function as part of the Brainex assessment demonstrated improvement of a higher-order cognitive function, responsible for understanding and connecting ideas. It probes functions involved in tasks that enable an individual to reason using logic, and to connect and process complex relationships and concepts.¹¹ Since the Brainex assessment was embedded within the intervention, participants might have benefitted from the repeated testing resulting in a learning effect. Because repeated testing could improve learning in individuals with BI,³¹ this positive outcome could therefore be a task specificity finding as it is evident in different interventional studies.^32,33 On the other hand, the logbook information maintained by each participant demonstrated that none of them had received any physical activities other than the CSN during the intervention and/or during the follow-up period. This indicated that the positive impact achieved by the participants was most likely due to the beneficial effect of the intervention. However, due to the small sample size, we could not carry out any covariate analysis by considering the logbook information as a covariate. Similarly, although not statistically significant, there was a trend toward improvement in short-term memory in the Creyos assessments as well. These Creyos assessments were not embedded within the intervention. Thus, the improvement in the Creyos assessment tasks further supported the outcome of the symbol relation assessment indicating the beneficial effect of the intervention. Furthermore, the beneficial effect of the intervention was probably sustained for at least up to the follow-up period, because the Creyos data on two post-intervention time periods (immediately after intervention vs. follow up) were not significantly different. Since the women did not participate in any specific cognitive therapy between the post-intervention and follow-up period (as indicated in their logbooks), the improved function was most likely due to the beneficial effect of the intervention. This, in turn, might have resulted in improvement in QoL, since the results demonstrated a trend toward improvement in all the TBI-QoL domains. However, due to the small sample size, the outcome of this study should be interpreted cautiously. There is a dearth of studies investigating the effectiveness of rehabilitation interventions designed specifically for IPV-BI as reported in a recent scoping review.³⁴ Therefore, we were unable to contrast and compare the outcome of the current study directly with other studies in the context of IPV-BI.

Lower scores on the short-term memory domain in survivors of IPV-BI

As a post hoc secondary objective, we found that the cohort in this study had lower scores than women who had not experienced IPV-BI on the short-term memory domain, which was measured with the “number ladder,” “spatial span,” “token search,” and “paired associates” tasks. Previous neuroimaging studies have shown brain structural abnormalities in survivors of IPV-BI leading to memory dysfunction.^35,36 Based on this evidence, lower scores for IPV-BI participants in the current study in the above-mentioned neurocognitive tasks indicated dysfunctions in one or more associated regions of the brain. The neurocognitive dysfunction revealed in this study is also consistent with the findings of one of our earlier studies, in which survivors of IPV-BI demonstrated cognitive-motor deficits.³⁷ We could not include pre- and post-intervention imaging or other brain mapping techniques to support intervention outcome because there is a dearth of studies investigating the effectiveness of rehabilitation interventions designed specifically for IPV-BI. This literature gap has also been reported in a recent scoping review.³⁴ Therefore, we were unable to contrast and compare the outcome of the current study directly with other studies in the context of IPV-BI.

Study implications, limitations, and future directions

Since this was preliminary work, the outcome of this study has limited implications for use in clinical practice. However, the intervention was well-structured, and feasibility was established. Therefore, the results may serve as good evidence to conduct larger scale studies (comparative studies with controls, or randomized controlled trials). The sample size was small for hypothesis testing. As a result, we were also not able to: (1) compare outcome data between various subgroups (e.g., with vs. without depression or anxiety, or PTSD, or substance use, or adverse childhood experience, in higher vs. lower BISA score groups), (2) consider covariates such as demographics and/or mental health comorbidities in the comparison, and (3) look at relationships of the outcome variables with various demographic and clinical characteristics. Due to funding constraints, we were only able to recruit eight participants, although seven others were interested in taking part, and were on a waiting list. Many more survivors of IPV-BI have inquired about the rehabilitation program since then. Future studies with a larger sample size are warranted to address these limitations. On the other hand, we did not directly administer any intervention particularly to address psychopathological issues. That is why, as mentioned earlier, the psychopathological measures were considered simply as control measures. However, based on the nature of the CSN intervention, and the components incorporated within it (such as cognitive training, counseling, and mindfulness meditation), participants might have benefitted from the intervention for any psychopathological issues as well. We recommend future studies consider measurement of psychopathological variables before and after the intervention to examine the intervention-induced changes in these variables. Additionally, inclusion of objective measures such as neuroimaging and blood-based biomarkers as outcome measures would further strengthen the outcome of the study. Recruitment of heterogenous participants in terms of age, sex, gender, education, ethnicity, socioeconomic status, etc. in future studies will further improve the generalizability of the outcome.

Conclusions

The feasibility of the CSN intervention was established by showing its effectiveness in recruitment, adherence, engagement, and retention among IPV-BI survivors, along with informal anecdotal feedback that suggested the intervention was appropriate. The initial results are encouraging in enhancing cognitive abilities in a population that is still not well researched. These findings indicated preliminary support for the feasibility and acceptability of the intervention and imply the need for more extensive studies to determine the effectiveness of the intervention, the specific details of its effectiveness (e.g., dose, duration, and components), and the impact of the intervention across a wider range of outcome metrics.

Authors’ Contributions

S.P.A.: Conceptualization, intervention administration, data analysis, methodology, writing (original draft), writing (review and editing). C.M., K.K., and K.R.: Data collection, writing (review and editing). K.M. and P.v.D.: Conceptualization, methodology, supervision, writing (review and editing).

Footnotes

Acknowledgments

The authors wish to acknowledge the community organizations who supported this project through promotion, recruitment, and execution, including BrainTrust Canada (Kelowna, B.C.), Nanaimo Brain Injury Society (Nanaimo, B.C.), Central Okanagan Elizabeth Fry Society (Kelowna, B.C.), Connect Counseling and Therapy (Kelowna, B.C.), William and Associates Counseling Services (Kelowna, B.C.), Kelowna Women’s Shelter (Kelowna, B.C.), and Mamas for Mamas (Kelowna, B.C.). Thanks also go to Mark Watson and Shaun Porter, formerly of ABI Wellness, and Maggie Coyne, formerly of Nanaimo Brain Injury Society, for their support. The authors extend special gratitude to the valued, lived experience survivors of IPV-BI who supported this project with their time, energy, and attention as research participants. Finally, the authors would like to show deepest gratitude to all the individuals and the organizations who directly or indirectly worked with them to accomplish this study.

Author Disclosure Statement

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

This work was supported by grants from the Department of Women and Gender Equality (GV18315-01), Canadian Institutes of Health Research (013902), Canadian Foundation for Innovation, and an anonymous donor (012153).

Abbreviations

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