Thank you everyone for joining tonight's member community session. So before we get started, I wanted to review a few housekeeping notes. As a reminder, this session is being recorded and will be available along with the ability to claim your CME through the Academy's online learning portal. For the best attendee experience, please mute your microphone when you're not speaking. To ask a question, please use the raise your hand feature or unmute yourself if you're called upon. You can also use the chat feature to type your question. Please note that time may not permit that the panel feel every question, but we'll do our best. And now I'll turn it over to Dr. Caldera. All right. Can I get a thumbs up if you can hear me, Dina? Good, perfect. Well, good evening and thank you for joining us, everyone who's here virtually on this evening. I am Kristen Caldera. I'm live to you from Madison, Wisconsin, from the University of Wisconsin. I am currently the CNS community chair and have had the privilege to work with many of these wonderful faces on camera now. They're hardworking, they're enthusiastic, and I will tell you they do a lot to support this community. I wanted to start with thanking two of our outgoing chairs for their two years of service. Heidi Fusco joining us from New York University and Marilyn Pachinko joining us from Edward Hines VA near Chicago. Thank you to both of you for these last two years for organizing and presenting, as well as letting us bounce ideas off of you for our practices, as well as helping us grow what we want the CNS community to be. Our three chairs who will continue next year are also here. We have Dina Hassaballah joining us from University of Seattle. It looks like we have flowers in the background. She's been instrumental to updating our library if you haven't checked it out on FizForm for the very many must-reads for CNS practitioners. She's also helped a ton with this presentation tonight with lots of emails and organizing speakers. So thank you sincerely. Diane Mortimer is our current chair elect. She's joining us from the Minneapolis, Minnesota VA. Thank you again for helping us navigate the intricacies of the AAPMNR organization. You always seem to know someone who knows someone who knows an answer. Katie Eltonji wasn't able to be with us tonight. She is a recent TBI fellowship graduate who started at Shirley Ryan and is continuing with us next year and really helping us figure out how to best support our trainees. She is the one that was responsible for our live virtual session where we invited people currently in training to talk with people live about what they do in CNS, whether they were fellowship trained or other trained. So she was really wonderful to work with throughout all of that. We have elections this week for two of our positions. The candidates will be posted on FizForm. Please take a look. You can vote right there. Voting will close Wednesday so that we'll have our new chairs on Thursday, which brings me to my final note. If you're joining us in Baltimore on Thursday morning from nine till 10 Eastern, we have a quick meet and greet. There are lots of community meetings at that time. I encourage you to go to many of the different ones that are at that time, but please just stop by and say hello. And with that, I again, thank you for coming. And I invite Dr. Hassaballah to take over with the next introductions. Thank you, Dr. Caldera. And thank you to everyone who's joining us tonight and everyone who's joining in later for the recorded session. It is my privilege to introduce all of our faculty. And I'm going to start with Dr. Brian Greenwald. One moment. So Dr. Greenwald is currently the Medical Director of the Center of Brain Injuries and the Associate Medical Director of JFK Johnson Rehabilitation Institute. He is a professor in the Department of Physical Medicine and Rehab at Rutgers Robert Wood Johnson Medical School. He is a professor in the Department of Physical Medicine Rehab at Hackensack Meridian School of Medicine and is also the Director of the Brain Injury Medicine Fellowship at JFK Johnson Rehab Institute. Dr. Greenwald is currently involved as the Medical Director of the JFK Johnson Traumatic Brain Injury Model Systems of Care Grant funded by the National Institute of Disability, Independent Living and Rehabilitation Research. Dr. Greenwald has been the recipient of multiple awards for his clinical work, research work and teaching. Dr. Greenwald has published multiple articles and book chapters in the areas of brain injury rehabilitation and is currently involved in several research studies to improve the care of brain injury survivors. It is my privilege to introduce to you all Dr. Brian Greenwald as part of our lecture series. Let me share my screen. Okay, thumbs up, everybody can see it? Okay, okay. Well, today, thank you for inviting me to talk about this, I think actually upsetting topic, but an important one for us to understand is as physicians and people, especially people taking care of persons with brain injury are really trying to better care for the population just in general. So today we're going to talk about, so we're going to talk about our learning objectives are to increase awareness of intimate partner violence in the physiatry community, to explore incidents and characteristics and patterns of brain and spinal cord injury in victims of IPV, to provide routine screening tools for physiatrists to use to assess survivors for brain injury so they can obtain timely referrals for neuro rehabilitation services to improve quality of life for these survivors. So I have no relevant disclosures. This topic was something that I was interested in. I published this article earlier this year with Kellyanne Costello. This article is in Brain Sciences, which is an open access journal. And so you'd have opportunity to read this article without necessarily needing a big academic institution to help you get this article. But a lot of the information I'm going to talk about today is in this article that we published earlier this year. So let's first start off with talking about definition, the definition of intimate partner violence. So we're talking about violence by a current or former spouse or partner in an intimate relationship against the other spouse or partner. It's been, I'm going to start calling it IPV just for simplicity. IPV can take a number of forms, including physical and verbal, economic, emotional, and sexual abuse. And unfortunately, so much of the injury that we see in persons who suffer from IPV is to the head and neck. And obviously the risk of traumatic brain injury with regards to head injury and the risk of strangulation with secondary brain injury when we're talking about neck injury. So let's talk a little bit about definitions. I'm suspicious a lot of the people here online with us are familiar with this, but it's an insult to the brain caused by an external physical force. And I really, I put that in there and I underlined that because we're talking about something different than stroke or brain tumors or other type of brain pathology. It's an external physical force to the head that may produce a diminished or altered state of consciousness resulting in impairments of cognitive abilities or physical functioning. And unfortunately, so much of what we see after traumatic brain injury, let's say unlike stroke, as an example, we see much more physical disability. Much of the disturbance that we see after traumatic brain injury across the spectrum of severity is really the behavioral, the emotional and cognitive difficulties. And these impairments may be temporary or permanent and cause partial or total functional disability or psychosocial maladjustment. And we're gonna talk a little bit more about that psychosocial maladjustment. So, across the spectrum of severity of traumatic brain injuries, some of the harder, some of the more difficult to recognize brain injuries often in mild traumatic brain injury. And I put up there this definition put forth by the ACRM that was published in the Journal of Head Trauma Rehabilitation all the way back in 1993. So 1993 seems like yesterday to me, but it was a while ago, I recognize that. In reality, this same definition has been used consistently by all the organizations that have published definitions since, including the military and the World Health Organization, American Academy of Neurology. But it's a, the definition talks about it's a traumatically induced, again, trauma, I'm talking about some sort of trauma to the head, induced physiologic disruption of brain function as manifested by at least one of the following. So the loss of consciousness. And so part of the reason that this article back in 1993 was written was that prior to 1993, if you didn't have a loss of consciousness and then had symptoms of brain injury, they thought you must be faking it. Amnesia for events before or after injury, an alteration of mental status often talks about being as the person who's feeling dazed or confused or a focal neurologic event that may or may not be transient. And so here we can see seizures, alterations in balance, alteration in vision. I think some of the challenges of this definition and then some of the challenges of why certainly persons with mild brain injury and I'll put mild in quotes, but persons with mild brain injury are often under-recognized because a lot of this, unless it's loss of consciousness, which we now understand only occurs about in 10% or less of mild brain injury cases. Many of these other things are how the person felt afterwards, right? So the only the person themselves could tell us if they have amnesia before or after the injury, only the person themselves can tell us if they really felt dazed or confused. And certainly we've seen the person seizing, that's one thing, but that even some of the focal neurologic deficits that we see are kind of based on how the person is feeling. So to look at the upper limit of where you go into moderate severity brain injury, so it needs to be a loss of consciousness of 30 minutes or less. If it's greater than 30 minutes, that would be a moderate severity brain injury, a GCS of 13 to 15 after 30 minutes and a length of post-traumatic amnesia or this post-traumatic confusion for less than 24 hours. Again, separating mild severity brain injury from moderate and severe brain injury. So strangulation, as I mentioned again, you really also need to consider this as another potential cause of injury to the brain. And so I think there's been so much discussion over these last, certainly the last decade plus, that traumatic brain injury is a silent epidemic. And so oftentimes I see my patients suffering from this silent epidemic because they walk in, they may be suffering from a lot, again, this cognitive, behavioral, emotional issues, headaches, balance issues, dizziness, other things that they're, other symptoms that they're feeling, but they're not missing their head. They're not necessarily, you know, walking around with a brace on their arm or their leg. You know, they're not, they may not be recognized to all the challenges that they're facing. And again, in traumatic brain injury, we talk about it as a silent epidemic. We've certainly seen this discussed a lot with regards to our veterans and, you know, with regards to in sports industry, injuries and how the person's often suffering in silence without being recognized as someone who's had an injury and needs care. So I remember the good old days when you could say the CDC and people are like, oh, of course, well, that must be really obviously true to the CDC. I hope that this, all this data, this all published data, I'm sure it's all good. But the CDC estimates this about 1.7, the CDC estimates that there's 1.7 million in traumatic brain injuries per year. The CDC also estimates about 5.3 million people living in the United States with a TBI disability. When you think about that, that we're talking about 2% of the population. In this article by Jonathan Silver, he actually talks about as high as 8.5% of the US population. And he bases it on a study that he did, an epidemiologic study that he did in New Haven, which is really just sort of a study of knocking on people's door, asking them whether they've ever had an injury to the head with or without a loss of consciousness and found that certainly people who said that they had an injury to the head with a loss of consciousness, which I said is only one part of the population of people with mild traumatic brain injury, that there's a significant difference between the non-injured population in this epidemiologic study and the injured population. And Dr. Silver estimated it could be as much as 8.5% of the US population has the long-term effects of traumatic brain injury. We certainly know that overall traumatic brain injury is a leading cause of neurologic disability in America and certainly across the world. So one of the challenges again, as far as diagnostics and getting people to treatment is that such a large percentage of traumatic brain injuries are mild in severity. So 85% is the general recognized number of when we look at traumatic brain injuries overall about somewhere between 10 and 15% are moderate to severe and mild about 85%. Unfortunately, as you can see here, there's those that mild traumatic brain injury that often goes undiagnosed and secondarily untreated. So we were talking about mild traumatic brain injury. So again, you tend to see people who are conscious, a regular may have an alteration in mental status, but often that GCS 13 to 15, they may be seen in the emergency room, they may be seen in a physician's office, but unfortunately these injuries often go underreported, undiagnosed and secondarily untreated. When we look at this pyramid, we can appreciate, so again, those 1.7 million traumatic brain injuries every year at the very least. And so really the 1.7 represents sort of the top three parts of this pyramid that the deaths, the hospitalizations and the emergency room visits, those are the ones that really the CDC is able to get the data on. But we know also that so many people receive either other medical care, again, not in a hospitalized setting or no care at all. And it's really that base of the pyramid where a lot of these sort of long-term survivors, these people who are long-term challenged by their brain injury are. So again, the official estimates don't include that 400,000 plus traumatic brain injuries treated in physicians' offices. That's again, not included in that CDC data. Then almost 90,000 people treated in other outpatient settings. The official information also doesn't include people who don't seek medical advice, which is thought to be somewhere estimated about 25% of all moderate and severe, all mild and moderate traumatic brain injuries. It also doesn't include data from the federal military, the Veterans Hospital, where we know also that unfortunately too many people with traumatic brain injury are. So again, looking at unfortunately how well TBI is identified or unfortunately not identified. Again, as I mentioned, about 25% of persons surviving a traumatic brain injury admitted even to the hospital will go unrecognized. The emergency room, there's been multiple studies saying somewhere between 35 and 50% of persons who showing up to the emergency room are treated and released without being diagnosed with especially a mild severity brain injury where there's nothing on CT scan or MRI. Unfortunately, similarly at clinics and in physicians' offices, you know, this often goes under recognized in persons who've had brain injury. And again, so many people never even seek medical care. So besides the medical system not doing a great job in recognizing it, so many people don't even seek medical care. What I think the challenge is also is that the person who's suffered the brain injury, including the person who suffered IPV, they may not realize that they've had a traumatic brain injury, right? So maybe they didn't have a loss of consciousness. Maybe they were just dazed and confused. They were in a situation, but they also may have cognitive difficulties that limit their ability to understand that they've had a brain injury there. They shouldn't be the ones dependent on to be looking to whether they've had a brain injury or not. So where are all these patients who have been missed traumatic brain injuries? Unfortunately, they're in populations where we don't want them to be, right? So as I was saying that this, in people who have suffered domestic violence or IPV, we know that there are much higher rates of traumatic brain injury or brain injury also related to strangulation. When we look at the alcohol use disorder or the substance abuse disorder population, we also see much higher rates of traumatic brain injury. And that group, the incarcerated population, the psychiatric population, there's certainly a chicken and the egg issue there, right? So did the people become alcohol abusers, substance abuse abusers, end up in jail, psychiatric populations, because they had a brain injury? Or does the brain injury sort of, did they have issues before that? Did they have alcohol use issues that led them to a brain injury? Were they incarcerated leading them to a brain injury? Are they psychiatric patients leading them to risk of brain injury? Well, sort of interesting question. Similar to the homeless population, there's been now a number of studies that have looked at the homeless population. Also, so many more patients than you'd expect, and this population that have suffered a traumatic brain injury. And again, that chicken-egg challenge there. So shaken baby syndrome, unfortunately, higher rates in the HIV population. And again, sort of the missed opportunities in the multi-trauma patient. I've just seen a patient like that where, although he had been treated in a good rehabilitation, they had a good hospital and a good rehabilitation center, he'd had a lot of fractures, had a lot of pain issues related to that. There's really not much question that he suffered a concussion related to this, high force motor vehicle collision. But kind of once all his fractures healed, they said, you know, bye-bye. And it wasn't. Fortunately, someone reckoned he's struggling at work, struggling at home. And fortunately, one of his treaters, not related to the accident, said, hmm, maybe he had a brain injury. You should see that guy, Greenwald. So I think, but it was, again, it's sort of one of those situations where, like the records, I looked at the initial records, it makes it very clear. I think he had a loss of consciousness, had, you know, a significant injury to the head. But then so much of the focus was on the fractures and the pain related to that. And, you know, the sleep issues, the mood issues related to having pain and this and that. And sort of once that was done, they're just like, bye-bye. And this poor guy is like, hey, you know, I'm still suffering from troubles. And that's really where, I think where the potential sort of mispatients are. And you can see in all these different groups how the challenges that they're having could be, you know, misunderstood. And that we're recognizing what brain injury, what the role of brain injury is in this population. So I'd say it's in the same way we talked about traumatic brain injury being a silent epidemic. Unfortunately, IPV plus or minus brain injury is certainly an under-recognized major health problem in the United States. So when we look here at the issues that we're talking about, so certainly and unfortunately, women suffer very high rates, you know, relatively speaking, each year of domestic violence. And it was, you know, I had a chance to see Dr. Valera's presentation and the pain concussion presentations a couple of weeks ago at the North American Brain Injury Society meeting. And it's really eye-opening as far as the high rates, the high prevalence and incidence of IPV amongst women, just terrible, honestly. As a man, it sort of makes me feel like putting my head down but just such misery, honestly. Unfortunately, you see 30% of battered women seen in the ER report at least one episode of lost and crunches in the past and 67% having residual problems that were potentially head injury related. Always such good work by Dr. Corrigan and his group in Ohio. So these numbers, which I know Dr. Valera is gonna talk about more, talk about some of these challenges. But I mean, we know that, you know, we teach that the ratio of, in traumatic brain injury, the ratio of men to women is three to one. Men are certainly a very male dominated disease type thing. And I stole this from one of the presenters in the pink concussion group that men often acquire their traumatic brain injury through their behavior. Again, we're mostly trying to show up to women, you know, driving fast, drinking a lot of alcohol, beating up other guys or hoping to do those things at least. But women unfortunately often acquire their brain injury through the behavior of men. Such terrible history we have there. So what are some of the challenges in identifying IPV? So we talked already about some of the challenges recognizing brain injury overall. We've got to recognize the stigma in this situation, right? So rich or poor, nobody wants to talk about sort of this type of misery in their life and then maybe hiding it. We got to recognize that there's risk across the spectrum, black, white, brown, you know, rich, poor, that, you know, that men, women, you know, of all sexual orientation, that's really there's risk across the spectrum. There's certainly some groups that we know that there are a higher risk, a higher percentage. And we know that females of childbearing age, individuals with disability, persons who've had previous traumatic brain injury, a low annual income, minority race, unfortunately female military veterans and the LGBTQIA plus community also. And certainly when it comes to that last group, there's so much that we're still learning as far as the challenges that they've faced. We don't even really know what COVID has brought. You know, there's certainly been a lot of fear about that, about people being home with each other and sort of the frustration about being locked at home for a long period of time. Certainly, unfortunately more that we'll have to learn with regards to that. This is actually from the article that myself and Kellyanne published going over some different screening tools that can be used or that are commonly used. Certainly one of the things is just recognize that a brain injury has occurred. The BISC, the Brain Injury Screening Questionnaire, which was based out of Mount Sinai is certainly one of the most sensitive and specific skills that can be used as far as looking for the person has had a brain injury or not. Certainly the Ohio State University TB identification method is also excellent at looking at that. I hear a number of other scales also that can be very useful as far as looking and screening for persons who may have had a brain injury or related to IPV. So we got to think about some of the common changes that we see after traumatic brain injury and think about how that might relate to some of the problems that people are discussing that we see. So, you know, the physical changes, fatigue and sleep issues and headaches and chronic pain, sensory changes, dysregulation, body temperature, dizziness, but really so many of the changes that we see after traumatic brain injury are more, again, the cognitive, behavioral and emotional issues. And some of the particular challenges, the executive functions and how that might relate to some of the risks that someone with a brain injury might be willing to take on. Again, how some of that may lead to also some of the social and interpersonal challenges. And unfortunately, secondarily, some of the emotional disturbances that we see after traumatic brain injury, including high rates of depression and anxiety and emotional ability and lack of motivation and irritability. In particular, with IPV, some of the common presenting signs that are more common that we see in traumatic brain injury are related to IPV or IPV and traumatic brain injury. So neurologic issues like headache and confusion and memory loss, gastrointestinal issues, unfortunately, alcohol cirrhosis, loss of appetite, abdominal pain, malnutrition, but GU issues. Here's some things to be looking for with regards to strangulation, right? So hoarseness, petechiae in the conjunctiva, petechiae injuries to the scalp or the external ear, psychiatric considerations that are more common in the IPV population. And then looking at others, such as the bruises for unclear etiology, back pain, acquired thrombocytopenia, post-traumatic wounds, all things that should make us as clinicians think, what do we need to be thinking about in this population? Is it possible that IPV is an issue here? Unfortunately, in brain injury just in general and certainly just as much in IPV, lack of identification may lead to misdiagnosis, right? To attributing the challenges to something else, which unfortunately misdiagnosis can lead to inappropriate treatment. Certainly a mismatch between treatment and cognitive impairment and certainly recognizing cognitive impairment and how that may limit a treatment or may need to specialize treatment is certainly important. Unfortunately, academic and vocational failure, increased risk of psychopathology and unfortunately, higher rates of incarceration. As far as treatments is sort of recognized against some of the barriers to treatment and we talked about stigma and how we need to also think about the importance of healthcare versus maintaining the safety of the person, looking for subtle signs and symptoms, recognizing how the person who is suffering from IPV may have fears about what the effect they would have on their children if they admit to it, as always with traumatic brain injury, it's a tailored treatment plan, including certainly a range of clinicians that we all know well, but the importance of also working with social services and domestic violence professionals in this and so if IPV is the etiology of the injury to making sure that we're getting them involved also. So unfortunately, we're not getting there. So unfortunately, overall outcomes, we see poor mental in IPV and IPV traumatic brain injury, poor mental and physical health, higher rates of PTSD and certainly there's been so much fear about the cumulative effects of repeated injuries and also the risk to future generations, right? Seeing these behaviors and then what effect does that have on the children and their behaviors? In summary, both IPV and traumatic brain injury have high incidence and prevalence in the United States and around the world. I certainly don't want to say that this is an issue only in the United States. Both can be seen as really silent epidemics. Fortunately, there's high rates of traumatic brain injury in people who have suffered IPV, really recognizing and screening for IPV and traumatic brain injury is certainly critical for improving outcomes and when we're thinking about treating a traumatic brain injury related to IPV, we need to make sure that we're utilizing the right resources to make sure that they get the best treatment possible. Thank you very much. Thank you so much, Dr. Greenwald. It's amazing to see how many different populations intimate partner violence affects and how that can affect whether it's the socioeconomic status, the return to work, just amazing how much it just goes across. Thank you so much. Our next speaker who I have the privilege of introducing is Dr. Diane Mortimer. Dr. Mortimer is the Medical Director of Inpatient Brain Injury and Polytrauma Rehab at the Minneapolis VA Healthcare System. She's the Associate Program Director for the Brain Injury Medicine Fellowship at the University of Minnesota Department of Rehabilitation Medicine. She has worked with patients affected by neurotrauma across the continuum from the ICU to chronic settings. She's had the opportunity to engage in presentations, publications and clinical research involving neurorehabilitation and related topics. Dr. Mortimer is also the Chair Elect of the CNS Community Executive Council and has been a dedicated member of the physiatry community in academics and clinical care. Thank you all and I'm gonna turn it over to Dr. Mortimer. Awesome, can you guys, hopefully you can see that and hear that. Okay, good. So I'm gonna switch it to, here we go. So thank you so much, Dr. Greenwald and Dr. Valera and Dina, Dr. Hassanbala. Just kind of switching gears quick here for a little bit of information about spinal cord injury, which could occur as a result of intimate partner violence, you know, being the CNS Council, we wanted to include spinal cord injury and because we know that's an important part of this topic as well. Unfortunately, though, there's not very much literature about spinal cord injury caused by intimate partner violence. It's still important to talk about for various reasons. So just a quick overview of the general facts and figures. In the US every year, there's about 18,000 new spinal cord injuries. That's mostly traumatic, although there's other causes of trauma. Although there's other causes as well, the prevalence then turns out to be somewhere between 250 and 370,000. This is per the Spinal Cord Injury Statistical Center through their model systems. So kind of not just people in their study, but people that they're kind of estimating these numbers to be the average age about 43 and males account for 78% of these new spinal cord injury cases. So not quite as common as TBI, of course, but certainly very, very important. So the facts and figures continued. I just wanted to kind of highlight some of the information that we know about etiology of spinal cord injury. Going through these numbers, about 38.6% are vehicular causes. Then the 32% falls. Acts of violence come out at 14%. Sports, 8%. Medical surgical, say cancer. Things about 4% and other not given about 3%. And I think it's important to kind of focus on this just for a second, because sort of like what Dr. Greenwald was just saying for TBI, it's very likely that some of the injuries that these represent were related to intimate partner violence. We just don't classify it right. We don't just write that down. We don't keep track of it that way. But sometimes saying, well, why were you in that car? How is it that you fell? You know, what was that act of violence? And some of these others slash not given, how did those injuries occur? So it's very possible, in fact, probably likely that intimate partner violence had a role in some of these injuries, but we're not classifying it and we're not coding it or tracking it. So we don't really have the data to share with you here. There is a pretty good study that came out last year about people who had spinal injuries. So not injuries to the cord, but injuries to the spine. So these are known victims of intimate partner violence, about 700 of these people. So they were able to kind of classify them, look at them. They knew they had injuries to intimate partner violence and then kind of reviewed the records. Of those 688 people, 21 of these people, so about 3% had injuries to their spines. In this study, no one had injuries to the cord, which was very good. Of course, we're happy about that, but still the trauma was significant enough to cause injury to the spine in 21 of these people and that accounted for 41 injuries. So 21 people and some of them had multiple injuries. Of the people who were injured and that sustained spinal injuries, 19 out of 21 were female. And the median age of these 21 people was 43 with pretty wide range there. And then we get back to this etiology issue, right? So when you think, when they classify the people, the etiology of the spinal injury of the 21 people in this study who had spinal injuries as a result of intimate partner violence, blunt trauma or direct assault accounted for 38%, falls accounted for 38% and the incidental or not reported accounted for 24%. And so I think when you take this and think about the previous slide about the etiologies of spinal cord injuries, it is certainly likely that some spinal cord injuries are also caused by some of these mechanisms. The level of injury in these 21 people, most common places to sustain spinal injuries after intimate partner violence was in that upper lumbar area. The next most common was in the upper and mid thoracic area. One particular scary case of a C2 fracture as well. I know it's sort of like Dr. Primontz said, this can be disturbing to talk about and sort of to think about, but I think it's important that we do that. So this slide just talks somewhat about how do people sustain spinal injuries after intimate partner violence? And certainly this would also probably relate to how people might sustain spinal cord injuries as well, of course. So when you think of the hyperflexion and hyperextension that occurs when there's blunt trauma to the face and the head, so can cause fractures, particularly a lamina of the bone, part of the bone that's just that little bit, there's a little bit of weakness there and spinous processes or transverse processes. So we tend to learn when we think of trauma, we work in trauma, we think of needing some high degree of force or some high velocity injury. So it's pretty troubling to think about a fist or someone being thrown against something with enough force to cause a fracture of these bones, but that certainly probably happens. And then getting back to these strangulation injuries and whiplash type injuries, of course, the hypoxia and things that can affect the brain, but then when you think about this degree of force as the neck is being shaken and the head is kind of moving, however, it is doing on that fulcrum, right? If it's going forward or backward or rotating, there's at least some, there could be at least some pulling or pushing, shaking, but then also if there's some forceful lateral rotation, as someone is trying to resist, certainly there can be fractures of transverse processes and other parts of the bone. And certainly if those fractures are bad enough, or if there's ligamentous damage, we might certainly see core damage as well. In this study, they did have a number of, in their publication, a number of these injuries, some imaging. So see, here's one of the one on the left. They didn't quite specify in that one. That was sort of the one of the unknown types of injuries, but it was known intimate partner violence or some type of trauma. And the injury there to the vertebral bodies of C7, T2, T3, and T4. And then the one on the right was reported as a fall, following or as part of intimate partner violence. And certainly that L1, L2, there's the, I can't move my little thing here, but you can see the avulsion and the, a little bit of avulsion, it's hard to see, of course, the reproduction, but certainly some trauma occurred to these people. So just kind of summing up here, again, we wanted to include spinal cord injury. I wish there was more data and more hard stuff to share with you, but I think this is important to think about and important enough to include even with the limited information we have about it. I think it's very likely that this topic is understudied and it's very, very likely that cases are either underreported or just not fully classified, right? So we know someone had a fall. We know someone had some blunt trauma, but we don't necessarily classify it as intimate partner violence. I think it's really interesting that in kids, the presence of a spinal cord injury, particularly in a younger child, is considered a likely indicator of non-accidental trauma, not guaranteed to be non-accidental trauma, but something that warrants investigation. So we do think about it in kids and maybe we should be thinking about it in adults as well. And it's also possible, I think this goes to some of the stuff Dr. Greenwald was talking about as well, is that when people are seen for one thing, that's what we treat and we might not be looking for other things as well. So if somebody has a TBI or some other trauma, we're treating that and it might not be right away that that injury to the cord is really noted. And by the time it's noted, it's not necessarily related to that trauma. So I think I would end with this consideration. Maybe we should, I think we should include in our assessment of patients with spinal cord injury, some consideration of whether intimate partner violence was a contributing factor in how they sustain that injury. So thank you. And I'm going to hand it back to you guys. Thank you, Dr. Mortimer. And just kind of going around what you're saying. Yeah, absolutely. In a pediatric population or even in a geriatric population, I think questions become a little bit more concerning when there's a fall, if there was someone at home, if it was witnessed versus unwitnessed. And I think we question it less so in that in-between population, regardless of age and sex. But thank you so much. And then to all of our participants, I will be, Dr. Hildera and I will be keeping a list of all the questions and saving it for the Q&A at the end. So thank you for submitting your questions. Please continue to do so and we'll definitely get them addressed at the end. It is my privilege now to introduce our last speaker, Dr. Eve Valera. Dr. Valera is an associate professor in psychiatry at Harvard Medical School and research scientist at Massachusetts General Hospital and has worked in the domestic violence field for over 25 years using a range of methodologies to understand the neural, cognitive and psychological consequences of brain injuries from intimate partner violence. Most recently, her focus has been on transgender women as well. She regularly lectures internationally with examples being South Korea, Spain, France, Columbia, Canada, China, and Japan, and has received national as well as international recognition for her work. She was recently involved in the New York Times Magazine, Forbes, and the CBC Canadian Radio. She has been the recipient of numerous awards, including the prestigious Robert D. Bucht Founders Award, the Rappaport Research Fellowship in Neurology, the Pink Concussions Domestic Violence Award, and the Women Making History Award, as well as the Anne Klebanski Visiting Scholars Award. Dr. Valera is passionate about raising awareness and educating all relevant stakeholders about this tremendously overlooked public health problem. And so I introduce to you all Dr. Eve Valera. Dr. Valera. You are still muted. Oh, let me see if I can unmute you in one moment. Ah, I think I can now can you hear me. Yeah, go ahead. I'm like, I know I hit it. So thank you so much. So, so much to everyone who coordinated to allow me to be here for the invitation. As I just said, I am extremely passionate about this, I think this is a topic that is completely underappreciated in so many ways, and it is actually. It's just so incredibly important for us to have a greater understanding and a greater appreciation of. I understand that there's two other sessions going on now. But if you just look at the numbers there's like 13 participants, and we're like seven of the organizers are here so clearly there's not I mean there may be, it may just be that there's not a lot of people whatever, but it's not surprising people don't see this as a problem they don't recognize it, but we are making progress and the fact that Dana you have brought me here and and Dr Greenwald here to talk about this and and present this means the world to me because it means you've recognized it means other people are, and we're slowly making progress, so I don't necessarily see it as a bad thing that there's not more people here, I see it as a great thing that I've been, you know, asked to speak on this, so it's all good, but it just sort of speaks to my point. So I'm going to share my slides now and as I'm doing that I will say is a couple of folks have alluded to IPV is not a fun topic. I'm not, you know, there's just no two ways about it. It's not fun it's not pretty. And it's embarrassing I think as as a community as a society as a world that we let this happen that so many women are affected by it. And there's so little concern over it in general. So, I'm going to be talking about IPV and I'm gonna be talking about the intersection of IPV and brain injuries, and it's not always going to be pretty. So, if you are someone who's experienced partner violence or a brain injury and you're not sure and you, whatever I mean, I respect that if you want to leave or turn this off or don't want to watch that. I totally respect that people should take care of themselves first in case this is triggering to anybody, but this is something that needs to be said, and hopefully if you have been affected hopefully this will help you as well. So I have no relevant disclosures. IPV or intimate partner violence has all already been defined briefly by Dr. Grunewald and I'll just say it's a violence perpetrated by current or former. And just so people know that doesn't have to be somebody who you're currently with still. I've had women who have been tracked down by partners who they've left, and been, you know, well, really bad things have happened to them. And in the news, you can see people who have left their partners, and then their bodies are no joke that just found this body was cut up and found in two suitcases. This is not, these are not idle threats when women are afraid to leave their partners because they might be killed. So, any violence perpetrated by current or former spouse partner significant other boyfriend or girlfriend. Some other really horrible horrible facts. IPV is the leading cause of homicide for women globally. I never ever bet. I'm not a gambling person. But if you were to tell me that somebody, a woman was murdered. That's all the information I had. I would say, where's your partner. The most likely bet is that it's not a partner and that won't always be your partner, but that's where your money should be you should always absolutely investigate that which to me is extremely, extremely saddening. Also, the IPV is also the most common form of violence against women. So again, people are supposed to love take care of us cherish us etc other people who are most likely to inflict injury upon us. You know, don't worry about walking out the street, walk about going into your home right if this is something that you're experiencing. And it's found across all socioeconomic boundaries. I think some people like to think. You know, I know that you know the Latinas are the black people are the colored people are the people in the ghettos or whatever, that's where it really happens and maybe there's some be some shoving, but that no, it is a global public health epidemic doesn't matter who you are, whether you're rich whether you're poor. It is very true as Dr. said that some people are disproportionately affected. If you are lower income, that might disproportionately affect you in there and there are people of color are disproportionately affected and absolutely transgender women for example are disproportionately affected, but it does not mean that it does not happen at high rates, and other communities and populations, and it does, and it is global. Okay, so what's the real numbers well as has been alluded to earlier one in three women experience, physical or sexual inmate partner violence, you can get different numbers the CDC has a one in four number for for something a little bit different. But the bottom line is, is this number is high. So, I want you to just think of nine women, you know, you may not be able to conjure that many women all at once. But just, you know, we probably know at least the money and I want you to think of not that one, not the two but the three of those women who've experienced partner violence, because those the yacht. Now I'm not gonna say it's going to be the same for absolutely everybody, but you won't necessarily know because it's very stigmatizing. I've had people come up to me afterwards who have known for years, and I'm like, thank you for doing what you do. Yeah, this is part of my, I don't like to talk about it but yeah and I'm like, wow, right. It's not something, you know, and if I feel comfortable talking about it myself as someone who might be abused etc. I may not want to bring it up to somebody else because people shirk away, they don't necessarily want to hear it's not a fun topic and it's not. There's, there's no sugarcoating it it's just not fun. So, what I want to do, what I, the reason I emphasize this, you know, in this context by saying like so many people are affected by this is because I feel like when people feel like this is something that affects me, or my family, or the people I know, we're much more likely to be engaged and actively want to participate in solving the problem. When we think it's somebody else's problem. You might care if you're a good person, you might say, well, I got too much stuff to think about, but I'm telling you right now these are our daughters, these are our sisters, these are our colleagues, these are our mothers, these are our friends. You may not know it but I guarantee you, you know people who are affected, and maybe in more ways than you realize. So, I want to also talk about those numbers in a slightly different way as well. And say that what we know is that partner violence has always been high. Now since COVID, rates of partner violence have escalated, and the severity of partner violence has escalated. And we don't have the data yet, but it's horrifying to me that Roe v. Wade has been overturned, because now there's going to be many, many women who may have previously been able to obtain abortions and this is not whether or not I support or don't support abortion. I'm not even taking a stance on that. What I'm about to say is that women are most likely to be abused or one of the high rates of being abused is during pregnancy, and during the months right after having a baby. So, this is very, very, very, very likely to increase rates of partner violence in many ways. And so we just have a really, really bad situation on our hands. So, I left this slide blank for a minute because I just want to listen, I want to read something to you really quickly, because this, this kind of came across my desk, and it, it's a real life story of a lot of the things that I talk about or the Dr. Greenwald mentioned, and it's very, it's very short and I didn't write this it's from an article and if I put it on a slide I would probably, you know, quote the person but so just, just so you know I actually, I didn't write it let's just leave it at that. Here it is. The abuse escalated during her pregnancy. One night when their baby was a few months old, BL said her husband pounded her against concrete outside their house, so ferociously that she knew he wouldn't stop until she was dead. Somehow she knocked his glasses off, caught him off balance and ran for her life. Her obstetrician never asked her about her broken toe, her purple bruises, the clumps of hair torn from her head. Abuse is a taboo thing to talk about she said. The health system, her health system failed her. Although looking back she wonders, even if her doctor had brought it up, would she have answered honestly? I was very ashamed and broken down, because abusers break you down inside, they make you feel it's your fault, they make you feel small. So these are just, it's just a snapshot of what women may experience and partner violence. And hopefully that also tells you how there could be this intersection, a very horrible intersection of IPV and brain injury. So what we know, aside from just this little, you know, story that I found that came across my desk, you know, literally a week or two ago, is that 80 to 90% of injuries to women are to the head or neck. And here, not trying to be sensationalistic, but I've had women tell me about being stomped on the head with work boots, punched in the head repeatedly with fists, hit in the head with hammers. Autopsy reports that show hammer marks in women's heads. And women being slammed in the head with baseball bats. This is, I'm not making this up, and it's not that this is rare. So what do you think? Could this maybe be causing traumatic brain injuries? Yeah, absolutely. But when I started looking at this back in graduate school in 1997-ish, there wasn't a single article addressing the possible intersection of traumatic brain injuries and intimate partner violence, which to me is crazy. Now there's a little bit more, but we're still so, so far behind relative to the leaks of data and information we have on men with brain injuries from athletics or the military. So in my study, this is a study of 99 women that I looked at, I found that most women who had experienced intimate partner violence sustained an IPV-related brain injury. So if we have here, what I'm showing you here real briefly, the 42M here is 42 million women who by the one in three statistic over the age of 15 has experienced intimate partner violence in the U.S. alone. What I found was that 74% of the women in my sample reported at least one brain injury from their partner. And even more frighteningly, 51% repetitive brain injuries from their partner. For some of them, too many to count. So that could be over 21 million women walking around in the U.S. with undiagnosed, unrecognized, repetitive brain injuries. How is that even possible? Now, I will grant that this was a sample of convenience, but say you cut this in half. Say you cut it again in half. Five million women in the U.S. walking around with repetitive brain injuries from their partners. No matter how you slice it, this is just unacceptable on so many levels. So we also did a review across 18 articles, and we basically provide some estimate of IPV-related brain injury, just on what's out there. Because there are no good epidemiological studies, because this isn't really an important topic. No one has decided it's important enough to do an epidemiological study. All these other things are important, but not IPV-related brain injury. So we found that there was actually a wide range, and this is across 18 studies. And what we found here was that on the high end, we had 100% of the sample. Everyone in the sample reported a brain injury. Now, I don't really think that every single person who's experienced partner violence has sustained a brain injury. But some studies do find that. On the low end, 27%. So if you just look at samples granted of convenience, the range is wide, but there's a high, low point if we're looking at this. This is not a trivial thing. In my sample of 99 women, who I talked about earlier, found that IPV-related brain injuries are associated with poor cognitive and psychological outcomes. Having more brain injuries was associated with poor performance on tests of memory, learning, and cognitive flexibility, or the ability to go back and forth quickly between tasks. These women have higher ratings of general distress, depression, worry, anxiety, and traumatic stress. So here these women are not only having greater challenges just thinking normally, learning, remembering, going back and forth between tasks, but then they're also laden with higher levels of psychological distress. And these were related to the brain injuries. We controlled for abuse severity itself, psychopathology and substance abuse, for the cognitive functions for the psychopathology and substance abuse. And it is not just that this is because they're in these psychologically abusive relationships that they're having these problems. There was a link between the brain injuries, the number and recency of brain injuries, and these negative outcomes. For a second, I want to talk about brain connectivity. Why do I want to talk about brain connectivity? We'll get to that in a second. But we can measure it really easily. We use MRI to measure brain connectivity, and we can look at both structural connectivity, which measures parts of brain cells that connect different brain regions. And we also can measure functional connectivity, which is just measuring regions, like basically deals with regions of the brain that are working together, but not right next to each other. So, for example, a region in the frontal lobe that's connected to the temporal lobe or the occipital lobe. And they communicate with one another, and we can tell that by using certain sequences in the MRI. And we know that both structural and functional connectivity are critical for optimal brain function, and ultimately critical for optimal behavior. So this is really important for what we're looking at here. Traumatic brain injuries involve injury to brain cells that can affect both structural and functional connectivity. So this is really important. And this is just a little illustration of how we can think about brain injuries that are quote-unquote mild, but result in all these problems down the road. And if you put someone in the scanner, you don't see anything, right? It looks like they have a normal brain most of the time. Well, as most of you here looking at this know, this is a neuron. It's just a cell in the brain. And this is the cell body. And the important part here is this axon here. And it's long and thin, right? And so when you have these really strong forces, acceleration, deceleration, or rotational forces, some of which Dr. Greenwell mentioned, you can have a tearing of this axon or a breaking of this axon. And when that happens, that neuron or brain cell may not be able to communicate with other brain cells effectively or communicate at all with other brain cells. And so that's going to create problems, right? And these are microscopic. And what happens is these may have breakages in all different parts of the brain, right? And it's not necessarily one big clump. So if you do a brain scan, you don't necessarily see anything. But what you might have is something that's called diffuse axonal injury. Diffuse because it's all over. Axonal because it's affecting this axon. And injury, well, because there's an injury. So that's one way to explain how we may not see anything on a brain scan. And so, oh, everyone's fine. They don't have a concussion. Well, no, it doesn't matter. You can still have a concussion. Most concussions are, by definition, it's a complicated concussion if you see something on the image. So that's just a quickie there. So what I did, I'm just going to tell you really quickly about two of my studies involving neuroimaging. And this one is on functional connectivity. And what I found in this first study, very short and simply, is that brain injuries from partner violence, the number and recency of brain injuries, were associated with functional connectivity, which was then associated with memory and learning. And so this is just a schematic of the brain. We've sort of just cut it in half so you can see the two regions we looked at. These were a priori regions based on work that had been done in other folks who had sustained brain injuries, not women who had experienced partner violence, but other folks, where they found something that we tried to sort of replicate. And so you don't need to know this. If you're interested, it's the connection between the posterior cingulate and the right anterior insula. And I can talk about that if anyone knows more details, but most people don't necessarily care about that level. But what we do care about is that the more recent and the greater number of brain injuries a woman had, the less positively these two brain regions communicated with one another. And that was similar to what we've seen in other brain injury populations. And really importantly here is that the less these two brain regions communicated with one another, the worse women tended to be able to learn a list of words and remember that list of words 20 minutes later. I think we can all agree that memory and learning are things that are critical to proper everyday functioning. In this other study, looking at structural connectivity in the brain, I find that IPV-related brain injuries were associated with structural connectivity and the posterior and superior coronaradiata. Now, again, you don't need to understand these names and exactly what they mean, but for the people who understand this and want to know this, I'm showing it. The bottom line is that what was shown in a study of repetitive brain injuries in football players, American football, we basically replicated in these women. And so we've had three a priori regions of interest that we looked at. And what we found was that there was a negative association between the brain injury score and a measure of water diffusion or fractional anisotropy in the posterior coronaradiata and the superior coronaradiata. So two of the three regions that we were testing. So you don't need to know all those details, but that's for those of you who are more familiar with the brain. And are just like, oh, wow, I understand DTI, I understand fractional anisotropy, et cetera. But the bottom line is we're seeing things in women who've experienced partner violence that we see in these other fields. And there's, I think, one or maybe two other imaging studies out there now. But when these were published, that was it. And there's hundreds, thousands in these other groups. And so this is just showing you where we are and I'm trying to explain to you where we need to be, which is not here, which is much further along. So I'm going to touch on strangulation a bit. Again, this has been mentioned previously already today. And why? Strangulation is a serious form of abuse that can cause not necessarily a traumatic brain injury by that definition of TBI, but an acquired brain injury. Strangulation is not choking. Choking is when you have something lodged inside your throat. Now, if a woman who I'm working with says, oh, I was choked, that's fine. I'm not going to say you shouldn't use that word because that's her experience and that's how she sees it. And in fact, because we understand that, we will say, has a partner ever choked you? We might say that. But in an academic setting, I really avoid using that. We talk about strangulation because that's really what it is. And I think it speaks to the seriousness of the assault that the person has sustained. It's an external attack on the neck. And terms that you will hear associated with strangulation are asphyxia, hypoxia, and anoxia. And they are just different terms relating to depriving the body of oxygen, that if there's enough of that can lead to unconsciousness or death. If you talk about hypoxia, that's a partial loss of oxygen to tissue. If you talk about anoxia, that's a complete absence of oxygen to tissue. So when you hear these terms, asphyxia, hypoxia, anoxia, or anoxic brain injury or hypoxic brain, that's what we're talking about, depriving those parts of oxygen. And that's one of the main things you need to understand here. When we have strangulation, basically we have a form of asphyxia from external pressure placed upon the neck, such that there's an obstruction of blood flow either from or to the brain, be it the jugular or the carotid, or an obstruction of the airway. So if we look over here at this video, sorry, my pictures are over, people are overviewing my picture here. If we look at these, the jugular vein is most lateral on the side of the neck, and then the carotid is a little bit more internal. And the jugular is taking out kind of the, quote unquote, dirty blood, the oxygen's been used up. And the carotid is bringing in fresh blood. And if you block the jugular and not the carotid, then you have blood going in, no blood going out. So you can have increased intracranial pressure because there's not enough space. You have something going in, nothing going out, one closed space, you might have problems from that. Now, if you block both, you don't necessarily have a problem with increased pressure because now you don't have blood going in, but now your brain's not getting that oxygen-rich blood that it needs all the time. It is remarkably easy to put pressure on the neck such that you can block both of these. Men will sometimes, and not just men, I mean, I've talked about this. I study women, and most of the people who I've ever interviewed have spoken about men, so I do speak in gender terms, but it can happen either way. But people, we'll just say, have been known to strangle women until they start to go out, and then bring them back, strangle them again, and then bring them back. So it's remarkably easy to do. If you push harder, you may break the trachea or block the trachea, and that's a little bit harder, but still not necessarily that hard. So strangulation is not hard to achieve. Rates of strangulation and partner violence vary depending on how it's measured, but the numbers are very high. If you just ask, did your partner ever choke you? 86% in a, this is unpublished data, but in that sample of 99 women reported at least one event of being choked by the partner. So not rare, right? And this is a very common number if you look at other data as well. If you ask in a way that elicits the response of understanding whether or not there was an alteration in consciousness. So after anything your partner ever did to you, did you ever lose consciousness, feel dizzy, dazed, disoriented, confused, et cetera? And they say, yeah, from him putting his hand or whatever, something around my neck, 27% in this recently published paper. Actually, this was one paper, sorry, that I published in 2003, reported at least one AIC or alteration in consciousness from strangulation. So we call that a strangulation related alteration in consciousness. And then what I did more recently was I looked at whether we could see relationships between strangulation alterations in consciousness and cognitive psychological outcomes. And indeed I could in a paper that was published earlier in JHTR. And we found that women who experienced alterations in consciousness from strangulation were more likely to have poor performance on tests of memory, both long-term and working memory. And we're more likely to have higher ratings of depression and post-traumatic stress. And I controlled for histories of child abuse, because we know women who experienced partner violence are very, they're much more likely to have child abuse than women in the general population who haven't experienced partner violence. And we also controlled for a number of partner-related TBIs because those often do go hand in hand. So there is another link here. So it's a double whammy. You can be strangled and have some type of cognitive, basically potential brain injury, and then you can have a TBI. And so we don't even, we haven't even scratched the surface of what the interaction of that might be. So what can I do? I mean, this is all doom and gloom. This is really horrible. And I know, I mean, we should be thinking this is horrible. Oh my gosh, how is this happening? And so I like to offer some suggestions. Well, start the conversation. As I've sort of said earlier, and has been said by previous members of this panel, we need to start talking about intimate partner violence and the possibility of brain injury. Not as if it's this thing that everyone should be afraid of and that people should be embarrassed of. If I broke my arm, if I broke my arm, I shouldn't be afraid to tell somebody I broke my arm, right? Or why should I be afraid to show that I have an injury because somebody did this to me. And there's a lot of stigma and stuff associated with that, which I get, I don't have the time to go into it. But we want to change that. We want this to be something that people can talk about and people can be comfortable talking about. And I urge people to always keep in mind that the high likelihood that IPV-related brain injury or strangulation may have occurred if you're working with somebody who has experienced partner violence, right? And have the right questions been asked because a woman won't necessarily know that she sustained a brain injury. And she won't necessarily recognize the importance or the relevance of reporting that she sustained a brain injury. She's like, well, I really needed to get that arm fixed because I can't go to work with a broken arm. But you know, he hit me on the head. You know, he does that like how that happens every week. You know, I might lose consciousness. Maybe I'm just dizzy for a few hours. You know, I go to work. It's not the same. And a negative scan, as probably everyone here knows, does not mean there's no brain injury. Brain injuries unseen behind closed doors are likely to be misinterpreted or missed. And I think this is really, really important because someone who's just sustained a brain injury or not even necessarily just, but you know, maybe still having post-concussive symptoms may seem disoriented, confused, distractible, inconsistent, having headaches, uncooperative, dizzy, maybe off balance. If you were a police officer, a law enforcement officer, or you were a paramedic and you showed up at a scene and you saw someone, a woman looking like this and a man saying, oh, there wasn't anything that happened. You know, you see some beers on the counter or something. This was just, it was just a loud argument. And she looks like this. Nah, she's drunk. She's intoxicated. Maybe something like that's going on. Or really, maybe she just sustained a brain injury. And unfortunately, what's usually assumed, there's not, I don't have a study to show this, but I will tell you anecdotally, what's usually assumed is that it's substance abuse. People aren't out there thinking, oh yes, she just sustained a brain injury. You know, except for a small few people who are being trained and understanding this a lot better now. And so we always have to entertain this idea. So brain injuries may make it harder for a woman to survive, escape, or keep her children. It may make it harder to assess danger, defend herself against further abuse, make and remember safety plans, go to school or hold a job, leave the abusive partner and live on her own for some of these reasons. And then access necessary services that she wants to leave, like adapt to living in a shelter. It's gonna be hard to live in a shelter if you just sustained a brain injury. We have to learn new rules. There may be bright lights, lots of motion, new noises, screaming kids, et cetera. And also, if you're having cognitive challenges, you know, dealing with legal issues and trying to retain custody of your children, et cetera, can be extremely challenging if you're running on all thousand cylinders, right? But now if you've just sustained a brain injury, not gonna help. But I just wanna make sure people don't think that it means a woman is unfit. That is not something that, you know, should ever be used against a woman. Like children should not be taken away from her, et cetera. And I do need to say this because there has been at least one case where somebody actually, I think, tried to do that. And there's probably more that I don't know about. But the bottom line is just think about it. If a woman is riding down the street on her bike and she falls and sustains a concussion, you're not gonna take her kids away, right? She may have problems. She may need a recovery period, but you're not gonna take the kids away. So it doesn't mean that this is reason for taking the kids away. So this is one of the reasons I say, people say, oh, wait, we don't wanna tell people, we don't wanna let anyone know that she has a brain injury because then it may make it mad for her. And it may be the case that we don't necessarily wanna know, let a judge know or somebody or the defendant or whatever. We may not, but the woman absolutely should know and has the right to know. And for most women, well, every woman I've ever spoken to who I know of, it has been liberating. So finally, I just wanna end by saying, we wanna interact with women in a way that is sensitive to the possibility of a brain injury. These are not specific to IPV, but just things that you might do if you're working with someone who sustained a brain injury. So just in general, guidelines of sensitive interactions. So minimize distractions, be in quiet locations, make short meetings and take breaks, avoid loud noises and bright lights, repeat information, prioritize goals, make them smaller steps and write them out. So oftentimes women might get to a shelter and they may have a list, a laundry list of things to do. And if they come back a week later with nothing to do, it may be like, ah, this woman's not really working out in the shelter because she hasn't done anything. Well, maybe she's just frozen because you gave her a whole list of things to do. She just sustained a brain injury and she can't, her executive function is not right there, but to even figure out what to do first. So it's just an example of something that might happen. Just, we don't know because we haven't studied this enough, but we do know that women have problems in shelters. Talk slowly into the point, double check with her to be sure that she understood the information. And then just some more. And again, you can find this pretty much anywhere. You might look at brain injury rehab work, one task at a time and stick to the task at hand. Be factual and concrete. Allow extra time for her to complete tasks, maybe fill out forms or make calls, especially when it involves legal information. Point out possible consequences of decisions she may need to make. Provide respectful feedback on problem areas that affect her safety if she thinks she is functioning better than she is. And encourage self-determination and identify strengths. These last three are really important because you may just think, oh my gosh, this woman, what the heck? She's like making the stupidest decisions. And don't do that, Jamie, that's stupid. You're just gonna do this. No, that's not what we want here. You wouldn't wanna do that anyway, but especially if you just sustained a brain injury, you could just say, okay, I get it. You could do that, but if you do that, this is what might happen, right? Instead, why don't we think of another way where we're gonna have a more positive outcome? And find out what the strengths are, because I'm telling you, the women who I've spoken to have strengths. I mean, the stories that I have heard and seeing women come out on the other end, it's truly remarkable. To say that these women are anything but really strong and survivors is an understatement. So my last bit, who do I think needs to know this information? And I say, everybody. Nurses, lawyers, nurses, doctors, law enforcement, paramedics, women themselves. We really need to raise awareness about this and make sure that there's more than seven people who have come to watch this the next time. Every woman we know should know because they may be suffering silently. First responders need to understand that maybe they're walking into a scene that the woman has sustained a brain injury and it's not something else that may be misinterpreted. And that carries on into the judicial system where if a police race down, women appears intoxicated, man telling straight story, blah, blah, blah. Well, when she gets to the judge, what's she gonna say? She's not gonna get the benefit of the doubt if she says, no, I really wasn't. IPV support staff. Many women who, there have been IPV support staff who've said, oh, wow, yeah, there's a lot of women who have mental problems. Yeah, and oh, I would totally work with this woman differently now. And that little bit of knowledge can go a long way. So, and affected women themselves, we want them to understand the potential impact of brain injury and its consequences on their lives. It may be interfering with their ability to function. If they want to leave, they may think, oh, I can't, I'm too stupid. I'm too dumb. I can't even do X or Y. And it may be the brain injury and helping them understand that may be helpful. And under the possible long-term effects, we don't know anything about the long-term effects of repetitive brain injuries in women who've experienced partner violence. Maybe neurodegeneration early on increased dementia risk. We don't know, but I would be really surprised if there weren't bad consequences in the long run, given what we know about other things, but we don't have the data. So I'm not out there saying that women are sustaining these horrible neurological deficits in the long run, but we do need to understand that there's a possibility of such. And even I might go as far as to say there's a likelihood of such, but we need to understand that. I've had women come to me at later ages where they're in a very happy, safe, loving relationship, and they're wondering why they're struggling. Why am I still struggling like this? I feel so blessed in my new relationship. We've been married for 10, 15 years, and then they think they're dementing. I mean, this is just an example of a woman who came to me. And then she saw an article about IPB-TBI that I'd written. She was like, oh, check, check, check, that's me. And it made her feel so much better because then she could sort of make some more sense of what happened in her life. And she's made a lot of positive changes, et cetera. So with that, I just want to end on a positive note. Remember, every little bit of support helps. And you know what? I don't think we take advantage of our younger generation is not enough, but maybe this is one opportunity to tap into them because starting young is the best way when it comes to partner violence. And so this little line here, create opportunities to inspire empathy and action in the next generation. My niece, who's 13 years old at the time, knew what I did, and she was very crafty, and she decided to start making these bracelets that come with this little saying. For any woman who has sustained partner violence, it's free of charge. And we've passed these out in Quebec, and I forget all different areas in the United States, et cetera, but we've written it in French, Spanish, and English. And it basically says, hi, my name is Veronica, and I made this bracelet to help you remember that you are deserving of beauty, recognition, and hope. And women have worn, I've seen the same woman a year later, and she's still wearing the bracelet. It's been met with tears, et cetera. So little things like this can help. And my son, who is taxed, they had a fundraiser at school, Dimes to Dollars. They were expected to raise like $37 or something like that. And he fought for pink concussions, because he knows I'm a part of pink concussions in the domestic, the PIBI, the Brain Injury Task Force. And so they did, they raised, they did a fundraiser for pink concussions, and he ended up raising over $300, and he presented to the PIBI Task Force, no joke, by himself, in his room. Here he is, he found that backdrop and everything. And he presented this, this was at least a couple of years ago, maybe even three years ago, and he's only 11 now. So things can be done, and I think that we need to make changes. And I think starting young is a good way to start, but that's not where we should end. So to some, IPV-related brain injuries are very common, they're very dangerous. And I do really believe it's our ethical responsibility to recognize that these are happening, and to intervene. And with that, I will close. Thank you very much. And that's my email, if anyone wants to email me. Thank you so much, Dr. Valera, and to all of our speakers and faculty. I'm gonna go ahead and start with some of the direct, and then the everyone messages that were sent. One message to the whole group, and please, any of the faculty, please feel free to speak up. And I think, Dr. Valera, you'd also hit on this, as well as Dr. Greenwald, that with strangulation, more hypoxic or acquired-type injuries, has there been also any findings of dysphagia in this patient population, or trouble swallowing? Yes. I'm sorry, I did actually answer that in the chat, but yeah. That would be one. In terms of strangulation, one of the signs will be trouble swallowing, sore neck, hoarseness. Sometimes the hoarseness, I think, almost can be permanent. And it's rare, but sometimes you can have a carotid dissection, which could actually result in death, I think, weeks later. That's very rare, but nonetheless, it's not trivial. And there could be something here that could cause swelling, but there's often no marks. And in one study, like 50% around that, of the women who had been strangled, there were absolutely no visible marks, right? So if you say, oh, well, you couldn't possibly have been strangled because there's no marks. And as I was mentioning, you don't have to do much. It requires extremely little strength. So you can see how you could easily strangle somebody and kill them without even leaving a mark. But dysphagia is definitely a sign. And when you do see signs of strangulation, they're often red. Like as Dr. Greenwald was saying, you may see petechia, you may see blood in the eye. Petechia anywhere above the line of strangulation, so representing the burst blood vessels. And they're like bruising behind the ears. You might even see, and this is, you know, if she has scratch marks, it might be her trying to get hands or whatever off the neck. Some of that stuff, maybe shortly. And kind of piggybacking off one of the questions that came and you just mentioned dissection. And one of the questions specifically asked, has there been any studies looking at post-dissection stroke in this patient population? I don't know specifically if they, I mean, there have been some reported instances where, like I said, it's rare and I don't know exactly how many have been found, but there's, that was the carotid dissection was reported much later. And then it was determined that she had been strangled. In terms of the stroke, I don't actually know. The Strangulation Institute might know that answer a lot better. Gail Strack is one person who could definitely go to for that question. Another question that came is that, is there any data in TBI or SCI of injuries from gunshot wounds inflicted by an intimate partner? Well, I mean, what I study is mainly looking at the effects of repetitive brain injuries. Guns are used in many IPV cases. Don't get me going when it comes to guns. I just think it's absolutely horrible that we're, as a society, we just love our guns so much. But women are definitely murdered and injured by guns from partner violence. I don't know specifically what that looks like in terms of brain injury from guns. I don't know if Dr. Greenwald knows any better, but I mean, I think that would be something that would probably fall in the more moderate to severe spectrum and wouldn't be as common as the repetitive brain injuries that we see pretty regularly. And I think also that the rate of mortality after guns is very high. So these aren't patients we necessarily see in our population, but obviously would be a significant challenge and I'm sure is a common challenge in this group. Thank you. One question that came was, how can physiatrists help increase resident and fellow exposure to this patient population? And this is something, you know, I definitely have questions on is, I feel like this was not exposed to me during my own training. And I think a lot of people probably can echo this. It is probably something we saw later, you know, early on in practice. So going back to the question, you know, how can physiatrists help increase resident and fellow exposure to this patient population? I mean, I guess I'm not sure if I'm understanding exactly, but you probably are being exposed to this patient population. You're just not recognizing it because you haven't been trained to. So if that's the question, then I would say just, you know, part of the answer there is to recognize that you are being exposed, that, you know, if you're seeing a lot of women, you got to know that at least some of them are experiencing partner violence, right? We just know that by the numbers. Now, not all of them are sustaining brain injuries. Not all of them, you know, it's going to be physical injuries, but the more people you see, the more likely it is that you're going to see people who experience IPV, and the more IPV people you see, the more likely it is that you're going to be seeing people who have experienced brain injuries from that IPV as well. So the way you address that is really by asking the questions, you know, have you ever, you know, I mean, and again, this is a whole nother ball of wax, so to speak, because then people say, oh, well, what do I do if I ask that question? I mean, then like, and so there are some places where they do try to set things up so that there's a support network where if it is recognized that IPV and or IPV-related TBI has occurred, then there's a direct spot to bring these people. And that's the ideal situation. But if you're working with somebody and something may not seem, I mean, I'm always in favor of screening for IPV at any rate and I think that does happen depending on where, I mean, I know I've been in the hospital and somebody said, you know, do you feel safe at home? I mean, it's better than nothing, I guess. And whatever, so I know it happened, but other times I don't get that. So it's not consistent. But if we do that and women feel comfortable, the other thing is, and I know I'm going on a little bit, but when there's not any type of rapport or a woman doesn't feel a connection, and I will tell you many marginalized groups or groups where not, you know, like white females will not necessarily feel connections to their doctors and will not trust them. Like this one woman, she was stigmatized and she's like, well, they even believe me and don't feel like they will be understood anyway. So there's a lot of barriers to potentially getting that information. But the more we have connections with our patients, the more we actually see them as like fellow human beings as best as people need to work on and get out, the more likely it is that that information will be elicited or will come out naturally. I understand there's issues of time and insurance and all that stuff. So I'm not saying I have the answers, but I'm saying that is something that would help. How possible that is, I don't know, but, you know, these are the things. And then once that's been established, I mean, you can also go as far as to say as many women who've experienced partner violence have been hit in the head or have experienced, you know, traumas to the head that can really have long lasting symptoms. Do you think that's ever happened to you? I mean, so there's, you know, it depends on how much time you have, et cetera, but you have to know that these are things that are going on before you've been in a position to consider asking these things. Absolutely. One- Actually goes to- Oh, go ahead, Dr. Greenwald. I think that goes to the point of the ACGME. You know, brain injury fellowships and spinal cord fellowships are ACGME accredited. You know, I mean, when we got our ACGME accreditation, we had to say that we were gonna provide education to the fellows in all these different things. Certainly there are, when one looks at brain injury, they look at, you know, looking at brain injury in the young and the elderly and in the military and other specific groups, but I don't remember anything with regards to IPV and how we should be teaching the fellows about this. And like we've been talking about, really you need to know it even exists before you can hope to sort of screen for it or think about it and recognizing. And as I can see here in the chat, brought up that, you know, certainly persons with disability, of course, which we're all taking care of every day as physiatrists have higher rates in general of IPV. So just sort of recognizing that it's there and maybe advocating to the ACGME that this is something that fellows should also be taught. And the ACGME is always looking at what their requirements are to be taught. And that would be just one more thing that the fellowship programs have to say, yes, you know, we teach this to the fellows so that they're at least exposed to it and are sensitized to. Yeah. I mean, think about how many times across, you know, whether it's our residents, our fellows, or our own training, opportunities to go to a football games and be part of the medical team or, you know, volunteer at MSK and spine clinic. But how often have we been told, let's go to a, you know, a domestic violence shelter and provide screenings and reach out. You know, I don't think that's something that's even out there as far as in my small world. So, you know, I think there's definitely, as Dr. Greenwald, Dr. Valera said, there's an opportunity to improve, number one, how we're screening, but also open up the topics in the training, starting with our resident and fellows and maybe even one day our medical students. And then going back to the comment that Dr. Greenwald brought up, and it, you know, very good point, Richard Harvey says, I just want to point out that our patients with any disability are at high risk of partner violence. And sadly, they will not report it because if they're separated from their partner, they will likely end up in a nursing home and are fearful of that happening. This probably happens more than we realize. Absolutely great point. One other thing is that has there, or are there active studies looking at, you know, IPV leading to CTE? I mean, I know, you know, unfortunately, because sports, that's where a lot of money is, it's a sexy topic, but how often are we looking at the sequelae of IPV leading to CTE? Has that something that's been studied? Well, I mean, and that's what I was getting at at the end. We haven't, no, because I mean, if you look at the, in terms of structured studies, looking at the direct relationship, you know, as direct as you can, you know, in this type of work, in this type of science, between brain injuries and other outcomes, there is nothing there. I mean, I'm one of the few people who has actually done studies really systematically looking at it. There's a handful of us who have done work in this area or related to this, but not a lot. And we have not had the opportunity yet to do these, well, I mean, I actually have, there may have been one or two grants that I may have applied for, which I didn't get, whatever, but we absolutely need to. One thing I don't want to do necessarily is compare, and I've changed my stance a little bit on this, and because I think CTE is a real, real hot topic, and I think it's really important to understand, but I also think in the scientific world, there's a lot of controversy on what CTE really is. Its definition has changed over time. And are there really higher rates of people who have CTE and not? There's a lot that gets said about CTE that's not necessarily backed by the science, I think. And, you know, CTE is frightening. So the one thing I don't want to do is have women think, oh my gosh, because I've had women say, oh, I have CTE. I know I'm a living example of CTE. And they're probably terrified, thinking, oh my gosh, this is me, this is going to happen the rest of my life. I'm going to just go downhill. And that may not be the truth, and we don't know. So I don't want women being overly afraid that this is their destiny. And I don't believe that. Is it good to have repetitive brain injuries? No. Is it going to be bad near the end of their life? Is there an increasing likelihood of that? Yeah, probably, you know, I would say yes, unfortunately, but it doesn't mean it's CTE, which is just horrible, right? We don't even know exactly what CTE is because the definitions change. So that's where I try to be a little more cautious, but really your question is getting at, do we know end of life neurodegeneration or outcomes? And we don't. Anecdotally, I know that it doesn't seem good, right? But I think once people know and they realize what they're dealing with, they can actually, it's much better for them. Well, thank you so much to all of our speakers, Dr. Greenwald, Dr. Mortimer, Dr. Valera. Thank you to Leanne Drago, our AAP Menard host, a staff member, to all of the people joining us and those of you watching this recording. We really hope that this was a topic that just continues to open more areas of interest for you to go and further talk about this really important subject. It affects all of us, whether you're an interventional spine, a pain doctor, a TBI doctor, a spinal cord doctor, this is a patient population that you have likely run into. So thank you, everyone. Have a wonderful evening. And again, thanks for joining.

intimate partner violence

traumatic brain injuries

IPV prevalence

increased awareness

underreporting of IPV

healthcare providers

physical injuries

emotional trauma

long-term health problems

intersection of IPV and brain injuries

IPV-related brain injury

recognizing signs of strangulation

repetitive brain injuries from IPV