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MPN regularly provide bespoke PBS assessments, plans and training for care environments that support clients with various types of brain injury and challenging behaviours.

Positive behaviour support (PBS) is an approach that aims to understand and address the causes of challenging behaviour in people with brain injury, and to promote positive outcomes for them and their carers. Challenging behaviour can include aggression, self-injury, verbal abuse, property damage, and non-compliance. It can have a negative impact on the person’s quality of life, as well as their relationships, health, and safety.

PBS is based on the principles of applied behaviour analysis, which is the science of how behaviour is influenced by the environment. PBS involves conducting a functional assessment of the challenging behaviour, which means identifying the triggers, consequences, and functions of the behaviour. For example, a person may display aggression because they are frustrated, bored, or in pain, and because they get attention, escape from a task, or obtain something they want as a result of their behaviour.

Based on the functional assessment, PBS develops a behaviour support plan that includes proactive strategies to prevent or reduce the challenging behaviour, and reactive strategies to manage the behaviour when it occurs. Proactive strategies may involve modifying the physical and social environment, teaching new skills, providing meaningful activities, and reinforcing positive behaviour. Reactive strategies may involve using calm communication, distraction, redirection, or removal of the trigger.

PBS also involves monitoring and evaluating the effectiveness of the behaviour support plan, and making adjustments as needed. PBS requires collaboration and consistency among all the people involved in the person’s care, such as family members, carers, and professionals. PBS also respects the person’s dignity, rights, and preferences, and seeks to enhance their wellbeing and participation in their community.

PBS has been shown to be an effective and ethical approach to managing challenging behaviour in people with brain injury. It can help to reduce the frequency and severity of the behaviour, as well as the use of restrictive practices, such as medication, seclusion, or restraint. It can also improve the person’s mood, self-esteem, social skills, and quality of life. PBS can also benefit the carers, by reducing their stress, increasing their confidence, and improving their relationship with the person.

Chronic traumatic encephalopathy (CTE) is a degenerative brain disease that is associated with repeated head impacts and injuries. CTE can cause cognitive, behavioural, and emotional problems, such as memory loss, depression, aggression, and dementia. CTE can only be diagnosed after death by examining the brain tissue for abnormal deposits of the protein tau.

Tau is normally found in neurons and helps stabilise their structure and function. However, repeated head trauma can cause tau to become misfolded and clump together in tangles, which interfere with the normal functioning of neurons and cause them to die. The tau tangles also spread to other regions of the brain over time, affecting different cognitive and emotional functions. The disease is classified as a tauopathy, a group of neurodegenerative diseases that share this common feature.

CTE has been found in the brains of many former athletes who played contact sports, such as American football, boxing, and rugby. Rugby is a popular sport in the UK, with millions of players at various levels, from amateur to elite. Rugby involves frequent collisions and tackles, which can result in mild TBI. These impacts can damage the brain and increase the risk of developing CTE. CTE in rugby was the lead story in the Times today.

A recent study by Stewart and colleagues examined the brains of 31 former rugby players who donated their brains to research institutes in the USA, UK, and Australia. The study found that 21 of the 31 brains (68%) had CTE. The study also found that the risk of CTE increased with the length of rugby career, with every extra year of play increasing the risk by 14%. The study did not find any difference in the risk of CTE between amateur and elite players, or between forwards and backs.

The study suggests that rugby players are at a high risk of developing CTE, and that the risk is related to the duration of exposure to head impacts, rather than the level or position of play. The study also highlights the need for more research on the prevalence and severity of CTE in rugby players, as well as the potential long-term consequences of the disease.

The study has implications for the prevention and management of head injuries in rugby. The rugby authorities, such as World Rugby, the Rugby Football Union, and the Welsh Rugby Union, have a duty of care to protect the players from brain injury and its consequences. They should implement measures to reduce the frequency and intensity of head impacts in rugby, such as lowering the tackle height, enforcing the concussion protocols, and limiting the number of games and contact sessions. They should also provide education and support to the players, coaches, referees, and medical staff on the recognition and removal of head injuries, and the importance of seeking medical attention and following the return-to-play guidelines.

Rugby is a contact sport that involves a high risk of head injuries and concussion. Therefore, there are several measures in place to prevent, recognise, and manage concussion in rugby players. Some of these measures are:

• World Rugby has developed a Concussion Guidance document for non-elite level rugby players and non-medical professionals, which provides information on what is concussion, its causes, symptoms, recognition, management, and return to play. It also includes medical referral indicators and resources for advanced care.

• World Rugby has also introduced a Head Injury Assessment (HIA) protocol for elite adult teams, which is a three-stage process to assist with the identification, diagnosis, and management of head impact events with the potential for concussion. The HIA protocol consists of an off-field assessment tool, a post-game assessment, and a 36-48-hour post-injury assessment.

• World Rugby has also launched a Recognise and Remove campaign, which aims to educate players, coaches, parents, and officials on how to spot the signs of concussion and how to safely remove players from the field of play. The campaign also promotes the importance of seeking medical attention and following a graduated return to play protocol.

• World Rugby has also implemented a six-stage Graduated Return to Play protocol, which must be followed by players who have been diagnosed with concussion before they can participate in full contact training or playing. The protocol includes a period of rest, symptom-limited activity, non-contact training, full contact practice, and return to play.

• World Rugby has also established a HIA Review Process, which monitors and evaluates the compliance and performance of the HIA protocol by teams and match officials. The review process involves independent experts who analyse the video footage and medical reports of all head impact events and provide feedback and recommendations.

CTE is a serious and potentially preventable brain disease that affects many former rugby players. It is vital that the rugby community continues to take action to protect the current and future generations of players from this devastating condition.

Dr Moore recently edited and contributed to the textbook:

https://www.routledge.com/Neuropsychological-Aspects-of-Brain-Injury-Litigation-A-Medicolegal-Handbook/Moore-Brifcani-Worthington/p/book/9780367569587

Aiming to focus on the importance of neuropsychological evidence and the role of the neuropsychologist as expert witness in brain injury litigation.

This thorough, evidence-based resource fosters discussion between the legal profession and expert neuropsychological witnesses. The chapters reflect collaborations between leading personal injury lawyers and neuropsychologists in the UK. Key issues in brain injury litigation are addressed that are essential to an understanding of the role of the neuropsychologist as expert witness and of neuropsychological evidence for the courts. These include neuropsychological testing, assessment of quantum, vocational rehabilitation, mental capacity, forensic outcomes, the frontal paradox, mild traumatic brain injury and more.

Combining the scientific and legal background with practical tips and case examples, this book is valuable reading for legal professionals, particularly those working in personal injury and clinical negligence, as well as trainees, students and clinicians in the field of neuropsychology, neurorehabilitation and clinical psychology.

1. Introduction
2. Legal Principles in Litigation
3. Premorbid Abilities: Cognition, Emotion and Behaviour
4. Neuropsychological Testing in Brain Injury Litigation: A Critical Part of the Expert Neuropsychological Examination
5. Paediatric Outcomes after Traumatic Brain Injury: Social and Forensic Risk Management in Multidisciplinary Treatment Approaches
6. Effort Testing, Performance Validity, and the Importance of Context and Consistency
7. Mild Traumatic Brain Injury and Persistent Neuropsychological Symptoms
8. The Frontal Lobe Paradox
9. Assessing Mental Capacity in Brain Injury Litigation
10. Legal Principles of Quantum
11. Practical Applications of Quantum Principles
12. Conclusion: Formulating Neuropsychological Opinion in Brain Injury

         Phil S. Moore, Shereen Brifcani and Andrew Worthington

The following technical terms are used to orientate around and within the brain and its structures:

Top=dorsal/superior

Bottom=ventral/inferior

Front=rostral/anterior

Back=caudral/posterior

Medial=mid-line

Lateral=away from mid-line

Contralateral=opposite side as

Ipsilateral=same side as

Unilateral=one side only

Bilateral=both sides

Proximal=close

Distal=distant

Approximately 50% of people who acquire a brain injury will go on to develop chronic anxiety and/or depression (Anson & Ponsford, 2006). Thus there has been a focus on understanding this process in order to help. However, adjustment is a complex process. For a start Impairment does not linearly equate to disability, because disability has a social context, hence it is socially constructed (see Johnston, 1996). Therefore, the process of adjustment to brain injury is mitigated by internal and external, controllable and uncontrollable cognitive, emotional, social, and psychological factors. The literature on adjustment diverts down many lines of enquiry. There is of course the founding theories of Kubler-Ross (1969) on the stages of grief. This model has undergone many updates moving away from a linear stage model of grief to an acceptance model describing the common feelings of loss in a wider context. This model has great therapeutic use in brain injury, but it still lacks the specificity in predicting positive adjustment and coping. Of course, brain injury carries with it an increased likelihood of specific cognitive factors that may affect coping. For example, reduced problem solving ability, mood dysregulation, lability, memory difficulties, reduced concentration and so on. However, researchers now believe the impact of this is less obvious than one might assume. For instance, although these cognitive dysfunctions are more prevalent in severe brain injuries, adjustment appears to be inversely correlated to severity self awareness and insight is not always a good thing (see Brown & Vandergoot, 1998 ‘quality of life’ studies). Poor adjustment has often been associated with self-blame, excessive worry, ruminative thoughts, wishful thinking, misuse of drugs and alcohol and general avoidance (Anson & Ponsford, 2006). In addition there appears to be a significant gender divide with females more likely to seek systemic support and males more likely to cope in isolation. Researchers have managed to specify positive predictors of adjustment. Some of these include: a problem solving approach, low expectation of outcome and realistic hopes & goals, an internal locus of control, healthy levels of self esteem, use of humour, personal resilience, high premorbid intelligence, and supportive families/home environments. But perhaps, one quotation defines adjustment best by summarising three wishes:

“People want something to do, somewhere to live and someone to love” (McColl et al. 1998).

Following an acquired brain injury, often a client experiences changes in cognition, emotion, personality and behaviour.

Cognitive rehabilitation is a treatment for acquired brain injury clients to help improve everyday function.

It involves specialist assessment in order to specify skills and strategies for the ABI client and their carers/family.

It may involve behavioural advice, pen and paper tasks to practice, psychoeducation, computer programs and apps, or skills to use in everyday life.

For many it is a vital part of the rehabilitative process alongside physical forms of rehabilitation. It provides a way of reaching optimal trajectories of recovery and can improve client insight, wellbeing and safety.

Unfortunately the health system is limited with regards to access to cognitive rehabiliation, length of cognitive rehabilation and resources for cognitive rehabilitation.

Dr Moore can provide bespoke cognitive rehabilitation assessment and treatment within the South West of England in cases where funding is approved by solicitors.

Email psychologyassessment@yahoo.co.uk for for information of to make an enquiry.

The following technical terms are used to orientate around and within the brain and its structures:

Top=dorsal/superior

Bottom=ventral/inferior

Front=rostral/anterior

Back=caudral/posterior

Medial=mid-line

Lateral=away from mid-line

Contralateral=opposite side as

Ipsilateral=same side as

Unilateral=one side only

Bilateral=both sides

Proximal=close

Distal=distant