Identifying the research question

This scoping review aimed to answer the question, “what is the extent and nature to which rehabilitation, including the types of rehabilitation interventions, is available to or accessed by people who are experiencing TBI through mechanisms of violence?” This question informed the development of the search strategy, selection of relevant literature, charting of the data, analysis of the findings, and reporting of the results. Table 1 operationally defines key terms such as TBI, rehabilitation, and violence, which have been used to guide all steps of the review.

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Table 1. Definitions for traumatic brain injury (TBI), rehabilitation, and violence.

https://doi.org/10.1371/journal.pone.0310803.t001

Identifying the relevant studies

The search strategy was informed by previous scoping and systematic reviews [21, 22] and was developed through an iterative process in collaboration with an information specialist and members of the research team who hold content and research expertise in the areas of TBI, violence, and rehabilitation. Three concepts were used to build and finalize the search strategy (violence, TBI or cognitive impairment, and rehabilitation). The final search strategy consisted of combining these concepts in the following way: [(violence) AND (TBI or cognitive impairment) AND (rehabilitation)] OR [(rehabilitation) AND (violence-related TBI)]. To identify relevant peer-reviewed literature, the search strategy for the MEDLINE® ALL (in Ovid, including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily) database was first developed and then translated to the following seven databases: Embase and Embase Classic (Ovid), Cochrane CENTRAL Register of Clinical Trials (Ovid), CINAHL (EBSCO), APA PsycINFO (Ovid), Applied Social Sciences Index and Abstracts (Proquest), Criminal Justice Abstracts (EBSCO), and Nursing and Allied Health (Proquest). There were no language or date restrictions placed on the search strategy. However, a search filter was applied to exclude animal studies. Searches were conducted across the different databases in January 2023.

This scoping review also included grey literature described as reports from brain injury, violence, and rehabilitation organizations. These reports were obtained from organizations’ websites by manually searching through the websites and consulting with stakeholders. EndNote X8.2 was used for deduplication and reference management, and Covidence was used for deduplication and screening. For more details about the search strategy for each of the seven databases and the list of organizations searched to identify grey literature reports, please see S1 File.

Selecting the studies

All peer reviewed articles as well as grey literature reports identified from the search were subject to the following inclusion criteria:

1. Describe and/or document rehabilitation interventions and/or services provided by healthcare providers or professional disciplines as defined in Table 1
2. Include individuals who sustained a TBI through interpersonal violence as defined in Table 1
3. Report primary research findings

The following articles were excluded:

1. Dissertations, conference proceedings, and articles that are narrative, commentaries, or describe a theory/framework without presenting primary research findings
2. Articles looking at the broader brained injury/cognitive impairment population without specific mention of TBI

Using Covidence and the criteria outlined above, two reviewers screened all English and non-English language titles and abstracts independently. Articles were considered for full-text review at this stage if they included persons with TBI or acquired brain injury or cognitive impairment and rehabilitation. Scoping and systemic reviews were also considered at this stage if they met these inclusion criteria. Eligibility for all non-English language articles was assessed using the published English abstract. A pilot screen of 20 titles and abstracts was conducted between the two reviewers until a minimum 80% agreement was reached. The resulting average agreement was 95.9% (kappa 0.880) at the title and abstract screen for English and 96.3% (kappa 0.867) for non-English language articles.

At the level of full-text screening, each article was independently screened by two of three reviewers. Any primary research articles identified from the reference lists of scoping and systematic literature reviews included at the level of title and abstract screening were extracted and independently screened based on the above criteria. Similar steps were followed to extract grey literature reports. All non-English language articles were translated into English using Google or DeepL Translate. A pilot screen of 10% of eligible full-text articles was conducted until a minimum 80% agreement was reached between the two reviewers. The resulting average agreement on the full-text screen was 95.1% (kappa 0.690) for English and 96.4% (kappa 0.650) for non-English language articles.

Charting the data

A data charting form was created to extract relevant information to answer the research question. Data were charted independently by two reviewers and peer-reviewed by two reviewers. Any discrepancies in the charting of the data were discussed and resolved by consensus with a third reviewer. The charting table is presented in S2 File.

Collating, summarizing, and reporting the results

Findings from this scoping review are presented using a descriptive numerical summary of the included studies, which are reflected in the data charting table, as well as a qualitative content analysis to describe the extent and nature to which rehabilitation is available to and accessed by people who experience TBI through interpersonal violence. The findings from the quantitative and qualitative content analysis were used to answer the research question and identify research and practice priorities for survivors of violence-related TBI.

Consultation

Preliminary findings were shared with members of a Program Advisory Committee (PAC), who bring forward several forms of expertise. The PAC includes front-line staff and service providers in the violence and brain injury sectors, healthcare professionals who provide care or support for persons with TBI and survivors of violence, as well as researchers and trainees who conduct research on the intersections of violence, brain injury, and rehabilitation. The PAC provided feedback regarding the preliminary findings of the review, which was then integrated in the discussion of the findings.

Rehabilitation that addresses TBI sequalae without consideration for violence as a mechanism of injury (N = 44)

Forty-four of the 57 articles (77.2%) documented and/or described rehabilitation interventions that addressed TBI sequalae without consideration for violence as a mechanism of injury, beyond reporting sample characteristics (i.e., the number of participants who sustained their TBI through violence). Rehabilitation interventions were delivered primarily in hospital settings, including inpatient and outpatient units, and a few in the community [34, 35] and in shelter or residential settings [36]. Healthcare professionals involved in delivering the rehabilitation included physical therapists or physiotherapists, occupational therapists, speech therapists, art therapists, blind rehabilitation specialists, nurses, rehabilitation assistants, optometrists, and psychologists.

Twenty-one of the 45 articles (46.7%) documented but did not further describe the rehabilitation intervention, setting, or rehabilitation professionals seen by survivors of violence-related TBI. Examples of rehabilitation in these articles included inpatient or acute and outpatient rehabilitation, neurorehabilitation, and various therapies, such as intensive physical therapy and psychiatric treatment. In contrast, 23 articles documented and/or described rehabilitation that targeted specific outcomes, such as sensory input and sensory processing, behavioural, systemic or biological, cognitive, psychological, and motor functioning as well as functional or related to day-to-day support or support for life activities (e.g., activities of daily living, work, community living, and social participation). Specific examples of rehabilitation that addressed TBI sequalae related to sensory input and sensory processing included visual restitution training, scanning therapy, and auditory processing program, while rehabilitation interventions that addressed behavioural challenges associated with TBI included anger self-management training and neurorehabilitation program for aggression. Rehabilitation in all 45 articles focused on individuals with TBI in general, and no considerations for violence as a mechanism of injury were reported.

Rehabilitation that considered violence-related TBI (N = 13)

A total of 13 articles (22.4%) documented and/or described rehabilitation that considered violence-related TBI by (1) investigating the rehabilitation profile (i.e., sociodemographic profile or outcomes) of survivors of violence-related TBI (N = 8) and (2) designing rehabilitation programs for survivors of violence-related TBI (N = 5).

Eight articles investigated the rehabilitation profile of survivors of violence-related TBI by comparing the sample of participants who experienced violence-related TBI to those who sustained TBI through other mechanisms of injury. In these articles, rehabilitation was delivered in inpatient rehabilitation settings [16, 37, 38], a specialized TBI acute rehabilitation unit [39], a level 1 trauma center [40], and a pediatric hospital and outpatient clinic [41]. Only one study specified what type of rehabilitation program or services patients received in a rehabilitation unit such as physical therapy and occupational therapy [42]. It is worth emphasizing that consideration of violence-related TBI in these articles is limited to a description of survivors’ sociodemographic profile and outcomes. It was not reported if or how violence as a mechanism of injury was considered in the rehabilitation process.

Of these eight studies, three described the sociodemographic profile of survivors of violence-related TBI. Often, survivors of violence-related TBI were unmarried [38, 39], young males or men from a racial background other than White [38–40], and with a history of substance use [39, 40]. These individuals also often had a shorter length of stay in acute care [39] and accessed services through government (e.g., Medicaid) funding [41].

All eight studies investigated rehabilitation outcomes for the population. Four of the eight studies compared rehabilitation outcomes between violent and non-violent TBI groups, such as TBI due to motor vehicle collisions and falls [16, 37, 38, 40]. Differences for survivors of violence-related TBI included significantly lower scores on reintegration to normal living which continued over 3 to 6 months post-discharge [16]; small significant differences in functional improvements over time [38], and greater likelihood to be discharged home than to inpatient rehabilitation [40]. However, the latter was reported to possibly be more related to the type of injury deficit and services needed rather than the mechanism of injury. One study investigated the rehabilitation outcomes of bombing survivors specifically and discussed the challenge of short-term rehabilitation stays, long-term disability, and limited funding for ongoing rehabilitation [43]. Three studies focused on pediatric survivors of abusive head trauma. While one article noted no significant differences in functional impairments post-discharge [37], two reported significant neurological impairments (e.g., epilepsy, motor, attention and visual deficits, sleep disorders, language abnormalities, and behavioural problems) [42] and regressions in learning, fine motor, and expressive language [41] after several years of abusive head trauma.

Five studies described rehabilitation specifically designed for survivors of violence-related TBI. Four of the five studies focused on IPV resulting in TBI [31, 35, 44, 45] and one on child abuse [46]. These rehabilitation interventions were delivered in an inpatient setting [46], a non-profit facility in a metropolitan area [31] and non-profit community based agencies supporting survivors of domestic violence [45] and persons with brain injuries [35]. A multidisciplinary team was often involved; specific providers included physicians [45, 46], neurologists [44], physiatrist [44], occupational therapists, [31, 44, 46], physical therapists, speech language pathologists [44, 46], social worker [31], and violence impact coordinator [35]. These rehabilitation interventions focused on ensuring safety and preventing violence [31, 44, 46]; regaining or improving self-regulation and control [31, 44, 45]; and addressing violence- and/or TBI-related challenges [31, 35, 44, 46].

Ensuring safety and preventing violence

Three studies reported on safety planning and violence prevention, with two in the context of IPV. Safety planning and violence prevention were particularly important to individuals who were still connected to or residing with the perpetrator of the abuse. For example, critical questions in an article on feminist psychotherapy were centred on helping the individual avoid physical violence and leave the relationship [44]. Individuals who received feminist psychotherapy benefitted from therapy by implementing suggestions for safety. Examples of these suggestions included moving into a relative’s home during therapy and not revealing the location of a new workplace to the perpetrator.

Safety was also an identified need in an initial needs assessment that was part of an occupational therapy (OT) intervention for survivors of IPV who have sustained a TBI [31]. Safety in this intervention encompassed not only safety planning but also community safety, particularly for survivors who were also experiencing homelessness. Women were taught skills related to these two domains. Examples included identifying safe locations and important documents and items to take, recognizing the signs of a worsening violent incident, and creating a plan where neighbours could call the police if they hear sounds of violence. Community safety skills included identifying signs of danger on the street or in shelters, avoiding revictimization and understanding the link between substance use and assault.

Finally, one article reported on violence prevention in the context of child abuse and the role of OTs in providing education to the family and the community. Although safety planning was not explicitly mentioned in the study, mandatory strategies to ensure the child’s safety were reported and included determining a legal guardian, monitoring all visits by family, and providing family education and training as rehabilitation is ongoing, to all caregivers, including suspected abusers [46].

Education regarding the rehabilitation profile of violence-related TBI

Findings regarding the profile of survivors of violence-related TBI are consistent with the findings of an earlier scoping review on brain injury as a result of violence [9]. Survivors of violence-related TBI were often unmarried young males or men from a racial background other than White who have a history of substance use [38–40]. They were more likely to use government-related funding, have a shorter length of stay in acute care and rehabilitation [39, 40], and poorer outcomes with regard to reintegration to normal living [16]. However, this review adds to the evidence base by including studies on the pediatric population. While one study showed no differences in terms of functional impairment between children who experienced abusive head trauma and those who did not [37], studies that examined the long-term rehabilitation and outcomes of this group noted significant neurological impairments and challenges in learning, fine motor and expressive language [41, 42].

These findings substantiate earlier findings regarding the unique needs of this population, and given rehabilitation’s current one-size-fits-all approach, advocates for increased education and awareness regarding the distinct profile and outcomes associated with violence-related TBI. Several studies have reported on the potential benefits of education on TBI rehabilitation, including enabling providers in recognizing TBI signs and symptoms [19], addressing negative views regarding TBI [19, 47] and facilitating detection and access to appropriate services [22, 48]. In the context of this work, such education is a step towards rehabilitation providers recognizing and being better equipped to address the challenges experienced by survivors of violence-related TBI and modifying existing rehabilitation interventions to accommodate their unique needs.

Research regarding the rehabilitation needs of survivors of violence-related TBI through mechanisms other than abuse

This review identified few research articles that described rehabilitation for survivors of violence-related TBI. While several conceptualizations of violence (e.g., assault to the head, fights, and terror attacks) were reported, the limited number of articles that described rehabilitation for violence-related TBI focused on survivors of abuse. This finding suggests that the rehabilitation needs of individuals who sustained their TBI through other circumstances of violence are either unknown, not described in the published literature, or are not being addressed in TBI rehabilitation.

Worth noting are aspects of rehabilitation interventions that were reported to be important and/or beneficial for survivors of violence-related TBI, specifically abuse: safety planning and violence prevention, regaining or improving self-regulation and control, breaking down goals and matching an individual’s functional level, navigation support and longer duration of rehabilitation. First, safety and violence prevention was relevant not just in the home for survivors who still reside with the perpetrator of the abuse, but also in the community, especially for survivors experiencing homelessness [31, 44]. However, we cannot confirm whether this is an important consideration in the pediatric population, as there was only one study on child abuse included in the review. Second, interventions focused on improving and regaining self-regulation and control were beneficial for improving IPV survivors’ mental health symptoms, reducing stress, managing anger, and attaining stability and well-being [44, 45]. However, the connection between violence as a mechanism of injury and self-regulation and control as a goal was not clearly reported in these studies. Third, breaking down goals while matching an individual’s functional level [31] as well as navigation support [35] were beneficial in helping survivors feel less overwhelmed and in making tasks more manageable. These aspects of the rehabilitation were intended to address cognitive impairments from TBI and/or trauma that make accessing services a complicated and challenging process and that hinder survivors from leaving abusive situations [31, 35]. Finally, a longer duration of rehabilitation should be considered, as often a series of gains and relapses rather than linear recovery is expected for survivors of IPV-TBI. As such, they may require longer periods of time before they can make small changes [31]. These aspects of the rehabilitation interventions, while intended for survivors of abuse, could be integrated and further investigated in existing or future rehabilitation interventions for the broader population of individuals who sustain TBI through violence.

Also worth noting and integrating in rehabilitation interventions are aspects of rehabilitation interventions for violence-related TBI that have already been identified as ways of adapting rehabilitation interventions for other groups experiencing TBI or individuals with TBI more broadly. These include adaptations or compensatory strategies for TBI and individualized treatment plans [21, 22, 49]. These are worth highlighting as these aspects of the rehabilitation interventions were noted to also be beneficial for survivors of violence-related TBI. However, the studies did not elaborate on how such aspects would be beneficial for this group in particular. Further research is needed to explore the rehabilitation needs of individuals with lived experience of TBI that resulted from other mechanisms of violence other than abuse. Such research will aid in the design and development of programs for the broader population of individuals who sustain TBI through violence.

Explicit considerations for intersecting social determinants of health in rehabilitation for violence-related TBI

Finally, there is a need to explicitly consider intersecting SDoH in the rehabilitation process (i.e., access, service delivery and outcomes) for violence-related TBI. This review found that studies did not always report important demographic characteristics such as sex, gender, race, ethnicity, and socio-economic status, and only three considered intersections with health disparities, such as experiences with homelessness and involvement with the CJS. Even when sociodemographic characteristics were reported, there was no information regarding how or if they were considered in the rehabilitation process. It is crucial that SDoH is considered, given that violence-related TBI has been found to be associated with a particular demographic profile (i.e., unemployed with a history of substance use and CJS involvement and from a racial and ethnic minority group) [9]. Intersecting SDoH could also create more barriers to rehabilitation. For example, illiteracy [34], transportation challenges [50], and lack of resources, including finances and cost of treatment [43, 51] were some of the barriers to rehabilitation identified in included studies. There is also evidence regarding the differential rehabilitation needs and experiences of racial and ethnic minorities, such as Black persons [11] and Indigenous populations [52] and discrepancies in outcomes for individuals from culturally and linguistically diverse backgrounds [53]. It is clear that intersecting SDoH shape rehabilitation access, experiences, and outcomes, and thus require consideration in the design of interventions or adaptations for existing interventions for survivors of violence-related TBI. While none of the included studies provided any information about how to modify rehabilitation for persons with violence-related TBI based on sociodemographic characteristics such as race, ethnicity, or gender, three of the five studies that provided rehabilitation for survivors of violence-related TBI noted the importance of culture in assessment and treatment. These studies noted the importance of setting goals that are congruent with individuals’ cultural values [31], selecting culturally relevant assessments [44], and increasing culturally competent services for survivors. Addressing these priorities is a critical step toward addressing inequities in healthcare for individuals with TBI. Important to note is the lack of consideration for a trauma-informed approach to rehabilitation given intersecting SDoH and the need for trauma-informed rehabilitation care, particularly for this clinical population of individuals who sustained a violence-related TBI.

We acknowledge the following limitations of this scoping review. First, this review may be subject to publication bias. While we aimed to minimize this by searching for non-English language articles, the websites that we searched for grey literature were all in English; as such, we may have missed potentially relevant non-English grey literature reports. Second, because we only included published reports, rehabilitation programs that may be relevant but not formally reported were not captured. Lastly, we are unable to comment on the efficacy of the rehabilitation programs and interventions unless reported in the article, as this is outside the scope of this review. However, we acknowledge that this information is critical and warrants future investigation.