A report by the Centre for Mental Health – “Traumatic brain injury and offending. An economic analysis” states that approximately 1.3 million people in the UK are living with head injury-related disabilities, with these injuries causing around 160,000 hospital admissions each year.

TBI also has a marked impact on the economy, at a cost of £15 billion a year. This figure comprises lost work contributions, premature death and health and social care costs. This £15 billion does not, however, include the human cost of head injury to the injured and their families’ well-being and quality of life, which is clearly the biggest cost.

It was mooted that correlations of depressive mood with anxiety and cognitive complaints seemed compatible with some degree of lack of self-awareness of cognitive and behavioural difficulties in the TBI patient group.

A further study on identity, grief and self-awareness after traumatic brain injury (Carroll E., and Coetzer R., Identity, grief and self-awareness after traumatic brain injury Neuropsychological Rehabilitation 2011; 21: 289-305) revealed that 90% of participants suffered from low self-esteem at levels deemed clinically significant.

TBI is also a huge “hidden disability” within prison populations, according to the University of Salford. Prisoners who have had head injuries are more likely to experience a variety of mental health problems including severe depression and anxiety, substance use disorders, anger and suicidal thoughts.

At the one-year evaluation, 83% of the participants ranked themselves above their pre-course rating in an understanding of their strengths and limitations. Other positive changes over the same time span included: ability to rely on others (50%), higher self-esteem (58%) and improvement in problem solving (50%). It was commented that the outdoor challenge course allowed therapists to help the participants recognise and acknowledge their thoughts, feelings and behaviours during the course and that one year later the participants were calling on this understanding to improve their daily functioning.

Another UK pilot programme (Walker A., Onus M., Doyle M., et al., Cognitive rehabilitation after severe traumatic brain injury: A pilot programme of goal planning and outdoor adventure course participation. Brain Injury 2005; 19: 1237-1241), incorporated a context-sensitive approach to cognitive rehabilitation with a focus on goal planning with goal attainment as an outcome measure. The results revealed a high level of achievement (over 80%) on selected, identified, specific and mainly practical goals. In discussing the results, the authors considered that the strength of the project appeared to lie partly in the motivation provided by the outdoor activity course, which appeared to later encourage participants to work towards broader goals.

A comparison group matched as far as possible to the experimental group who did not attend the course was also evaluated using Quality of Life Analysis. The findings were as follows:
1. Understanding: Participants reported that they gained insight into personal strengths, limitations and unexpected capabilities as a result of engaging in the programme’s activities.
2. Re-integrating Identity: Participants identified increases in self-confidence and competence and this had a positive impact on their sense of identity. Several participants noted that they felt they had more control and responsibility for the direction of their life.
3. Acceptance: Participants stated that the OOE outdoor activitycourse had helped in the processing of their acceptance of the impact of their injuries on their lives.
4. Restructuring: Participants who attended most of the follow-up groups were seen to report most improvements as shown by QOLI evaluation. This may be the result of the follow-up group providing time for reflection, to set and refine personal goals as well as group encouragement and support.

It has been shown that post TBI an individual may have to cope with a reduction in cognitive abilities, a reduced ability to plan and make decisions, mental health difficulties such as depression, and psychosocial problems with a lack of self-awareness, self-esteem, self-control, apathy or aggressive behaviour (Levin HS., Goldstein FC., Williams DH., et al. The contribution of frontal lobe lesions to the neurobehavioural outcome of closed head injury in Frontal Lobe Function and Dysfunctional 1991 p318-338 New York: Oxford University Press).
Physical exercise is known to improve physical health and also to have a positive effect on mental alertness and mood in the general population. The pathology associated with TBI can be characterised by a reduced capacity of neurons to metabolise energy and sustain synaptic function which often results visibly in emotional and cognitive problems (Wu A., Ying Z., and Gomez-Pinilla F., The salutary effects of DHA dietary supplementation on cognition, neuroplasticity, and membrane homeostasis after brain trauma. J Neurotrauma 2011; 28: 2113-2122). The neurogenerative effects of exercise are beneficial to neurocognitive functioning and neuroplasticity and the detrimental effects of TBI on the vasculature may be reduced by carefully selected exercise/activity programmes. It has been suggested that the concept of exercise providing a “scaffolding” may aid the understanding of the benefits of exercise to the injured brain. It is thought that physical exercise reinforces the adaptive processes of the brain post TBI, facilitating the development of existing networks, helping to compensate for those lost through damage (Archer T., Influence of Physical exercise on Traumatic Brain Injury Deficits: Scaffolding Effect 2011 Neurotox Res (online) DOI 10.1007/s12640-011-9297-0).

Rehabilitation aims to provide the tools needed for people to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. This should be relevant to their daily life. This holistic approach with contextualised interventions results in “learning by doing and reflection”. Experiential learning and rehabilitation through outdoor activity is therefore not simply about the specific skills learned or the satisfaction of completing a challenge; but with improvements in self-esteem, self-awareness and self-confidence, lifting of mood and clinical depression, as well as cognitive improvements. Importantly learning can then be internalised, and transferred and applied to daily life.