In this episode of BIScussions the format flips and Eky Popat interviews Natalie Mackenzie, founder and cognitive rehabilitation therapist at BIS Services, about the subject she is best known for pushing to the front of every rehab conversation: brain injury fatigue.

Natalie makes the case that fatigue belongs beneath attention at the base of the cognitive hierarchy, and that when it goes unmanaged it gets mistaken for something else. Clients described as disengaged, lacking initiation or non-compliant are very often clients whose fatigue nobody has assessed properly.

What Natalie and Eky cover:

• Why fatigue is spoken about far more often than it is measured, and what a proper assessment looks like
• Two to four weeks of structured logging, why it stops there, and the risk of clients hyper-focusing on fatigue
• Triggers and vulnerabilities: light, noise, children, vestibular dysfunction, emotional load, medication, hydration, missed meals
• Distinguishing brain injury fatigue from vestibular symptoms, migraine and pre-existing conditions , and what gets missed when a post-injury ME diagnosis leaves the brain injury out of the picture
• The education piece, including motorways becoming B roads, and why analogy and storytelling do the heavy lifting
• Scheduling therapy around cognitively optimal windows, getting fatigue evidence into the rehab plan, and why inconsistent MDT practice makes client consistency impossible
• Reading fatigue in a session: fidgeting, hair twisting, face scratching, and clients who report being fine until they are not
• Recharge that is not sleep, the points system, and why crochet is restorative for one person and cognitively expensive for another
• Why improving fatigue scores can dip as clients do more, and why that is progress
• Fatigue in the workforce, and CRAs using the same tools they deliver

Natalie also announces the digital version of the Fatigue Management Journal for the first time, with clinician and CRA logging being built in, and confirms a paediatric edition in development.

Resources

The Fatigue Management Journal, digital: The Fatigue Management Journal, pace your day, notice your patterns The Fatigue Management Journal, print edition: available on Amazon Fatigue courses for case managers and MDT members, and the brain injury membership: Home - BIS Services Cognitive Rehabilitation Contact Natalie: [email protected] Instagram: @thebraininjurytherapist

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In this episode of BIScussions, Natalie and Eky are joined by Sarah Griggs, partner in the London office of Irwin Mitchell's Serious Injury Team and the firm's national brain injury coordination lead, for a conversation from the legal side of neurorehabilitation. Sarah shares her route into law via an English degree and a small-firm training contract, and how she came to specialise in traumatic brain injury, capacity issues, and securing interim payments to get rehab funding flowing fast. They discuss what genuinely distinguishes a specialist catastrophic injury lawyer, how to choose the right solicitor (APIL accreditation, asking about experience, avoiding jargon and red flags), and the fine line between close, trusting client relationships and professional boundaries across cases that can run many years. Sarah, Natalie and Eky explore why brain injury remains hard to evidence, particularly "walking wounded" cases, the rising demand for detailed reporting, cost-budgeting and proportionality pressures, delayed interim payments, and the disruption of frequent team and case manager changes. They also reflect on family support as a recognised need, how environment shapes outcomes, redefining independence and interdependence after brain injury, and Sarah's work with ABIL, Headway East London and UKABIF. A warm, honest look at connection, communication and why early rehab matters.

Natalie Mackenzie and Eky from BIS Services welcome their studio guest, Elizabeth Nightingale, founder of Nightingale NMT, to discuss neurologic music therapy (NMT) in brain injury rehabilitation. Elizabeth shares her background, training, and how NMT differs from traditional music therapy through standardised techniques and a functional assessment-led "transformational design model," using music as treatment and aiming to remove it as skills generalise.

She explains how NMT supports speech and language (including melodic intonation therapy for aphasia), cognition, sensory-motor goals, and family-based rehabilitation, with examples including bespoke songwriting for pediatric receptive language and joint working with physio.

The episode also covers referrals, outcome tracking, myths about needing to be musical, using music in anxiety regulation, PDOC assessment via MATADOC, access routes, and Elizabeth's expert witness work.

In this episode of "BIScussions," Natalie and Eky are joined by Mike, BIS's talent acquisition manager, to discuss recruitment challenges in brain injury community support and why getting it right matters for client outcomes. They explain BIS's focus on hiring psychology graduates, the importance of balancing academic knowledge with soft skills, and how CV screening, a demanding application form, multi-stage interviews, and client meet-and-greets shape a lengthy process.

The team describes the "dreaded Venn diagram" of matching candidates to referrals based on skills, location, driving ability, personality, interests, and cultural competency, plus the use of hold lists. They cover external delays, funding changes, schedule shifts, retention impacts from the COVID cohort, increased wellbeing supports, rural recruitment issues, AI use in applications, planned gamification, and anticipated 2026 needs including reasonable adjustments for neurodiverse and mental health-related accommodations.

In this BIScussions episode, Natalie and Eky are joined by Cam, BIS's ILT coordinator, to explain independent living trials (ILTs) for people after brain injury: their purpose, how BIS runs them, and the staffing, evidence, and practical challenges involved. They describe ILTs as structured, safe opportunities for positive risk-taking that establish a client's long-term support needs, with success defined by evidence gathered rather than perfect performance. Drawing on lessons from "The Link," a community-style, non-clinical smart-tech house, they explain why BIS shifted from a single property to delivering a portable 12-week Independent Living Trial Assessment (ILTA) in clients' own communities. They outline a three-phase approach that scaffolds skills, introduces strategies and assistive tech, then reduces supervision to test independence, emphasising client buy-in, MDT collaboration, family involvement, and skilled observation by rehab assistants. Key barriers include property sourcing, funding delays, and recruitment/matching needs, including cultural considerations.

In this episode of BIScussions, Natalie and Eky explore the varied role of CRAs in neuro rehab and focus on supporting clients with brain injuries on holidays, including unusual activity requests and the "can-do" ethos of making goals possible within safe parameters. They describe how holidays can reveal increased cognitive challenges, reduced insight, sensory overload, and changing behaviours, making constant supervision, daily reporting, and careful boundary-setting essential. Drawing on experiences such as taking a client on a cruise, they explain the importance of bespoke holiday guidelines, detailed risk assessments, logistics planning, and often sending more than one CRA due to fatigue, safety, and evidence collection demands. They also discuss how holidays can provide valuable data for litigation and help families build confidence, sometimes serving as a stepping stone toward independent living trials.

In this episode of "Biscussions," Natalie & Eky revisit pregnancy and brain injury, focusing on challenges when clients become pregnant after injury and on parenting from birth through adulthood. They discuss the complex role of community rehabilitation assistants (CRAs) in scaffolding parenting without overstepping, gaps in professional understanding (including medical staff), and the need for more training and research. A key case involved long-term support, a CRA acting as a birthing partner, 24/7 packages, collaboration with nannies and other disciplines, and significant safeguarding difficulties and delays with social services. They highlight issues of insight, fatigue, changing routines, medication and epilepsy risks during pregnancy, cultural differences and judgments about parenting, boundary and attachment challenges for children, and the importance of planning and funding for parenting support in medicolegal claims.

Eky Popat's Journey: From Rehab Assistant to Operations Director at BIS Services Natalie Mackenzie introduces Biscussions and spotlights Eky Popat, BIS Services' operations director and registered manager, exploring her 15-year journey in brain injury rehabilitation. Eky shares studying psychology and child psychology, realising school work felt too routine, and applying widely before joining BIS as a rehab assistant after a relaxed coffee-shop interview with Natalie and Clive. She describes being thrown in at the deep end, shadowing clients, and gaining confidence when trusted to cover Natalie's caseload. Eky recounts progressing from CRA to team lead and into operations, developing policies and a staff handbook, and completing the Certified Brain Injury Specialist (CBIS) accreditation in 2017. She discusses adapting operations during COVID, taking on registered manager responsibilities in 2022 alongside Level 5 study and personal challenges, and emphasises trust, mentoring, self-belief, and overcoming imposter syndrome.