Early neuro-rehabilitation in traumatic brain injury: the need for an African perspective

Traumatic brain injury (TBI) is a global public health challenge, affecting about 69 million individuals annually and being one of the leading causes of mortality [1, 2]. In sub-Saharan Africa (SSA), an estimated 3.2 million people sustain TBI annually, and these numbers are expected to rise to 14 million by 2050 [3]. It is a major cause of disability among young adults, and there is a need, therefore, for multidisciplinary management for a healthier and more productive population [4]. Furthermore, recent studies estimated that over 40% of patients who were hospitalized as a result of an acute moderate to severe traumatic brain injury show long-term disability [5]. Therefore, TBI has adverse consequences in terms of cognitive and physical functioning, which makes rehabilitation interventions an integral part of its management [6]. Meanwhile, these services are effectively implemented in developed countries, but this is often overlooked in most of SSA. Therefore, the objective of this viewpoint is to highlight the importance of early neuro-rehabilitation in the management of traumatic brain injury patients and the increasing need for the development and implementation of early neurorehabilitation guidelines reflecting the African context.

The management of traumatic brain injury is ideally based on the initial severity of the TBI and any other sustained injuries, how those injuries developed or changed over time, and how the injuries affected the person’s capacity for self-care [7]. For instance, the management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation, and the aims of its management are prophylaxis and prompt management of intracranial hypertension and secondary brain injury, maintenance of cerebral perfusion pressure, and ensuring adequate oxygen delivery to injured brain tissue [8, 9]. Generally, care of a TBI patient should begin at the site of the injury, with the aim of securing the patient’s airway and maintaining adequate ventilation and circulation. Patients with moderate or severe TBI should be transferred to a tertiary care centre with neurosurgical facilities as soon as possible [9]. This is important as outcomes in TBI patients have been found to be influenced by transport methods, the duration of transit, and whether the responding team is led by a physician or a paramedic, as well as discharge against medical advice (DAMA) [9] (Buh et al.,2023; accepted). According to the World Health Organization (WHO) Emergency care system [10], emergency care should be delivered minutes to hours after traumatic brain injury and should consist the following: bystander care, notification and dispatch (communication), pre-hospital care at a local clinic or health centre, transportation and referral to an adequate treatment centre, hospital-based emergency care, and then continued care, in a neurosurgical unit, intensive care unit (ICU), etc. It should be noted that half of the patients who die from TBI do so within the first 2 h after injury, making prehospital assessment and interventions, critical [9]. One of the main TBI management pillars is neurosurgical intervention as patients often harbour intracranial hematomas and the mainstay of treatment for substantial hematomas is surgical evacuation. Neurosurgical means include craniotomy, intracranial pressure monitoring, and ventriculostomy [11]. TBI is extremely heterogeneous; therefore, people who experience traumatic brain injury may follow multiple care pathways and receive multiple types of interventions to assist them in recovering from the physical, cognitive, emotional, and behavioural consequences of their injuries. Care options include inpatient and/or outpatient rehabilitation, nursing home care, and community-based services [7]. Disparities in TBI care between high-income countries (HIC) and low-middle-income countries (LMICs) is a common reality from injury site to after-discharge rehabilitation, as most LMICs do not have sufficient resources to implement safe care after TBI [12]. Furthermore, sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural–urban disparity in trauma care access and the disadvantage of the poor [13]. Buh et al. [14] in Cameroon identified disparities in TBI care provision attributable to financial constraints regarding computed tomography (CT) scanning and continuation of care, since health insurance for all is not available. Furthermore, neurosurgical care which is one of the pillars in the management of traumatic brain injury is not sufficient in Africa. Despite the high burden of TBI in Africa, there is disproportionately low access to neurosurgical services, which are most often only localized in big towns or cities at the detriment of the rural communities which have little or no such services. Barriers to seeking neurosurgical services in Africa are mainly due to socioeconomic factors of cost, lack of infrastructure, and human resources, which continue to be at the heart of poor delivery of health care generally in the region [15]. Also, it is estimated that about five million neurosurgical cases go untreated each year and that Africa has one of the highest neurosurgical workforce deficits [16, 17]. According to Ukachukwu et al. [18] Africa will have 3418 neurosurgeons by 2030, with a deficit of 5191 neurosurgeons, based on population workforce targets. This alone indicates a large disparity that would greatly impact TBI care in Africa. Furthermore, multidisciplinary or neurorehabilitation teams are lacking in most of Africa. These disparities down the chain of TBI care greatly affect rehabilitation outcomes after TBI.

Rehabilitation has been defined by the World Health Organization as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” [19]. Neurorehabilitation of TBI is a vast, multifaceted topic ranging from early rehabilitation of patients with impaired cognitive, physical, communication, and sensory function resulting from nervous systems problems to support and reintegration of patients in their social and professional environments [5]. The existing research suggests that early onset neurorehabilitation in the trauma centre and more intensive neurorehabilitation in the rehabilitation environment help to aid recovery and improve functional outcomes in patients with moderate to severe TBI as compared to standard care [20]. Similarly, there is evidence that early neurorehabilitation of patients with highly complex needs is cost-effective in the long term [21, 22]. It has been reported that patients with severe traumatic brain injury who received early rehabilitation interventions experienced shorter acute phases, shorter hospital stays, and better performance at hospital discharge [23]. Moreover, children who received early rehabilitation in intensive care units had shorter and more efficient rehabilitation after discharge [24]. Furthermore, several studies have demonstrated that early mobilizations and respiratory physiotherapy reduce patient stay at the reanimation [25, 26]. A Cochrane Review of adults with traumatic brain injury of working age found that intensive rehabilitation appears to lead to earlier gains [27]. Data on the effects of early neurorehabilitation (ICU, hospitalization) in LMICs in general and in Africa in particular is extremely rare. However, the first and only study in South Africa that evaluated the effects of early neurorehabilitation (Physiotherapy) in the management of paediatric traumatic brain injury and concluded that children who received early physiotherapy services (airway clearance: vibrations, tracheal stimulation, positioning, manual cough assist, suctioning; functional treatment: mobilization in and out of bed, strengthening, get education, bed mobility, caregiver education) well tolerated it and had better outcomes. Also, most of the children who received early neurorehabilitation during hospitalization were not recommended for further treatment after discharge [28]. They, however recommended further studies with larger sample to draw adequate conclusions on the role of early neurorehabilitation in TBI outcome. Furthermore, a case study in India was reported by Lalwani et al. [29] on a 23-year-old man who sustained a TBI (diffuse axonal injury), he received rehabilitation at three levels: (i) in the neurosurgery ICU (guidance and counselling of family members, manual positioning in 2 h intervals, manual chest vibrations and percussion, chest proprioceptive neuromuscular facilitation (PNF), end-expiratory pressure, facilitating technique like quick icing and quick stretch); (ii) in the neurosurgery ward (thoracic expansion exercises, bilateral active range of motion exercises both upper and lower limbs, isometric exercises for quadriceps and hamstrings, stretching, out of bed mobilization with wheelchair); and (iii) physiotherapy rehab (functional electric stimulation, more strengthening for the limbs and trunk muscles, verticalization with tilt tables, coordination exercises, gait re-education). They concluded that the TBI survival had a remarkable progress in the physical and functional health of the patient.

It is important to note that, while early neurorehabilitation after TBI is currently well-established in developed countries, it is not the case in Africa and, in particular, SSA.

A well-coordinated multidisciplinary team with input from a physical medicine and rehabilitation (PMR) consultant is required to provide hyperacute rehabilitation following TBI. Some of the goals of early multidisciplinary rehabilitation after TBI are highlighted in Table 1. Hyperacute rehabilitation is managed with regular multidisciplinary team meetings reviewing the patient’s goals and also meeting with the patients and families to help manage expectations, facilitate transitions through stages of recovery, and try to provide a reasonable picture of the recovery process [6, 30]. Some of the early rehabilitation strategies, like practising bed mobility, transferring to a chair, neuromuscular electrical stimulation, and ambulation [31], are all employed by the team to help prevent complications of immobility.

Despite growing evidence on the benefits of early neuro-rehabilitation of patients with moderate to severe TBI, it still remains unimplemented in most of Africa, especially Cameroon. As of today, only a few studies have investigated the effect of integrating rehabilitation into acute TBI care, most of which are in high-income countries [27]. However, some studies report a few barriers to early neurorehabilitation in TBI, including concerns about intracranial pressure (ICP), cerebral blood perfusion, and cerebral perfusion pressure, as well as organizational barriers like increased staff financial resources and concerns about the safety of the interventions for patients in the ICU [23]. In order to improve outcomes and reduce the tremendous burden TBI places on Africa, it is still crucial for Africa to lead the discussion on what kind of early neuro-rehabilitation model should be adopted for patients with TBI and at which stages of the care pathway. Most developed countries have early rehabilitation provisions and guidelines for moderate to severe TBI, with little relevance and applicability in low-income countries. There is a desperate need to develop and implement early neuro-rehabilitation guidelines and services for traumatic brain injury in LMICs, where the burden of TBI is most felt. This would reduce hospital lengths of stay and improve long-term outcomes, as previously reported.

The following issues may be the focus of a collective reflection in an effort to develop and implement guidelines for neurorehabilitation in TBI, from hyperacute to community settings in Africa:

In conclusion, neurorehabilitation should start at the time of admission and continue from the intensive care unit through the community for the moderate-to-severe TBI population. There is a need to develop, agree on, and implement guidelines on early neuro-rehabilitation interventions for patients with moderate to severe traumatic brain injury in the African region. This will reduce inequalities in recommending rehabilitation services and the timing of various rehabilitation interventions. Most importantly, it will help TBI survivors by improving their outcomes, which will reduce the burden of TBI in LMICs, where it is quite high, and disparities in care for various reasons are a common reality.