Management of Traumatic Brain Injury in Low Resourced Settings

Original Editor - Zillah Whitehouse

Top Contributors - Naomi O'Reilly, Kim Jackson, Admin, Rachael Lowe, Eugenie Lamprecht, Uchechukwu Chukwuemeka, Jess Bell and Tony Lowe  

Introduction

Countries can be categorised by their Gross National Income (GNI) (Previously known as the Gross National Product - GNP). Gross national income is a measurement of a country's income that includes all the income earned by a country's residents and businesses, including any income earned abroad. Countries are classified by the World Bank into four categories - high-income, upper-middle-income, lower-middle-income and low-income. Low and middle-income countries (LMICs) are often also described as "low resourced settings" or simply LMICs.

Fig.1 Low Income Countries 2019

Epidemiology of Traumatic Brain Injuries in LMICs

TBI is a major cause of death and disability worldwide and LMICs are disproportionately affected. The World Health Organisation (WHO) estimates that almost 90% of the global deaths caused by injuries occur in low- and middle-income countries (LMICs). Traumatic Brain Injury is also the main cause of one-third to one-half of these trauma-related deaths and represents the greatest cause of death and disability.

Road Traffic Injuries (RTI) are strongly connected to the global incidence of traumatic brain injury and give reason to why the LMICs experience nearly 3 times as many cases of traumatic brain injury proportionally than high-income countries (HICs). According to Laccarino’s epidemiological study, the proportion of traumatic brain injuries resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%).

Interestingly a study carried out in 2009 comparing traumatic brain injury in 46 countries identified that whereas people were over twice as likely to die after severe traumatic brain injury in LMIC, there was half the likelihood of being disabled after mild and moderate traumatic brain injury. The reasons for this were suggested to be

• Socio-cultural: the culture has a different definition of what is defined as disabled.
• Environmental: e.g. the increased availability of informal carers.

Management of Traumatic Brain Injuries in LMICs

Clinical guidelines for TBI management have been shown to improve outcomes. While current guidelines are effective in the developed world, they have been less effective in low resource settings, possibly due to lack of infrastructure, equipment, and trained personnel. It has been proposed that the development and implementation of contextually adapted guidelines in resource-limited settings should also result in better outcomes in LMIC.

There is often a scarcity of neurosurgical personnel in low-income countries, it is important therefore that all health professionals should be aware of the assessment procedures for newly admitted traumatic brain injury patients and able to identify patients who may require urgent review or referral.

Often equipment, such as MRI scanners and Intracranial pressure monitors are not available so instead, clinical clues must be used.

• A study done in Malawi suggested that monitoring changes in the Glasgow Coma Scale (GCS) and heart rate correlated strongly with mortality and therefore could effectively be used for triage of critically ill patients with traumatic brain injury.
• A similar conclusion was made in a study by Subaiya that found advanced age, GCS, pupil reactivity, the presence of a major extracranial injury and time from injury to presentation to be predictors for intracranial haemorrhage (ICH) in traumatic brain injury patients from LMIC.

Limited resources are a major challenge in LMICs. A study done in Rwanda recognised that, due to limited resources for both hospital and patients bearing costs, the current guidelines for traumatic brain injury as promoted in high-income countries, were not suitable to be followed. The authors, therefore, recommended a predictive model should be used to allocate resources by demonstrated need. These findings are important to be recognised by physiotherapists working in LMICs as similar strategies may need to be implemented with the allocation of rehabilitation input and equipment.

• For example, as much as a several-month intense physiotherapy programme may be ideal for restoring good movement patterns, a compensatory approach and early discharge may be appropriate if the family are selling land to afford the hospital admission and live a distance from a health facility.

The lack of resources and trained professionals in LMICs has led to the recommendation that more central specific TBI services be created and training made available if staff are to provide evidence-based TBI care.

Solutions with Locally Made Resources

Equipment and appliances for management of impairments and functional limitations can be limited in supply and expensive in cost in LMICs and therefore alternatives may sometimes be required.

Bubble Peep (PEP bottle)

A simple positive expiratory pressure device improves; collateral ventilation, secretion clearance, and functional residual capacity.

Research suggests the following requirements;

1. PEP for secretion clearance

Goal: improve airway clearance in individuals with respiratory infections, postoperatively with complications such as hypersecretion, impaired forced expiratory ability, and mucociliary clearance.

Requirements

• 1 or a 2-litre bottle.
• Tube: Diameter of tube >8mm; Length of 30-45cm.
• water level: 10-20cmH2O (resistance).

Instructions

• Take a deep inspiratory breath.
• Hold the breath for 1-2 seconds.
• Followed by an activated expiratory breath.
• Repeat.
• 10 reps (when the individual struggles to clear secretions effectively and productively)

2. PEP to increase lung volumes

Goal: increase lung volume and gas exchange as well as reduce atelectasis.

For individuals post-surgery, or individuals with cystic fibrosis (CF), pulmonary conditions and neuromuscular conditions.

Requirements

• 1 or a 2-litre bottle.
• Tube: Diameter of tube >8mm; Length of 30-45cm.
• water level: 10-20cmH2O (resistance).

Instructions

• Take a deep inspiratory breath.
• Followed by a slightly activated expiratory breath, and not to end of expiration (this assists 'breath stacking').
• Repeat.
• 10 reps/ waking hour (if ineffective increase sets and not reps).

3. PEP to reduce hyperinflation

Goal: improve ventilation and gas exchange.

For individuals with COPD and CF.

Requirements

• 1 or a 2-litre bottle.
• Tube: Diameter of tube >8mm; Length of 30-45cm.
• water level: 5-10cmH2O (resistance).

Instructions

• Calmly take an inspiratory breath.
• Followed by a prolonged activated expiratory breath - slow and with low resistance, to full expiration.
• Repeat.
• 30 reps/ waking hour.

Instructions for homemade PEP Bottle

Fig.2 Bubble PEP

Foam Splints

Foam mattresses are readily available in low-income countries and can be utilised to make simple splits for both prevention and correction of contractures.

Fig.3 Banana Plant Splints

Cardboard Splints

For patients with a mild or moderate tone, cardboard can be used if necessary to make resting splints.

Fig.4 Cardboard Splint

Banana Plant Splints

Fig.5 Banana Plant Splints

Water Filled Gloves

Fig.6 Water Filled Glove

A latex glove filled with water and used to help position the patient to avoid pressure sores is a long used adjunct in pressure sore management in low resource settings. There is some debate as to whether they succeed or not in their objective and further research in this area would be beneficial.

Further ideas, particularly for children although some could be adapted for adults, can be found in the book “Disabled Village Children” by David Werner.

Community Based Rehabilitation

The World Health Organisation has recognised the benefit of Community Based Rehabilitation (CBR) for people with disabilities in LMIC. A systematic review carried out by Iemmi in 2015 found moderate to high evidence that Community Based Rehabilitation is beneficial to people with physical disabilities although none of the studies had looked specifically at Traumatic Brain Injuries.

Community Based Rehabilitation is implemented along with the following four principles as agreed upon during the Community Based Rehabilitation Review of 2004:

• Participation
• Inclusion
• Sustainability
• Self-advocacy

However, before the Community Based Rehabilitation Review of 2004, practitioners considered the following as the Community Based Rehabilitation Principles and these are still considered relevant and clear to the practitioners:

1. Equality - The principle states that human beings are: All born equal, entitled to equal rights and should share the same responsibilities. It is important to note each develops as a unique individual with different abilities. These differences do not make us unequal in worth. It is important to differentiate ‘being’ and ‘doing’ when applying that principle. The principle helps in fighting prejudice against people with a disability.
2. Dignity - Dignity is the quality that deserves or earns respect. It is possible when society;
   • Recognises that all human beings have equal rights and worth;
   • People are willing to share the available resources in order to promote their self-esteem;
   • Recognises the principle of full participation in societal activities.
3. Social Justice- The principle emphasises that services and opportunities are for all people and not for a numerically small group among them. The principle emphasises the importance of equalisation of opportunities and promotes the vision of positive discrimination and affirmative action.
4. Inclusion - The state of being included within a group or structure - persons with disabilities must be included in every aspect. Mainstreaming - disability must be mainstreamed in all programmes. Consider disability issues/persons with disabilities at all programme levels; planning, implementation, monitoring and evaluation.
5. Use of Locally Available Resources - For sustainability, Community Based Rehabilitation promotes the use of locally available resources as these will be affordable and available as they are found within that particular locality. This also includes the human resource that is; the involvement and training local people as Community Based Rehabilitation workers as they live within that community.
6. Empowerment - To empower is to make someone stronger and confident, especially in controlling their life and claiming / advocating for their rights. Persons with disabilities understanding that they alone, along with others, have the power to change a situation if they so wish.
7. Solidarity - Solidarity is unity or agreement of feeling or actions especially among vulnerable groups, with the purpose of emphasising that human life is shared by all. A solidarity that fosters human life should be seen as a privilege of all but not charity for some. It should therefore be shown among those who are dependent and need help e.g. the PWDs, the children and the elderly. Solidarity is one of the main principles of society without which there would be no survival.

Preventative Strategies

Preventative programs aimed at reducing the incidence of TBI will also help to reduce the burden. A significant way to reduce the impact of TBI is road safety initiatives and physiotherapists in low income countries are ideally placed to be at the forefront of developing, promoting and supporting these health promotion activities. In many low-income countries motorcycles are used to provide public transport, these commercial riders may not have licences and if they do they are often given without licences without proper road training. Helmet wearing is often viewed as optional by the riders even if there is legislation for their use. A study done in an urban setting in Uganda showed only 18% of riders wearing helmets, it is expected that the percentage would be lower in rural settings where there is less police presence. Below are a few examples of initiatives working to reduce accidents and injuries caused by motorcycle riding:

Another example initiative is the Awareness Drive on “Road Safety” organised by D Y Patil University, School of Physiotherapy, India. The awareness drive began with a presentation on the dos and don’ts of safe riding followed by a practical demonstration in open space on a two-wheeler. The points of awareness included everything from changing a tyre, engine and oil maintenance and pillion riding, followed by a  practical demonstration. Students then had the opportunity to assess their riding skills on a Two Wheeler using India’s first computerised simulated bike, which would assess all the minor mistakes of the rider.

Resources

World Health Organization:

• Rehabilitation
• Community Based Rehabilitation
• Putting Evidence into Practice in Low-Resource Settings
• Compendium of Innovative Health Technologies for Low-Resource Settings
• Assistive Technology