Rehabilitation of Acquired Brain Injury in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Wendy Walker, Tarina van der Stockt, Kim Jackson and Jess Bell 

   

Introduction[edit | edit source]

While accurate data is scarce, traumatic brain injury remains a common neurological consequence of disasters and conflicts. A wide range of mild, moderate, and severe traumatic brain injury occur as a result of overpressure, gun shot wounds, a blow to the head, penetrating injury, and crush injuries following the huge kinetic energy released by rapid-onset natural disasters and armed conflict. Shockwaves from blasts, e.g. bombs or exploding debris, can also cause damage to the brain as well as open or closed head injuries, with children more vulnerable due to their size and relative frailty e.g. thinner skin and softer skull bones. Non-traumatic causes of brain injury including cerebral malaria, meningitis, stroke related to cardiovascular or sickle cell disease, tumour causing pressure on the brain or near drowning, also continue to be seen in conflict and disaster settings. Given that patients with severe, catastrophic brain injury are more likely to die due to the level of injury and the limited availability of neurosurgery and ventilatory care, rehabilitation professionals are more likely to see patients with mild and moderate head injuries.

Given the many potential sources of acquired brain injury, disaster preparedness planners and emergency medical personnel face a major challenge in preventing and managing neuro-trauma within this context. [1] In settings of disaster and conflict, brain injury management is particularly complex, as it is frequently complicated by the presence of poly-trauma, such as associated skull (and other) fractures, open wounds and internal injuries when in disaster and conflict settings. Individuals with acquired brain injury may face long-term physical, cognitive and behavioural impairments with residual neurological deficits, as well as medical complications, all resulting in lifestyle consequences; these necessitate comprehensive interdisciplinary management, including medical, surgical and rehabilitation. [2] All rehabilitation professionals working in disasters and conflicts should be able to provide aftercare information to patients with mild brain injury or suspected brain injury, including how to recognise the following signs of deterioration. [1]

Table.1 Signs of Deterioration in Acquired Brain Injury
Symptoms that may Indicate Deterioration following Brain Injury
  • Unconscious patient or altered consciousness (the patient can’t keep their eyes open)
  • Unusual tiredness
  • Headaches that worsen or do not resolve
  • Increased tiredness (feeling sleepy when normally would be awake)
  • Double incontinence
  • Dizziness or loss of balance
  • Nausea or vomiting
  • Irritability or altered mood
  • Slurring of words or problems understanding speech
  • Difficulties with concentration or memory
  • Weakness in one or more limbs
  • Visual problems, such as difficulty focusing or sensitivity to light
  • Seizures
  • Any bleeding or discharge of clear fluids from the nose or ears

Immediate Emergency Care[edit | edit source]

Early diagnosis and treatment of traumatic acquired brain injuries can be challenging under normal circumstances, and these challenges are exacerbated in the aftermath of disaster and conflicts due to to the chaotic environment including damaged infrastructure, poor communication and shortages of relevant health and rehabilitation workers, particularly neurotrauma specialists. [3]

During this early stage, immediate diagnosis and treatment is key to minimising the development of secondary brain injuries; this is a massive challenge, particularly in low resource countries where medical infrastructure and availability of state-of-the-art neurological care is already scare and may be further limited as a result of disaster or conflict. Family members are often separated, and symptoms of post traumatic stress disorder can be common during the post acute phase.

As a result, early deployment of specialised emergency medical teams to meet the immediate needs of disaster victims is a key element of the immediate emergency response, and is guided by a range of World Health Organization initiatives, including Emergency Response Frameworks (Standards and Guidelines); Coordination Mechanisms, and the Emergency Medical Team Accreditation Process ensuring that rehabilitation professionals form part of the Emergency Medical Teams. [3][4]


Figure 1: Emergency Medical Team Rehabilitation Referral Pathway for Traumatic Brain Injury


Specialised care teams are defined by the World Health Organization as “National or International teams embedded into Emergency Medical Teams or a National Facility to provide specialist care”, which may include rehabilitation teams; they are deployed based on the response required to meet specific needs at the request of the host health authorities. These teams should be multidisciplinary and need to be integrated into a disaster or conflict response and management plan and their skills need to be shared with local rehabilitation and health-care providers through mentoring and educating/training." [2]

A specialised care team that is focused on traumatic brain injury rehabilitation in a disaster or conflict setting should include: [2][4]

Table.2 Emergency Medical Team for Management of Acquired Brain Injury
Rehabilitation Interventions General Applicability of Recommendations in Disaster Settings
Weak
Team Composition Minimum Technical Standard;

A traumatic brain injury specialised rehabilitation team should be led by a rehabilitation physician and comprise of at least three other professionals from different disciplines, including rehabilitation medicine, nursing, physiotherapy, occupational therapy, speech and language therapy, and psychology. In addition, a team lead is required to represent the care team at health coordination level

Qualification and Experience Minimum Technical Standard;

Rehabilitation professionals in a traumatic brain injury specialised care team should have at least 6 months’ experience working in a traumatic brain injury unit or with traumatic brain injury patients in a major trauma center and at least 3 years of postqualifying clinical experience

At least one team member, preferable the team leader, should have experience in emergency response and all team members should have undergone training in working in austere environments

Rehabilitation Equipment Minimum Technical Standard;

Specialized care teams for rehabilitation should have capability to rapidly provide the equipment here.

Length of Stay Minimum Technical Standard;

A team that embeds into a local facility should plan to stay for at least 1 month with evidence of a exit strategy and release mechanism.

Rehabilitation[edit | edit source]

The overriding objective of acquired brain injury care in disaster settings has now extended well beyond survival and acute management to include implementation of rehabilitation structures which work towards reintegration of the individual with an acquired brain injury back into home and community. The World Health Organization's minimum standards for rehabilitation recommendations for managing patients with traumatic brain injury following a disasters include: [2][5]

  • Cognitive and neurological changes should be monitored and regularly assessed
  • Early referral to a step-down facility using local rehabilitation providers and support networks, as required
  • Appropriate mobility aids prescribed for mobility deficits using local service provider
  • Patients with long term or permanent nerve injury considered for orthotic device, sought from a local provider
  • Referral pathways identified for microsurgery for appropriate patients


Rehabilitation is a vital element of the treatment and management process post traumatic brain injury in a disaster setting and should prepare individuals with long-term impairment, their care providers and local rehabilitation personnel to manage their ongoing needs over a longer term and should be started early following any disaster.[5] Early rehabilitation should focus on comprehensive assessment for neurological and functional limitations and individualised treatment programs for specific functional goals with ongoing monitoring of outcomes. The goal of early rehabilitation in a disaster setting is to improve functional outcomes and restore as much independence in the patient as possible, while minimising secondary complications, with an emphasis on patient and care giver education about realistic expectations and self-management strategies. Survivors of traumatic brain injury need support for acquisition of essential skills for maximum return to their previous level of functional independence, regardless of whether specific impairments can be eliminated. [2]

Guidelines[edit | edit source]

Independently extracted, compared, and categorised evidence-based rehabilitation intervention recommendations for rehabilitation interventions were synthesised from currently published traumatic brain injury Clinical Practice Guidelines, developed by the Department of Labor and Employment (DLE); Scottish Intercollegiate Guidelines Network (SIGN); Department of Veterans Affairs/Department of Defence (DVA/DOD); and American Occupational Therapy Association (AOTA) for applicability in disaster settings. [5] As a result of the complexities related to the environment, resources, service provision, and workforce in disaster and conflict settings many recommendations for traumatic brain injury care are challenging to implement, and more advanced interventions are generally not applicable due to limited access to services, trained staff/resources, equipment, funding, and operational issues.[5]

Patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioural feedback, basic compensatory memory/visual strategies, basic swallowing/communication, and psychological input are the key recommendations from a rehabilitation perspective that have been found to be most applicable for survivors of acquired brain injury in disaster and conflict settings. The following table outlines the general applicability of clinical practice guidelines for acquired brain injury in disaster and conflict settings.[5]

Table.3 Guidelines for Rehabilitation Interventions in Disaster and Conflict Settings
Rehabilitation Interventions General Applicability of Recommendations in Disaster Settings
Weak Moderate Strong
Patient Education
  • Traumatic Brain Injury Education
  • Management of Traumatic Brain Injury
  • Simple Rehabilitation Interventions 
  • Social Support Services
  • Prognosis
    • Short-Term Outcomes
    • Long-Term Outcomes
Gait, Balance and Mobility
  • Treadmill Training
    • With Body Weight Support
    • Without Body Weight Support
  • Computer-based Interventions
Task-Specific Training

Repetitive Training

  • Conventional Overground Training 
  • Prescription of Assistive Devices
Spasticity and Muscle Tone
  • Special Seating
  • Special Positioning Devices
  • Botulinum Toxin Injection
  • Therapeutic Nerve Block
  • Motor Point Block
  • Functional Electrical Stimulation
  • Intrathecal Baclofen
  • Surgery
  • Oral Anti-Spasticity Medications
  • Education and Therapy
    • Active Control
    • Force Production
    • Functional Muscle Training
  • Simple Splints 
  • Simple Orthoses
  • Casts
Sleep Disturbance Management
  • Sleep Education
  • Physical Activity
  • Relaxation Therapy
  • Modification of Sleep Environment
  • Psychological Interventions
  • Dietary Modification
Cognitive Rehabilitation
  • Assistive Technology 
  • Structured Experiments
  • Game Formats
  • Computer-based Treatment
  • Behavioral Interventions 
  • Internal Strategies
  • Memory Training
  • Attention Strategy Training 
  • Meta-Cognitive Strategies 
  • Visuospatial Skills Training
  • Basic Compensatory Memory Strategies
  • Direct Feedback
  • External Aids
  • Learning Techniques
  • Group Therapy
  • Psychology Interventions
Behavioural and Emotional Disorders
  • Social Skills Training
  • Peer Mentoring Program
Comprehensive Neurobehavioural Program
  • Contingency Management
  • Positive Behavioral Program
  • Physiotherapy
  • Functional Skills Training
  • Sleep Education
  • Cognitive Behavioral Therapy
  • Individual Education
  • Family Therapy
  • Group Therapy
Activities of Daily Living
  • Home Assessment and Modifications
  • Environmental Assessment and Modifications
  • Constraint Induced Movement Therapy
  • Adaptive Equipment
  • Guided Practice in ADLs
  • Equipment Training
  • Caregiver Training
Post-Traumatic Headache Management
  • Biofeedback 
  • Acupuncture
  • Physical Activity
  • Relaxation Therapy
  • Sleep Education
  • Dietary Modification
  • Psychological Interventions
Service Delivery
  • Social Skills Training
  • Behavioral Intervention 
  • Peer Mentoring Program 
  • Telemedicine
  • Inpatient Rehabilitation Program 
  • Home / Community Based Rehabilitation
  • Family and Carers Support

Summary[edit | edit source]

“Rehabilitation can greatly increase survival and enhance the quality of life for injured survivors.”[6]

Current advances in disaster and conflict response and management have improved survival rates for those with acquired brain injury, resulting in increased number of survivors. Traumatic brain injury is one of the more common complex injuries post sudden onset disaster and survivors often have long-term physical, cognitive and behavioural disabilities, residual neurological deficits, medical complications and lifestyle consequences, which necessitate comprehensive interdisciplinary management, including medical, surgical and rehabilitation. The goal of early rehabilitation in disaster and conflict settings is to improve functional independence and successful reintegration into the community, with an emphasis on patient education about realistic expectations and self-management strategies. [2][1]

Rehabilitation professionals are now considered key health care members and as such are involved in all phases following disasters and conflicts, including early involvement with emergency medical teams. Several unique areas of skill are offered by rehabilitation professionals, including those of assessing and treating casualties with acute injuries, and possibly preventing or lessening the burden of chronic dysfunction amongst patients after the emergency phase, with a major strength being our focus on functional outcomes combined with the ability to carry out thorough assessments, often with limited resources. [2][1]

Resources[edit | edit source]

Technical Standards for Medical Teams[edit | edit source]

Rehabilitation in Conflict and Disasters Field Support[edit | edit source]

Profession Specific Guidelines[edit | edit source]

References [edit | edit source]

  1. 1.0 1.1 1.2 1.3 Lathia C, Skelton P, Clift Z. Early rehabilitation in conflicts and disasters. Handicap International: London, UK. 2020.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Amatya B, Vasudevan V, Zhang N, Chopra S, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury rehabilitation teams in sudden-onset disasters. The Journal of the International Society of Physical and Rehabilitation Medicine. [serial online] 2018 [cited 2019 Oct 19];1:72-94. Available from: http://www.jisprm.org/text.asp?2018/1/2/72/249854
  3. 3.0 3.1 Regens JL, Mould N. Prevention and treatment of traumatic brain injury due to rapid-onset natural disasters. Frontiers in public health. 2014 Apr 14;2:28.
  4. 4.0 4.1 Vasudevan V, Amatya B, Chopra S, Zhang N, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury specialist rehabilitation teams in sudden-onset disasters (for Disaster Rehabilitation Committee special session). Annals of Physical and Rehabilitation Medicine. 2018 Jul 1;61:e120.
  5. 5.0 5.1 5.2 5.3 5.4 Lee SY, Amatya B, Judson R, Truesdale M, Reinhardt JD, Uddin T, Xiong XH, Khan F. Applicability of traumatic brain injury rehabilitation interventions in natural disaster settings. Brain injury. 2019 Aug 24;33(10):1293-8. DOI: 10.1080/02699052.2019.1641748
  6. Sphere. The Sphere Handbook 2018 Humanitarian Charter and Minimum Standards for Humanitarian Response. 2018 Available form: https://www.spherestandards.org/handbook-2018/