Building beyond high-tech hegemony: Traumatic brain injury neurorehabilitation from Padua to Abi Addi.

Worldwide, lives are permanently impacted daily by traumatic brain injury (TBI), often via road traffic accidents (RTA) involving cars, bicycles and two-wheel motor vehicles, such as motorcycles and mopeds. More than 70% of TBIs occur in low- and middle-income countries (LMICs) like Ethiopia and Uganda, largely due to acquired head injury via RTA, most commonly among children and young adults aged 5-29 years (1, 2).

TBIs present as brain tissue damage with accompanying lactic acid accumulation in the area. This results in altered energy metabolism and eventual necrosis and apoptosis, also known as cell deterioration and death, resulting in potentially irreversible damage (3). TBIs often require long-term rehabilitation led by physiotherapists, occupational therapists and nurses, with additional support for potential adverse psychological effects of the incident or RTA. However, rehabilitation teams face numerous hurdles to delivering quality services: a lack of international guidelines guiding practice and optimal use of rehabilitation resources, high patient demand for care, and limited hospital and community resources. Furthermore, the variable nature of TBIs regarding severity and type means recovery timelines are unclear, leaving families and patients under additional stress. There is evidence supporting a reduction in long-term economic burden from immersive inpatient programmes, where TBI patients are cared for by a multi-disciplinary team of physiotherapists, nurses, occupational therapists and other professionals (4). These programmes often last several months, and the upfront cost of these may not be feasible for many facilities in LMICs, particularly in rural areas, due to lower funding (5).

Global regions such as sub-Saharan Africa have need for greater investments in neurorehabilitation (6). A review of neurorehabilitation of TBIs investigated disparities in physiotherapy across sub-Saharan Africa, and proposed a benchmark for neurorehabilitative guidelines to be mirrored across the region. In some cases, particularly in lower severity TBIs, the gap between prolonged stay in ICU and successful discharge was early critical care physiotherapy: strategies such as mobilising patients out of bed in the first 24 hours, using respiratory aids like suctioning to remove sputum from the airway for infection prevention, and implementation of social time were of importance. The review found that these low-cost and low-barrier strategies are inconsistently implemented across various African settings, despite being key components of neurorehabilitation of young adults with TBIs in high-income countries (HIC) (8).

Complex TBI cases require additional input, though, particularly in later stages of rehabilitation, where the focus is on a return-to-function. Technological advancements are being made rapidly by medical device companies. The Italian company Khymeia is innovating the outlook of neurorehabilitation by leveraging technologies like virtual reality (VR) and telemedicine with a wide range of VR platforms, handhelds and devices. Their virtual reality rehabilitation system (VVRS) which has relevance for TBI and acquired brain injury rehabilitation, uses immersive environments to foster neuroplasticity, improving patients’ chances at full recovery (9). How can advanced technologies, such as VRRS, reach those living in countries, such as Ethiopia which carries a disproportionately high burden of TBI, notably in the Tigray region, yet have centralised neurorehabilitation services to metropolitan areas such as Addis Ababa (10)? A subaltern health strategy advocates for frugal adaptation and reverse innovation for equitable outcomes. This may be achieved by redesigning neurorehabilitation technologies to a more simplified, gamified products that maintain clinical algorithms and scientific rigour. Also, global health partnerships could be reenvisioned, instead of conventional academic partnering of Global North and Global South, bilateral partnerships could be formed, linking for example an Italian tech company with Ethiopian research institutions to develop locally appropriate products. An adolescent suffering a TBI should be able to access a device facilitating brain recovery whether they live in Padua or Abi Addi.

Hero image: Image courtesy of Vecteezy.

References

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