The role of neurorehabilitation in neurotrauma: A global perspective

This is the authors' abstract. We don't add key points for this paper.

INTRODUCTION Traumatic brain and spinal cord injuries are the largest cause of death and disability. Traumatic brain injury (TBI) and spinal cord injury (SCI) have resulted in 8.1 million and 9.5 million years lived with disability, respectively, in the 2016 Global Burden of Disease.[1] The costs to individuals, their families, their communities, and society are even greater. The incidence of neurotrauma is projected to increase over time with higher population density and more use of vehicles. The impact on healthcare services from an increasingly elderly population remains a socioeconomic challenge.[2–4] While public health policy focused on primary prevention is vital for curbing the incidence, effective neurorehabilitation can lessen the burden of disability associated with TBI and SCI.[5] However, there are many challenges limiting the generation of evidence base and delivery of neurorehabilitation for people following neurotrauma. WHAT IS NEUROREHABILITATION Neurorehabilitation is a specialized field concerning the assessment, treatment, and management of people with acquired neurological injuries. It encompasses interventions to address the physical, cognitive, and emotional challenges. The multifaceted neurological functions require a multidisciplinary approach to assessment. Health and care workers include neurorehabilitation physicians, neurologists, psychiatrists, physiotherapists, occupational therapists, speech and language therapists, neuropsychologists, social workers, and specialist nurses. The goal of neurorehabilitation is to maximize the quality of life in people with neurodisability by regaining lost functions, functional adaptation, and developing mental well-being with an individualized approach. VARIETY OF NEUROTRAUMA Neurotrauma is not a uniform entity. Falls and motor vehicle collision injuries are the most common causes of TBI, yet they seem to affect different demographics; the former are more common in the aging population and the latter in younger adults. The resultant brain injury may be focal or diffuse and to a different extent. Hemorrhagic and contusional injuries are readily identifiable using conventional neuroimaging modalities. Diffuse axonal injury (DAI), representing widespread neuronal and axonal damage, is often under-recognized by standard magnetic resonance imaging sequences.[6] As the extent of DAI is associated with functional outcome, accurate quantification of this injury can identify those with higher rehabilitation needs.[7] It is also uncommon for people to suffer neurotrauma in isolation. Traumatic injuries to other body systems often complicate secondary prevention strategies. An international prospective observational study of 1635 patients receiving emergency neurosurgery demonstrated the substantial baseline characteristics and treatment across countries.[8] Combined neurotrauma, with concomitant brain and spine injuries, is also an area of growing concern. While individually TBI and spinal injury have received significant attention, their combined occurrence lags behind in its depth of insight and understanding.[9–11] Furthermore, efforts are ongoing to identify optimal management pathways in situations of neurotrauma in the context of polytrauma.[12,13] ACCESS AND RESOURCES FOR HEALTHCARE PROVISION Access to qualified and experienced professionals for the assessment and delivery of neurorehabilitation is a problem. The disparities in resource allocation for aspects of neurorehabilitation exist nationally and internationally. The Spanish Society of Neurorehabilitation highlighted deep inequalities in the evaluation of neurorehabilitation needs due to different healthcare systems in Spain.[14] Some regions have set standards of care for neurorehabilitation following TBI.[15–17] The applicability of these guidelines to other healthcare settings may be limited. Compounding these limitations, prehospital resuscitation and in-hospital management vary substantially between countries. Access to neurosurgery, and basic surgical care, is limited in low-and middle-income countries (LMICs).[18,19] TRANSFERABILITY OF RESEARCH EVIDENCE Research into neurotrauma is often conducted in high-income countries (HICs). Mechanistic insights into TBI and SCI are generalizable to LMICs, but the transferability of clinical research findings may be hampered by the differences described before. For example, intracranial pressure (ICP) monitoring is considered a standard management strategy in patients with severe TBI in HICs. When compared to routine clinical and imaging assessment, ICP monitoring was not shown to be superior for patients with severe TBI in Bolivia and Ecuador.[20] However, the principle of early neurorehabilitation following neurotrauma is recognized across all healthcare settings. Research evidence to support the delivery and efficacy of this is currently lacking. ROLE OF NEUROREHABILITATION FOLLOWING NEUROTRAUMA Evidence drawn from existing literature supports early neurorehabilitation in the trauma center and intensive neurorehabilitation programs in rehabilitation facilities.[21] This early intervention is cost-effective in the long term in people with complex needs.[22,23] Reported advantages of early rehabilitation include shorter acute phases, shorter hospital stays, and better performance at hospital discharge.[24] Studies demonstrating these findings are from HICs, so the applicability to LMICs is uncertain.[25,26] NEED TO CLARIFY NEUROREHABILITATION AFTER NEUROTRAUMA There are many areas of research needed to support a standard framework of neurorehabilitation for people with neurotrauma. We need to identify the optimal timing of rehabilitation to maximize long-term impact on recovery in HICs and LMICs.[21] The development of an instrument for formulating personalized rehabilitation plans should focus on applicability across healthcare settings. While advances in assessment modalities such as neuroimaging and metabolic biomarkers are relevant and can inform mechanistic insights, there must be clear translational purposes.[27] Pharmacological augmentation of neurorehabilitation with neuroprotective agents has the potential to benefit the whole population with neurotrauma,[28] especially if drug repurposing is feasible.[29] The concept of transdisciplinarity is interesting as proposed for African countries.[30] In this framework, team members create an ordered list of active problems, but the hierarchy is dynamic throughout the patient’s journey. There is a collaborative responsibility toward addressing the issues. CONCLUDING REMARKS Neurorehabilitation after neurotrauma is an essential and dynamic field of health care that offers hope, support, and healing to individuals who have experienced TBI and SCI. It addresses the physical, cognitive, and emotional challenges posed by these injuries, striving to optimize recovery and enhance the overall quality of life for survivors. The significance of neurorehabilitation cannot be overemphasized. It begins with early intervention, recognizing that the timely initiation of rehabilitation can prevent complications and lay the foundation for a more successful recovery journey. Neurorehabilitation focuses on restoring lost functions, be it relearning daily activities, managing cognitive deficits, or maximizing mobility. It takes a holistic approach, involving a team of dedicated healthcare professionals, adaptive technologies, and community integration strategies to empower individuals on their path to independence. However, as we contemplate the role of neurorehabilitation after neurotrauma, it is vital to acknowledge its global perspective. Disparities in access to care, shortages in the healthcare workforce, and financial barriers persist in many regions, leaving some individuals with limited opportunities for rehabilitation. Bridging these gaps and promoting equitable access to neurorehabilitation services are paramount. The future of neurorehabilitation lies in continued research and innovation. We must explore advanced assessment tools, personalized treatment approaches, and the latest technological advancements to tailor rehabilitation to individual needs. Furthermore, global collaboration in research, knowledge sharing, and best practices is essential to drive progress in this field, where it is greatly needed.