An Overview of Traumatic Brain Injury Care in Latin America

Melina Longoni Di Giusto, MD Juan Carlos Arango Lasprilla, PhD

Traumatic brain injury (TBI) is an acquired insult to the brain from an external mechanical force that may result in temporary or permanent impairment 1. At present, the World Health Organization (WHO) has identified TBI as one of the leading causes of disability and death in young adults in the world, and it is expected that by 2030 it will be the third leading cause of premature death in the world 2. Regarding the incidence of TBI in Latin American countries, there are no precise data given the absence of national records, however, some epidemiological studies conducted in countries such as Mexico23, Ecuador 3, Argentina 4 or Brazil 5 have reported incidence rates between 70 to 360 new cases per 100,000 inhabitants with traffic accidents as the main cause 6–9, followed by acts of violence.

The mortality rate after trauma in Latin America is estimated to be 75,5 per 100,000 inhabitants 7. According to WHO, more than 90% of deaths caused by a TBI occur in low-middle income countries are due to a number of risk factors such as living below the poverty line, residing in a conflict zone 10, the lack of prevention measures, and poor health systems 11, as is the case in Latin American countries. Poor health care is one of the factors that most influences the high mortality rate in Latin American countries. In the first place, there is an inadequate distribution of patients across the various hospitals due to the lack of regionalization. In addition, the poor organization of emergency transport leads to a considerable delay in arriving at the hospital. Moreover, unlike high-income countries, where air transport is generally available for rapid transportation in the most severe cases, in Latin American countries, transport is by land, which may take several hours, especially when coming from rural areas. In addition, on many occasions, due to this lack of organization, patients must be relocated to other centers when it is discovered that there is no availability of beds in the intensive care unit (ICU), further decreasing the chance of survival. Secondly, hospitals often do not have sufficient resources.

This is often seen in the lack of adequate personnel as well as a scarcity of diagnostic or intervention tools or technology, such as basic neuromonitoring systems, necessary to provide quality care. In fact, in many of these countries there are not enough neurosurgeons to meet the demands of the population, and the few that are available are usually located in major cities, leaving suburban and rural areas without adequate coverage. Finally, the lack of qualified specialists tends to result in the absence of long-term follow-up, or follow-up carried out by another nonspecialized professional, increasing the risk of severe disability with higher costs for the healthcare system, the family, and society 12 .

In most Latin-American countries there is no universal public healthcare. In some countries, the percentage of people without healthcare coverage is high. For example, in Bolivia, 39% to 44% of the population is without healthcare coverage. Panama happens to have one of the highest levels of coverage in the public system (85%). The lowest percentages of the populations with healthcare coverage within the public system correspond to Bolivia (35%), Paraguay (46%), Argentina (48%), and Uruguay (53%). In all countries the coverage of the private system is much lower than that of the public system, especially in El Salvador, Honduras, Guatemala and Peru. Therefore, considering the low income of individuals within these populations, the percentage of patients who are able to receive the benefits of rehabilitation is very low 13 .

For those with TBI in most Latin American countries who present to the emergency room, the primary focus of care is to ensure their survival. In the event that the patient is admitted to an inpatient rehabilitation facility after leaving intensive care, they are evaluated by the rehabilitation specialist and the entire interdisciplinary team, setting goals according to the patient's presentation to maximize functional independence and prevent secondary complications. Only in recent years, in some hospitals, in a few countries, has the rehabilitation physician (physiatrist) been incorporated into the ICU. For this reason, the early intervention of a rehabilitation team is scarce; most being limited to having a physiotherapist in the ICU. The lack of early intervention by rehabilitation providers, places patients at greater risk for complications in the subacute and chronic stage, such as pressure injuries, contractures, joint deformities, pain, etc.

In addition, a high percentage of patients who survive a TBI are left with physical, cognitive, emotional, and behavioral sequelae that lead to varying degrees of disability, limiting or preventing return to employment and reintegration into other aspects of society 14–16 . As expected, the rehabilitation services offered to these patients once they are discharged are quite scarce and depend mainly on the family's financial resources since public support is limited or nonexistent.

Because there is a general scarcity of local inpatient rehabilitation hospitals for the subacute stage of recovery after brain injury, most patients will return home to be cared for by family members. In the culture of Latin American countries the family unit has an essential value, so at the moment when an individual survives an injury that results in a disability, it is their family members who take complete responsibility for all aspects of the person’s care. The lack of resources and supports, can result in a significant amount of burden on family caregivers 17 .

Regarding this issue of caregiver burden, several studies have been carried out in Latin American countries with the aim of determining the impact that TBI has on caregivers. For example, Arango-Lasprilla et al. (2010) analyzed the most important needs in a group of family caregivers in Colombia, who reported access to health information and community and professional support networks as primary needs for the care of their relative 18. Similarly, Leibach et al. (2014) studied the relationship between family needs and mental health of a group of Mexican caregivers and found that family health needs were associated with all mental health indices of the caregiver 19 . Household needs were associated with the caregiver's depression, burden and anxiety. In addition, social support needs were related to satisfaction with the caregiver's life, information needs were associated with burden, and financial needs with self-esteem. On the other hand, Stevens et al. (2013) concluded in their study with the Mexican population that family dynamics have a strong influence on the mental health of the patient with even greater influence on the caregiver 20. Caregivers with high family satisfaction and family cohesion tend to have a low burden and high satisfaction with life that in turn is related to lower levels of depression 21 . In summary, while there is a need for further study on the epidemiology of TBI in Latin America, existing studies have shown the incidence of TBI to be high with contributing factors associated with the socioeconomic situation of these countries. On the one hand, a high percentage of citizens live in conditions of poverty and conflict zones, which give rise to greater risk for injury. On the other hand, there is a scarcity of prevention policies or health systems that provide a solution to this problem. People who sustain a TBI, therefore, tend to suffer a series of sequelae that, in most cases, are not treated in rehabilitation centers, given the lack of public support, availability of care, and the economic limitations of family members. For these reasons, the economic, social, and emotional burden falls on family caregivers, affecting their mental health and quality of life with poorer long-term outcomes for TBI survivors.

In order to improve TBI prevention and care in Latin America, we offer some recommendations for all Latin American countries, based on Corley and colleagues (2019) and our experience in the field 22 .

To prevent TBI and assist rapid assistance and intervention:

• Legislate safety in the work place and mechanisms for compliance, • Legislate public health measures such as the mandatory use of helmets and seatbelts, • Finance and prioritize well-designed and properly maintained road infrastructure, • Include pre-hospital, such as paramedic and/or ambulance services, as part of national healthcare plans, • Strengthen pre-existing trauma infrastructure and personnel for neurotrauma (e.g., CT scanner, critical care unit, 1 neurosurgeon per 200,000 people).

To improve in-hospital and follow-up TBI care:

• embed neurotrauma within a universal health coverage package, • develop more specialized in-patient rehabilitation services and outpatient rehabilitation centers, • increase the number of rehabilitation professionals in the health system, including, physiatrists, psychologists, occupational therapists, speech and language pathologists, and physical therapists, • form partnerships to work together with family and community services • create national trauma registries with systematic data collection about TBI outcomes

To build capacity of neurotrauma and neurorehabilitation health care professionals:

• engage in cross-country partnerships to share best practices, • offer quality training, possibly with international experts as possible, • develop specialized post-graduate programs and continuing education programs,

To advance knowledge in the field:

• develop and validate culturally appropriate assessment and diagnosis tools, • develop and conduct effectiveness research on rehabilitation programs tailored to the cultural and socioeconomic characteristics of Latin America (e.g., to return to work or integrate into the community and/or family life).

All of this together will help to advance the development of more optimal trauma prevention and care systems in Latin America. This will not only improve survival rates, but also the quality of life of these patients and their families.

References

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Author Bios

Melina Longoni, MD, is an MD specialized in Physical Medicine and Rehabilitation, Hyperbaric Medicine, Wound Care, and Expert in Natural Therapies. She received her medical degree from the Universidad Abierta Interamericana in Rosario, Argentina, where she also works in the research department of the University. Currently she is the Medical director of the ReDel Rehabilitation Center in Tigre, Buenos Aires, the Director of Disability of the Municipality of Ituzaingó, Ministry of Health in Buenos Aires. She also serves as a scientific advisor for BBraun Medical Argentina and is involved with numerous professional organizations including Secretary for the Argentine Interdisciplinary Association for Wound Healing (AIACH) where she also is the coordinator of the Rehabilitation Committee. She is the President of the Latin American Medical Rehabilitation Association - Residents Committee (AMLAR-Res), Vice Chair of the America´s Committee of A.S.I.A., and a member of the Latin American Committee for Rehabilitation Research (CLAGIR) and the Advisory Board Sustain Our Abilities.

Juan Carlos Arango-Lasprilla, PhD, is currently a Research Professor at BioCruces Vizcaya Health Research Institute in Bilbao, Spain. He has been instrumental in securing grant funding as PI and co-PI. Dr. Arango has received many awards for his accomplishments in the area of neuropsychology including awards from the National Academic of Neuropsychology, the American Psychological Association, the International Brain Injury Association, the International Neuropsychological Society and The American Congress of Rehabilitation Medicine. He has published more than 350 articles and book chapters and edited 11 books. Dr. Arango has been a guest editor of 12 special issues in prominent rehabilitation journals. Dr. Arango has lectured at Grand Rounds at more than 100 different universities across the globe. He organized and chaired 4 international conferences on neuropsychology, cultural issues and Brain Injury Rehabilitation. Dr. Arango is a founding member of the Colombian Neuropsychological Society, and he founded the IberoAmerican Journal of Neuropsychology. His research focuses on understanding and addressing the cognitive, psychological, and emotional needs of individuals with brain injury and their families. He is particularly interested in under-served populations, such as Spanish speakers, and carries out research in the US, Europe, and Latin America. He was PI of a large, multi-center norming study in which more than 14,000 adults and children from over 15 Latin American countries participated. Thanks to his leadership, normative data by country is now available for the 12 most commonly used neuropsychological tests in each respective population.