Worldwide, traumatic brain injury (TBI) has become a leading cause of death or disability with road traffic accidents causing the majority of these injuries. In fact, accidents from car or motorcycle crashes is now the 10th leading cause of disability adjusted life years (DALYs), up two places in just the last twenty years. However, across different global regions, the incidence of traffic accidents as well as the recovery rate of patients varies significantly. For example, road safety between 2010-2013 improved in high income countries but decreased in low and middle income countries. Specifically, the risk of death from a road accident was lowest in Europe (9.3 per 100,000 population) while it increased throughout Africa (26.6 per 100,000).
In Uganda, for example, road accidents, specifically motorcycle crashes, account for 27-60% of visits to the country’s health centers. Part of effective post-trauma follow-up care is to assess and treat the neuropsychological state of each patient, something that is, unfortunately, not available to most Ugandans. Without this assessment, it is difficult to plan follow-up rehabilitation and care.
In a recent study published in BMC Neurology, researchers enrolled patients who had been diagnosed with a recent TBI at a major Ugandan hospital, along with healthy volunteers including family and friends of the patients, to assess their neuropsychological function six months after the injured group had been admitted to the hospital.
A Cogstate battery of computerized tests was used to assess six different areas of cognitive function, including psychomotor speed (Detection), visuo-motor function (Chase), visual attention (Identification), visual learning and memory (One Card Learning), working memory (One Back) and spatial problem solving (Groton Maze Learning Test). In addition, any post-traumatic stress symptoms were assessed by the PTSD checklist-civilian version (PCL), depression was assessed by the Self Reporting Questionnaire and physical disability was assessed by the Functional Independence Measure (FIM).
Of the 171 TBI patients recruited for the study, 96 returned six months after their discharge for the testing. Of those patients, thirteen were under the age of 18 so they were not included in the study outcomes. The results summarize the remaining 81 patients as well as the 137 healthy volunteers who were also 18 years of age or older.
On the Cogstate tests, patients performed significantly worse than healthy volunteers on the measures of psychomotor speed, visual attention and working memory. Overall, 28.4% of the patients experienced impaired cognition on at least one test six months after their accident and would benefit from cognitive rehabilitation services. But, as the study authors noted, “This service is currently not available at the tertiary hospital though experimental cognitive rehabilitation studies have been carried out among children in the same setting.” The researchers also called for increased public health programs to address helmet use among Ugandan motorcycle riders as well as follow-up assessment and care protocols for patients with TBI; “Psychological assessment and interventions need to be integrated into the routine management of TBI in Uganda. Assessment can include brief computer or tablet-based neuropsychological assessments, such as the Cogstate system used in this study to monitor progress and determine cognitive rehabilitation needs. This can be done within six months of discharge and follow-up as deemed necessary.”
Dr. Adrian Schembri, Director of Clinical Science at Cogstate, agrees that neuropsychological testing within this population is essential to providing proper follow-up care for TBI patients in Uganda and worldwide; “The broad age range of the sample, the geographical location and the varying severity of injury presented a range of challenges, with the authors adapting a series of assessments of post-traumatic stress disorder symptoms, depressive symptoms and physical disability tests, in addition to a Cogstate computerized battery suitable for both children and adults. The flexibility of the Cogstate test battery is evident in this study, with like-for-like cognitive domains being evaluated at a baseline assessment following admission, and over 6 months to provide a measure of longitudinal change. Adopting this battery is an East-African population builds on the existing evidence for the cross-cultural adaptability of the tests among pediatric and adult populations, which bodes well for clinical trial designs seeking to utilize these cognitive tests in global trials or in regions of the world where extensive research has not been conducted previously.”