Barriers to Spinal Cord Injury Rehabilitation in Low-Resource Settings: A Critical Narrative Review and Conceptual Synthesis

Sidra Tul Muntaha; Mansoor Ahmad; Muhammad Adnan; Iqra Javed; Muqaddas Yaqoob; Areesha Tanveer; Warda Khan; Etisam Wahid; Shahzad Ahmad; Ayesha Nisar

doi:10.61919/mmg6yk14

Authors

Sidra Tul Muntaha Doctor of Physical Therapy, Dadabhoy Institute of Higher Education, Karachi, Pakistan Author https://orcid.org/0009-0002-9429-1146
Mansoor Ahmad MBBS, International University of Kyrgyzstan, Kyrgyzstan Author https://orcid.org/0009-0001-8686-8606
Muhammad Adnan Assistant Professor, City University of Science and Information Technology, Peshawar, Pakistan Author https://orcid.org/0009-0002-7752-5705
Iqra Javed Doctor of Physical Therapy, Ziauddin University, Karachi, Pakistan Author https://orcid.org/0009-0005-8247-5310
Muqaddas Yaqoob Lecturer, Swat Institute of Rehabilitation and Medical Science, Swat, Pakistan Author https://orcid.org/0009-0001-4948-0063
Areesha Tanveer Doctor of Physical Therapy, Dadabhoy Institute of Higher Education, Karachi, Pakistan Author
Warda Khan Handicap International, Peshawar, Pakistan Author https://orcid.org/0009-0000-4918-1592
Etisam Wahid University of Veterinary and Animal Sciences, Swat, Pakistan Author https://orcid.org/0009-0009-0227-3735
Shahzad Ahmad University of Veterinary and Animal Sciences, Swat, Pakistan Author https://orcid.org/0009-0001-6319-7934
Ayesha Nisar Mahaban Hospital, Topi, Swabi, Pakistan Author https://orcid.org/0009-0003-7459-1093

DOI:

https://doi.org/10.61919/mmg6yk14

Keywords:

Spinal cord injury; rehabilitation; low-resource settings; low- and middle-income countries; access to care; neurorehabilitation; health systems; community reintegration

Abstract

Background: Spinal cord injury is associated with long-term disability, secondary complications, reduced participation, and substantial dependence on rehabilitation services. In low- and middle-income countries, rehabilitation access remains constrained by fragmented service delivery, limited workforce capacity, financial barriers, weak referral systems, and poor community-based support. Although previous literature has described individual barriers to rehabilitation, less attention has been given to how these barriers interact across the continuum of care. Objective: To critically synthesize evidence on barriers to spinal cord injury rehabilitation in low-resource settings and develop a conceptual framework explaining how multi-level barriers influence access, continuity, participation, and outcomes. Methods: A structured narrative review was conducted using PubMed/MEDLINE, Scopus, Web of Science, and CINAHL. Literature published between January 2010 and March 2026 was considered. Eligible sources examined spinal cord injury rehabilitation or directly relevant disability rehabilitation services in low- and middle-income countries, with focus on access, service delivery, continuity, barriers, or outcomes. Evidence was synthesized thematically across system-level, service-level, socioeconomic, and patient-level domains, with particular attention to transition points across the rehabilitation pathway. Results: Twenty-two studies/sources were included in the narrative synthesis. The evidence consistently showed that rehabilitation barriers operate cumulatively rather than independently. System-level constraints, including policy gaps, limited financing, and workforce shortages, contributed to restricted service availability and weak referral pathways. Service fragmentation, high out-of-pocket costs, transport barriers, limited community-based rehabilitation, low awareness, stigma, and poor adherence further disrupted continuity of care, especially during transitions from acute care to rehabilitation and from institutional rehabilitation to community reintegration. Conclusion: Spinal cord injury rehabilitation in low-resource settings is best understood as a pathway-level systems challenge. Effective reform requires integrated rehabilitation planning, structured referral and discharge systems, community-based rehabilitation expansion, financial protection, and context-specific strategies to reduce geographic and social inequities

References

1. Lee B, Cripps RA, Fitzharris M, Wing P. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord. 2014;52(2):110-116.

2. Cripps RA, Lee BB, Wing P, Weerts E, Mackay J, Brown D. A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention. Spinal Cord. 2011;49(4):493-501.

3. Reynolds TA, Stewart B, Drewett I, Salerno S, Sawe HR, Toroyan T, et al. The impact of trauma care systems in low- and middle-income countries. Annu Rev Public Health. 2017;38:507-532.

4. World Health Organization, International Spinal Cord Society. International perspectives on spinal cord injury. Geneva: World Health Organization; 2013.

5. Reinhardt JD, Middleton J, Bökel A, Kovindha A, Kyriakides A, Hajjioui A, et al. Environmental barriers experienced by people with spinal cord injury across 22 countries: results from a cross-sectional survey. Arch Phys Med Rehabil. 2020;101(12):2144-2156.

6. Jorge A, White MD, Agarwal N. Outcomes in socioeconomically disadvantaged patients with spinal cord injury: a systematic review. J Neurosurg Spine. 2018;29(6):680-686.

7. Barclay L, McDonald R, Lentin P. Social and community participation following spinal cord injury: a critical review. Int J Rehabil Res. 2015;38(1):1-19.

8. Neill R, Shawar YR, Ashraf L, Das P, Champagne SN, Kautsar H, et al. Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework. Int J Equity Health. 2023;22(1):91.

9. Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low- and middle-income countries. Int J Environ Res Public Health. 2018;15(10):2165.

10. Uddin T, Islam MT, Rathore FA, O'Connell C. Disability and rehabilitation medicine in Bangladesh: current scenario and future perspectives. J Int Soc Phys Rehabil Med. 2019;2(4):168-177.

11. Burns AS, O'Connell C. The challenge of spinal cord injury care in the developing world. J Spinal Cord Med. 2012;35(1):3-8.

12. Tian T, Zhang S, Yang M. Recent progress and challenges in the treatment of spinal cord injury. Protein Cell. 2023;14(9):635-652.

13. Booth S, Kendall M. Benefits and challenges of providing transitional rehabilitation services to people with spinal cord injury from regional, rural and remote locations. Aust J Rural Health. 2007;15(3):172-178.

14. Rathore FA, Farooq F, Muzammil S, New PW, Ahmad N, Haig AJ. Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan. Arch Phys Med Rehabil. 2008;89(3):579-585.

15. Rathore FA, New PW, Iftikhar A. A report on disability and rehabilitation medicine in Pakistan: past, present, and future directions. Arch Phys Med Rehabil. 2011;92(1):161-166.

16. Khan F, Amatya B, Mannan H, Rathore F. Neurorehabilitation in developing countries: challenges and the way forward. Phys Med Rehabil Int. 2015;2(9):1070.

17. Rathore FA, Mansoor SN. Neurorehabilitation in Pakistan: needs, challenges and opportunities. Khyber Med Univ J. 2016;8:59-60.

18. Solomon RM, Dhakal R, Halpin SJ, Hariharan R, O'Connor RJ, Allsop M, et al. Telerehabilitation for individuals with spinal cord injury in low- and middle-income countries: a systematic review of the literature. Spinal Cord. 2022;60(5):395-403.

19. Alve YA, Bontje P. Factors influencing participation in daily activities by persons with spinal cord injury: lessons learned from an international scoping review. Top Spinal Cord Inj Rehabil. 2019;25(1):41-61.

20. Pacheco Barzallo D, Oña A, Gemperli A. Unmet health care needs and inequality: a cross-country comparison of the situation of people with spinal cord injury. Health Serv Res. 2021;56:1429-1440.

21. Covell MM, Naik A, Shaffer A, Cramer SW, Alan N, Shabani HK, et al. Social determinants of health impact spinal cord injury outcomes in low- and middle-income countries: a meta-epidemiological study. Neurosurgery. 2024;94(5):893-902.

22. Ranjbar Hameghavandi MH, Khodadoust E, Hassan Zadeh Tabatabaei MS, Farahbakhsh F, Ghodsi Z, Rostamkhani S, et al. Challenges in traumatic spinal cord injury care in developing countries: a scoping review. Front Public Health. 2024;12:1377513.

23. Scovil CY, Ranabhat MK, Craighead IB, Wee J. Follow-up study of spinal cord injured patients after discharge from inpatient rehabilitation in Nepal in 2007. Spinal Cord. 2012;50(3):232-237.

24. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: a systematic review. Afr J Disabil. 2013;2(1):1-6.

25. Borg J, Lindström A, Larsson S. Assistive technology in developing countries: a review from the perspective of the Convention on the Rights of Persons with Disabilities. Prosthet Orthot Int. 2011;35(1):20-29.

26. Bright T, Kuper H. A systematic review of access to general healthcare services for people with disabilities in low- and middle-income countries. Int J Environ Res Public Health. 2018;15(9):1879.

27. Rahman A, Ahmed MS, Taoheed F, Hasan MS, Helal SU, Hossain SS, et al. Spinal cord injury in Bangladesh, 2011-2021: an 11-year single-centre epidemiological study. medRxiv. 2025. doi:10.1101/2025.10.08.25337543.

28. Draulans N, Kiekens C, Roels E, Peers K. Etiology of spinal cord injuries in Sub-Saharan Africa. Spinal Cord. 2011;49(12):1148-1154.

29. Tinney M, Chiodo A, Haig A, Wiredu E. Medical rehabilitation in Ghana. Disabil Rehabil. 2007;29(11-12):921-927.

30. Atijosan O, Rischewski D, Simms V, Kuper H, Linganwa B, Nuhi A, et al. A national survey of musculoskeletal impairment in Rwanda: prevalence, causes and service implications. PLoS One. 2008;3(7):e2851.

31. World Health Organization. Rehabilitation in health systems. Geneva: World Health Organization; 2017.

32. Stucki G, Bickenbach J, Gutenbrunner C, Melvin JL. Rehabilitation: the health strategy of the 21st century. J Rehabil Med. 2018;50(4):309-316.

33. Shakespeare T, Bright T, Kuper H. Access to health for persons with disabilities. Geneva: Office of the United Nations High Commissioner for Human Rights; 2018.

34. Mitra S, Posarac A, Vick B. Disability and poverty in developing countries: a snapshot from the World Health Survey. Washington, DC: World Bank; 2011.

35. Thietje R, Hirschfeld S. Epidemiology of spinal cord injury. In: Weidner N, Rupp R, Tansey KE, editors. Neurological aspects of spinal cord injury. Cham: Springer; 2017. p. 3-17.

36. Middleton JW, Dayton A, Walsh J, Rutkowski S, Leong G, Duong S. Life expectancy after spinal cord injury: a 50-year study. Spinal Cord. 2012;50(11):803-811.

37. LaVela SL, Wu J, Nevedal AL, Harris AH, Frayne SM, Arnow KD, et al. The impact of the COVID-19 pandemic on individuals living with spinal cord injury: a qualitative study. Rehabil Psychol. 2023;68(1):12-22.

38. Jesus TS, Landry MD, Dussault G, Fronteira I. Human resources for health and rehabilitation: six rehab-workforce challenges for the century. Hum Resour Health. 2017;15(1):8.