This case study highlights some strengths and limitations of spinal cord injury rehabilitation in lower-income countries. Mr. Dee’s rehabilitation supports the findings of the Brazilian study that demonstrated neurological outcomes in low- and middle-income countries can result in recoveries comparable to those in industrialized nations.27

In Mr. Dee’s case, his type and level of injury, access to high-quality healthcare services (based on government policies and a socialized health insurance system), and a team that was trained and knowledgeable about the treatment and rehabilitation of SCI, all collectively contributed to his positive functional recovery.

However, there was still a significant disconnect between rehabilitation aiming at a “body functional recovery” and a more comprehensive rehabilitation whose goal is successful community reintegration. Some of these outstanding issues arose in the assessment – the patient’s perspective made explicit his concerns about work and income.

But what can be accomplished in a single six-week Rehab Cycle is limited. Constraints among a hospital or rehabilitation center’s human and financial resources, particularly in low-income countries, often necessitates greater focus on body functional aspects of spinal cord injury than on longer term comprehensive issues.

Nevertheless, in this area the rehabilitation team excelled, allowing Mr. Dee a greatly improved level of functioning. A minority of SCI patients in low- and middle-income countries may be able to access community-based rehabilitation programs. However, the reach of such programs is limited and in Mr. Dee’s rural and remote region of Thailand, such services were neither available nor planned.

A minority of SCI patients in low and middle-income countries may be able to access community-based rehabilitation programs.

Poor prospects for employment

Discussion

Given the importance of employment for both financial security as well as the patient’s overall well-being and life satisfaction, comprehensive rehabilitation often includes a vocational component among the various psychosocial interventions. Given Mr. Dee’s specific circumstances (age, education, etc.), even the functional gains he made were not likely to improve his chances at securing a job or regular employment.

This left his future uncertain with many open questions. How would he best enter his house given the steps? Would he be able to earn an income? Would state social services consider him eligible for the monthly disability payments that would greatly ease the family’s financial burdens? Much remained to be clarified.

Given Mr. Dee's specific circumstances, even the functional gains he made were not likely to improve his chances at securing a job...

However, Mr. Dee’s case was not without hope: as emphasized by the physical therapist, family and community would naturally play a large role in assisting him through their rehabilitative support. His daughter would complete her education and hopefully be able to earn an income for the family. His wife would continue to offer her support – a positive factor, and not only for Mr. Dee’s emotional status.28

Recap

Mr. Dee’s case provides only one example of rehabilitation of SCI in a low-income country. He possessed a number of facilitating factors (access to a skilled rehabilitation team, state insurance, a supportive family, an educated daughter, etc.) and some barriers specific to his situation (lack of employment, few options for comprehensive rehabilitation integrating aspects of vocation and environment, accessibility issues, etc.).

To minimize their effects, each of these barriers would require specific interventions, possibly undertaken in successive Rehab Cycles. However, such an expansive rehabilitative program was not available to him.

This case emphasizes the urgent need to address gaps in comprehensive rehabilitation, moving beyond the short-term concerns focused on body functioning, to exploring avenues of sustainable, long-term reintegration through innovative and cost-effective approaches.

This case emphasizes the urgent need to address gaps in comprehensive rehabilitation...

Community-based rehabilitation in both low- and middle-income countries and for those in need and lacking available resources in industrialized countries may be a promising path to ensuring those with disabilities have their needs met comprehensively.

As the WHO maintains its efforts to ensure the integration of those with disabilities around the world, CBR will no doubt be an important tool in making rehabilitation available.

Mr. Dee's rehabilitation supports the findings of the Brazilian study that demonstated neurological outcomes in low- and middle-income countries can result in recoveries comparable to those in industrialized nations.

Furthermore, efforts at integration should necessarily involve the full spectrum of key issues that promote independence in daily living (environmental, occupational, educational) and continued health maintenance.