This article describes the differences and similarities in post-acute care for patients with spinal cord injuries in Canada, the United States, and Mexico. It provides a comprehensive description of the current state of spinal cord injury post-acute care in each country, including the prevalent practices, rehabilitation continuum of care, as well as challenges and opportunities related to clinical services, psychosocial factors, economic considerations, and cultural influences.
Key points
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Post-acute care for patients with spinal cord injury has distinction and similarities among Canada, the United States, and Mexico based on the health care system of each of the countries.
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The three countries differ in education, resources, continuum of care and the presence of model systems specialized for patients with spinal cord injury.
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Canada, the United States, and Mexico share disparities in access to care, lack of specialized care in rural areas, and community support.
Overview
Sustaining a spinal cord injury (SCI) is a life-changing neurologic condition that significantly impacts an individual’s life, health, and environment . Worldwide, SCIs have a serious effect on mortality, morbidity, and health care systems’ expenses due to their complexity. SCI frequently results in various motor, sensory, and autonomic deficiencies. This multifaceted condition not only influences patients’ psychological, sexual, and physical well-being but also results in disadvantages from lost productivity in the economic areas .
The term, “post-acute care” encompasses the comprehensive treatments and rehabilitation individuals undergo after receiving immediate medical care following their injury. The provision of timely and optimal rehabilitation of individuals with SCIs remains a challenge for health care systems worldwide . While there are clinical guidelines available, no standardized model of SCI health care delivery exists internationally. There are also challenges in helping individuals with SCI transition from acute to post-acute care, which includes acute rehabilitation and discharge to the community .
In this review, we examine the state of post-acute care for SCIs, including current challenges and opportunities in North America. Canada, the United States, and Mexico have different medical infrastructures influenced by various social, financial, and cultural values. We explore the various rehabilitation programs, resources, models, and delivery of care in each country to understand the stages of post-acute services for SCI individuals.
Mexico
Overview of Health Care in Mexico
Mexico is one of the most populous countries in the world, with 128,455,567 inhabitants in 2023, with about 6,179,890 people with disabilities of different types in Mexico , . There are substantial disparities in access to health care, particularly for people with disabilities. Larger cities have specialized institutions with treatments similar to those offered in high-income countries. In contrast, patients in marginalized communities may not have access to basic health care, which evidence suggests is not adequate for people with disabilities .
Health care in Mexico is provided by government-run public hospitals, private hospitals and clinics, and private physicians. It is characterized by a special combination of coverage mainly based on the employment status of the people. That is, formal workers receive health care through the Instituto Mexicano del Seguro Social (IMSS), while state workers are covered by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), and individuals without formal employment receive management in a third system under the Instituto de Salud para el Bienestar (INSABI). Additionally, other health systems exist for military and navy personnel and oil workers. Since 2020, there has been a fusion of different public health systems, leading to improved free and quality health care for the entire population.
In addition to this division, health care in Mexico is organized into three levels. The first level of care comprises community health centers, mobile care units, health houses, and rural or community general hospitals. Health promotion, disease prevention, and diagnosis and treatment of common illnesses are managed on this level. The second level of care refers to specialized general hospitals, which provide comprehensive specialized services, for example, internal medicine, gynecology, general surgery, and pediatrics. Finally, the third level of care is found in high-specialty hospitals, where diagnosis and medical care for diseases requiring greater technical complexity are offered, for example, oncology, spine and hand surgery, neurology, or SCI medicine.
Post-acute Care Practice for Spinal Cord Injuries
In Mexico, there are 1834 registered physiatrists, which is equivalent to 3370 people with disability per Physical Medicine and Rehabilitation (PM&R)specialist. Currently, no medical specialty is dedicated to the care of individuals with SCI. As a result, these patients are often managed by orthopedic surgeons, neurosurgeons, neurologists, and physiatrists with advanced studies in neurologic rehabilitation.
Due to health care disparities present in Mexico, individuals with SCI face differences in care depending on their location. If an individual sustains an SCI in one of the major cities (ie, Mexico City, Guadalajara, or Monterrey), they are likely to be taken to a hospital equipped with a sufficient multidisciplinary team for their post-acute care. However, in remote communities, patients are taken to the nearest general hospital, where there is often a lack of trained personnel. In addition, definitive SCI management can take days to weeks as patients are referred to the larger city hospitals for care ( Fig. 1 ).
Rehabilitation Continuum of Care in Mexico
The National Institute of Rehabilitation in Mexico City is a third-level institution whose mission is to prevent, diagnose, treat, and rehabilitate disabilities through scientific research, human resource development, and specialized medical care of excellence with a humanistic approach.
Patients with SCI are either directly admitted (15% of cases) or referred from outside hospitals (85%). After they have been medically stabilized, intensive therapies are started in an inpatient setting for 4 to 12 weeks (or more if needed). Integrated sessions with the multidisciplinary team to establish patient-centered goals are carried out weekly. Once rehabilitation goals are attained, the patient is discharged with home adaptations if needed. Currently, basic medical assistance equipment (wheelchairs, seats, diapers, catheters, dressing materials, orthosis, walking aids) is provided by the government, independent of the individual’s income. If the patient needs more equipment (eg, for transfers, adaptations for daily living activities, sexuality), then the patient and their family can acquire it, or it is handmade by the occupational therapists or the patient. Finally, the patient receives home health care to promote social participation and continue preventing, detecting, and managing complications.
Patients are stabilized in other centers in big cities and then discharged home. Only after their discharge, are they referred to inpatient rehabilitation centers—two of which are public, and two are private in the whole country. Once they finish rehabilitation, they continue therapies via home health care or as an outpatient. Patients requiring invasive mechanical ventilation or experiencing metabolic or surgical complications are kept in the acute care hospital until their medical issues resolve, thereby delaying their referral to rehabilitation centers. Most complex cases are medically stabilized but then are discharged home without rehabilitation follow-up.
Marginalized communities hardly have access to a basic health system, which evidently is not adequate for people with disabilities. These patients often migrate to large cities during rehabilitation, return to their communities, and relocate again in case of complications ( Fig. 2 ).
Challenges in the Post-acute Care of Individuals with Spinal Cord Injury
There are many challenges in Mexico related to the care of individuals with SCI. The lack of information, which impedes an objective assessment of the current situation, is undoubtedly the main challenge faced by health care professionals in managing SCI. Other challenges also include limited access to specialized rehabilitation care and services and financial, educational, and community barriers.
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Lack of information about SCI and resources:
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There is a lack of understanding regarding the epidemiology, sequelae, and clinical course of SCIs. The lack of information increases the social, physical, economic, and emotional burden on the patients and families. ,
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There is also a lack of knowledge regarding resources for SCI. For example, an independent organization called the “Administración del Patrimonio de la Beneficencia Pública” donates wheelchairs, seats, or other high-cost equipment; however, it is poorly utilized as a resource, increasing the economic burden on the family.
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Limited physical and timely access to rehabilitation and specialized care:
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While there exists a multicenter, national system called the Sistema Nacional para el Desarrollo Integral de la Familia (DIF), which is responsible for promoting social assistance and providing therapy services to people with disabilities, none of these centers offer specialized care for SCI.
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Comprehensive and specialized rehabilitation services are only available in major cities, which delays or prevents adequate treatment of individuals with SCI.
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There is no SCI model system in Mexico, and the “SCI” diagnosis was only included in the health system disease catalog in 2023.
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Financial barriers:
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The cost of long-term care, assistive devices, and rehabilitation is a significant barrier for individuals and their families. While the government provides durable medical equipment and medications, the resources are often scarce and of poor quality.
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Educational gaps:
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There is a general lack of awareness and education about SCI among health care professionals in medical school, nursing, psychology, and social work programs, and a vast majority of universities still do not include SCI as part of the core curriculum. Only 3 universities offer a rehabilitation course, which was only started in 2010 at Mexico’s largest university.
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There is also a general lack of research on SCI in Mexico, including epidemiology, incidence and prevalence, and social and community barriers to reintegration.
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Social stigma and reintegration:
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While there is little information about stigmas related to SCI, other neurologic and musculoskeletal disabilities have shown the effects of institutional stigma on community reintegration. They have diminished access to social services and educational and employment opportunities, difficulty covering their care, treatment, and therapies and have reduced opportunities to establish peer and romantic relationships. There is also the built environment issue, with a lack of accessibility in urban infrastructure and transportation, making participating in the community difficult for people with disabilities.
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Current and Future Opportunities to Improve Post-acute Care for Individuals with Spinal Cord Injury
Current and future opportunities to improve post-acute care for individuals with SCI in Mexico should focus on multiple strategies that address gaps in education, clinical practice, community outreach, and governmental policies and advocacies.
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National registry:
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SCI national registries exist in many countries, which help identify changes in epidemiology, recovery patterns, complications incidence, and the impact of practice changes. This year, Mexico has started the development of a national registry to gain knowledge about the incidence, prevalence, clinical, and sociodemographic characteristics of Mexican individuals with SCI, though it will still be years before its implementation.
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Education and research:
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Investing in research, innovation, and collaboration with international partners can facilitate knowledge exchange and lead to advancements in SCI treatment, rehabilitation, and assistive technologies.
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A fellowship for neurorehabilitation was also started in 2002, which is a one year training program primarily focused on SCI management and rehabilitation in acquired brain injury.
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Clinical practice:
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Multidisciplinary care teams have proven to reduce inpatient mortality, diminish length of stay, and improve outcomes. Establishing strategically placed multidisciplinary teams with specialized training in the proper management of SCI can expand care and coverage for SCI to more remote areas.
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In addition, implementing telemedicine practices can improve access to health care and assist in tracking patients’ progress and providing timely interventions and adequate follow-up.
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Community rehabilitation programs:
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Establishing community-based rehabilitation programs can enhance accessibility to care and support services for individuals with SCI, fostering a sense of community and peer support. In Mexico, these programs have been implemented by the DIF centers for the most prevalent disabilities, with promising results.
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Policy, advocacy, and awareness campaigns:
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Developing and implementing policies promoting a national SCI care model that prioritizes and advocates for SCI care, rehabilitation, and accessibility can contribute to a more supportive environment for individuals with SCI.
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Clinics care points
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Significant disparities exist in SCI care in Mexico, and an SCI model of care should be developed to ensure that individuals with SCI in marginalized areas receive proper treatment.
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Many strategies to overcome the principal challenges in Mexico have proven beneficial in other countries and conditions and should be incorporated into SCI care.
Canada
Overview of Health Care in Canada
There are 39 million people living in Canada, and around eight million Canadians have one or more disabilities. SCI affects more than 86,000 people in Canada, with around 3675 new cases reported yearly.
The Canadian Healthcare System has public funding from the federal government; however, individual provinces determine its allocation. Provinces like Alberta have a single health care system model, while others have multiple health care systems. Canada does offer universal coverage, known as Medicare, which provides equal access to medical and hospital services. . As the initial point of contact for patients, primary health care providers coordinate their care with specialized in-hospital services, long-term care, and community services.
The care of individuals living with SCI in Canada varies among provinces and rural and urban settings. The absence of standardized SCI care contributes to a lack of uniformity in services, affecting the quality of care. SCI care is often provided by specialists with expertise in neurorehabilitation, as there is no formal fellowship program for SCI medicine in Canada. At some sites, some physiatrists have completed an SCI medicine fellowship in the United States. Long-term SCI follow-ups are often done by family physicians (58%) or by physiatrists (14%).
Post-acute Care Practice for Spinal Cord Injuries
With respect to post-acute SCI care, all main provinces in Canada have specialized inpatient rehabilitation programs. These programs are connected with tertiary and secondary-level trauma care services in urban areas. Provincial SCI organizations exist and are unified by national organizations such as the Spinal Cord Injury Canada and the Praxis Spinal Cord Injury Institute.
Rehabilitation Continuum of Care in Canada
Following severe SCI, patients are hospitalized to level I trauma centers after being transferred from regional trauma centers or local emergency rooms. Once stabilized, they are moved to SCI inpatient rehabilitation units, where the average length of stay is 78 days. Most patients get discharged to the community with home care and/or outpatient therapies and rely on their primary care physician for management. Outpatient rehabilitation programs for SCI usually involve multidisciplinary services, including physiatry, neuro-pulmonary, neurosurgery, neuro-urology, sexology, neuro-psychiatry, physical and occupational therapy, and neurology services ( Fig. 3 ).
There are no costs typically associated with acute care and inpatient rehabilitation. However, community services, such as physical therapy, occupational therapy, or home care are not usually covered throughout all provinces.
Unlike the United States, there is not a formal SCI model of care available in Canada, but there are efforts to build one. As part of these efforts, multiple sites have come together to create best practice guidelines in 2021. One such panel convened to develop the Canadian Spinal Cord Injury Best Practice Guidelines. These guidelines cover several domains, such as individual chronic SCI health conditions, with considerations for ideal SCI Care Systems components. Moreover, there is a national accreditation process for SCI acute care and inpatient rehabilitation, which aims to standardize the quality of care provided to people with SCI in the country.
Challenges in the Post-acute Care of Individuals with Spinal Cord Injury
While Canada offers fully covered acute care and inpatient rehabilitation for individuals with SCI, lack of knowledge and information impacts care quality, especially for rural or low-income populations, contributing to health disparities in education, employment, and social opportunities, particularly among Indigenous populations.
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Allocation of resources:
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Allocation of health care resources is largely dependent on individual provinces. Alberta, for example, has public provincial care delivered via a unified system. However, other provinces may have inadequate support, leading to disparate levels of care. Community services, including physiotherapy, recreational therapy, vocational rehabilitation, and financial support, can be publicly or privately funded, which could mean out-of-pocket expenses for people with SCI.
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Lack of specialized care:
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Residents with SCI in rural areas are more likely to lack specialized care, increasing their reliance on nonspecialized practitioners. This leads to greater disparities in maintaining health, preventing secondary complications, and reducing access to opportunities for education and employment, thereby affecting overall quality of life.
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Diminished access to SCI resources:
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Limits to accessing digital media due to lack of Internet remain a challenge for individuals in low-income housing or rural areas, affecting access to information regarding SCI care.
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Employment opportunities:
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Employment post-SCI represents an economic challenge, with only one-third of Canadians with SCI returning to work after their injury. There are challenges with consistent income to cover basic needs, but there is also the loss of health benefits usually linked to formal employment and psychosocial effects regarding identity and a sense of belonging.
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Psychosocial and community support:
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While most provinces have peer support programs fully dedicated to supporting the psychosocial needs of people with SCI through the WHO Community Based Rehabilitation Framework (SCI-Alberta, SCI-Ontario, SCI-BC), there is a lack of standardization across provinces as they operate independently.
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Indigenous populations:
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The health inequities experienced by Canadians with SCI are more pronounced for Indigenous populations. In the province of Saskatchewan, there is an increased prevalence of trauma in general and a disproportionate amount of Indigenous people in this province experience traumatic SCI. Studies have shown increased length of stays, longer transition to the community due to lack of resources, high rates of secondary complications, hospitalizations, and increased utilization of emergency departments. This is driven by systemic racism, lack of accessible housing and infrastructure, and lack of funding.
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Current and Future Opportunities to Improve Post-acute Care for Individuals with Spinal Cord Injury
Improving post-acute care for SCI in Canada entails exploring and adapting different models of care to improve the experience during transitions through the continuum of care. Opportunities for improvement can be pursued at the clinical, community, and educational levels.
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Clinical Care
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Transitional rehabilitation model:
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Developed in Australia to help close the gap in the delivery of care for individuals with SCI in remote areas, this focuses on the transition from inpatient rehabilitation to the community with the creation of well-supported transitional housing that reduces hospital length of stays and offers education and coordination of care with local care providers. This model of care can benefit those in remote areas through telephone or telemedicine support lines.
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Independent living model:
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The independent living model, also known as self-managed care, removes environmental and social barriers to care access. Individuals with SCI can recruit, select, manage, and reimburse their care providers. This model has been shown to achieve a greater degree of positive outcomes, such as better life satisfaction and better health outcomes.
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Community support
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Vocational rehabilitation:
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There are some efforts led by the Praxis Spinal Cord Institute to call leaders to help with the reintegration of people with SCI into the workforce. Otomanelli and colleagues demonstrated the efficacy of an intense vocational rehabilitation program, modeled after mental health vocational programs, on successful return to work rates.
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Mental health support:
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Providing psychosocial support via online-based interventions on the inpatient and outpatient teams can benefit individuals at all stages, addressing the high levels of depression and anxiety experienced by individuals with SCI.
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Education and research:
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Praxis Spinal Cord Institute and the Spinal Cord Injury Canada are responsible for establishing the Rick Hansen Spinal Cord Injury network in 2004 to collect data on over 8000 participants and design guidelines to help unify SCI care across Canada.
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Special research should be taken into consideration for the geriatric population with SCI. Exploring the availability of resources that prioritize social participation can help these individuals continue to live engaging lives and create a sense of community. Further support and research can also benefit the Indigenous populations with SCI in Canada by pushing for additional housing availability and rural support.
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Clinics care points
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Absence of established protocols and regional health care systems, Canada’s decentralized care for SCI exacerbates disparities in health care by contributing to accessibility discrepancies.
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Continuing to develop transitional rehabilitation in Canada may facilitate multidisciplinary cooperation and bridge the gap between inpatient recovery and community reintegration.
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