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

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