Rehabilitation Critical to Successful Surgery Outcomes

A few years into their efforts to ramp up capacity to conduct brain surgeries at Uganda’s Mbarara Regional Referral Hospital, the team at the Duke Global Neurosurgery and Neurology (DGNN) program thought everything was going well. It had helped Ugandan partners launch a neurosurgery training program, and its early graduates were leading complex brain surgeries at the hospital, one of just two in the country that offered neurosurgery.

But there was a problem: When DGNN evaluated medical records of patients who had brain surgery at the hospital, they found many did not fare well in the weeks and months after surgery.

“The big miss was after the surgery. They had complications, because there was no rehabilitation,” said Michael Haglund, M.D., Ph.D., a Duke professor of neurosurgery and global health who leads the DGNN. “We had patients who were experiencing worse outcomes because there were no discharge orders when they left the hospital.”

The finding underscored the importance of post-operative care to patients’ long-term recovery, and it sparked an effort to improve rehabilitation services at the hospital. Several clinicians and researchers involved in the project discussed the work, as well as wider efforts to enhance rehabilitation care across African countries, at a Think Global event hosted by the Duke Global Health Institute on March 26.

“There’s a difference between success in surgery and success in patient outcomes,” said Kira Bullock, DPT, a neurologic physical therapist who leads the rehabilitation partnership for DGNN. “A patient’s experience involves multiple people.”

Rehabilitation care encompasses a range of services and specialists who help patients improve their ability to manage daily functions, such as speaking, walking or eating. While there is overwhelming evidence that rehabilitation is critical to long-term patient success, panelists said it is often not prioritized in health systems that lack the resources or trained staff to offer comprehensive services. 

“Rehabilitation is an unfunded priority in most African nations,” said Etienne Ngeh, DPT, head of the Physiotherapy Department at St. Louis University Institute in Cameroon and coordinator of the African Rehabilitation Network. “While presently we are gaining a bit of political attention, we still have failed to attract adequate financial and human resource allocation.”

Ngeh noted that African countries on average have just two trained physical therapists per 100,000 residents, less than 2 percent of the workforce in European countries, and very few have specialists trained in speech, occupational therapy or other types of rehabilitation services. 

“The need for rehabilitation services cannot be met by the current workforce,” said Atwongyeire Night, a senior physiotherapist at Mbarara Regional Referral Hospital in Uganda. “This makes it very difficult for all patients who could benefit from these services.”

Night noted that only a handful of specialized hospitals in Uganda have rehabilitation specialists on staff, and services are not offered at all in primary care facilities. Even where outpatient services are available, a lack of staffing means that they are often only able to see patients on one or two days a week, leaving many without the support they need to regain function. Without wider access to specialized rehabilitation, many patients may never regain the ability to work or support themselves, putting them at risk of poverty and other health problems, she said. 

At Mbarara, rehabilitation specialists are attempting to compensate for gaps in care by providing more training for caregivers to support patients’ recovery after they leave the hospital, said Herman Kazibwe, Ph.D., a researcher at the Mbarara University of Science and Technology. But Kazibwe emphasized that caregivers are often juggling many responsibilities and may have limited time to devote to rehabilitation. 

“One of the biggest challenges we’ve found is that after discharge, these caregivers are overwhelmed by the amount of roles they have,” he said. “We are trying to help them with some techniques to make things easier.”

But the most important steps to advancing rehabilitation services in low- and middle-income countries will only come with more attention, funding and training, panelists noted. They emphasized that research such as the ongoing work with DGNN can help by continuing to produce strong evidence that rehabilitation services are not a luxury, but an essential part of helping patients recover from trauma. 

“It’s not just the talk,” Ngeh said. “We have to demonstrate our impact as well.”