Most patients hospitalized for stroke or traumatic brain injury (TBI) are sent home without specialized inpatient rehabilitation care, despite evidence that intensive therapy significantly improves recovery outcomes. A new study published in Neurology Open Access found that access to these critical rehabilitation services remains inconsistent and may not be equitable across different patient populations.

What Does the Research Show About Rehabilitation Access?

Researchers from TIRR Memorial Hermann in Houston analyzed hospital discharge data from five states (Florida, Georgia, Maryland, New York, and Washington) between 2016 and 2019, tracking the outcomes of more than 444,000 patients with stroke, traumatic brain injury, or traumatic spinal cord injury (TSCI). The findings were striking: only 21.8% of stroke patients and 13.7% of TBI patients were discharged to inpatient rehabilitation facilities (IRFs), while 53.5% of all patients went directly home.

For comparison, patients with spinal cord injuries fared better, with 43.5% receiving inpatient rehabilitation care. The researchers found that these discharge patterns remained stable over the four-year study period, suggesting a systemic issue rather than a temporary trend.

"Receiving intensive rehabilitation after stroke, traumatic brain injury, and spinal cord injury can improve a person's recovery, yet access to inpatient rehabilitation care remains inconsistent and may not be equitable," said Farhaad S. Vahidy, M.B.B.S., Ph.D., coauthor of the study at TIRR Memorial Hermann.

Farhaad S. Vahidy, M.B.B.S., Ph.D., TIRR Memorial Hermann

Who Is Most Likely to Be Denied Rehabilitation Care?

The study revealed significant disparities in who receives rehabilitation services. Certain patient groups were substantially less likely to be discharged to inpatient rehabilitation facilities compared to others:

• Insurance Type: Patients with private insurance were 35% less likely to receive institutional rehabilitation compared to those on Medicare, suggesting that insurance coverage decisions may be limiting access to care.
• Income Level: Patients living in the highest-income neighborhoods were 12% less likely to be discharged to rehabilitation facilities than those in the lowest-income areas, a counterintuitive finding that warrants further investigation.
• Race and Ethnicity: Non-Hispanic Black patients were 29% more likely to be discharged home rather than to institutional rehabilitation, indicating potential disparities in care recommendations or access.
• Age and Sex: Older patients and women were more likely to receive institutional rehabilitation, though this may reflect differences in injury severity or comorbid conditions rather than equitable care allocation.

When researchers compared inpatient rehabilitation facilities to skilled nursing facilities (SNFs), another pattern emerged: non-Hispanic Black patients were less likely to be sent to the more intensive IRF setting, while those with private insurance and higher area income were more likely to access IRFs over SNFs.

A Gender Gap in Brain Injury Care

A separate Ontario study published in the Canadian Medical Association Journal uncovered another troubling disparity: women with traumatic brain injury are 26% less likely to receive trauma care than men, even when researchers accounted for age, underlying health conditions, and injury severity.

The study analyzed more than 55,000 adult patients admitted to Ontario hospitals for TBI between 2009 and 2020. Roughly 25% of women were admitted to specialized trauma centers, compared to nearly 40% of men. This gap persisted even when comparing patients with the most severe brain injuries.

Trauma centers offer dedicated trauma bays, advanced diagnostic tools, and specialized surgeons available around the clock to manage life-threatening injuries. Early access to these facilities can be transformative for recovery outcomes.

"Accessing trauma care quickly after a TBI really can be life-changing," said trauma surgeon Dr. Najma Ahmed, head of surgery at St. Michael's Hospital in Toronto.

Dr. Najma Ahmed, Head of Surgery, St. Michael's Hospital

Researchers and clinicians point to potential unconscious bias in emergency department triage settings. Women tend to experience falls from standing, which may be interpreted as less severe than motor vehicle crashes more commonly seen in male patients. Additionally, older women's symptoms like confusion, nausea, or difficulty finding words may be under-appreciated during rapid triage assessments.

Why Does Early Rehabilitation Matter?

Brain injury encompasses a wide spectrum of conditions, from mild concussions to severe traumatic damage. The Glasgow Coma Scale, a standardized assessment tool, classifies injuries by severity based on eye opening, verbal response, and motor response, with scores ranging from 3 to 15. Mild TBI (scores 13-15) may cause brief headaches and concentration problems, while severe injuries (scores 8 or below) can result in prolonged unconsciousness, permanent cognitive and physical impairment, or death.

Symptoms vary widely depending on injury severity and affected brain regions. Mild TBI typically produces transient headache, dizziness, brief disorientation, nausea, and fatigue, with most symptoms resolving within days to weeks. Moderate to severe TBI can cause prolonged unconsciousness, post-traumatic amnesia (confusion and inability to form new memories), weakness or speech disturbance, and significant behavioral changes.

Cognitive difficulties are among the most persistent long-term consequences of significant brain injury. Impaired memory, slowed processing speed, difficulty with attention and planning, and emotional dysregulation can profoundly affect quality of life and the ability to return to work or independent living. Structured rehabilitation programs help address these challenges through specialized therapy and support.

How to Reduce Your Risk of Brain Injury

• Use Protective Equipment: Wear helmets during cycling, contact sports, and motorcycling. Helmets provide meaningful protection against head trauma from falls and collisions.
• Practice Vehicle Safety: Always use seatbelts and ensure children use age-appropriate car seats. Seatbelt use significantly reduces traumatic brain injury risk from road traffic collisions.
• Prevent Falls in Older Adults: Implement fall prevention programs that include home hazard modification, strength and balance training, and regular medication review, since falls are the leading cause of TBI in older populations.
• Avoid Alcohol and Substance Intoxication: These are among the most modifiable risk factors for brain injury. Intoxication impairs judgment and coordination, increasing injury likelihood and worsening neurological outcomes if injury occurs.
• Use Proper Concussion Protocols: Participate in high-contact sports only with adequate protective equipment and evidence-based concussion management protocols to reduce repeat injury risk.

Prior history of TBI is itself an independent risk factor for future injury. Structural and physiological changes from an initial injury reduce the brain's resilience to subsequent trauma, and repeated impacts before full recovery carry a cumulative burden.

What Happens When Rehabilitation Access Is Limited?

The real-world consequences of limited rehabilitation access are significant. Francene Gillis, a high school English teacher from Nova Scotia, slipped on black ice in winter 2016 and was diagnosed with a concussion and whiplash at her local hospital. She was sent home to rest, but a week later, nausea and vomiting sent her back to the hospital for admission. However, she was not transferred to a trauma center, partly due to her rural location, and did not see a specialist for months after her injury.

Gillis struggled with long-lasting symptoms including severe balance issues, speech impairment, and intense brain fog that cut short her careers as both a teacher and columnist. Her experience illustrates how lack of prompt access to specialized care can have ripple effects on long-term recovery and quality of life.

Experts emphasize that while the disparities identified in recent research are concerning, the next step is understanding the underlying causes. Whether differences in outcomes result from unequal access to trauma care or other factors requires further investigation. What is clear is that the gap in rehabilitation access deserves immediate attention from healthcare systems and policymakers.