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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 107-112

COVID-19 pandemic, challenges, and opportunities for neurorehabilitation in Bangladesh: A narrative review

1 Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
2 Department of Neurorehabilitation, East Kent University Hospital, Kent, UK

Date of Submission03-Sep-2020
Date of Decision12-Mar-2021
Date of Acceptance06-Apr-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Moshiur Rahman Khasru
Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka-1000
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPRM-000113

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COVID-19 pandemic challenged the health-care system globally. It intensified the existing burden of rehabilitation of neurological patients. That adverse impact has been more profound in developing countries. This is an exploratory narrative review conducted during May 1 to July 31, 2020 to reflect on the COVID-19 impacts and how to address the challenges of rehabilitation services in Bangladesh. Nonsystematic review methods were used, and to some-extent, the Preferred reporting items for systematic review and meta-analysis statements were followed for this review. Bangladesh is a Lower–Middle-Income Country currently facing multiple challenges with more than 16 million people with disability. The country has world's sixth highest density of population and currently further burdened with the largest refugee camp of the world. It has serious shortage of health-care workers at different levels making COVID-19 preparedness and mitigation difficult. The neurorehabilitation services faced serious challenges. There is no database or registry for stroke, spinal cord injury, or traumatic brain injury. The rehabilitation teamwork is facing daunting challenge at the height of COVID-19. Despite shortage of work force, funding, infrastructures, poor awareness, and difficult professional relationship within the rehabilitation team, neurorehabilitation services are gradually developing in Bangladesh.

Keywords: Bangladesh, COVID-19, lower-middle income country, neurorehabilitation

How to cite this article:
Uddin T, Khasru MR, Islam MT, Shakoor MA, Emran MA, Sakel M. COVID-19 pandemic, challenges, and opportunities for neurorehabilitation in Bangladesh: A narrative review. J Int Soc Phys Rehabil Med 2021;4:107-12

How to cite this URL:
Uddin T, Khasru MR, Islam MT, Shakoor MA, Emran MA, Sakel M. COVID-19 pandemic, challenges, and opportunities for neurorehabilitation in Bangladesh: A narrative review. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2022 Sep 28];4:107-12. Available from: https://www.jisprm.org/text.asp?2021/4/3/107/321980

  Introduction Top

According to the World Bank, Bangladesh, a lower–middle Income Country, is currently facing daunting challenges with about 24 million people living below the poverty line.[1] This country has the sixth highest density (1239/km2) of population in the world which creates additional challenges for COVID-19 preparedness, mitigation, and post-COVID rehabilitation. For example, the maintenance of environmental hygiene and social distancing is nearly impossible.[2] Bangladesh spends only 2.64% of gross domestic product on health, which is the lowest in the South Asia Region.[3] 64.3% of the total cost of health-care services is privately purchased by patients. The money is used mainly for purchasing drugs and medical consultations.[4] Bangladesh is facing serious shortage of health-care workers at all levels with a poor understanding of skill-mix ratio. There are an estimated 08 hospital beds, 3.05 doctors and 1.07 nurses/10,000 populations. Most of them work in urban secondary or tertiary hospitals; whereas 70% people of Bangladesh live in the rural areas.[5] Current estimations made by the Bangladesh Directorate General of Health services, that only 4.2% of the patients in the country receive treatment at licensed health-care facilities.[6] According to disability world report by the World Health Organization (WHO), it is estimated about 15% of the population across the world has some form of disability.[7] It is estimated that Bangladesh has more than 20 million people with disability.[7] Compared to the general population, people with a disability tend to experience poorer health and are at greater risk of developing secondary health problems. In addition, they face barriers in accessing accredited rehabilitation program. There was an estimate that people of the elderly population (>60 years) will grow from 7 to a staggering 65 million by the end of this century. This would increase demands on the health system including neurorehabilitation.[8] Rehabilitation is not considered as a health priority in many countries. There is <10 skilled rehabilitation workers for 1 million people at low and lower-middle-income countries of the world.[9] Neurorehabilitation is a relatively new concept in Bangladesh. Bangladesh has an estimated 16 million persons with disabilities. There are about 133 trained physiatrists, 250 neurologists, and 150 neurosurgeons in BD. Most of them work in the urban areas only.[7],[10] Currently, available therapy professionals in Bangladesh include 2400 physiotherapists, 250 occupational therapists, 260 speech language therapists and 60 orthotist, 1500 rehab nurse, some social workers.[7] Only a fraction of these therapy staff is immediately available to the vast number of patients living in the rural areas. Organized stroke rehabilitation guidelines and stroke registry is yet to be developed. National Institute of Neurosciences hospital has a 100-bedded Stroke Unit with few rehabilitation professionals.[11] Center for the Rehabilitation of the Paralyzed, A Charity organization, admits more than 400 people with spinal cord injury (SCI) each year. However, that team is yet to develop a physiatrist led interdisciplinary rehabilitation services.[7]

The humankind faced an unprecedented challenge with destabilization of the health-care system due to COVID 19 pandemic in 2020. Epidemic started in Wuhan, China and spread to all the continents. At the time of this review paper, 213 countries and region have been affected with severe acute respiratory syndrome coronavirus (SARS-CoV-2) causing COVID 19. As of August 31, 2020, more than 25 million people have been identified as confirmed cases with more than 800 thousands death.[12] Despite having limited facilities for testing SARS-CoV-2 virus, Bangladesh is one of the five countries reporting most COVID-19 cases in Asia with 312996 cases and 4281 deaths with 1.37% case fatality rate and 65.5% recovery rate as on August 31, 2020.[13],[14] The governments have adopted quarantine and restriction for traveling and mobility ('lock-down') as a measure to prevent spread of the virus.[15],[16]

According to the WHO,[17] more than 13% disease burden is due to neurological and psychiatric diseases. The cumulative burden of neurological conditions is more in developing countries probably due to the lack of rehabilitation facilities, awareness, and lack of statutory social care programs. The evidence base for improvement of functional ability and pain through rehabilitation services is now robust.[18],[19] Information about neurological manifestation and neurorehabilitation approaches is limited and about 60% of the available papers related to neurological manifestation in COVID are expert opinions.[20] Hypoxic brain injury and immune-mediated central nervous system (CNS) damage may occur in COVID-19.[21] Neuro-rehabilitation services for non-COVID patients were hampered due to lockdown in both developed and underdeveloped economies.[22] This situation is worse in low-resource settings. Developing countries are struggling to provide acute medical care during the pandemic.[23] Rehabilitation, including neuro-rehabilitation is not getting priority. There is a lack of understanding on the need for neurorehabilitation services during or post-pandemic period. This review is aimed at exploring the current situation of neuro-rehabilitation services at the height of the Pandemic in Bangladesh to which may benefit service planning in other lower-middle income country.

  Materials and Methods Top

Our narrative review is based on an “experts panel” group discussion conducted in between May 1, 2020 and July 31, 2020 in Bangladesh. Ten professional experts including physiatrists participated in providing opinions[24] provided in [Table 1]. Six expert physiatrists conducted the literature review. Nonsystematic review methods were used and to some extent, the PRISMA statements [Figure 1] were followed for finding out the information sources, categorising the studies and searching the studies to improve the review.[25],[26] A consensus was achieved to decide on the inclusion and exclusion criteria. Relevant literatures were searched on the chosen topic using Pub-Med, Google Scholar, Science Direct, and Banglajol with the key words COVID-19, Coronavirus disease, Neurological complications, Neurorehabilitation and challenges.[27] Sources such as Popular Science and WebMD.com were excluded. The other sources such as daily newspapers or conference articles were not included to use as sources for the review. Articles having methods of randomized controlled trials were preferred. Journals containing only abstracts and unpublished articles (e.g., dissertation for any degree) were excluded.[28] The search covered all articles published during the Pandemic, i.e., December 2019 upto July 2020., Bangladesh, The following points were considered when conducting searches: (i) The author and any possible conflict of interests, (ii) The purpose of the article, (iii) The author's hypothesis and whether it is supported or not for neurorehabilitation, (iv) How the literature will contribute to our specific theme, and (v) Whether the opinions expressed by the author (s) are valid. A summative statement by each author was tabulated and was organized based on the topic, knowledge gap, logic, the problem with plausible solution. All the data were transcribed manually and categorized into themes.
Table 1: Professional experts provided neurorehabilitation-related opinions

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Figure 1: PRISMA flow diagram for articles selections

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COVID-19 impacts of rehabilitation and neurorehabilitation services

At the onset of lockdown, most of the government and private hospitals reduced admission of nonemergency and non-COVID patients including neurological disorders.[29] A number of private hospitals shut down, all services. As a result, neurodisability worsened for people with neurological conditions. Patients were also reluctant to attend to the hospitals due to fear of contracting the virus. According to Anadolu agency, 881 (11% of all cases) health workers including physicians, rehabilitation health professionals, nurses, technologist, and others were infected in Bangladesh as of May 1, 2020.[30] About 100 doctors died and many of the health care professionals including rehabilitation team members contracted coronavirus, which made the situation worse.[31] Non-COVID chronic care patients with stroke, SCI, brain injury, and other neurological disorders have lost previously gained functional abilities and developed complications such as pressure ulcers, bowel, and bladder dysfunctions.[29] The neurological complications of COVID-19 included stroke (62%), altered mental state (31%), and CNS vasculitis (1%).[32] Among all strokes, ischemic and hemorrhagic stroke was 74% and 12%, respectively.[32] Other neurological disorders associated with COVID-19 included headache, Guillain-Barre Syndrome, and encephalitis.[33] Hussain et al. described the loss of work-related income of persons with SCI in the Bangladeshi population.[34] This study found that one-third of the respondent's family members were living above extreme poverty line of US Dollar 37.50/month per individual before the SCI, whereas 91% of the respondent's family members were living below the extreme poverty level after the injury.[34] It is assumed that the situation deteriorated during the pandemic. According to Rahman et al., about 70% of the people with SCI live in the rural areas of Bangladesh,[30] whereas trained rehabilitation professionals work in urban areas only.[35]

Challenges of neurorehabilitation in Bangladesh

Universal health coverage of the WHO is defined as ensuring that all people have access to the required health services including prevention, promotion, treatment, rehabilitation, and palliation of sufficient quality to be effective without exposing the user the financial hardship.[21] Bangladesh is facing a growing burden of noncommunicable diseases despite some achievements in Millennium Development Goal (MDG) targets. Neurorehabilitation service deficit include shortage of rehabilitation professionals, poor awareness about team functioning, and lack of early referrals from acute medical teams.[7],[9],[10]

The population in Bangladesh is aging with increasing life expectancy. Hence, people with chronic conditions are rising. The WHO estimated that there would be a need of double fold for “Rehabilitation key in the 21st century”.[36] Pandemic had made the situation worse. COVID-19 national strategic planning did not include rehabilitation experts.[29] Specific challenges for neurorehabilitation services were identified at the height of COVID-19 pandemic. These include (a) poor inter-specialty relationship among neurologists and rehabilitation physicians, (b) lack of adequate number of trained rehabilitation team workforce and team functioning, (c) inadequate health education for rehabilitation health-care workers for patient safety procedures, d) deployment of physician specialists and rehabilitation professionals in COVID care[29] (e) lack of dedicated beds for stroke, SCI, brain injury and other neurological disorders, (f) poor internet capability and capacity to support telemedicine (g) inadequate government supports for trainee placements, infrastructure developments, strategic collaboration, research and development, (h) disrupted educational activities, training and research, and (i) nonavailability of affordable assistive devices.[29]

However, Bangladesh tried to overcome to the challenges during this pandemic. Hospital admission to rehabilitation facilities were started quickly albeit restricted to postacute cases of stroke, SCI, brain injury, Guillain–Barre Syndrome. Consultations for referral cases were made through rationing of the specialists. Telemedicine was introduced quickly and Rehabilitation professionals were persuaded to implement that rapidly. Accessibility and awareness raising campaign to public used various social media such as Messenger, WhatsApp, FaceTime, Tango, Imo, and Zoom. Academic activities for the residents were resumed online through Zoom. Video demonstration regarding rehabilitation and therapeutic exercises was promoted for the patients in need.[29]

Opportunities of neurorehabilitation in Bangladesh

Recently, Bangladesh has achieved gains in population health, achieving the MDG 4 target of reducing under-five child mortality and improving other key indicators such as maternal mortality, immunization coverage, and survival rates from some infectious diseases.[37] Several national and international guidelines and standards of rehabilitation care for neurological disease were documented in the literature.[38] Disease-specific rehabilitation guidelines were developed by many developed nations such as (i) United Kingdom, (ii) the Netherlands, (iii) Sweden, (iv) Scotland, (v) Estonia, (vi), South Africa, (vii) Australia, (viii) Singapore, (ix) United States, and (x) New Zealand. These guidelines focused on service delivery and outcome measures were considered for effective neurorehabilitation.[38]

Although neurorehabilitation is a newer concept in BD, rehabilitation medicine in Bangladesh is gaining popularity among younger clinicians and started to receive support at national, regional, and international arena.[7] Younger physiatrists show greater interests to work with the neurologists in a collaborative team ethos. There have been gradual improvements in collaborative attitude within multi-disciplinary rehabilitation professionals such as physiotherapists, occupational therapists, medical social workers, speech and language therapists, and others. Newly introduced goal setting through multidisciplinary rehabilitation team meetings at the University PMR department along with the collaborations at national and international institutes are the promising steps.[11] PMR Bangladesh keep an active membership with Asia SCI Network, Asia Oceania Society of Neurorehabilitation, and World Federation of Neurorehabilitation. PMR members are contributing to these reputable organizations with knowledge transfer in both directions. Very recently, a common platform was established known as “Bangladesh Society for Neuro Rehabilitation (BSNR).” BSNR consists of neurologists, neurosurgeons, physiatrists, and allied health professionals of Bangladesh and organized its first international seminar in December 2019.[29] Recently, introduced interventions such as Constraint-Induced Movement Therapy in patients with stroke, weight-supported treadmill walking training for both lower limbs weakness, electromyography-biofeedback including other virtual feedback were introduced in some of the rehabilitation centers. Academic and training programs were updated recently with expectations of developing more quality physiatrists and neurologists to face the unmet rehabilitation challenges.[7]

  Conclusion Top

COVID-19 in Bangladesh overwhelmed the health sector and it impacted the rehabilitation services severely. However, this adversity has created new opportunities by allowing clinicians to be more aware and reflective. That insight may help persuade the strategic leadership to develop neurorehabilitation service in Bangladesh as international Standards and Guidelines are becoming available more due to the webinars.

Author contribution in the manuscript

Author TU conceived the idea of the project. Authors TU, MRK, AE and MTI were involved in all aspects of the review process and development of the manuscript. TU, MAS, MRK and SM coordination and prepared the final draft of the manuscript. MRK, MAS, and SM provided valuable input into design and critically reviewed the manuscript. All the authors read and approved the final manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1]

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