Neurorehabilitation as a Cornerstone of the Brain Health Plan

Abstract

Background: Neurorehabilitation plays a central role in restoring and maintaining brain health across lifespan. However, its contribution is often underestimated in public health policies. Aim: This paper aims to highlight the importance of neurorehabilitation within the brain health frameworks, advocating for its full integration into global and national health strategies. Main content: We discuss the unique characteristics of neurorehabilitation, including its interdisciplinary structure, long-term scope and role in prevention. We underline how the ICF model provides a bridge between clinical practice and public health policy. Key prevention strategies and the potential of digital technologies are also examined. Conclusion: A stronger integration of neurorehabilitation into brain health policy can yield individual and socio-economic benefits. We call for strategic political and structural efforts to expand its availability and recognition.

1. Introduction

The aim of this paper is to critically discuss the significant potential of neurorehabilitation in supporting brain health initiatives. It provides a structured perspective that bridges clinical practice, public health and policy. We begin by outlining the characteristics of neurorehabilitation, followed by its alignment within the ICF framework. We then explore its role in prevention, future integration strategies and policy implications.

The World Health Organization defines rehabilitation as “a process aimed at enabling people with disabilities to achieve and maintain optimal physical, sensory, intellectual, psychological, and social abilities and functions” [1]. Rehabilitation constitutes an essential health service component for individuals presenting with acute or chronic health conditions, impairments, or injuries that compromise functional capacity. As such, rehabilitation services should be universally accessible to all individuals requiring intervention. However, on a global scale, there remains a substantial gap between the need for rehabilitation and the availability of services. In low- and middle-income countries, more than 50% of people do not receive the rehabilitation services they require [2].

Rehabilitation functions as a complementary, long-term intervention to other therapeutic modalities such as medical and surgical treatments, thereby facilitating recovery processes and optimizing clinical outcomes. Systematic evidence demonstrates that when rehabilitation is integrated within comprehensive health systems, it significantly reduces morbidity and mortality [3,4,5,6,7], enhances functional capacity and performance outcomes [8,9,10,11,12], extends independent living duration [7,13,14], and demonstrates cost-effectiveness across healthcare settings [15,16,17,18].

An indication for neurological rehabilitation (neurorehabilitation) is made for patients with neurological diseases yielding functionally relevant symptoms and rehabilitation potential. In the majority of cases, treatment is given in close succession to acute treatment (e.g., following an acute cerebrovascular event, a traumatic brain injury, or a neurosurgical procedure), or it may be administered once or repeatedly during the course of chronic neurological conditions, such as multiple sclerosis or Parkinson’s disease. Possible delivery models of neurorehabilitation are inpatient, outpatient, at home, in the community, eldercare rehabilitation, and telerehabilitation [14].

2. Characteristics of Neurorehabilitation

Neurorehabilitation constitutes a subspecialty within rehabilitative medicine, distinguished from other rehabilitative disciplines by several unique clinical and methodological characteristics.

2.1. Multidimensional Impairment Profile and Interdisciplinary Management

Neurological pathologies typically manifest as complex, multisystem disorders affecting several functional domains simultaneously, rather than presenting with isolated symptomatology. This multidimensional deficit pattern compromises the patient’s global functional integrity, necessitating comprehensive, interdisciplinary therapeutic interventions. The evidence-based management approach requires a multidisciplinary team comprising neurologists, physiotherapists, occupational therapists, speech-language pathologists, neuropsychologists, and medical social workers. This collaborative framework operates within a patient-centered care paradigm, acknowledging the heterogeneity of therapeutic objectives and the variability in available healthcare resources across different clinical settings.

2.2. Heterogeneous Disease Severity Spectrum

Neurorehabilitation encompasses an extensive continuum of disease severity, ranging from focal neurological deficits, such as isolated speech disorders, to severe, multisystem impairments requiring intensive medical supervision. For patients with profound neurological compromise and complex medical needs, specialized early neurological rehabilitation units have been established to provide concurrent intensive medical management and rehabilitative interventions.

2.3. Extended Temporal Treatment Requirements

The chronic and progressive nature of many neurological conditions necessitates prolonged rehabilitative interventions, often extending over months to years. To accommodate these extended therapeutic requirements, healthcare systems have developed specialized long-term rehabilitation infrastructure, predominantly delivered through outpatient care to optimize use of resources and improve patient accessibility. However, most of the current models for outpatient neurorehabilitation remain limited in terms of accessibility, quality and coordination, also in more sophisticated healthcare systems. In Switzerland, a large proportion of patients suffer from a more than 80% drop in therapy dose at the transition from inpatient to outpatient neurorehabilitation [19].

2.4. Evidence-Based Therapeutic Principles and Technological Integration

Contemporary neurorehabilitation is based on three fundamental evidence-based therapeutic principles: early intervention initiation, high-intensity therapeutic delivery, and task-specific functional training. These principles are operationalized through the systematic integration of advanced technological platforms, including robotic-assisted therapy systems and computer-mediated interventions. In sensorimotor rehabilitation of severely impaired patients, robotic-assisted therapeutic modalities enable the delivery of high-intensity, repetitive training protocols that exceed the capacity of conventional therapy approaches, thereby optimizing therapeutic outcomes [20,21].

Neurorehabilitation increasingly incorporates innovative therapeutic modalities, including immersive virtual reality environments, augmented reality applications, and non-invasive neuromodulatory techniques [22,23]. Neuromodulatory interventions encompass transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), neurofeedback protocols, and non-invasive vagus nerve stimulation. These methodologies are designed to augment neuroplasticity mechanisms and facilitate functional recovery through targeted neural circuit modulation. Consequently, neurorehabilitation promotes the clinical translation and integration of emerging neurotechnologies into standard clinical practice.

2.5. Therapeutic Objectives and Clinical Outcomes Framework

The primary therapeutic strategy prioritizes the restoration of impaired neurological functions, including cognitive, motor, and sensory domains. When complete functional recovery is not achievable—as frequently occurs in clinical practice—compensatory strategies and environmental modifications are systematically implemented to maximize functional independence and community participation. These interventions may include implementing assistive technology, modifying the environment (such as home accessibility adaptations), and providing adaptive equipment.

Concurrent therapeutic interventions focus on structured caregiver education and skill development programs to support sustainable care provision while preventing caregiver burden and burnout syndrome. The ultimate therapeutic objective encompasses the facilitation of psychological adaptation and acceptance of altered functional capacity among both patients and their support systems, proving to them that a meaningful quality of life can be maintained despite the persistent neurological impairments.

3. Integration of the ICF Model in Rehabilitation Practice and Brain Health Strategy

The International Classification of Functioning, Disability and Health (ICF) represents a comprehensive framework developed by the World Health Organization and published in 2001 [24,25]. This classification system employs a biopsychosocial model to systematically describe individual health conditions and their multidimensional impacts on daily functioning (Figure 1). The ICF framework demonstrates relevance in rehabilitation contexts, where complex interactions between physical, psychological, and social determinants frequently influence therapeutic outcomes [26].

3.1. Application in Neurorehabilitation

Within neurorehabilitation practice, the ICF model is of fundamental importance by enabling healthcare professionals to conduct holistic assessments of the impact of neurological conditions and the treatment objectives. The framework promotes interdisciplinary collaboration that prioritizes not only the patient’s limitations but also social participation opportunities and individualized patient requirements [27]. Through ICF model implementation, therapeutic objectives can be more precisely defined, facilitating the development of individually tailored rehabilitation protocols. This approach supports person-centered care models wherein interventions are systematically designed around individual goals, environmental contexts, and life circumstances. The ICF provides standardized terminology for interdisciplinary teams, thereby enhancing communication and coordination across medical, therapeutic, and social service domains. Furthermore, the ICF framework supports a comprehensive outcome measurement and evaluation encompassing not only changes in clinical assessments but also the patient’s capacity for meaningful activity and participation in everyday life.

3.2. ICF Model Integration with Brain Health and Neurorehabilitation

The World Health Organization’s brain health definition emphasizes that brain health transcends mere disease absence, representing instead a dynamic state supporting overall well-being, productivity, and quality of life throughout the lifespan [28]. The definition reflects the multidimensional nature of brain health, encompassing cognitive functions, motor control, sensory processing, emotional regulation, and social integration [29].

Both brain health promotion and neurorehabilitation emphasize functional optimization as core objectives. Brain health correlates with individual capacity for productive engagement and stress management, while neurorehabilitation focuses on improving function among individuals with neurological disorders through evidence-based therapeutic interventions. This shared focus on functionality is reflected in the convergent goal of quality-of-life improvement across both paradigms.

The ICF model demonstrates particular suitability for brain health characterization, as it captures multifaceted health and functioning aspects while integrating prevention, early detection, and intervention strategies. The framework considers environmental influences and personal attitudes on well-being, enabling comprehensive understanding of brain health that extends beyond diagnostic parameters to focus on individual quality of life outcomes.

3.3. Scientific Integration and Policy Implications

The ICF model provides a scientifically grounded, integrative framework that bridges neurological rehabilitation objectives with broader brain health initiative visions. Its systematic adoption ensures interdisciplinary coherence and facilitates shared understanding crucial for developing effective policy, standardizing clinical practice, and advancing research in brain health domains.

4. Prevention Strategies in Neurological Rehabilitation

Prevention constitutes a fundamental component of both neurological rehabilitation and comprehensive brain health strategies. Neurological disorders represent the primary cause of disability and the second leading cause of mortality worldwide [30,31]. Demographic changes resulting from an increased prevalence of chronic and neurodegenerative conditions emerge as principal contributing factors to this epidemiological burden. Notably, many neurological diseases and their associated chronicity could be prevented through modification of lifestyle and environmental risk factors.

Current epidemiological evidence demonstrates substantial preventable disease burden: 45% of dementia cases, 50% of cerebrovascular accidents, and up to 84% of stroke-related disability-adjusted life years (DALYs) could potentially be avoided through targeted preventive interventions [32,33,34].

4.1. Hierarchical Prevention Framework

Prevention strategies in neurorehabilitation are systematically categorized into three distinct levels [35,36]:

(1)

Primary prevention aims to prevent disease onset before pathological processes develop, thereby achieving incidence reduction. This approach particularly targets modifiable risk factors through promotion of healthy, neuroprotective lifestyle behaviors. Primary prevention strategies focus on population-level interventions that address established risk factors for neurological conditions.

(2)

Secondary prevention encompasses early disease detection and prompt therapeutic intervention to favorably influence the disease trajectory and hinder progression. This approach emphasizes diagnostic screening protocols and timely treatment initiation to minimize long-term functional consequences and disability development.

(3)

Tertiary prevention seeks to prevent complications of established neurological conditions, alleviate symptom burden, and maintain quality of life and functional independence. Rehabilitation interventions exemplify tertiary prevention strategies, including physiotherapy and occupational therapy, designed to prevent complications such as falls, spasticity development, or contracture formation.

4.2. Rehabilitation as Primary Prevention Platform

Neurorehabilitation settings provide unique opportunities for primary prevention implementation. Adherence to neuroprotective lifestyle modifications represents both the most critical requirement for an effective brain health initiative and its greatest implementation challenge. The extended treatment duration characteristic of neurological rehabilitation, combined with intensive multidisciplinary team engagement, creates optimal conditions for lifestyle modification initiation and maintenance to support long-term brain health preservation.

This integration of prevention strategies across the rehabilitation continuum demonstrates the potential for neurorehabilitation to function not only as a therapeutic intervention but also as a platform for comprehensive brain health promotion and disease prevention.

4.3. Preventive Measures in Neurorehabilitation: A Brain Health Perspective

Neurorehabilitation involves numerous preventive measures that are fundamental to maintaining and promoting brain health. The following comprehensive approach addresses both immediate rehabilitation needs and long-term health outcomes through evidence-based interventions.

4.3.1. Cerebrovascular Disease Management

Cerebrovascular diseases constitute the most prevalent diagnosis in inpatient neurorehabilitation settings. Research consistently demonstrates that implementing inpatient rehabilitation following stroke significantly reduces both mortality rates and the likelihood of requiring long-term care [37,38].

While acute care hospitals typically establish initial pharmacological secondary prevention strategies, rehabilitation clinics play a crucial role in continuing and refining these protocols. During rehabilitation, new clinical findings may emerge that necessitate therapeutic adjustments, such as newly diagnosed atrial fibrillation detected through long-term ECG monitoring or abnormal laboratory results. This creates valuable opportunities for rehabilitation teams to collaborate with acute care providers in reviewing and optimizing secondary prevention strategies based on ongoing diagnostic assessments. Inpatient rehabilitation proves particularly effective in managing key cerebrovascular risk factors, including arterial hypertension, diabetes mellitus, and dyslipidemia. These conditions require sustained monitoring and individualized therapy, making the extended inpatient rehabilitation setting ideal for optimization. The comprehensive approach combines medication management, dietary interventions, and smoking cessation programs with educational initiatives designed to enhance long-term treatment compliance and adherence.

Importantly, vascular risk factor evaluation in neurorehabilitation often extends beyond stroke patients, regardless of the patient’s primary diagnosis. For these patients, rehabilitation provides significant primary prevention benefits.

4.3.2. Physical Activity and Motor Function Restoration

Regular physical activity ranks among the most critical modifiable factors for brain health [39]. Physical activity benefits extend beyond motor-coordinative functions to include improvements in cognitive performance, emotional well-being, and overall health-related quality of life [40,41,42]. Approximately 90% of neurorehabilitation inpatients present with motor deficits. Beyond paresis, additional neurological symptoms such as ataxia, neglect, general muscle weakness, or visual disturbances can further compromise motor abilities. Given that most patients prioritize mobility restoration as their primary rehabilitation goal, motor therapies delivered through physiotherapy, occupational therapy, robotics, and sports therapy form the cornerstone of neurological rehabilitation.

Achieving optimal mobility restoration during inpatient rehabilitation establishes the foundation not only for independent living but also for sustained physical activity engagement post-discharge. Alongside motor skill restitution, compensation strategies through assistive devices play an equally important role in mobility restoration.

A fundamental function of neurological rehabilitation involves enabling and promoting individualized physical activity programs tailored to each patient’s health status. Since long-term health benefits depend on continued regular physical activity post-rehabilitation, treatment teams must collaborate with patients during inpatient care to develop practical strategies that will integrate physical activity into their daily routine.

4.3.3. Nutritional Interventions

Neurological conditions often require immediate dietary modifications, while long-term healthy nutrition remains a cornerstone of brain health [43]. Recognizing this dual need, nutritional counseling and dietary adjustments should be integral components of neurological rehabilitation programs. The nutritional approach should address both immediate adaptations required by the current neurological condition and provide sustainable frameworks for maintaining a healthy diet following rehabilitation completion.

4.3.4. Sleep Health Management

Sleep disturbances affect approximately one-third of neurological rehabilitation patients, representing a significant but often overlooked health concern. Common sleep-related issues include insomnia, parasomnias, and sleep-related breathing disorders [44].

Sleep problems may be pre-existing conditions, consequences of the neurological disorder itself, or results of hospital-specific factors such as disrupted sleep–wake cycles, medication effects, or environmental disturbances from lighting or noise. Adequate sleep quality proves especially crucial during rehabilitation, as sleep contributes to physical well-being, mental health, and provides the foundation for optimal performance and learning capabilities essential for successful rehabilitation outcomes [45,46]. Despite sleep disorders representing important brain health factors, they frequently receive insufficient attention during neurological rehabilitation. However, sleep medicine can be effectively integrated into rehabilitation programs with manageable resource requirements. Beyond screening protocols, various diagnostic methods are now available for inpatient settings, including actigraphy, pulse oximetry, and simplified polysomnography. Following diagnosis, rehabilitation programs can initiate evidence-based treatments. For insomnia, the most common sleep disorder, this involves implementing cognitive behavioral therapy rather than relying primarily on sedative medications.

4.3.5. Mental Health and Psychological Support

Patients with neurological conditions frequently experience comorbid mental health challenges. Most neurological disorders requiring rehabilitation are associated with elevated risk of depression. Among stroke patients, at least one-third develop treatable depression, typically manifesting during the subacute rehabilitation phase [47,48]. Depression affects not only mental well-being but also negatively impacts rehabilitation outcomes and subsequent social reintegration. Neurological rehabilitation facilities possess the multidisciplinary resources necessary for comprehensive therapeutic approaches, incorporating pharmacological interventions, psychotherapy, and social support strategies. Standard rehabilitation interventions, including physical activity programs, social integration initiatives, pain management, and cognitive rehabilitation, also contribute significantly to improving mental health outcomes.

4.3.6. Cognitive and Social Integration

Cognitive activity and social interaction represent crucial elements of brain health [29]. Adequate cognitive function serves as a prerequisite for successful socio-professional reintegration. More than one-third of patients with stroke and multiple sclerosis experience cognitive deficits requiring specialized neurorehabilitation. Cognitive rehabilitation programs aim to enhance abilities such as memory, attention, concentration, and problem-solving skills through multidisciplinary therapeutic approaches.

Group therapies provide valuable and efficient opportunities for patients to interact with others facing similar challenges, fostering social exchange and mutual support while preventing social isolation. Neuropsychological interventions can promote adaptive coping strategies, including problem-focused actions, information seeking, social support utilization, and lifestyle modifications. Occupational therapy is useful for improving activities of daily living that depend on preserved cognition. Unfortunately, cognitive and, in particular, neuropsychological outpatient rehabilitation often suffers from insufficient resources, both in terms of reimbursement and skilled personnel, limiting the accessibility and dose of interventions, in a phase of recovery where fine-grained cognitive deficits become increasingly relevant for successful social and professional participation.

One of the key missions of rehabilitation is to promote the post-discharge social environment reintegration. This process occurs with the support of social services and considers pre-morbid social circumstances, actively involving partners, families, and broader social networks.

5. Future Directions and Technological Integration

While acute neurological treatment and inpatient neurorehabilitation operate under well-defined treatment protocols and quality standards, continuation of post-discharge care often lacks standardization and depends heavily on variables such as the amount of outpatient support and accessibility of therapy. Most healthcare systems do not provide specialized outpatient follow-up care through rehabilitation facilities, and funding for such services remains limited.

As a result, the vast majority of outpatients only benefit from about 10% of the neurorehabilitation dose advocated by international evidence-based recommendations [49].

However, sustainable brain health improvement requires long-term implementation of adequate health-promoting measures. To achieve this objective, both neurological rehabilitation and brain health initiatives should leverage emerging technologies, including digital solutions, artificial intelligence, and social media platforms.

Digital health applications, particularly mobile health technologies such as smartphone applications and wearable devices, can support rehabilitation programs and promote lifestyle modifications through motivational elements, such as encouraging regular physical activity. Robot-assisted and sensor-based rehabilitation techniques show particular promise in improving brain health in the outpatient phase, including home-based rehabilitation, community programs, and elderly care settings. Modern technologies, including digital health applications and telerehabilitation platforms, will make interactive and multimodal care continuation by rehabilitation clinics technically feasible. Extended reality has the potential of bringing complex neurorehabilitation approaches to the home of patients, increasing the dose and intensity of treatment. Health-related data, encompassing movement patterns, cognition, nutrition, cardiovascular parameters, and sleep metrics, can be continuously collected and utilized for health assessment and treatment planning refinement.

This approach would enable long-term evaluation of the rehabilitation progress and facilitate meaningful treatment continuation and prevention strategies extending beyond inpatient neurorehabilitation. Once established, such digital or hybrid rehabilitation and health programs could be made accessible to a broader population, including regular health information provision and telemedical or teletherapeutic interactive services for individuals or specific population groups.

Rehabilitation facilities could leverage their extensive brain health expertise to evolve into comprehensive Brain Health Centers. However, significant challenges remain regarding financing mechanisms and human resource development for these expanded services.

6. Conclusions

Neurological rehabilitation holds a pivotal position in promoting brain health through its multidisciplinary expertise and therapeutic capabilities. Rather than simply restoring lost abilities, rehabilitation empowers individuals to achieve fulfilling lives despite neurological challenges. By framing neurorehabilitation as a strategic pillar of brain health policy, we emphasize its underutilized role in long-term prevention, cost-effective care and digital health integration. This perspective provides policy-relevant insights and supports the call for systemic change.

The objectives of brain health and neurorehabilitation demonstrate remarkable alignment. Neurorehabilitation specialists possess extensive knowledge in improving brain function, with prevention naturally embedded within the rehabilitation process. Patients show peak receptivity to educational interventions during recovery, motivated by the desire to prevent future occurrences. The inpatient setting provides optimal conditions for comprehensive patient education on proactive health measures. However, the availability of adequate neurorehabilitation post-discharge is heavily limited and requires immediate attention from policy makers and stakeholders alike.

The objective of a continuum of brain healthcare not only applies to the different phases of a neurological disease or treatment, but also conceptually. Brain health and disease should be viewed as a continuum rather than discrete states; also, individuals without brain conditions can benefit from holistic approaches. The brain health framework expands traditional prevention beyond cardiovascular risk factors to include sleep optimization and the promotion of social integration and participation.

Brain health promotion should be recognized as an intrinsic component of neurorehabilitation practice. Conversely, the distinctive, holistic methodologies of neurorehabilitation can advance brain health initiatives across broader populations. Thus, neurorehabilitation is positioned as both a beneficiary of brain health principles and a catalyst for their implementation in comprehensive neurological care and prevention strategies.