Spaulding Rehabilitation

Patients with spinal cord injury, traumatic brain injury, stroke, and amputation enter Spaulding Rehabilitation's inpatient and outpatient programs to rebuild function when acute hospitals discharge them into a world whose physical and social infrastructure was not built around their changed bodies.

ENABLE Model location

• Builder-side Interventions → Design Accessible Experiences
• Builder-side Interventions → Iterate to Address Shortcomings
• Builder-side Interventions → Provision Resources for Accessibility
• Builder-side Interventions → Provide Support Channels
• Navigator-side Compensations → Switch to an Alternative

What it is

Spaulding Rehabilitation Hospital opened its current 132-bed flagship building in the Charlestown Navy Yard in April 2013, consolidating decades of rehabilitation medicine in Massachusetts into a $225 million waterfront facility designed from the ground up to accommodate patients using wheelchairs, walkers, and other mobility aids.¹ Perkins&Will designers and Partners HealthCare administrators elevated the first floor thirty inches above the 500-year flood level, built earth berms and swales to deflect storm surge, and placed patient floors high enough to stay operational if the ground floor floods.² The hospital operates as a teaching partner of the Harvard Medical School Department of Physical Medicine and Rehabilitation and holds NIDILRR Model Systems designations in spinal cord injury, traumatic brain injury, and burn injury, the only institution nationally to hold all three at the same time.³ The broader Spaulding Rehabilitation Network now includes four inpatient facilities and 25 outpatient centers across Eastern Massachusetts, and Spaulding Rehabilitation Hospital Boston kept its #2 ranking in the 2025-2026 U.S. News rehabilitation list.⁴⁵

Spaulding's SCI and TBI programs put design interventions into clinical practice. Clinicians build therapeutic regimens, adaptive equipment configurations, and home-transition plans that attempt to rebuild a person's functional capacity before discharge. Therapists provide a minimum of fifteen hours of rehabilitative therapy per week during inpatient stays, tracking functional improvement in self-care and mobility against national benchmarks drawn from comparable rehabilitation facilities.⁶ Spaulding's 2024 SCI quality page says the program served 346 patients, kept the same 15-hour weekly floor, and provided 24-hour physician and rehab nursing care.⁷ The Spaulding Adaptive Sports Centers extend this work into the community, provisioning coaches, equipment, venues, and staff for year-round programming in wheelchair basketball, hand cycling, adaptive kayaking, rock climbing, and sled hockey across Boston, Cape Cod, the North Shore, and Sandwich.⁸⁹ The Kelley Institute for Adaptive Sports Research studies the effect of adaptive sport participation on employment and community integration outcomes, and its current about page calls the institute a national model.¹⁰

When patients who trained during inpatient rehab return to communities that lack accessible gyms, pools, or trails, the Adaptive Sports Centers function as a switch to an alternative. They create a network of accessible venues that substitutes for the ordinary infrastructure that excludes them. The ReWalk robotic exoskeleton program, launched at Spaulding in 2015 in partnership with ReWalk Robotics, gave a subset of SCI patients access to powered upright walking that commercial gyms and community recreation programs could not offer.¹¹ These programs name a limit as much as they demonstrate a capability. Every adaptive program that Spaulding runs exists because the built environment outside the hospital still forecloses the same activities for most of its participants most of the time.

Why it matters

The Massachusetts Rehabilitation Hospital that preceded Spaulding opened in 1970, the year Congress extended Medicare coverage to inpatient rehabilitation for the first time. Before Medicare, catastrophic injury routinely produced permanent institutionalization for working-class and low-income Americans; the acute hospital discharged survivors into nursing facilities or family homes with little systematic effort to restore functional independence.¹² Josiah A. Spaulding, a Boston civic leader, led the campaign to build a dedicated rehabilitation facility, and the renamed hospital inherited a post-war paradigm in which medical professionals defined the goals and pace of recovery. That paradigm treated disability as a pathological deviation from a normal body and positioned rehabilitation as the mechanism for returning the patient to normative function or, failing that, supervised dependency. Spaulding enters this historical sequence as the institution that operationalized the post-Medicare rehabilitation model in New England, absorbing successive facilities through the 1990s and 2000s and consolidating rehabilitation medicine in the region into a single credentialed network.

The independent living movement that Ed Roberts launched at the University of California Berkeley in the early 1970s challenged the institutional logic Spaulding inherited directly. Roberts and the Rolling Quads argued that disabled people held the expertise on their own lives and that rehabilitation professionals who controlled the terms of recovery reproduced the dependency they claimed to treat. The Berkeley Center for Independent Living, founded in 1972, built consumer-controlled alternatives to medically supervised institutions.¹³ Mike Oliver, in The Politics of Disablement (1990), extended this critique, arguing that the rehabilitation professions had institutionalized an individualist response to a social problem. The built environment and economic system concentrated risk in disabled bodies.¹⁴ Spaulding's 2013 redesign acknowledged some of this history. The Charlestown building incorporated universal design features throughout, widened corridor clearances for wheelchair users, and added three times the therapy space of its predecessor. The architectural shift signaled that rehabilitation had absorbed, at least formally, the access design principles that the disability rights movement had spent decades demanding.

Inpatient rehabilitation in the United States runs as a privately billed service within a system where Medicaid and Medicare reimbursement rates determine which patients can access which intensity of care. Spaulding's inpatient programs accept patients who can tolerate the three-hour daily therapy minimum that Medicare requires for acute inpatient rehabilitation classification, a threshold that excludes many medically fragile SCI and TBI survivors who are routed instead to skilled nursing facilities with less intensive programming.¹⁵ The adaptation tax that SCI patients carry after discharge reaches well beyond what rehabilitation can address. First-year costs for high-level tetraplegia average over $1 million, and lifetime costs from injury at age 25 exceed $4.7 million, figures that do not include lost wages averaging nearly $72,000 annually.¹⁶ Home modification alone, for wheelchair-accessible entries, widened doorways, roll-in showers, and ramp installation, runs between $5,000 and $75,000 depending on existing structure, costs that insurance rarely covers and that Spaulding's discharge planning teams iterate toward solutions without being able to fund. Research on SCI discharge patterns found that 10 percent of patients stayed in hospital beyond their planned discharge date while searching for accessible housing, with delays averaging sixty days.¹⁷

Alison Kafer, in Feminist, Queer, Crip (Indiana University Press, 2013), names the "curative imaginary" as the organizing premise of rehabilitation medicine. She argues that the proper destination of disabled life is normalized function and that any deviation from that trajectory represents failure.¹⁸ Kafer's analysis describes the temporal logic built into Spaulding's clinical model. Rehabilitation assigns a trajectory, a schedule of recovery milestones, and a discharge date, encoding the expectation that patients will progress toward able-bodied norms or exhaust their covered days. Henri-Jacques Stiker, in A History of Disability (University of Michigan Press, 1999, originally 1982), traces the twentieth-century rehabilitation paradigm to the aftermath of the First World War, when French and Anglo-American states restructured care around the goal of returning injured veterans to productive labor. Stiker argues that this integrationist ideal treats difference as a problem to be erased through prosthetics, exercise, and medical intervention, disciplining disabled bodies toward a normative standard the culture cannot tolerate deviating from.¹⁹ Patients who stabilize at functional states that rehabilitation medicine classifies as incomplete recovery do not necessarily experience their lives as incomplete. The Autistic Self Advocacy Network and disability justice organizers have documented the gap between institutional definitions of successful rehabilitation and disabled people's own accounts of flourishing, arguing that the former consistently underweights independence from the institution as distinct from independence from assistance.²⁰ The Spaulding Adaptive Sports Centers partially bridge this gap. They fund and staff programming that treats competition, recreation, and community participation as ends rather than as proxies for clinical improvement.

People with SCI who lack adequate discharge support carry primary health risks that Spaulding's clinical programs cannot prevent. Secondary conditions, including pressure ulcers, urinary tract infections, spasticity, and chronic neuropathic pain, grow from inadequate community-based follow-up and inaccessible housing that produces prolonged immobility and inadequate hygiene conditions. The WHO's April 2024 fact sheet says more than 15 million people live with SCI, that secondary conditions can cause premature mortality, and that many restrictions on participation come from insufficient medical care, rehabilitation, assistive technologies access, and barriers in the physical, social, and policy environments.²¹ In one community reintegration study, 84.5 percent of SCI survivors reported secondary health conditions affecting participation, with pressure sores (28.16 percent) and spasticity (16.90 percent) the most frequent, both preventable through adequate attendant care, accessible housing, and regular specialist follow-up, none of which rehabilitation hospitals supply after discharge.²² The precarity that many SCI survivors face in securing housing, insurance coverage, and attendant care converts the functional gains achieved at Spaulding into partial gains. Spaulding can restore mobility within the hospital building, but inaccessible stairwells and unmodified bathrooms constrain that mobility again at home, and the hospital does not fund a standing post-discharge support channel that would keep patients connected to clinicians, peer mentors, or accessible-housing coordinators once billable therapy ends.

Spaulding's concentration of all three NIDILRR Model Systems designations in one institution lets its researchers run longitudinal cohort studies that no individual SCI, TBI, or burn unit could sustain alone. The Rehabilitation Outcomes Center and the Kelley Institute for Adaptive Sports Research feed those findings back into clinical protocols, and peer institutions cite the Adaptive Sports Centers as a model. Spaulding still cannot require cities, landlords, or recreation systems to make the outside world accessible before discharge. The hospital can design therapeutic regimens, but it cannot mandate accessible housing construction. It can run adaptive sports programs, but it cannot make community gyms, pools, and recreational trails wheelchair-accessible. Patients leave Spaulding for homes, gyms, and streets built on the same exclusionary defaults that made specialized rehabilitation hospitals necessary in the first place.

Real-world examples

In the news

She was told she might never walk again. Now she's running Boston. (March 2026)
-- Autumn Sloboda, Boston.com

• A patient who underwent emergency surgery to remove a spinal tumor in 2021 completed rehabilitation at Spaulding and went on to run the Boston Marathon. Intensive inpatient and outpatient rehabilitation, adaptive movement training, and community programming supported that recovery path after acute surgery. Coverage like this also centers runners and walkers more often than patients who stabilize at partial-ambulatory or wheelchair-using function.

In the news

Boston's adaptive sports community cheers on Team USA at Paralympics (August 2024)
-- Meghan Smith, GBH News

• Spaulding Rehabilitation hosted a watch party for the 2024 Paris Paralympics opening ceremony, drawing patients with MS, vision impairments, cerebral palsy, and stroke recovery who participate in the Adaptive Sports Centers. Keja MacEwan, director of operations, described the center's goal as helping people "enter sport for the first time, or return to sport for the first time." The Adaptive Sports Centers function as a switch to an alternative for participants whose local recreation infrastructure excludes their equipment and mobility needs.

• Spaulding's Race for Rehab program fielded 78 Boston Marathon runners in 2024, raising over $925,000 to fund adaptive sports and rehabilitation programs. Participants included patients, staff, and community members running on behalf of people who could not.²³

• Spaulding launched a ReWalk robotic exoskeleton program in 2015, enrolling qualifying SCI patients in powered walking training. The program gave inpatients access to upright locomotion that no community gym then offered. That access usually ended at discharge unless patients could afford personal devices, which cost $70,000-$80,000.¹¹

• Research through the Spaulding-Harvard TBI Model System, continuously funded by NIDILRR since 1999, tracks long-term outcomes for TBI survivors through a national cohort database that has informed clinical guidelines across the Model Systems network.³

What care sounds like (builder-side interventions)

Care at the design and iteration stages of rehabilitation involves clinicians who plan for the environment a patient will return to, not only the functional baseline they will leave with:

• "We're building your discharge plan around the apartment you're going back to, not an idealized space. If the bathroom isn't roll-in accessible, we need to solve that before you leave, not after."
• "Adaptive sports isn't a bonus program. It's part of your rehab. We want you competing in hand cycling twelve months from now because that keeps you active, connected, and out of the secondary-condition spiral."
• "We ran the simulation with your actual home measurements. The doorway at your mother's house is twenty-six inches. You'll need a different chair configuration or she'll need a modification before we discharge you."
• "Your insurance authorized three weeks of inpatient. We need to use that time to train your caregivers, not just you, because your rehab doesn't end when you leave this building."
• "The Kelley Institute data shows that SCI patients who enter adaptive sports within the first year of injury have measurably better community integration at five years. We're scheduling your first session before discharge."

What neglect sounds like (builder-side interventions)

Neglect at the design and iteration stages produces plans that treat discharge as the end of the care obligation:

• "We met the Medicare minimum. Three hours of therapy a day for three weeks. The outcomes are what they are."
• "Home modification is a family responsibility. We can give you a list of contractors."
• "We don't have capacity to do a home visit before discharge. We'll send you the standard checklist."
• "The outpatient program has a six-week waitlist. We'll refer you and you can get started then."
• "Adaptive sports is a nice-to-have. The priority is getting you to discharge criteria."
• "We designed the new building for current patients. What happens in the community is outside our scope."

What compensation sounds like (navigator-side compensations)

Compensation describes the labor SCI and TBI survivors undertake when discharge planning does not extend to the built environment they return to:

• "I spent my first month home in bed because the ramp wasn't installed yet. I had to ask my brother-in-law to carry me up the steps until the contractor came."
• "My OT gave me a list of adaptive gyms. There's one in the whole city that has hand cycles and it's forty minutes away by paratransit. I go when I can arrange the ride, which is twice a month."
• "The hospital gave me a discharge plan for a house I no longer live in. The new apartment has a different layout and none of the modifications transfer. I figured out the workarounds myself."
• "Rehab ends and then you're just out there. My physiatrist is booked three months out. My PCP doesn't know enough about SCI. I found the SCI community online and that's where I actually get my follow-up care."
• "I have a pressure sore because I've been sitting in a chair that doesn't fit right. The hospital fit me before I lost another ten pounds. I've been trying to get back in to have it adjusted for two months."

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All observations occur within the context of inpatient and outpatient rehabilitation services in the United States, specifically the Spaulding Rehabilitation Network serving Eastern Massachusetts.

Footnotes

1. Spaulding Rehabilitation Hospital, "New State-of-the-Art Hospital to the Public," spauldingrehab.org/about/news/new-spaulding-hospital-charlestown; confirmed by Boston Globe coverage of the April 2013 patient transfer. ↩

2. Alex Wilson, "How to Make a Hospital Resilient: A Tour of Spaulding Rehab," Resilient Design Institute, resilientdesign.org/how-to-make-a-hospital-resilient-a-tour-of-spaulding-rehabilitation-center; Urban Land Institute, "Spaulding Rehabilitation Hospital," Developing Urban Resilience case study, developingresilience.uli.org/case/spaulding-rehabilitation-hospital. ↩

3. Spaulding Rehabilitation Hospital, "Spaulding's SCI, TBI and Burn Injury Model System Sites Renewed by NIDILRR," spauldingrehab.org/about/news/spaulding-sci-tbi-and-burn-injury-model-system-sites-renewed-by-nidilrr. ↩ ↩²

4. Spaulding Rehabilitation, "About Spaulding Rehabilitation." https://spauldingrehab.org/about ↩

5. Spaulding Rehabilitation, "Spaulding Rehabilitation Earns #2 Rank in U.S. News & World Report 'Best Hospitals'." July 29, 2025. https://www.spauldingrehab.org/about/news/us-news-2025 ↩

6. Spaulding Rehabilitation Hospital, "Spinal Cord Injury Program Quality and Safety," spauldingrehab.org/locations/spaulding-rehabilitation-hospital/quality-safety/quality-sci. ↩

7. Spaulding Rehabilitation Hospital Boston, "Spinal Cord Injury Program at Spaulding Rehabilitation Hospital Boston." https://spauldingrehab.org/locations/spaulding-rehabilitation-hospital/quality-safety/quality-sci ↩

8. Meghan Smith, "Boston's adaptive sports community cheers on Team USA at Paralympics," GBH News, August 30, 2024, wgbh.org/news/local/2024-08-30/bostons-adaptive-sports-community-cheers-on-team-usa-at-paralympics. ↩

9. Spaulding Rehabilitation, "Adaptive Sports & Recovery." https://spauldingrehab.org/conditions-services/adaptive-sports ↩

10. Kelley Adaptive Sports Research Institute, "About Us." https://spauldingrehab.org/research/programs-labs/adaptive-sports/about ↩

11. ReWalk Robotics / Lifeward, "Spaulding Rehabilitation Hospital Launches Exoskeleton Rehabilitation Program with ReWalk Robotics," ir.rewalk.com/news-releases/news-release-details/spaulding-rehabilitation-hospital-launches-exoskeleton, December 2014. ↩ ↩²

12. Spaulding Rehabilitation Hospital, "History of Spaulding Rehabilitation," spauldingrehab.org/about/history. ↩

13. Center for Independent Living of North Central Florida, "History of Independent Living Movement," cilncf.org/cil-history; National Independent Living Program, "History of the Independent Living Movement," nilp.org/history-of-independent-living-movement. ↩

14. Mike Oliver, The Politics of Disablement (Macmillan, 1990); Mike Oliver (disability advocate), Wikipedia, en.wikipedia.org/wiki/Mike_Oliver_(disability_advocate). ↩

15. National Academies of Sciences, Engineering, and Medicine, "Rehabilitation and Long-Term Care Needs After Traumatic Brain Injury," in Traumatic Brain Injury: A Roadmap for Accelerating Progress, ed. Matney C, Bowman K, Berwick D (Washington, DC: National Academies Press, 2022). https://www.ncbi.nlm.nih.gov/books/NBK580075 ↩

16. Christopher & Dana Reeve Foundation, "Costs of Living with Spinal Cord Injury," christopherreeve.org/todays-care/living-with-paralysis/costs-and-insurance/costs-of-living-with-spinal-cord-injury, citing 2010-2014 data. ↩

17. George Forrest and George Gombas, "Wheelchair-accessible housing: Its role in cost containment in spinal cord injury," Archives of Physical Medicine and Rehabilitation 76, no. 5 (May 1995): 450-452. https://doi.org/10.1016/S0003-9993(95)80576-1 ↩

18. Alison Kafer, Feminist, Queer, Crip (Indiana University Press, 2013), iupress.org/9780253009340/feminist-queer-crip. ↩

19. Henri-Jacques Stiker, A History of Disability, trans. William Sayers (University of Michigan Press, 1999; originally published in French in 1982), press.umich.edu/Books/A/A-History-of-Disability3. ↩

20. Autistic Self Advocacy Network, position statements, autisticadvocacy.org; discussed in context of independence redefined by the disability justice movement in Nick Walker, Neuroqueer Heresies (Autonomous Press, 2021). ↩

21. World Health Organization, "Spinal cord injury." April 16, 2024. https://www.who.int/en/news-room/fact-sheets/detail/spinal-cord-injury ↩

22. Meenakshi Mohan and Roumi Deb, "Barriers and Facilitators during Community Reintegration of People with Spinal Cord Injury: A Qualitative Study." https://pmc.ncbi.nlm.nih.gov/articles/PMC11036166 ↩

23. Spaulding Rehabilitation Hospital, "Race for Rehab Team Crosses Finish Line and Surpasses $925,000 Fundraising," spauldingrehab.org/about/news/race-for-rehab-team-crosses-finish-line-raises-over-925000. ↩