B-0 The rehabilitation process
Last updated: March 17, 2025
The rehabilitation process is covered in detail on this site. The original syllabus for the Rehabilitation Medicine curriculum had four competencies. However, as I wrote this section, I realised that the original “assessment competency” was faulty; it had to be split into two, and I have reported my epiphany. Thus, five competencies relating to this process are included in this section (B) syllabus, and this page explains why and how they were chosen. The competencies highlight some vital differences between the traditional biomedical approach to diagnosis and treatment and the rehabilitation approach. They reflect rehabilitation’s focus on disability and social functioning in contrast to the biomedical focus on disease and symptoms. They support the rehabilitation curriculum’s capabilities in practice given in the Rehabilitation Medicine curriculum and, slightly adapted, on this website and in a published article. In the diagram below, the competencies cover the biopsychosocial framework, data collection, formulation, rehabilitation planning, and evaluation.
Table of Contents
Introduction
All healthcare is concerned with solving people’s problems; if their problems are within healthcare’s remit, they become patients. Problem-solving processes are similar, whatever the problem, but the information needed, the frameworks used to analyse the data, and the actions required are determined by the problem and the expertise of the problem solver.
Success depends on the nature of the problem and the problem-solver’s expertise being appropriate for the situation. One issue in healthcare is the limited understanding in the biomedical community of what rehabilitation has to offer, so patients are never referred. This is exacerbated by insufficient provision of rehabilitation expertise.
Success also depends on rehabilitation professionals using a person-centred, disability-focused approach; knowledge of specific rehabilitation treatment techniques is insufficient. Thus, the syllabus prioritises five process competencies to ensure a holistic approach and effective use of specialist techniques and interventions.
Analogies: biomedical & rehabilitation
All healthcare problem-solving processes will have similar steps or stages, whether the focus is on a genetic alteration affecting movement control, management of persistent distressing anxiety, or helping someone whose leg has been amputated return to employment. The differences arise from the healthcare service’s focus of attention. Some specialise in diagnostic imaging of the body, some in diagnosing structural or physiological abnormalities, some in treatments, etc. Rehabilitation focuses on disability.
I have discussed the healthcare problem-solving process in detail before. Below, I have summarised the contrast between rehabilitation and acute biomedical services. Of course, professionals in most healthcare services take a broader view, but the service they work in may not. The table shows the similarities in process and the differences in long term goals, time frames, and involvement of other organisations.
Medical process
Clinical clerking: History of symptoms, examination, investigations
Diagnosis: Identifying a single causal disease or alternatives
Management plan. Considering immediate care and treatment and further investigations if needed
Rehabilitation process
Assessment: History of function and related context, observation of function, examination.
Formulation. Identifying the many causal and influencing factors and how they inter-relate.
Rehabilitation planning. Setting long term goals for social functioning including accommodation, and an action plan incuding additional assessment if needed.
Comment
Both involve collecting information to enable a formulation sufficient to plan further management
both are a summary of the situation, one focused on disease and the body, the other focused on disability and contextual issues
Both set out what will be done next, with the medical focus on identifying and treating disease. contast, the rehabilitation goals are social and the actions are multi-professiinal and include people from other organisations and agencies.
Reason for differences.
The specific differences arise from four inter-related features of rehabilitation:
- Its use of the biopsychosocial model of illness, which leads to:
- Its holistic nature, taking all factors into account rather than only the disease and factors directly relating to the condition, leads to:
- a need to use all evidence to create a formulation and
- a much greater dependence on multidisciplinary teamwork, more accurately defined as multi-professional teamwork and collaboration with other services.
The syllabus’s process competencies reflect the use of the biopsychosocial model and the three phases of the process shown above.
These competencies are used in all rehabilitation, regardless of any specialisation in a particular group of disorders or type of treatment. Consequently, every rehabilitation expert should have good knowledge and skills of these competencies, as demonstrated by their behaviours.
Rehabilitation process competencies
When writing the syllabus, we chose four competencies from the process; I have added a fifth.
These five competencies cannot cover the process comprehensively, and the knowledge and skills given as examples only cover some things that can be known. Additionally, I have emphasised the importance of an interest in matters outside any formal syllabus, such as humanities and wisdom. These characteristics can be learned and improved and usually develop with experience.
The five competencies are discussed briefly below. Each is linked to the appropriate page for more information.
Using the biopsychosocial model.
A good understanding of the biopsychosocial model is essential. It underlies all effective rehabilitation.
However, this crucial understanding is insufficient. The model must be used in every aspect of rehabilitation, including every aspect of a rehabilitation service. I have emphasised how this is a critical component of a nursing home’s expertise in rehabilitation.
Thus, the competency includes using it in all clinical and other contexts, such as service management, quality improvement, and research. This site extensively discusses the model, and I have written a detailed article about it.
Clinical assessment competency
This activity requires a systematic approach, just as traditional medical diagnostic training does; the difference is in the structure of the systematic approach, which is based on the biopsychosocial model’s domains.
The rehabilitation doctor must also retain good biomedical diagnostic skills acquired during their earlier training. Although rehabilitation focuses on disability, an accurate disease diagnosis is essential and should not be assumed. Disease determines prognosis, and treatable diseases should be treated.
The competency page discusses using a narrative medicine approach to obtain the patient’s perspective and the Oxford Case Complexity Assessment Measure as an aide memoir.
Formulation competency
Formulation is the other crucial competence. The term is widely used in psychiatry, another speciality that takes a holistic approach and focuses on behaviour rather than disease. Most of the evidence concerned with formulation comes from psychiatric research.
In my experience, rehabilitation clinicians rarely undertake or refer to a formulation, which is seldom available in notes, letters, or summaries. Documenting an explicit formulation encourages the clinician to think. It also facilitates a better-informed, open discussion among team members who otherwise would have differing views on causation and treatment.
This skill distinguishes rehabilitation professionals from colleagues who practice within a biomedical culture. It requires thinking about and analysing the whole range of matters influencing the patient’s management. Coupled with that skill, a suitable formulation requires the ability to summarise, communicate complex issues clearly, and document the reasoning.
Person-centred rehabilitation planning.
In a blog post, a model of person-centred rehabilitation, I discuss what the phrase means and its obstacles. Rehabilitation planning is discussed in detail on another page. Every rehabilitation expert must be competent in person-centred rehabilitation planning as an active team member and, sometimes, as the leader.
Success requires professionals to consider their interests and areas of expertise, not assuming that what they or their service can do is necessarily the best or even the correct thing to offer. Nonetheless, they have a responsibility not only to identify what else is needed but also to facilitate access to it.
One critical part of this competency is the ability to work with others in a team, an issue I have discussed in a blog post considering the supposedly different types of teams. I have discussed the characteristics of teamwork in detail in a chapter. Teamwork is so important that it is one of the seven rehabilitation-specific capabilities. This competency is central to it.
Evaluation.
Has our intervention helped you? Moreover, you should always ask yourself, if not the patient and family, if our intervention has harmed the patient. Rehabilitation cannot be considered free of risk and harm. Goal attainment scaling is often considered a good way to judge outcomes, but in a blog post, I suggest avoiding it because it is invalid and risks harm.
Nevertheless, one must always evaluate the effects of any action or whether changes seen, for example, in a progressive disorder warrant action. This competency is challenging because one must balance various matters, such as measuring what is important or using standardised measures of unimportant (to the person) matters.
This competency stresses the need to avoid measuring outcomes that can be measured, instead evaluating your effect on outcomes the person considers valuable. It also cautions against over-evaluating, suggesting you should target evaluation on interventions that carry greater risk or need significantly more resources than usual.
Conclusion
These five competencies will ensure an excellent rehabilitation expert. They lead to knowledge and skills that will be used throughout a professional career, however much the professional moves around different types of rehabilitation and, indeed, if they move into research, management, or a training post. They cover areas of clinical practice that are often not explicitly taught or assessed despite their importance.
