Rehabilitation thinking, a crucial skill
Last updated: October 29, 2025
Sara Ajina asked me to speak in London on what was important in rehabilitation, and soon after, Thomas Platz requested a similar talk in Freiburg, Germany, on December 4, 2025. I have spent about six months considering and refining the answer, and on October 25, 2025, I published an article entitled “Is rehabilitation’s unifying expertise its holistic scope and cognitive approach to the patient’s problems? An exploration.” My ideas have continued their evolution. This page is my current exposition on Rehabilitation Thinking, which I consider a crucial and decisive ‘unique selling point’ of rehabilitation. Earlier stages are available: rehabilitation thinking – 1 and holistic rehabilitation thinking – 2. You will find more detailed discussions in those posts than in the Clinical Rehabilitation article.
Rehabilitation thinking should be considered within the context of several related conceptual issues. Biomedical healthcare is gradually failing due to the pressures of multimorbidity, rising numbers of frail or dependent individuals, and insufficient social support, leading to hospital admissions for safety reasons. The paradigm employed by healthcare organisations, policymakers, and politicians needs to evolve into a biopsychosocial model of healthcare. This would facilitate and, potentially, enforce a more collaborative and practical discussion on how to address these challenges.
Table of Contents
Introduction
Two issues drove me to return to rehabilitation thinking, a topic I first discussed in 2002, when I wrote, “Rehabilitation is a way of thinking, not a way of doing.” Then, as now, I worried that rehabilitation professionals were transforming rehabilitation into another (bio)medical speciality. (See: Why physical medicine, physical disability and physical rehabilitation? We should abandon Cartesian dualism.) The emphasis was on physical medicine and physical treatments, and training focused on procedures such as injecting joints for joint pain, or muscles mainly with botulinum toxin. Another looming threat was an emphasis on technological solutions and computers, a promise that has not materialised.
This emphasis on Physical Medicine shifted focus away from the widely accepted need for holism. Procedural skills are not unimportant, although less highly trained professionals can carry out many of them once the necessity has been recognised. Nonetheless, concentrating on biomedical expertise inevitably diverts attention from other aspects.
The second issue was how to explain rehabilitation to others who recognised that it could help those recovering, but thought it pointless for anyone with significant cognitive deficits, a progressive disorder, any disability acquired at birth or in childhood, and sometimes, anyone who was elderly — which, when I began, meant anyone over 65 years old ‘because they are not working’.
Other issues concerned me. One challenge was defining “no rehabilitation” as a control condition in trials. This definition was more complex than defining rehabilitation! Another was explaining how spinal cord injury rehabilitation benefited patients.
The key to the conundrum.
The answer to all my concerns is simple – once you have seen it (which took me many years). One must not consider rehabilitation to be an intervention, a treatment. Moreover, though we have recognised it as a process for many years, we should not consider it akin to biomedical healthcare.
As I have discussed in my post, biopsychosocial healthcare, rehabilitation is an example of a fundamentally different healthcare model. Biomedical healthcare is concerned about the bodily physiological balance, whereas biopsychosocial healthcare focuses on the person’s biopsychosocial balance. Biomedical healthcare interventions influence bodily homeostatic mechanisms, whereas rehabilitation influences a person’s biopsychosocial homeostatic mechanisms. The biopsychosocial mechanisms are psychological and behavioural adaptation to circumstances, whereas the biomedical homeostatic mechanisms are physiological.
Thus, rehabilitation supports and enhances a natural behavioural and psychological adaptive process just as biomedical care supports and enhances bodily physiological adaptive processes.
This post takes you through the journey I have taken over the last nine months to reach this conclusion.
Spinal cord injury rehabilitation.
For decades, rehabilitation services struggled to get resources because biomedical people said, “There is no evidence that it works.” We utterly failed ourselves; evidence was hiding in plain sight. Between 1935 and 1955, the prognosis for a person with a spinal cord injury was transformed beyond all hope (in 1935), yet this happened without any huge advance in biology, pharmacology, surgery, technology, or any other part of biomedical healthcare.
Otfrid Foerster (Germany), Donald Munro (United States), and Ludwig Guttmann (Germany and United Kingdom) are the three best-known leaders, though doubtless many others contributed. Their contribution was to abandon pre-existing pessimism and to set about ensuring that the person first adapted effectively by maintaining their biomedical health. Simultaneously, the person had to adjust their behaviours and expectations. Thirdly, the healthcare services had to alter both the physical and social environment so that the person could fully rejoin society.
I have not found any evidence-based analysis of the main features of their approach. However, just considering the services and what typically happens, the main features I identify are:
- A fixed focus on the end goal of social reintegration, helping the person achieve active participation in society as an equal member of society
- A systematic approach to preventing avoidable, previously life-limiting secondary complications such as urinary tract infection, skin pressure ulcers, autonomic dysreflexia, and severe spasms
- Teaching the person how to take full responsibility for maintaining their health
- Helping with the complex processes of psychological (emotional and cognitive) adaptation to their losses and giving the person realistic new goals
- Supporting the person in obtaining vital equipment, housing, and other environmental changes and equipment needed
- Supporting the family, friends, employers, and others in adapting to the person’s new roles, care needs, and abilities.
- Providing life-time support as needed, especially supporting patients when they develop new, unrelated medical problems.
In simpler terms, the rehabilitation service takes a holistic approach covering every aspect of a person’s life now and in the future. It does so collaboratively across all organisational and funding boundaries. If this approach had been generalised across all disabling conditions once its success was evident — say, in 1955 — the standard of care for all patients would now be immeasurably better.
Recovery and rehabilitation.
Rehabilitation is closely associated with the concept of recovery, and many people still consider that rehabilitation will lead to recovery. I discussed Recovery, Recuperation, and Rehabilitation in a post in October 2024 that explores the concept in detail.
I draw primarily on Yael Friedman’s paper, On recovery: re‐directing the concept by differentiation of its meanings. I summarise her analysis thus: “She concludes by suggesting some changes in outlook. Recovery should be considered a process of moving away from a state. Further, the goal is soundness. She implies that this encompasses health, well-being, and functioning or is the opposite of malady, which encompasses illness, sickness, and disease. It also includes feeling whole, at home, and embodied.”
The main points to understand are that recovery:
- Does not refer to or imply regrowth of damaged tissues.
- Crucially, does not mean a return to a previous state, sometimes also referred to as ‘normal’.
Instead, it does encompass several aspects of change, with the central characteristic being an improvement in something. Thus, if used, recovery may refer to:
- Improving in one or more domains, such as social role functioning or new skills
- Achieving an activity by a different means, such as getting around in a wheelchair rather than walking, or writing with the non-dominant arm.
In my post, I suggest “one should not talk about a person’s recovery as if it were an outcome or a state. Instead, one should refer to the adaptation process and say that the person is adapting.”
Adaptation: the solution.
Understanding that adaptation to change is the primary process involved in ‘recovery’ is essential to understanding rehabilitation’s role.
All living things adapt to change in themselves or their environment. This is a defining characteristic of living things. It covers both individuals and species, thereby driving evolution. Humans are exceptional in their ability to adapt and change.
People adapt constantly day to day, over weeks, and over years. Our behaviours change as we grow up and, later, as we age. We change in response to our physical environment —for instance, dressing differently according to the weather — and to our social environment —for example, behaving differently when approached by a policeman or when entering a library.
In some circumstances, such as after losing a job, we may seek help and advice from others. This may extend to approaching expert professionals, for instance, asking a lawyer to assist with a divorce or house purchase.
Developing a malady (an umbrella term for disease, illness, condition, etc) that alters functional abilities is just another change, and the person will start adapting immediately. Indeed, in slowly progressive disorders, other people sometimes notice adaptive changes before the ill person does.
The key insight is that people automatically adjust in response to changes in themselves, caused by illness or natural physiological processes such as ageing and menopause. As part of this adjustment, they may seek or be offered assistance from a healthcare rehabilitation professional or service.
General Theory of Rehabilitation.
The General Theory of Rehabilitation is based on this insight. The theory proposes that, just as the body maintains physiological parameters within a safe range, so the person maintains biopsychosocial motivational factors within a healthy range. The former is based on physical characteristics, the latter on psychological factors. I will explain this because it underscores the crucial requirement that rehabilitation be holistic and person-centred.
In 1931, Walter Cannon published “Organisation for Physiological Homeostasis,” a seminal paper that established the basic feedback mechanism responsible for maintaining a person’s body in a healthy state. This mechanism keeps the biochemical milieu needed for effective bodily function relatively constant and responds to any change that might push it outside safe limits.
In 1942, John Fletcher first proposed that similar mechanisms could apply to a person’s psychological state in his paper, Homeostasis as an explanatory principle in psychology. David Marks developed this idea in 2018 in his book, A General Theory of Behaviour. He proposed that people maintain a healthy psychological state using a central homeostatic mechanism that alters behaviour or other variables. Further evidence for this mechanism is discussed in my original paper, “A general theory of rehabilitation: Rehabilitation catalyses and assists adaptation to illness.”
In 1943, Abraham Maslow published his paper, A Theory of Human Motivation, which proposed a hierarchical classification of motivational needs that is still widely used. I have discussed the application of Maslow’s hierarchy of needs, arguing that it provides a valuable framework for examining a person’s life goals. Subjective Wellbeing is related to a person’s satisfaction with the achievement of goals categorised in Maslow’s needs, suggesting they are a helpful way to view psychological homeostasis.
In my paper and elsewhere, I refer to a biopsychosocial homeostatic mechanism. The physiological homeostatic mechanism covers the biological component. This broader mechanism encompasses both psychological and social aspects of life, and so a biopsychosocial balance is a simple, appropriate term.
Adjustment mechanisms
The figures below show the general nature of the homeostatic mechanism.
The first drawing gives an overview. The motivation needs are on the right, with five categories. The discrepancy between the goal and the present state is fed back to the person’s central homeostatic mechanism. This evaluates the overall situation, including any internal or external changes, and determines what adjustments may be needed in behaviours or in the goals and their relative priorities. Goal adjustment resets the goals.
The second drawing shows schematically the steps taken by the mechanism. Most processes will be subconscious, and the conscious person will only be involved when major changes have occurred or are needed.
Adaptation is person-centred.
Rehabilitation must be person-centred because its roles, shown in the figure below, all enhance the person’s adjustment. Their unique motivational needs will inevitably influence their adaptation. Rehabilitation needs to facilitate their adaptation. This requires an understanding of the person and a framework to ensure all relevant factors are considered.
The World Health Organisation’s International Classification of Functioning introduced the concept of personal factors. I have discussed this concept, and Peter Halligan and I included personal context within the holistic biopsychosocial model of health. In their paper, An evidence-based patient-centered method makes the biopsychosocial model scientific, Robert Smith et al argued that being person-centred was closely related to using the model.
The figure below summarises the holistic biopsychosocial model as applied to an individual.
Principles and theories.
I have established two principles based on two theories.
Principle one:
- Rehabilitation’s role is to enhance a person’s natural adaptation to changes associated with their malady (illness, disease, condition)
- The foundational conceptual base is the General Theory of Rehabilitation, with additional concepts from Maslow’s theory of motivation.
Principle two:
- Rehabilitation must be person-centred, working with the person’s motivating goals.
- The foundational conceptual base is the holistic biopsychosocial model of illness, with additional concepts from Maslow’s theory of motivation.
Clinical reasoning, the third pillar.
Clinical reasoning in rehabilitation should be based on evidence, as in all areas of healthcare. Evidence includes research results on the effectiveness of interventions, prognostic factors, and interrelationships among variables. This evidence is sometimes called the field of Enablement theories.
However, the experience of the rehabilitation team and their knowledge of local resources are equally valid sources of information, primarily if team members critically reflect on their experience.
Clinical reasoning and practice depend on the two principles and three theories above, combined with an attitude of respect for others and a willingness to collaborate.
First, it must be systematic. Rehabilitation is complex, and it is easy to overlook or forget something important. The biopsychosocial model provides a sound, comprehensive framework for identifying relevant data. In more challenging cases, the Oxford Case Complexity Assessment Measure can assist. Maslow’s categorisation of needs provides a system for considering overarching life goals.
Next, it should usually focus on activities as both a starting point for collecting information and the main target of most interventions. Although the ultimate goals relate to social participation, participation depends entirely on the person’s functional capacity.
Last, it must be person-centred for all the reasons given earlier.
Using rehabilitation thinking.
“But I’ll never have the time to use that.” Many people say this when hearing about the biopsychosocial model of illness. Another common comment is, “But we cannot help with community activities (or social problems or work issues or leisure pursuits, etc), so why bother to ask about them? It’s not our job.” Doubtless, some people will say the same about rehabilitation thinking, so I will discuss its use in daily clinical work.
Rehabilitation thinking should be a mindset — how you consider every clinical situation — as, at present, biomedical thinking is the mindset for most clinical staff. The biomedical model extends from genes and biochemistry to the whole body, but no one expects to consider every level with every patient.
Your effort with each patient must be proportionate. However, even if you are just providing a replacement orthosis or a routine regular botulinum toxin injection, your thoughts should be guided by rehabilitation, not biomedicine. And, when faced with an intractable situation or any challenge, you should use this cognitive approach.
Moreover, rehabilitation thinking should inform your teaching, writing policies, quality improvement activities and all other professional activities.
One helpful approach is to ask yourself, “In five years, where will this person be living, who with, who else will they meet, and doing what meaningful activities?” Then ask, Is there anything I can do to help, including giving advice or referring to any agency?
Rehabilitation thinking outputs.
This approach to rehabilitation should yield three crucial outcomes for any person with significant issues as part of their illness.
- A holistic formulation.
This person-centred, biopsychosocial, systematic approach to assessment should identify the main factors affecting a person’s situation, especially those that can be beneficially changed. It should also offer the most accurate estimate of a person’s prognosis. - A person-centred rehabilitation plan.
The information gathered about the individual’s values, priorities, motivational needs, and life goals during the assessment process should facilitate effective planning. The plan should incorporate immediate, intermediate, and long-term goals and ensure effective coordination among the various professionals and organisations involved. - Individualised actions.
All actions should be specific to the individual’s needs and context, avoiding complete reliance on protocols or usual practice. All evidence must be assessed for its applicability and relevance to the patient.
Rehabilitation thinking: a summary illustration
Conclusion
Rehabilitation is not something you turn on and off, using it when you consider it necessary. It is a mental approach to all aspects of rehabilitation. It is vital when involved with more complex clinical issues, but it is equally essential when devising policies, managing services, doing research, and organising funding. It took me many years to make it my default way of thinking because the biomedical approach was so firmly embedded from childhood. A variant will underlie thinking in all specialists practising biopsychosocial healthcare.
However, I am not suggesting biomedical thinking is unnecessary or less important. A biomedical approach to problems is crucial, especially in the initial phase of any illness, to detect any bodily pathology, especially if it is curable, and to provide a prognosis. The diagnosis may determine life expectancy, likely impairments, and the prognostic field for other aspects of the future. Ideally, specialists in biopsychosocial specialities will use rehabilitation thinking as their default approach, but maintain sufficient biomedical thinking to react to new medical illnesses. And the reverse will apply to biomedical specialists.