Rehabilitation facilitates adaptation
Humans adapt to their circumstances and any changes in them; this includes adapting as skills and abilities change, for example, as a child or an adult grows older. It also includes adapting to changes arising as part of an illness. Adaptation is universal and natural. In childhood, adaptation is facilitated by education undertaken by parents, siblings, and anyone interacting with the child. As there is so much to learn, society takes an active role through a formal education system of schools and universities. People have always adapted to trauma and other sicknesses, for example, by using wooden legs after leg amputation, basic wheelchairs, and spectacles for poor vision. The drive to facilitate adaptation to sickness was economic and practical; injured soldiers, enslaved people, or gladiators could still return to work, and basic assistance was provided. Wars have been central to the development of rehabilitation, which continues a tradition of facilitating adaptation which has existed for centuries. This post explores this theme, demonstrating that the patient must actively participate in rehabilitation, setting the direction, learning, and eventually establishing a stable social position.
Table of Contents
Introduction
When your car breaks down so you cannot drive to work, you will likely seek a lift, take public transport, or phone in and work from home. Similarly, if you suffer acute back pain or headache, you may avoid certain activities, take painkillers, and wait until the pain is reduced. Further, if you lose or change your job, you may change your daily routine, learn new skills, and make new friends. Last, when you retire from work, have your first child, or leave high school, you will or did change many parts of your life.
When someone falls ill, they adapt immediately; even going to a doctor is an adaptive response to a new symptom or worsening disability. If some activity, such as walking or feeding, is affected, the person will adapt as far as they can, for example, by borrowing a walking stick or using a spoon. The adaptations will vary from using equipment and doing things in new ways to asking others to help or deciding not to attempt an activity, such as going upstairs.
Wheelchairs – an ancient adaptation.
Using a wheelchair to move someone with difficulty walking may have started in the second century BC in China and has undoubtedly since the sixth century AD. In 1595, a wheelchair was made for the King of Spain, and in 1655, the first self-propelled wheelchair was created by a clockmaker with paraplegia, Stephan Farfler (1633-1689). (See photographs here.) He used it for 34 years. Many designs were developed in the nineteenth century in the US, and many soldiers used them after the Civil War (See Wheelchair and User in the Nineteenth Century.)
Ill people being seen in healthcare have always had disabilities, but it was not until the Great War (1914-18) that healthcare services became systematically and sustainably involved. Before 1918, the service was known as rehabilitation, a name that has remained.
However, rehabilitation remained a practical speciality for many years without any definite conceptual basis. The biopsychosocial model of illness was introduced in 1977, but 2008 there was still no theoretical underpinning. In 2024, I published the first General Theory of Rehabilitation, which placed adaptation as the central feature.
Rehabilitation facilitates adaptation.
People with slowly progressive disorders often adapt initially without even noticing it, especially if it is not a neurological condition. In contrast, some people with a severe and sudden-onset condition such as a traumatic spinal cord injury are so psychologically shocked that they cannot start adapting even in simple ways. In addition, some people will recognise a need to adjust but not know there is a solution or may think of a solution but not know how to achieve it.
Thus, there are inevitably people who need help adapting. This is more likely for people whose onset is sudden and severe, who are in hospital with a severely debilitating illness such as sepsis, even if nothing is irreparably harmed, or who have neurological conditions affecting the brain.
Neurologically affected people are more likely to need help because the brain is crucial for successful adaptation. They may lose the ability to reason, solve problems, plan, or learn.
Rehabilitation can facilitate adaptation in three significant ways.
Formulation and prognosis.
Most people have a limited understanding of their disease, and often, their beliefs about it are untrue. However, the situation is worse for their adaptation. They may problem-solve the most immediate difficulties, such as how am I going to use a toilet, but they will often only manage a little more.
The main difficulties people have arise from the need for more accurate, relevant information. They will not understand how the disease relates to their losses and how the apparent losses lead to disabilities. Second, they will not know the prognosis in general, especially for basic lost skills or for their disabilities. Will the sensation in my leg recover? Will I be able to walk to work?
Arguably, rehabilitation makes its most outstanding contribution by identifying patients’ losses, relating these to their disabilities, and explaining how the disease relates to both and what they can expect over the next few weeks or months. If this is linked to straightforward advice they can follow unaided, many patients and their families will manage well.
Planning.
If the situation is more complex, or the condition has reduced the person’s ability to problem-solve, plan, and remember, rehabilitation has a further vital role in planning the course of adaptation. This includes an outlined long-term plan and, more importantly, an immediate short-term plan with specific actions identified and delegated to someone.
The plan must consider the patient’s aspirations, interests, values, and life goals. Setting goals is considered here and will be discussed further in this website section; I plan to write the page.
In the more straightforward cases, the patient and their family can often carry out the plan provided it is well documented and they can make contact if difficulties arise. The rehabilitation team should always plan a review meeting to ensure progress and give a further plan if needed.
In the more complex cases, when the patient or family cannot readily carry out the necessary actions, the rehabilitation team will undertake some or most of the required actions.
Rehabilitation team actions.
The third role of rehabilitation in facilitating adaptation is undertaking one or more actions or interventions to assist the person’s change.
I must stress here that this also requires a complete plan with person-centred goals. Coordinating the many actions and interventions typically seen in rehabilitation is essential. On another page, I will expand upon the patient’s goal-setting and rehabilitation-planning roles.
In broad terms, the rehabilitation team’s actions fall into the following groups:
- Teaching.
Help the person learn activities such as dressing, shopping, and buying a train ticket. At times, this will involve relearning how they did it before. Sometimes, it will include learning new ways of undertaking activities; often, it is learning new activities. - Self-management.
One vital educational role is teaching people how to manage their situation and take responsibility for further adaptation. In this context, people need to be taught how to set their own goals. - Aids, equipment, house adaptations, etc.
Rehabilitation teams have extensive knowledge of what equipment or adaptations are available and how they are funded. They have a vital role in giving advice, ensuring the person has what they need, and avoiding buying things they do not need. They may also help with funding or purchasing and teach safe use. - Lifestyle.
Exercise and a healthy lifestyle are crucial to achieving and maintaining the best adaptation possible. They can be challenging to achieve, and the rehabilitation team can offer advice and information. - Care and support.
Rehabilitation teams also have extensive knowledge about (physical) care and social and practical support. They can advise on what a person needs and how it can be found and funded, and sometimes, they can teach care staff specific care skills for the person.
All these rehabilitation roles depend on the patient’s active participation and engagement. Other pages give further details on how the patient can contribute and improve their adaptation.
Rehabilitation facilitates adaptation - implications.
Reconceiving rehabilitation as an adjunct to a normal existing process has several implications. Rehabilitation has been considered a specialist healthcare intervention like all others, such as cardiology or renal medicine. Most specialist healthcare services are external to a person’s normal life, used when needed but not part of it. However, rehabilitation is one of many resources used by everyone to assist throughout their lives.
Normalising rehabilitation.
This theory starts from the premise that adaptation is integral to life and occurs constantly. Throughout life, people depend on others to assist them with their adaptation and to learn the skills needed to adapt. The external help may be trivial, such as someone explaining how to use a new car, or substantial, such as attending a one-year training course to become a horticulturist.
Thus, according to this analysis, any person faced with change requiring them to learn and adapt, altering their behaviour so that they can continue the life they want, will seek and use help as needed.
Illness is one of many changes people face. Most people manage minor, short-term illnesses without any difficulty. Even significant diseases can be managed, provided there are no longer-term consequences and they do not last too long.
However, when an illness is more prolonged and progressive or causes persisting changes in the person’s abilities, the person may need additional help. Sometimes, the help will relate to adjusting work, further vocational training, or more education; existing social resources meet these needs. More commonly, the person will need help from a service familiar with the health condition. They require assistance from an expert rehabilitation service.
In summary, some people need help adapting to changes associated with a health condition; rehabilitation is the healthcare service that facilitates this adaptation.
Patient - an active participant.
This approach highlights the central status of the patient who will be looking for expert help to reestablish their life after disruption associated with illness. The person may not initiate contact, but once involved, the person must be the focus of attention. They wish to adapt and continue their life. Though few people articulate life goals, they will have values, aspirations, and desired social roles that guide their lives, influencing their adaptation.
Thus, the patient and rehabilitation team must discuss the person’s long-term, superordinate goals and consider actions that will continue progress towards them. Sometimes, these discussions may lead to changes in details reflecting likely long-term limitations imposed by the illness, but the general themes are usually retained.
Second, the person will inevitably have new things to learn, typically activities that have been limited or new activities to replace those that are no longer achievable. Learning an activity requires practice in various settings, with failures. This practice depends on the patient and is active; the rehabilitation team assists but cannot do the practice.
Health, illness, disability.
A third implication relates to health and rehabilitation’s goals. Some people might think that anyone who has a persistent disability or disease is ill (unhealthy). However, the General Theory of Rehabilitation suggests that health occurs when a person’s balance between their higher-level goals and their present position provides an appropriate level of motivation and is stable.
The essential components of this argument are:
- Normality (of health) cannot be defined. Many papers and books establish this.
- Well-being is probably a better measure than levels of disease or disability.
- Well-being is closely related to the discrepancy between achieving high-level goals and the current state.
- Adaptation aims to establish a stable situation where motivation and well-being are optimised.
The primary conclusion is that rehabilitation does not aim to return a person to their previous level of functioning or to achieve normality. Its goal is to facilitate the person’s achieving the best equilibrium between aspired goals and current position, best measures of well-being (quality of life).
These implications give a perspective on rehabilitation that differs from the traditional views held by many people. They emphasise that rehabilitation is one of many things that help a person adjust their behaviours and goals in response to external and internal changes in their life. They highlight how the person needs to be fully engaged in this process and that the intention is to optimise well-being, not achieve any specific level of functioning.
Conclusion
This page has considered, in more detail, ‘what rehabilitation is’. The discussion uses the General Theory of Rehabilitation to reframe rehabilitation as one of many ways a person adapts to a change in their situation. Rehabilitation focuses on adjusting and facilitating adaptation by understanding how diseases alter bodily function and the ability to undertake activities. This demonstrates why full participation by the patient is essential for rehabilitation to succeed.
