I have been asked to give a webinar on teaching healthcare professionals the expertise needed for specialist neurological rehabilitation. It is part of the World Federation for Neurorehabilitation and the Lancet Neurology Commission on Neurorehabilitation Lecture Series 2026, on 4 February 2026. I published my first analysis, Neurological rehabilitation: what specialist expertise is needed? I concluded that one should supplement the usual rehabilitation expertise with additional neurology training.
I know a lot about rehabilitation training, but much less about medical training in neurology. I reviewed the Speciality Capabilities in Practice within the General Medical Council (GMC)-approved specialist neurology curriculum for UK doctors. I also searched for a GMC credential, but the credentialing project has not progressed much.
I have, therefore, constructed an ad hoc set of four capabilities derived from the neurology training curriculum, relevant competencies in the Rehabilitation Medicine syllabus, other sources, and my experience. They are shown in the MindMap below. They need improvement and validation. Anyone may contact me for further information or advice, hopefully to initiate a more formal development process.
Table of Contents
Introduction
The UK Rehabilitation Medicine community discusses neurological rehabilitation in meetings, on social media, and elsewhere. There is an implicit recognition that different rehabilitation subspecialties exist, such as prosthetics, spinal cord injury, and musculoskeletal. The Medical Disability Society (soon renamed the British Society of Rehabilitation Medicine) emerged from rheumatology and initially included only the three subspecialties mentioned. Many active founding members (including me) practised neurological rehabilitation, and it soon became a major subspecialty, producing most of the research. I have written a more detailed history of the speciality’s medical society.
The UK doctors’ Rehabilitation Medicine curriculum does not mention subspecialties and does not include any subspecialty training. This was a requirement of the General Medical Council and was supported by the rehabilitation community (e.g. the BSPRM), which recognised the vital role of rehabilitation across all areas of healthcare.
However, clinical practice, healthcare commissioning, economic factors, and epidemiology recognise that neurological rehabilitation requires expertise beyond that provided during training. The question is whether neurological rehabilitation should be recognised as a speciality with its own curriculum. The General Medical Council is very unlikely to agree, and I support their approach.
The alternative is to devise a more formal approach to additional training after becoming an independent practitioner; in the UK, fully trained doctors are called consultants. There is no formal way to achieve this at present, other than GMC credentialling for doctors, which is a long, bureaucratic process. More importantly, the whole multiprofessional team needs additional training.
This page is an initial discussion of how best to ensure professionals have appropriate expertise in rehabilitation and neurology, leading to some detailed capabilities for the additional neurology training needed.
The UK neurology curriculum.
This was published in 2022. The curriculum includes six generic capabilities, the same across all postgraduate training programmes; eight clinical capabilities covering internal medicine and the acute medical take; and eight speciality capabilities. I will consider only the last eight.
The eight specialist capabilities are to be able to manage:
- disorders of cognition and consciousness
- headache and pain
- seizures and epilepsy
- inflammatory and infectious disorders
- movement disorders
- neuromuscular disorders
- traumatic brain disorders and patients needing neurorehabilitation
- neuropsychiatric disorders, and functional neurological disorders
The descriptors underneath each are the same for the first seven (a-g). I have condensed and simplified them. The doctor should:
- Understand the anatomy and neurophysiology
- Diagnose and assess clinically, and use investigations appropriately
- Anticipate, recognise, and manage complications
- Work as part of a multidisciplinary team
- Work with and refer to other professionals
The descriptors under the eighth (h) are that the doctors should
- understand how to identify and diagnose
- functional neurological disorders,
- common psychiatric disorders, and
- the spectrum of psychoses
- communicate a diagnosis of functional neurological disorder effectively
- initiate treatment of common psychiatric disorders
- know how to use the Mental Capacity Act and Mental Health Act
The curriculum also contains, in section 3.5, a large eight-page tabulated list of ‘presentations and conditions’, encompassing all likely clinical issues.
Other neurology curricula.
The Australian Neurology Advanced Training Programme covers:
- The clinical approach
- Presenting problems
- Investigations
- Management
The curriculum lists 13 presenting problems that, together, cover the entire field of neurology.
As far as I can tell, Canadian training programmes and curricula emphasise gaining experience over five years, and the same seems to be true in the United States. The European Union of Medical Specialists (UEMS) published the European Training Requirements for Neurology in October 2016. It details the areas of knowledge required and suggests appropriate durations of experience in different clinical areas, but provides little information on high-level outcomes.
Requirements in neurological rehabilitation.
In section 3.5 of the neurology training curriculum, a table lists the ‘key presentations and conditions’ that trainees should expect to learn about; these are clinical contexts. I presented a much briefer list of neurological conditions when I discussed “Neurological rehabilitation: what specialist expertise is needed?”. The post focused on rehabilitation expertise.
The brief list of neurological conditions covered all those traditionally seen in specialist neurology services:
- All disorders affecting the brain and spinal cord, including spinal cord injuries,
- All disorders affecting the peripheral neurological system, including the autonomic nervous system,
- All muscle pathologies.
The disease-specific expertise required in neurological rehabilitation is similar in kind to that required in most other specialities. The challenge arises from the much greater volume associated with neurological diseases, as the range of disabling conditions in neurology is much broader in number and clinical features.
The rehabilitation expert who works mainly, or only, with patients with neurological conditions needs expertise in the following domains. Much of this expertise applies primarily to doctors, but not all, and neurologically experienced therapists, nurses, and other professionals can often recognise concerning features that alter diagnosis or medical management.
Disease diagnosis.
At first sight, this may seem strange. However, in the UK, many patients are not referred from a neurology service, and many have not been seen by a neurologist. Moreover, some patients have seen a neurologist long before being seen by a rehabilitation service, without any review to confirm the accuracy of the initial diagnosis. Therefore, rehabilitation must always critically review the diagnosis, arranging or undertaking further review if there is significant doubt.
Next, for conditions with focal areas of damage, such as stroke, traumatic brain injury, and some neuropathies, the rehabilitation service needs to establish or confirm where in the nervous system the lesions are. The location(s) will focus attention on likely impairments; if unexpected losses are identified, this should alert the team to other possible causes.
Third, if new symptoms or signs occur, the team must establish whether they are part of the known disease or suggest a new and separate problem.
Lastly, a neurological rehabilitation team will often encounter rare diseases and rare presentations of common diseases. The team should have sufficient knowledge to be confident in the diagnosis. More importantly, they should recognise that they are an educational resource for doctors in training. They should establish and maintain close contact with the neurology training programme, both requesting and offering educational sessions.
Disease management.
Many neurological diseases can be controlled, if not cured. The rehabilitation service should be familiar with the treatments used for conditions seen in the service. They can then answer patients’ questions, monitor effectiveness, and inform the neurologist appropriately. Many treatments have side effects, and team members should be alert to common side effects and rare but potentially dangerous adverse events.
Symptomatic treatments.
The rehabilitation team should be expert in all symptomatic treatment, for example, of spasticity, pain, epileptic seizures, psychological distress, poor sleep, etc.
As part of this, the team must respond appropriately to symptoms. Usually, this means not overreacting and not immediately suggesting an investigation or that the disease must be progressing. The team will have much more experience with the longer-term and late natural history of neurological disorders than many neurology teams, becoming familiar with typical symptoms and their fluctuations.
What to expect.
What losses are likely or unlikely, and what will happen in the future? Both questions depend on an accurate disease diagnosis, and the answers require an appreciation of the uncertainty surrounding prognosis.
The rehabilitation team must be aware of the disease and, where relevant, the location of lesions so they are alert to typical losses and difficulties, especially those that may not be evident, such as most cognitive and perceptual problems. This ensures an efficient, effective, targeted initial assessment and formulation, avoiding unnecessary checks for unlikely losses and ensuring that relatively likely losses are not overlooked.
Conversely, if the team discovers an unexpected loss, it should immediately trigger a review of the diagnosis.
The prognostic field depends crucially on the diagnosis, but an individual’s prognosis is never certain; one can only provide a range of possible outcomes and timescales. This applies to all aspects, including life expectancy, functional recovery, and response to interventions.
Prognosis encompasses the ‘natural history’ and the potential risks and benefits of any interventions. As I have emphasised in my General Theory of Rehabilitation, natural history is a slippery concept because people adapt, and others inevitably influence change. Predicting the effect of an intervention is challenging. Randomised trials and other evidence may provide probabilities, but evidence cannot predict for an individual.
Nonetheless, giving a prognosis and knowing it are crucial. For example, there is little point in starting a five-month programme for someone likely to die in 3-6 months; at best, one could start a programme with a review planned for six weeks.
Other aspects.
Neurology training curricula also, quite correctly, encompass the diagnosis and management of emotional, cognitive, behavioural, and psychiatric changes associated with neurological conditions. This should be fully covered during rehabilitation training, but additional training is often appropriate.
Functional neurological disorders are also highlighted. Rehabilitation service professionals should also already have training in functional disorders, though this is a relatively recent development, mostly starting with Long-Covid.
Neurological rehabilitation services tend to see people with more severe and complex problems, especially those with unusual clinical features, such as prosopagnosia, visual hallucinations after infarction of the occipital lobes, and synaesthesia. Rare phenomena can be very frightening for the patient. The professional must be aware that unusual phenomena arise after neurological damage and explain them to the patient.
The UK and Australian curricula also emphasise general competencies, such as communication with patients and working in multidisciplinary teams. These are part of rehabilitation training.
Suggested credential capabilities.
Focusing on a few high-level educational outcomes seems the best way to evaluate training and recognise a trainee’s ability. It avoids rigid adherence to a programme of work across a series of settings and services, as well as the equally rigid approach to assessing a range of separate competencies. It gives trainers and trainees flexibility, and others reassurance that the person can be trusted.
I will propose some entrustable capabilities and suggest how they might be assessed. I recognise that they may seem most appropriate and essential for doctors, but other professionals should have sufficient expertise to understand the issues, contribute to the team process, and improve their own professional performance.
For each capability, the level of entrustability expected will vary across professions, depending on the extent to which neurology-specific expertise affects their clinical practice.
Each capability is prefaced by “The expert rehabilitation professional will …”. The capability gives the outcome, and below that are a selection of behavioural descriptors. Each capability, suitably reworded, should also apply to the service.
Neurological disease
“… review (a) the patient’s diagnosis, the locations affected, and impairments to ensure they are likely correct, and (b) disease-modifying and other drugs to monitor effectiveness and minimise adverse effects.”
Primary focus: neurological diseases and medical professionals.
Descriptors.
- Critically reviews the evidence available in the medical records, obtaining notes from other settings if needed.
- Takes a history from the patient and family, examines the patient, and obtains information relevant to diagnosis from team members.
- Critically and regularly reviews all medication, minimising all centrally-acting drugs unless there are continuing positive indications and evidence of net benefit
- Documents the evidence and gives a formulation of the disease diagnosis, mentioning any areas of uncertainty
- Documents drugs taken, and reasons for continuing or stopping each drug.
Comment:
This neurological capability is essential for the team. The doctor would be the main professional involved, explaining the implications of diagnostic information for rehabilitation. All teams delivering rehabilitation to neurological patients, including teams or single-handed professionals commissioned in the community, must have rapid and unfettered access to a professional with this capability.
Neurological prognosis
“… gives an explicit prognosis for life expectancy, significant possible (2% or greater) disease complications, and the speed and direction of change in functional abilities with estimates of the associated uncertainty.”
Primary focus: disease and disability; all professions
Descriptors.
- Discusses and explains the likely future of the disease, encompassing treatment, complications, and life expectancy.
- Discusses and explains the likely level of activities and social functions that are important to the patient.
- Always highlights the degree of uncertainty, giving possible (2%) upper and lower levels.
- Documents the estimates given and shares all information and the document with the patient.
- All information must be given explicitly, without ambiguity; fears about causing loss of hope are usually misplaced.
Comment.
This mixed neurological and rehabilitation capability is essential when planning rehabilitation and long-term goals with the patient. All team members must have this capability concerning their specific professional focus and should have at least some knowledge across all domains. As always, the service must have this capability, which requires a doctor to discuss likely complications and disease-modifying treatments.
Neurological symptoms
“… initiates and monitors symptomatic treatments of all types (e.g. surgical, orthotic, pharmacological) for all symptoms, including epilepsy, pain and less evident neurological symptoms.”.
Primary focus: disability and distress; all professions.
Descriptors.
- Actively asks about and considers pain and distress at appropriate intervals, discussing options for treatment with the patient and other team members before planning interventions.
- Considers and identifies all likely symptoms, discusses treatment options with the team and the patient, and develops a management plan.
- Documents the presence or absence of symptoms or similar issues that might be expected, and their management if needed.
- Regularly reviews all symptomatic treatments to determine whether they remain necessary and effective, aiming to minimise treatments with significant adverse effects.
Comment.
This is a rehabilitation capability. Nevertheless, a specific capability is required for neurological rehabilitation, as many neurological symptoms are either not recognised or not treated effectively by teams without adequate neurological expertise.
Unusual phenonema
“… is alert for and recognises the many unusual phenomena seen in people with neurological damage, such as visuospatial inattention, visual agnosia, perseveration, confabulation, etc. and identifies and explains them.”
Primary focus: Unusual neurological manifestations, all professions.
Descriptors:
- Avoids overlooking, ignoring, or not understanding the significance of less common phenomena arising from brain damage.
- Listens to, acknowledges, respects and analyses the patient’s reported experiences.
- Reports and discusses any unusual reported experience with other staff, especially the most experienced staff
- Researches the literature about the phenomenon if needed
- Explains that it is a rare but known consequence of brain damage, reassuring the patient and family that the perception is real (valid, not imagined or made up).
Comment.
All team members require this capability, because patients often disclose this type of information only to someone they trust not to say they are mad. The person most likely to recognise the phenomenon is someone who has worked with neurological patients for many years. Among the professions, speech and language therapists, clinical psychologists, and doctors with training in neurology or psychiatry are most likely to be familiar with it.
Discussion
These capabilities have focused on the clinical aspects of neurological disease that are vital for the rehabilitation of patients with neurological disorders. The broader capabilities in the neurological training curriculum included some on psychiatric and functional neurological disorders. These have not been added because training in rehabilitation already covers these conditions; they are already a significant part of rehabilitation’s caseload.
Highlighting pain and epileptic seizures is essential. Many patients will have pain due to neurological disease, such as central pain after a stroke and neuropathic pain after nerve injury. Much pain is not acknowledged or managed effectively. Most patients with brain disease are at risk of seizures, and inevitably, some will have their first seizure while attending for rehabilitation. Rehabilitation teams now know their patients well and can discuss the risks and benefits of treatment, including the potential for impaired cognition.
Although the diagnosis and direct treatment of disease are the primary responsibility of doctors, all professions can benefit from understanding disease. This understanding will improve their formulation and rehabilitation planning and enable them to provide their patients with more information.
Conclusion
There is no published curriculum, credential, or other recognised clinical diploma covering the neurological capabilities needed by professionals and services providing neurological rehabilitation. I have developed four capabilities, each with its own behavioural descriptors. They are untested. They may have face validity (i.e. look reasonably sensible) but require evaluation. Undoubtedly, they can be improved on.