Assessment in Rehabilitation.
Last updated: Marh 19, 2025
The Oxford English Dictionary describes the usual meaning of the verb, to assess, as being to “evaluate or estimate the nature, ability, or quality of” something. [OED] Rehabilitation has subverted and extended the original meaning of the verb, to assess, which was related entirely to a financial process for calculating how much tax a person should pay. In rehabilitation, clinicians use both the verb and the noun almost interchangeably with ‘to measure’. In addition, the words have taken on meanings like ‘to diagnose’ and ‘diagnosis’ in medicine. This page disentangles the various processes encompassed in a rehabilitation assessment and considers the goals of the assessment process. It shows that both measurement and assessment, as used in rehabilitation, involve collecting data and that the difference is in the purposes. Measurement quantifies against a standard; assessment discovers underlying causes and consequences. Rehabilitation assessment leads to formulation and planning, just as the State’s financial assessment of you leads to taxation and paying the State.
Table of Contents
Introduction
All healthcare is a problem-solving activity aiming to improve people’s quality of life or duration. All problem-solving starts with someone acquiring data to clarify the person’s problems and determine the causes and how the assessor might resolve them.
Rehabilitation is like all healthcare in that regard. However, it differs fundamentally from most other healthcare. Its analytic framework uses the biopsychosocial model of illness (here). It focuses on activities and how the person interacts with their environment rather than pathology, an abnormality within the body.
General systems theory recognises that systems can be open or closed [von Bertalanffy 1950][Charissa Cordon 2013]. The distinction is not binary, and there are degrees of openness. The biomedical healthcare model offers a closed problem-solving approach, where all aspects of an illness are attributed to a single disease. In contrast, the rehabilitation approach accepts that many factors from many domains influence a person’s illness, and there is no single cause.
Diagnostic data collection
Biomedical healthcare is mainly concerned with identifying and treating perceived bodily abnormalities. It starts from symptoms and signs and adds investigations if needed, culminating in a diagnosis. The data collected all relate to the person and their body, and the process is diagnosing to achieve a single causal diagnosis with a single treatment. Although the amount of data needed may be large, it is constrained mainly to the person. It is a relatively closed problem.
Anyone interested in medical diagnosis should read this online chapter on the diagnostic process from a committee on diagnostic errors in health care.
In contrast, rehabilitation needs to understand why the person’s activities are limited and how the situation can be improved. Goal-directed behaviours (activities) are influenced by a wide range of factors spanning the whole holistic biopsychosocial framework. By comparison, the information needed to analyse the situation is vast, and it will extend into many domains away from the person. It is a hugely open problem.
Consequently, it is no surprise that rehabilitation is interested in different data types. Given its prioritisation of activities, it uses a wider range of methods and investigations to collect data than most biomedical areas of healthcare. It is also no surprise that different terminology has evolved. In evolutionary terms, rehabilitation became isolated from mainstream healthcare and speciated, at least in its vocabulary. However, as with species, there are still similarities, and one may learn much by comparing the processes and terminology.
For example, biomedical diagnostic procedures are often overused without good reason, and clinicians can be overwhelmed with too much data. Much of the data is not helpful, and some suggest other problems unrelated to the presenting problem. It leads to overdiagnosis and new conditions with little evidence to support them.
Rehabilitation is not immune to this problem. Teams can become obsessed with collecting standardised data, often for no better reason than ‘our professional standards require us to do this’ or a consensus guideline suggests it. Ironically, the focus on collecting detailed data about a few domains of a patient’s situation may be associated with a lack of information about other significant and vital areas of the biopsychosocial model. It is usually better to have some knowledge about every domain, albeit in less detail. As with biomedical healthcare, incidental and irrelevant abnormalities may be detected.
In all healthcare, the solution is the same. All data should be collected for a specific purpose, and that purpose should lead to detectable benefits for a patient. If having an item of data will not alter any aspect of patient care, it should not be collected.
Therefore, the starting point must be: What are the assessment goals in rehabilitation? Why should we bother? There are goals, and we should worry, but only sufficiently to achieve them.
Goals of assessment
The assessment’s purpose and overall goal are to enable a sufficiently complete formulation, allowing the clinician to start safe and effective interventions. This means we must identify the problems and their causes. The word ‘problem’ refers primarily to limitations on activities or impairments, such as pain, directly affecting the patient. The term cause relates to anything that underlies the problems. The analysis undertaken when formulating the situation will be based on the holistic, biopsychosocial model.
In this context, the data collection process may achieve the following objectives, to discover:
- the problems the patient considers himself to have
- the issues others think the patient has
- any difficulties not identified by the patient or others
- the causes the patient and others believe have led to their problems
- factors associated with and possibly causing or exacerbating the problems
- factors that could be altered to lead to a reduction in problems
- factors that suggest a treatment is more (or less) likely to help.
We will consider each goal briefly.
The patient's perspective.
It is vital to start any assessment by asking the patient to tell you, in their own words, what they think their problems are. And it is crucial just to let them explain without interruption. They are the touchstone, and all other views must be related to the patient’s viewpoint. You are unlikely to succeed if you do not understand what the patient believes their problem is, the explanations they have for their problems, and their expectations of you and the service.
The perspective of others
This is also important. First, other people, such as family, carers, or other professionals, can draw attention to matters that the patient may not be able to because of poor insight, confusion, communication problems, reluctance, etc.
Second, they reveal the impact of the patient’s difficulties on the informant, which may give invaluable insight into their motivations and attitudes when considering rehabilitation goals. Last, other people (family, employers, funders) may have very different priorities for and expectations of you and your team.
Team perspectives
When there are no friends or relatives, team members may identify problems not admitted or forgotten by the patient. I well recall first realising a patient suffered incontinence when, on a home visit, I sat on a wet patch in an armchair!
However, it is important to avoid assuming that any problems a professional identifies should be managed. The patient may be aware but not concerned, or the problem might be long-standing, considered normal, or not worth bothering with. Everyone must also be alert to the professional interests of other team members and the risk of them imposing their views upon the situation and its solutions. Equally, you need to avoid assuming the problems you are interested in are as important to the patient or others.
Aetiology and causation.
The observed or reported problems will usually have several underlying causes, including, but not always, some specific diseases. There will always be many factors influencing the problem, worsening or ameliorating it sometimes quite significantly.
Identifying these factors across the biopsychosocial model requires a mixture of looking for what is likely and systematically exploring each domain sufficiently to identify significant influences, especially those that can be altered to improve the outcome.
Separating causative factors from contributing factors is not always possible, and the history will be more likely to identify causation.
However, the patient and many others will expect an explanation that includes causation, and it is wise to consider carefully which factors, if any, you may suggest as causative. It is equally essential to consider how you will phrase the relationships.
Moderating and influencing factors
One should investigate further when there is an unexpected observation, such as a greater degree of limitation on mobility than the observed weakness would suggest likely. The same applies to more extraordinary ability than observed losses would suggest is possible.
An exemplary rehabilitation professional will always be curious about observations, and the wish to understand and explain are vital characteristics. Not everything can be explained, but seeking explanations can disclose unsuspected information. Curiosity keeps your critical faculties active.
Treatable factors
One obvious goal of the assessment is to identify what can be done to help, which usually means thinking of a factor that can be altered in some way. Some will be obvious once you have thought of it, but it is easy to miss the obvious.
For example, in 1986, I visited the Astley Ainslie Hospital, the Edinburgh Specialist Rehabilitation Centre and saw a patient who was delighted with his rehabilitation. He had severe ataxia due to tearing of his cerebellar peduncles when he suffered a traumatic brain injury. The regional neurosciences centre tried to teach him to walk for two months after the injury, and he had become increasingly angry. They attributed his anger to frontal brain damage. When he arrived in Edinburgh, he had been given an electric wheelchair; he became a friendly, happy man fully engaged in all other aspects of his rehabilitation.
Thus, the assessment process must be reiterative. It should look for common factors associated with a difficulty and then work on less common causes, always being alert to clues that may reveal an unexpected treatable factor.
Prognostic factors
Few, if any, factors are known that predict who will benefit more than (or less than) others from an intervention. I explored this in a post discussing Rehabilitation Potential, and I concluded:
“I draw the following conclusions. The concept of rehabilitation potential is fatally flawed because the evidence suggests that any person with a disability may benefit from rehabilitation. There is no evidence to allow rational, fair selection into rehabilitation services. All criteria reflect personal (or team) prejudice and are used by commissioners to justify rationing.”
Assessment in rehabilitation .
How do healthcare professionals collect data to make a diagnosis. In biomedical care when identifying disease, experienced doctors use “a process of hypothesis generation and verification”. This is a practical approach when solving a closed problem. It is usually achieved by asking short, closed questions rather than listening. Screening for organ dysfunction with a rapid set of questions is also possible.
Diagnosis in rehabilitation is more challenging because there is never a single solution; the professional will explore several hypotheses. For example, a person’s limited mobility may arise from hip pain, reduced motor control after a stroke, embarrassment by their slow, limping gait, uneven ground, the lack of a walking aid, and fatigue. A wide range of data will be needed, some shared across hypotheses but most not. Moreover, new hypotheses may arise as the assessment progresses, such as a fear of falling adding to their problem.
Thus, a systematic approach is less straightforward, though not impossible. For example, one can work through a typical day, asking if there are any difficulties with sleep, getting out of bed, using the toilet, washing and dressing, etc. Alternatively, one can run through significant areas of activity such as personal care (the Barthel ADL index), domestic activities, work, community activities, etc. If difficulties are reported, one needs qualitative information about how an activity is limited and its consequences, not simply what it is and by how much.
I suspect that most assessments in rehabilitation follow a systematic, structured form tailored to the typical patient caseload. The challenge is avoiding excessive focus on collecting data, overlooking the purpose. with less thought about why. The approach that works well for doctors (and others) interested in identifying a single disease has been taken on without critical evaluation or realising that a rehabilitation assessment has utterly different goals.
Recommended approach.
For assessment in rehabilitation, my starting points are:
- only the patient knows what their problems are, even if they do not appreciate the full extent
- the patient is more likely to know what factors are relevant than the professional, even if they have not explicitly formulated them in that way
Therefore, the best approach is to let the patient tell you everything themselves. This approach is ‘active listening‘, where you let the patient tell you, not in a structured way, but freely following their thoughts. This approach may sound risky, but in my experience, it is often efficient and gives a great depth of information. The secret is to keep quiet, avoid asking any questions as far as possible, and allow the person and, if present, family members to tell you. (Also, see here for a second reference.)
You should listen, take extensive notes, and ask questions only to clarify something crucial. All other inquiries should wait. If you have time, you may structure your notes within the biopsychosocial framework.
A patient usually tells you almost everything you need to know, but the information is structured around their concerns and beliefs—it does not follow any other logical structure. However, the opportunity to discover the patient’s perspective is lost as soon as one tries to structure the conversation. Their cooperation and interest are probably lost because they perceive that you are following your interests and are not interested in their concerns.
Once the patient and the family have finished, you should review your notes to identify questions that need answering and ask about any areas of the biopsychosocial model that were missed. The page on patient-centred assessment provides much more detail, and its content is summarised in the MindMap below.
Structured assessment in rehabilitation
Listening actively provides a mass of vital information that the listener needs. The challenge is to record the information so that others can use it and find what they want quickly. With practice and experience, one can structure information as it emerges roughly on paper, using the headings from the different domains of the biopsychosocial model. Structuring your notes will often highlight areas you need to investigate.
Each multiprofessional team must discuss and agree on the best way to structure information in their clinical record. I can only put forward some thoughts. For example, the solution must be tailored to the work of the service or team. What is suitable for a high-volume outpatient service may not suit a low-volume inpatient service that sees complex patients or a day hospital service that has seen patients over many years.
The solution must use the biopsychosocial model as an underlying framework, both in terms of terminology and structure, so that anyone joining the team will immediately understand how the record is organised and what the words mean. I suggest that the OCCAM (see below) might form a useful summary on one or two pages. It could also create a valuable case complexity measure when asking for new resources or justifying existing ones.
The Oxford Case Complexity Assessment Measure, the OCCAM, is a structured record of items from all parts of the biopsychosocial model of illness with a few added items. It is based on another measure, the INTERMED, which has extensive evidence supporting its use as a case complexity measure. After listening to a patient, you will likely have the information to complete most items. If you bear it in mind when listening, you will occasionally ask a question to obtain specific additional information.
However, the OCCAM should not be used to structure the clinical history or examination, as that would disrupt the flow and reduce the information provided. Afterwards, you can ask specific questions to clarify points and fill in the lacunae. The OCCAM is a structured way to record and quantify complexity, and it inevitably ensures that each critical domain of the model is considered.
You can see (and download) the OCCAM here and download a spreadsheet for recording scores, sub-totals, and totals for multiple patients here.
Conclusion
On this page, I have suggested that the rehabilitation assessment process is equivalent to the medical diagnostic process, with one big difference. Medical diagnosis presents a closed problem that aims to identify a single disease within the body that is causing the patient’s problems. Everything focuses on that goal. Rehabilitation assessment is the opposite. It is an open problem with no single solution. It aims to understand a patient’s circumstances in their entirety so that it can resolve or reduce the issues they present with. Rehabilitation’s scope has no boundaries. Thus, the medical diagnostic process can use a hypothesis-testing approach, gradually eliminating possible diagnoses, but rehabilitation cannot. The goal of the rehabilitation assessment is to achieve a suitable formulation of the patient’s situation – what the problems are and how they arise. The formulation will necessarily be based on a holistic model of illness, the biopsychosocial model of illness, which enforces a patient-centred approach described on a second page here. The only efficient and effective way to achieve this is through listening to the patient, so-called active listening. Last, the information collected should be recorded in a structured way so that other team members can easily read it and find what they need to know. Naturally, the structure of the clinical record will need to be based on the biopsychosocial model of illness.
Table of pages on assessment
| Item/link | Title | Comment |
|---|---|---|
| Assess-01 | Assessment in rehabilitation. | The page in the 'process of rehabilitation' part of 'What is rehab'. It discusses the goals and assessment from several perspectives. |
| Assess-02 | Person-centred assessment. | This page uses Robert Smith's article to explain how and why sing the biopsychosocial modeel as a framework improves rehabilitation. |
| Assess-03 | B3a - Assessment competency | A page within the syllabus discuss what being competent means and how to achieeve it. |
| Assess-04 | Assessment competency | A blog post descibing an epiphany; I suddenly reaalised that th syllabus lacked an evaluation competency. |
| Assess-05 | Patient-centred assessment | Part of the 'what is rehab' section. I expand from the biopsychosocial model using a model of communication (four habits) to consider assessment/data collection. |