"Rehabilitation Potential" - A benefit or a barrier?

Rehabilitation is a process aimed at reducing impairment, increasing independence and autonomy, and enhancing well-being (Longley et al., 2018). For individuals with Acquired Brain Injury, rehabilitation interventions are often key (Cowley et al., 2021). However, access to and the intensity of these interventions frequently hinge on a crucial, yet complex and often debated, clinical judgement: the assessment of rehabilitation potential. As Enderby et al. (2017) observe, "being deemed to have rehabilitation potential or not is critical to the amount and type of rehabilitation a patient will receive".


The Double-Edged Sword of Clinical Judgement

The intention behind assessing rehabilitation potential is to ensure resources are directed toward those most likely to benefit. However, how this concept is understood and applied can paradoxically become a barrier, potentially excluding patients from services that could significantly improve their lives. This article explores the meaning, value, limitations, and risks of the concept, drawing on academic research to inform its clinical use.

Defining Rehabilitation Potential: More Than Just a Simple Prediction

There is no single, universally accepted definition of rehabilitation potential (Cowley et al., 2021). The literature suggests two key dimensions:

  • Prognostication: Predicting who is likely to benefit from rehabilitation (Cowley et al., 2022).

  • Outcome Measurement: Retrospectively identifying improvement and inferring potential from that response (Cunningham et al., 2000).

Historically, the term emerged in the 1950s with physicians rating potential as ‘definite’, ‘slight’, or ‘none’ (Reynolds et al., 1959; Whiting, 1950). Its current usage has evolved:

  • Prognostication involves anticipating therapy effectiveness, often early in the care pathway (Burton et al., 2015), especially in stroke care.

  • Outcome-based use reflects improvement achieved post-rehabilitation, such as measurable gains in ADLs (Cunningham et al., 2000).

This dual usage makes rehabilitation potential the "clinical currency" of access to services (Cunningham et al., 2000), even for individuals with significant impairments.

Despite its central role, the term remains ambiguous. Definitions vary widely, from functional gains (Wade, 2016) to psychological readiness (Wade, 2016) and ADL restoration (Rentz, 1991). Shun et al. (2017) note that "the concept is rarely defined" in a consistent, universally accepted manner.

Lack of Standardisation

Burton et al. (2015) stress that the term is "imprecise, inadequately defined and influenced by the non-clinical context." Without clear tools or algorithms, decisions rely on subjective judgement, which can lead to inconsistency and inequity.

Why Assess Rehabilitation Potential?

Clinicians assess rehabilitation potential for several key reasons:

  • Guiding Treatment Decisions: Determining suitability and intensity of rehabilitation (Enderby et al., 2017; Hakkennes et al., 2011).

  • Personalising Therapy: Tailoring therapy to the individual, especially after stroke (Chang et al., 2020).

  • Predicting Outcomes: Setting realistic goals and expectations (Chang et al., 2020).

  • Resource Allocation: Although often implicit, assessments affect access to finite rehabilitation resources (Enderby et al., 2017).

As Shun et al. (2017) observe, such decisions "can determine what rehabilitation services a patient can access". And, as Zhu et al. (2007) argue, "the most critical consequence to assessing a patient's rehabilitation potential is the impact on the patient's opportunity to access post-acute rehabilitation services."

The Assessment Process: Complex and Multifactorial

There is no standardised, operationalised model or clinical guideline for assessing rehabilitation potential (Burton et al., 2015). Instead, decisions are based on complex multidisciplinary reasoning involving:

  • Personal Factors: Psychological readiness, motivation (Cunningham et al., 2000).

  • Clinical Factors: Medical stability, frailty, and neurological functioning (Chang et al., 2020).

  • Contextual Factors: Availability of services and local policy (Cunningham et al., 2000; Enderby et al., 2017).

Mosqueda (1993) recommended a biopsychosocial model, but subsequent studies (Chang et al., 2020) highlight that psychological and social dimensions are often neglected. While some tools exist (Mosqueda, 1993), validated, widely used tools are rare. Reassessment over time is crucial: early assessments may miss potential that develops later (Enderby et al., 2017; Zhu et al., 2007).

Challenges, Criticisms, and the Barrier Effect

Several problems undermine the reliability and fairness of rehabilitation potential assessments:

  • Prediction is Difficult: Some clinicians view it as an "impossible task" (Burton et al., 2015). Patients may defy initial expectations (Enderby et al., 2017).

  • Lack of Clarity: The term's imprecision results in inconsistent practice and practitioner discomfort (Burton et al., 2015).

  • Risk of Harm: Labelling a patient as having "no potential" can lead to permanent exclusion from beneficial services. Wade (2016) warns that this may be considered a form of harm.

This gatekeeping function carries significant ethical weight, particularly when rooted in assumptions or flawed initial assessments. The very concept, when misapplied, can exclude rather than enable.

Concluding Thoughts

Rehabilitation potential is a vital yet problematic clinical concept. While intended to optimise care and resource use, its vague definition and subjective application risks excluding patients from transformative interventions. A clearer, more structured, and person-centred approach is urgently needed. As research suggests, reassessment over time, a biopsychosocial lens, and humility in prognostication are essential steps toward using this concept to support rather than hinder recovery.

References

  • Burton, C. R., Horne, M., Woodward-Nutt, K., Bowen, A., & Tyrrell, P. J. (2015). What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services. Disability and Rehabilitation, 37(21), 1955-1960.

  • Chang, W. H., Kim, Y. H., Bang, D. H., & Kim, S. T. (2020). Rehabilitation potential in stroke patients: A narrative review. Journal of Clinical Neurology, 16(4), 520-528.

  • Cowley, A., Goldberg, S. E., Barker, R. O., et al. (2021). The concept and evaluation of rehabilitation potential in older people: A systematic review. Age and Ageing, 50(2), 318-327.

  • Cunningham, L. N., et al. (2000). Predictors of functional improvement and success of rehabilitation in patients with brain injury. American Journal of Physical Medicine & Rehabilitation, 79(6), 516-523.

  • Enderby, P., et al. (2017). Why do we need a rehabilitation strategy for older people? Age and Ageing, 46(3), 357-360.

  • Hakkennes, S., Hill, K. D., & Brock, K. (2011). Selection for inpatient rehabilitation: Exploring variation in practice. Journal of Rehabilitation Medicine, 43(11), 884-889.

  • Longley, V., Peters, S., Swarbrick, C., & Bowen, A. (2018). What influences decisions about ongoing stroke rehabilitation for patients with palliative care needs? A qualitative study. BMJ Open, 8(2), e018453.

  • Mosqueda, L. (1993). Rehabilitation potential in the elderly. Western Journal of Medicine, 159(6), 710.

  • Reynolds, F. H. M., et al. (1959). Physical medicine and rehabilitation for the aged. Journal of Chronic Diseases, 9(5), 489-496.

  • Shun, D. A., et al. (2017). Exploring clinical decisions of rehabilitation potential. Physiotherapy Research International, 22(4), e1686.

  • Wade, D. T. (2016). Rehabilitation: a new approach. Part four: A new paradigm, and its implications. Clinical Rehabilitation, 30(2), 109-118.

  • Whiting, M. (1950). The role of rehabilitation in geriatric medicine. The Lancet, 255(6609), 69–72.

  • Zhu, C. W., et al. (2007). Effectiveness of rehabilitation potential assessments in post-acute care. Archives of Physical Medicine and Rehabilitation, 88(9), 1221-1226.

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