Factors that likely influence rehabilitation potential and recovery and predictions of the same include previous abilities, age at onset/injury, individuality, drive, underlying motivation, health, support, environment, the exact nature of injury and the exact nature of individual pre-morbid neurology.

Other influencers include our understanding of the brain, how it works, how it repairs and how it responds in the short, medium and long term after injury.

Alongside our developing but yet still poor understanding of how exactly treatments and therapies work, even where we ‘know’ that they do, it is therefore impossible to pinpoint and prescribe a very exact treatment or approach for a specific individual’s neurology, type of insult and likely natural recovery.

This makes us very cautious on positive predictions of recovery. We would hate to promise and not deliver, we don’t want to build ‘false hope’ to disappoint or let down clients and their loved ones. Thus we tend to err on the side of caution.

Added to this, it can be hardest of all to predict at earlier stages and a bit easier to see the trajectory as things develop over time.

Most clients and their nearest and dearest are new to the complex world of neurological injuries. Often they are happy at the initial survival when it was perhaps touch and go for a while.

Later down the line conversations of rehab potential are often had, commonly when services are working toward discharge or a slower stream rehab scenario. At this stage, clients and families often feel we are writing them off.

They see potential. Disagreements can ensue.

This is difficult – we don’t want to give false hope, yet we do (presumably) want each person to progress as far as possible.

I’ve never in my 30-plus years in this field met a therapist who didn’t want their patients to achieve the best possible results. Yet I have observed many differences of opinion between families and treating professionals, between professionals themselves and between predictions and actual eventual results.

This leads me to think of all predictions of potential – from professionals and non-professionals – as hypotheses.

Previously I listed the vast array of factors we have yet to fully understand, but which in combination must be what gives rise to the variety and individuality of each neurological presentation we meet.

From these many influencing elements, we must draw up hypotheses – and it is perfectly possible to have many and opposing hypotheses at any one time.

Hypotheses are a tool by which it is possible to identify each ‘best guess’ based on the information and understanding that is available.

Once proposed, the function of the hypothesis is to act as a statement of a possible outcome which can then be tested to see if it can be supported or not.

The language of the hypothesis gives a clear, inclusive and non-confrontational way to discuss differences of opinion.

In effect it is face-saving if outcomes are not what any hypothesiser suggested.

It allows everyone to feel heard and that their thoughts and observations have been considered.

Even more importantly, it allows goals and treatment plans to be built around testing the hypotheses that have evolved, lessening the risk of the client missing out on opportunities to improve.

Where progress is not made as hoped for, it facilitates healthier conversations and supports adjustment; in a way that doesn’t happen when the client and family remain at odds with treating professionals because they don’t feel heard and may feel they see things that the teams do not.

Families know their person and do indeed see things – consider, for example, the scenario in rehab centres and care homes especially, where there are many people on and off shift over the course of a few months.

Some – many – may know the client pretty well, but they are not spending several hours every day between the times when care and rehab inputs may shape what happens.

The family member who comes in – and regularly spends perhaps many hours with the person – often reports observations which differ from those of the professionals.

When not seen through professional eyes with their ‘trained assessment filters’, this information is often given less weight.

In my experience it would often have been wrong to dismiss this potentially valuable additional information as though the family see through ‘hope filters’ that are so distorting they cannot be a true measure.

I therefore make an argument to:
> Hypothesise
> Hunt down potential in whatever time you have to spend – robustly test any reasonable hypotheses proposed
> Measure and record directly to support or not a hypothesis
> Set timeframes for testing each hypothesis
> Educate clients and families about what makes a hypothesis – they may need to hypothesise in the longer term
> Allow those involved across the team and, beyond, have alternative opposite hypotheses – just test them!

Let’s stop thinking we know and start experimenting more with what is in front of us, using the evidence base we have but being mindful that we are still a long way from understanding enough to preach rehabilitation potential as a ‘truth’.

Vicki Gilman is a neurorehabilitationist and case manager at Social Return Case Management.