Persons with spinal cord injury (SCI) face extraordinary challenges beyond adapting to the physical aspects of their injury. They may also be confronted with functional limitations, and most importantly restrictions in participation within his or her physical and psychosocial environment. Considering this, a key goal of rehabilitation of persons with SCI is the reintegration into the community.1 2 3

Viewed in the context of the World Health Organization's International Classification of Functioning, Disability and Health (ICF), 4 a conceptual framework that reflects the dynamic interaction between body functions, body structures, and activities and participation of an individual within a social and environmental context, rehabilitation employs interventions that aim to optimise functioning starting in the acute phase and seen as continuing into community life. 5 6

SCI causes tremendous social and participatory disruptions in the daily lives of those living with SCI. Community reintegration (sometimes referred to as “community integration” or "community participation" 3 is a process that enhances a person's return home from a hospital or rehabilitation centre by minimising such disruptions and facilitating access to community-based programs and existing resources.1 This process of preparing a person for community reintegration can begin early in rehabilitation and involve different stakeholders including professionals of various disciplines.

Box 1 | Defining Community Reintegration in Persons with Spinal Cord Injury

Community reintegration is a complex concept that has been described as “the assumption or resumption of [a] culturally and developmentally appropriate social role” and “full inclusion and participation...in the physical and psychosocial environment" 2 or returning to "pre-injury roles and activities". 7 While the ICF does not specifically define community reintegration, many ICF categories are useful in framing what the process involves. For example, the ICF includes a chapter on major life areas, in which education, work/employment and economic life are addressed. Other relevant chapters address mobility, domestic life, interpersonal relationships, community life, recreation and leisure, religion and spirituality, human rights, and political life and citizenship. The ICF section on environmental factors highlight factors such as (but not limited to) support from family and other persons, accessibility of buildings and other physical environments, or health and other services. 4

Success of community reintegration is not easy to describe or measure. Norms in current multicultural societies are often elusive and unclear, covering a range of social behaviours at multiple levels. Nevertheless, it is clear that for persons with severe disability, such as resulting from SCI, community reintegration poses a challenge, involving a multi-faceted interaction between internal (personal) and external (environmental) factors, barriers and opportunities. Figure 1 is a simplified model that breaks down some of the interrelated elements that can promote or hinder community reintegration. 7

Figure 1. Interrelated elements that can promote or hinder community reintegration

Given the complexity of community reintegration, the challenge for a rehabilitation team is not only to help minimie the person's experience of disability, but also to decide on the appropriate time point to start community reintegration efforts for a specific person with SCI and to provide individualised guidance and support so that the person is empowered to gain the independence necessary to live in the community. 8

Factors that Impact Community Reintegration

Although increasing severity of a person's injury seems to negatively impact on the execution of many activities of daily living, 9 neither the type nor the severity of an SCI is a good predictor of long-term outcome. 2 The initial stage of medical rehabilitation generally aims to improve injury-related physical functioning. Nevertheless, interventions that focus only on physical functioning may not adequately prepare persons with SCI for community reintegration. 10 Success in community reintegration depends not only on a person's physical functioning but also on social participation and interrelated contextual factors. 8 9

There is a range of factors that can facilitate or hinder the transition into the community. 2 8 11

Examples of facilitating factors include:

• Support of family and friends
• Peer mentoring
• Returning to a familiar community or neighbourhood
• Availability of accessible and desirable housing
• Access to personal means of transportation
• Information on available services and resources in the community
• Availability of affordable community services and resources (including medical and social services)
• Personal factors such as self-esteem, coping style, assertiveness, self-assurance and self-sufficiency
• Self-determination

Examples of hindering factors (or barriers) include:

• Lack of general physical accessibility of services, living arrangements, etc.
• Low income level
• High cost of services, supplies and equipment
• Chronic pain and other health-related complications
• Negative and limiting societal attitudes including those from rehabilitation professionals

Issues to Address in Community Reintegration

Issues that should be addressed in community reintegration of a person with SCI include (but not limited to): 8 9

• Housing and household duties: Is there accessible and desirable housing available? Is personal assistance or assistive devices required to complete housework and outdoor maintenance?
• Mobility: Is there accessible public transportation available? How can driving be facilitated?
• Recreation: What cultural, sports and other recreational activities are accessible i.e. accessible location as well as transportation? Is personal assistance or assistive devices required to participate?
• Health maintenance: How can persons with SCI stay physically fit in the community? What resources are available for maintaining fitness?
• Pain management: What resources and strategies are available in the community for pain management?
• Sexuality: What resources and services e.g. psychosocial counselling are available in the community to address sexuality issues?
• Social supports: To what extent is support provided by family and friends? Is peer counselling and mentoring available? Are psychological services available?
• Employment: What can be done to optimize work participation?

For example, a vocational rehabilitation (VR) strategy to help return a person with SCI back to work should take into consideration the person's specific skills, workplace accessibility, availability of accessible transportation, possible needs e.g. continuing education, and possible work accommodations e.g. working from home. In addition, the VR strategy may include the reassessment of the person's vocational goals (which may change or develop over time) and planning for a new career. 8

Mobility and accessibility issues (physical barriers and lack of accessible personal and public transportation) can also have a significant impact on a person's participation in social activities. 8

Ideally the interventions that are implemented to deal with the multi-faceted issues faced in community reintegration are tailored to the individual person and empowers the person to become more independent. 8 10 11

The implementation of person-centred and empowering rehabilitative interventions is illustrated in the case study of Martin, a 26-year old man with SCI who had been engaged in a VR program at an inpatient rehabilitation centre. Martin's case shows how rehabilitation can help facilitate the transition from the hospital back into the community as well as long-term reintegration.