15 | Psychological Issues And SCI

Evaluation

After completing the intervention phase of the Rehab-Cycle® Ingrid's functioning was re-evaluated to assess the extent to which the goals she and her rehabilitation team had set at the beginning of the Rehab-Cycle® were achieved.

The assessment at the end of Ingrid's Rehab-Cycle® concluded five months of rehabilitation following her accident. While the first two months focused on the recovery of physical functioning, the last three months (time period of the Rehab-Cycle®) focused on increasing Ingrid's independence in daily living, including improving her emotional stability and psychological well-being.

The results of the final assessment was documented on the ICF Evaluation Display, a “before and after” visualisation (bar chart) of Ingrid's functioning at the beginning and at the end of the Rehab-Cycle®. It also displays whether the goals Ingrid and her rehabilitation team had set were achieved. See table 4.

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Table 4: ICF Evaluation Display; ICF Qualifier: rate the extent of problems (0 = no problem to 4 = complete problem) in the components of body functions (b), body structures (s), activities and participation (d) and the extent of positive (+) or negative impact of environmental (e) and personal factors (pf); Goal relation: 1, 2, 3, 4 refers to Cycle Goal 1, 2, 3, 4; SP refers to the Service-Program Goal; G refers to the Global Goal; Goal value refers to the ICF qualifier to achieve after an intervention. Goal achievement: + means achieved, - means not achieved.

The assessment at the end of the Rehab-Cycle® revealed that little progress had been made with regard to Ingrid's emotional stability and psychological well-being. Besides having to cope with her spinal cord injury (SCI), Ingrid also had to cope with the break-up of a significant relationship. The break-up with her boyfriend was a major stress factor that led to Ingrid's increased difficulties in handling stress. In particular, it negatively affected her participation in the rehabilitation process. Perceiving her rehabilitation schedule as overwhelming and exhausting, she regularly missed therapy sessions. As a result of continuing problems in coping and handling stress, Ingrid failed to achieve the intervention targets of d240 Handling stress and other psychological demands and coping strategies (personal factor), and consequently also cycle goal 4 ‘psychosocial well-being’. See Ingrid's ICF Evaluation Display (table 4).

It’s all quite hard to accept. The daily interventions just exhaust me. On top of that I am impatient, I feel sad most of the time, and there is lots of uncertainty...Nothing is improving as I had expected, and I constantly feel as though I’m waiting for things to get better...I know I have to be patient, but I find this very difficult to accept.

Ingrid, at the end of the Rehab-Cycle®

Despite this statement from Ingrid, the final assessment did show an increase in her acceptance of her health situation, as compared with the first assessment. This may have been related to Ingrid's expanded knowledge of SCI and improvement in relating to her own body. Both of these intervention targets were namely achieved at the end of the Rehab-Cycle®.

The final assessment also revealed that Ingrid made some modest gains in self-care. Although Ingrid achieved most of the goals set for the intervention targets in self-care, e.g. d510 Washing oneself, d520 Caring for body parts, and d540 Dressing, the progress that was made was from being completely limited (goal value of 4) to being severely limited (goal value of 3). Moreover, she continued to require assistance for these activities. Nevertheless, the rehabilitation team considered cycle goal 3 ‘increased independence in self-care’ as achieved, since the majority of the intervention target goals was met.

The gains in self-care was related to improved use of fingers, hands and arms; gains in fine hand use, and hand and arm use enabled Ingrid to perform some self-care activities with greater skill. Improved use of fingers, hands and arms was based on gains made in b7300 Power of isolated muscles and muscle groups, b755 Involuntary movement reaction functions, and b7603 Supportive functions of arm or leg. Overall, Ingrid's rehabilitation team considered cycle goal 2 ‘improved use of fingers, hands and arms’ as achieved.

"Although Ingrid was able to better her skill at manoeuvring a manual wheelchair, transferring herself from the wheelchair to the bed and vice versa remained a major problem."

In spite of improvements in some of the mobility-related intervention targets e.g. d465 Moving around using equipment, cycle goal 1 ‘improved mobility’ was not reached. Although Ingrid was able to better her skill at manoeuvring a manual wheelchair, transferring herself from the wheelchair to the bed and vice versa remained a major problem. In setting the goal value for mobility at “1” (mild limitations), Ingrid and her rehabilitation team had high hopes for a major improvement in mobility. Impediments to improvements in mobility were Ingrid's difficulty in maintaining her blood pressure and continued spasticity.

With regard to spasticity, Ingrid benefited from the therapy sessions in the pool. Unfortunately, the reduction in spasticity remained only during the therapy session and returned once the intervention stopped.

"...the results of the final assessment of this particular Rehab-Cycle® facilitated the planning of subsequent interventions."

At the end of the Rehab-Cycle® goal achievement and her functioning gains were less then what Ingrid and her rehabilitation team had hoped for. Nevertheless, Ingrid's functioning did improve, even if only slightly, and the results of the final assessment of this particular Rehab-Cycle® facilitated the planning of subsequent interventions.

ICF Research Branch CoordinatorICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI)

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