07 | Return-to-Work

Hippotherapy to Address Issues of Muscle Tone in the Lower Body

Assignment and Intervention

Every intervention target that was determined during the assessment phase of the Rehab-Cycle® was addressed by specific interventions allocated to corresponding members of the rehabilitation team during the assignment phase of the Rehab-Cycle®.

A medical doctor, nurse, physical therapist, occupational therapist, psychologist, social worker and vocational rehabilitation (VR) counsellor were assigned to each of the intervention targets documented on Martin's ICF Categorical Profile. Each rehabilitation team member took the responsibility for choosing and providing appropriate interventions to address the specific intervention target(s) allocated to them during the intervention phase of the Rehab-Cycle®. To facilitate coordination of the interventions, and individual responsibilities and resources of the multidisciplinary rehabilitation team, an ICF Intervention Table was created. See table 5. Martin's ICF Intervention Table shows all the intervention targets defined for Martin (as represented by ICF categories), the interventions themselves and the corresponding team member who was assigned to address each intervention target . 

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Table 5: ICF Intervention Table; Doc = Physician; PT = Physical Therapist; OT = Occupational Therapist; Psych = Psychologist; SW = Social Worker; VR = Vocational Rehabilitation Counsellor. The first value refers to the rating at the initial assessment, the goal value refers to the rating that should be achieved after the intervention, and the final value refers to the actual rating at the second assessment or evaluation. ICF qualifiers were used to determine these ratings (0 = no problem to 4 = complete problem) in the intervention targets. For the intervention targets representing the environmental factors, the plus sign next to the value indicates a facilitator.

Aspiring toward Vocational Reintegration  – The Interventions

To tackle Martin's aspiration to return to work (as reflected in his cycle goal 'vocational reintegration'), 'remunerative employment' was listed as a target for which the interventions of VR counselling and training were provided exclusively by the VR counsellor. These interventions corresponded to the activities executed during the activation phase of VR. At the beginning of the activation phase that started prior to the start of this Rehab-Cycle®, Martin took a typing course as a pre-requisite for participating in a computer course. Although Martin expressed initial misgivings, Martin and the VR counsellor agreed that he would receive computer training along with VR counselling. Martin's computer training began with a word processing course and ended one month later with a class on the basics of creating and using spreadsheets.

"...Martin and the VR counsellor agreed that he would receive computer training along with VR counselling."

Although VR counselling and training were the only interventions defined for addressing the intervention target of 'remunerative employment', and 'remunerative employment' was the only intervention target that was documented as corresponding to the cycle goal of 'vocational reintegration', this was not the only intervention target nor the only cycle goal that was relevant for successful return to work. The interventions related to the cycle goals of 'mobility' and 'self-care' were also very relevant to enhancing Martin's vocational potential. For instance, the various aspects of mobility  –  from the body functions perspective e.g. improvement of muscle power functions, to the perspective of activities and participation e.g. being able to move around independently using the wheelchair and driving motorised vehicles  – would affect Martin's ability to get to and from work as well as impact his mobility at the workplace. To improve his mobility, specifically to increase the power of isolated muscles and muscle groups and the muscles in his trunk, the physical therapist guided Martin's daily physical training using an exercise circuit, while the occupational therapist provided instruction and training to increase Martin's outdoor mobility using different equipment like the wheelchair or the Swiss-TracTM, as well as counselling on vehicle adaptation and driver training.

The nurse assisted and instructed Martin on optimal self-care strategies with the aim of enabling him to regain independence in this area of functioning. Being able to adequately execute self-care activities e.g. washing, dressing and regulating defecation are essential for successful work participation. In addition, the psychologist met Martin every week to support him in coping with his spinal cord injury and in increasing his self-confidence.

"Being able to adequately execute self-care activities...are essential for successful work participation."

During the intervention phase of Martin's Rehab-Cycle®, the flexibility to adapt the interventions to changes in Martin's functioning proved to be essential. For example, due to increasing spasticity experienced by Martin, hippotherapy, a form of physical, occupational and speech therapy using the physiological effects of riding on a horse, the use of a sauna, and instructions on specific spasticity-reducing body positions were implemented. 

The outcomes of the interventions and the change in Martin's functioning status were evaluated in the next phase of the Rehab-Cycle®  – the evaluation phase.

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