For each intervention target, appropriate interventions were identified and assigned to one or more of Simon’s rehabilitation team members.

The spectrum of interventions that support the recovery of walking ability is wide, 16 ranging from pharmacological interventions, 24, for example to eliminate spasticity, to interventions that involve physical activity, 5 9 10 12 13 15 for example to improve gait pattern. As mentioned in the section General Introduction, there is inconclusive evidence about the optimal intervention for recovering a person's walking ability. A systematic review of randomised control trials examining various types of locomotor training 15 and pharmacological interventions for spasticity 24 have led to inconclusive results. Despite the lack of evidence in support for one specific therapeutic approach, it seems that a combination of various approaches are commonly employed in clinical practice. 5 9 10 12 14 15

In Simon's case, the rehabilitation team decided to implement a combination of various interventions to address the intervention targets identified. The interventions and the corresponding intervention targets, as well as the rehabilitation team members who were responsible for implementing the interventions were documented on the ICF Intervention Table. See table 4.

Table 4: ICF Intervention Table; PT = Physical Therapist; Spo = Sports Therapist; OT = Occupational Therapist; SW = Social Worker. 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 and personal factors, the plus sign next to the value indicates a facilitator.

The decisions of the rehabilitation team on the best course of action took into account Simon's expressed needs, assessed limitations, recovery progress and and his overall context. The interventions selected were also determined based on available evidence and the rehabilitation team's clinical expertise.

Considering that Simon's medical status had improved considerably and that he had achieved a level of independence in self-care, nursing assistance was predominately required only for managing medications. Given that the cycle goals set focused on mobility/locomotion and hand and arm use, the majority of the interventions in this Rehab-Cycle^® were assigned to the physical, sports and occupational therapists, with several overlapping responsibilities.

"Given that the cycle goals set focused on mobility/locomotion and hand and arm use, the majority of the interventions in this Rehab-Cycle^® were assigned to the physical, sports and occupational therapists, with several overlapping responsibilities..."

To help further improve Simon's walking ability the rehabilitation team implemented various interventions that addressed different aspects of walking ability. For example, medication was administered to help control the spasticity that constrained Simon's locomotion. To address the biomechanical and physiological aspects of locomotion/walking the rehabilitation team implemented a combination of various intervention approaches:

• To improve respiratory functions as well as the control of voluntary movements in the trunk and limbs, Vojta therapy was provided. See box 4.
• To improve exercise tolerance, arm ergometer training was implemented. Though inconclusive, studies have shown that overall training can increase aerobic capacity.
• To reduce pain and increase mobility in the right shoulder, passive and active shoulder exercises as part of manual therapy were conducted.
• To improve standing and reaction functions, body balance training and table tennis were implemented.
• To improve bending and shifting Simon’s centre of gravity, repetitive training of specific activities was employed.
• To improve gait pattern functions, short- and long-distance walking, walking on different terrain and around obstacles, gait training indoors and outdoors including city training was provided.
• To improve the performance in everyday activities requiring locotion, Simon participated in city training that trained him to move around in outdoor and indoor environments other than home and the rehabilitation centre.

Box 4: Vojta Therapy

The Vojta Method, also referred to as “reflex locomotion”, is a therapeutic method of treating physical and neurological disorders. Developed by neurologist Professor Vaclav Vojta reflex locomotion involves applying pressure to defined reflex points on the body while in a lying position (on the stomach, on the back or on the side) to illicit reflex locomotion (or automatic, spontaneous movement responses). An important role is played by optimal joint angles of the extremities and the resistance the therapist employs against a specific body part while the person performs a sequence of movements. The resistance on the body part increases the tension in the corresponding muscles while strengthening the muscular activity in the abdomen, back, arms, and legs.16 25 26 27

Reflex locomotion focuses on the following therapeutic goals:

1. Maintaining body balance and posture when moving
2. Uprighting the body against gravity
3. Goal-directed grasping and stepping movements of the limbs

Vojta therapy was originally applied to children with cerebral palsy and later extended to adolescents and adults as a rehabilitative intervention.25 26 27

Benefits of Vojta therapy include but not limited to:26 27

• Improved mobility of the spine
• Correction of posture problems
• Increase in goal-directed use of hands and feet
• Improved breathing
• Better blood circulation to the skin
• Activation of bowel and bladder regulating functions
• Improved balance and reactions
• Increased efficiency of movements
• Decreased loss of muscle mass

While conclusive evidence for the effectiveness of Vojta therapy is lacking,16 25 Simon's rehabilitation team felt that Vojta therapy would successfully address Simon's problems in respiratory and neuromuscular functions.

"...the rehabilitation team implemented various interventions that addressed different aspects of walking ability..."

Simon’s sports therapist also contributed with a number of interventions, including strength and endurance training in the gym, water therapy to train hand and arm use, and table tennis to train Simon's ability to maintain a standing position. In addition, the sports therapist fostered Simon's participation in sports and leisure.

The occupational therapy interventions addressed cycle goal 2 ‘independence in carrying, moving, and handling objects’, including:

• Specific touch stimulations utilising different materials to improve touch functions
• Repetitive training to improve the control of voluntary movements and joint mobility in the upper extremity
• Therapeutic games that centred on improving fine hand functions, lifting and carrying objects
• Assistance and instruction in activities of daily living, such as preparing meals and dressing, to improve hand and arm use

Moreover, the occupational therapist provided Simon with city training aimed at improving his walking ability indoors and outdoors beyond his familiar environment in and around the rehabilitation centre and home.

In addition to the interventions involving physical activity, the occupational therapist assisted Simon with planning for future employment by coordinating with Simon’s former employer, organising driving lessons and facilitating his weekend home-stays.