Based on the assessment and goal-setting an intervention plan was created (Figure 3). To improve toileting, Marco’s doctor and nurse focused on interventions relating to defecation and urination functions (including regulation). He was instructed in the use of urinal condoms that would give him more control and freedom for relieving his bladder.
To improve his defecation functions, drug suppositories were prescribed and Marco learned to defecate manually using his fingers and hygiene (by Marco’s nurse). Additionally, to improve bowel movement, training in performing colon massage was undertaken. These training and counseling sessions also included topics such as diet (by the nutritionist),
As they showed me how to manually defecate, I thought, “I just don’t want to do this, I can’t” – it was really hard to accept. It’s still unpleasant, but I have to do it.
Defecating is really tiring and unpleasant and can take a very long time, especially when you use suppositories which “empty” the whole bowel. In the beginning I had no sensitivity at all and couldn’t tell when I need to go or when I’m finished. Using suppositories every second day at least gave me the possibility to plan ahead.
Regular urological examinations (including cystometry) were performed to monitor the progress and detect potential secondary conditions as soon as possible. Marco continued the use of the urinary condom. However, over the course due to high bladder pressure resulting from detrusor hyperactivity, urinating caused the condom to dislodge several times a week. This especially was the case when Marco mobilized or during the night while sleeping. Thus, a new option was needed.
While detrusor muscle paralyzation (with Botox) along with catheterization was one possibility, Marco decided against it. This was not only due to the discomfort of being catheterized, but especially because the insertion of the catheter into the urethra was painful for Marco. Thus, the alternative option was chosen; a minor surgical intervention was performed to place a stent in the urethra to provide internal support, allowing urination to occur more freely by holding the external sphincter open.
Marco’s physical and sports therapists focused on interventions that would improve mobility, involving a wide range of activities, with the hopes of optimizing both his capacity and performance. At the time however it remained unclear to what degree he would or could improve. The interventions started at the beginning at a low level, but could be increased during the rehabilitation program. Exercise tolerance functions were targeted through fitness training and swimming; to improve muscle power functions Marco performed specific strengthening training without and with equipment and sports such as archery.
Figure 3: ICF Intervention Table: Phys: Physician, PT: Physiotherapist, Spo: Sport therapist, Psych: Psychologist, SW: Social worker
Hippotherapy was applied to reduce the increased muscle tone functions. As Marco regained the ability to stand, movement and gait pattern functions were improved with body balance training (also in-water exercises), and gait training respectively; walking was improved through many of these mobility interventions as well as specific walking training on a device called a Locomat. At a later stage, Marco received crutches which should enable him to walk short distances. Also, the wheelchair which he still needed for longer distances, was fitted to improve Marco’s mobility both indoors and outside.
For the latter two cycle goals, vocational counseling was offered to explore possibilities for remunerative employment in a new career. An occupational therapist assisted with finding new accommodation with increased access, as adapting Marco’s former apartment was not possible or cost-effective.
A number of other interventions were also undertaken for targets relating to contextual factors that would serve to increase his independence in daily living. Coping strategies and resources were supported through counseling, as well as music and Feldenkrais therapies. His family was involved in education and counseling sessions that would give them the knowledge necessary to best understand Marco’s condition.
Finally, a critical intervention for Marco’s inflammatory disease was regular eye examinations undertaken by an ophthalmologist. In Marco’s case, eye inflammation was considered a key indicator of a possible relapse of his inflammatory disease. In the event of this sign, steroids and other medications could be used at an early stage to minimize the symptoms and to prevent relapses.