Shortly before discharge to the community, an evaluation of Martin’s functioning status was implemented. In a team meeting each health professional reported the results of those intervention targets for which he was responsible. A final rating of the problems in functioning was done by the team, the ICF Qualifiers were entered in the ICF Evaluation Display, and afterwards goal achievement was checked and discussed.
Cycle Goal 1: Vocational reintegration
In the course of Phase 2 (the Clarification Phase), Martin made significant advances, often on his own initiative. He pushed for a cognitive evaluation thinking that it would open new avenues of possibility for him. His hopes were later justified as the results revealed cognitive resources he hadn’t been aware of. Based on the outcome of this exam, the vocational counselor encouraged Martin to return to school, believing he had a possibility of attending university — an option Martin had never before considered. This gave a great boost to his self-esteem. In contrast to the former rehabilitation episode, Martin now became active by himself. He had been proactive in other areas, taking the initiative in reaching out to his network of friends and colleagues. This had opened even more possibilities. He contacted his former employer to explore possible employment options and discussed career issues with a friend. At his old workplace, he now had a chance of returning to a job that would need to be defined. The discussions with his friend sparked a new idea: Becoming a vocational coach for others who were having similar issues. Both of these prospects were very promising.
During the course of Phase 3 (the Integration Phase) Martin and his vocational counselor discussed and acted on these new possibilities. Despite the positive results of the cognitive evaluation, Martin made clear that he had no interest in returning to school. Regarding his former employer, a plan was worked out where he would commit to a one-third shift that would begin six weeks after his discharge from the program. At the same time, Martin also applied to begin a basic course on vocational coaching. This training would be undertaken over a period of six months and enable him to work with those facing obstacles to employment either through disability or social circumstances. From the last Rehab Cycle and Phase 1 of vocational counseling, Martin had come a long way in developing and realizing ideas for his vocation. His decision-making capacity had increased, evident in his proactive approach and the choices he was making. With his interest in the opportunities available to him sparked, Martin was in a very good position to begin a new life in his old community.
Cycle Goal 2: Independent housing and mobility
Prior to the accident, Martin had lived in a shared fifth-floor apartment with a friend. Without an elevator, this was not wheelchair-accessible and it was clear that he would need to move. He thought of two possibilities — finding a new apartment with his friend or looking for a place to live on his own. While Martin took responsibility for searching for an apartment, he had a difficult time making a decision on which path to follow. After much discussion with his social worker and psychologist, he decided to live on his own. His search, though time consuming, was successful and he found a wheelchair-adapted three-room apartment that needed very little further modification.
Regarding the interventions for independent mobility, Martin required both a driver’s license and a modified automobile. He successfully completed his driver’s training and examination shortly before his discharge and his car was purchased and adapted to his needs. He also needed a Swiss Track™ to increase his mobility in a wheelchair in the hilly area where he and his parents resided. While an order had been placed, his insurance company denied payment, presenting him with another financial and participatory burden. Without it, the activities he could participate in would be limited. Fortunately the Swiss Paraplegic Foundation agreed to subsidize the purchase of the device.
Figure 4: ICF Evaluation Display, ICF Qualifiers range from 0 = no problem to 4 = complete problem in the components of body functions (b), body structures (s), activity and participation (d) and from -4 complete barrier to +4 complete facilitator in the environmental factors. In personal factors, the sign + and – indicates to what extent a determined pf has a positive or negative influence on the individual’s functioning. 1, 2, 3 show the relations to Cycle Goals 1, 2, 3; SG is related to the Service Program Goal, G is related to the Global Goal.
Table 1: Spinal Cord Independence Measure (SCIM) over the course of rehabilitation
Cycle Goal 3: Recreation and leisure
During the course of Martin’s rehabilitation, he was exposed to a variety of sporting activities that included swimming, team sports and hand-biking. Given that his swimming skills were weak prior to the accident and a fear of the water developed after, he showed little interest (and likewise development) in this activity.
Hand-biking, on the other hand, thrilled him the most. So much so, in fact, that he began training on his own to improve specific muscle and movement functions for the sport. He is now considering purchasing a hand-bike, and following his return home, he plans on contacting a local wheelchair club to pursue this activity.
Cycle Goal 4: Optimized movement functioning
Despite Martin’s physical independence, he continued to suffer from pain and spasticity. Although the location of his pain shifted from his shoulder to closer to his spine, the manual therapy initiated was not effective at reducing it. Likewise, neither aquatic physical therapy, hippo therapy nor acupuncture were clearly successful at reducing Martin’s spasticity.