Developing a Functioning Profile
To develop an accurate profile of Ingrid’s current functioning state, her health care team utilized the World Health Organization’s Comprehensive ICF Core Set for SCI in the early post-acute context.16 This provided the rehabilitation team with a comprehensive perspective of functioning and served as the basis for her assessment. As in each Rehab Cycle, this assessment covered body functions/structures, activities and participation, and the impact of her personal and environmental factors. All aspects of functioning were assessed through both the patient and health professional perspectives to provide a complete assessment on which the rest of the cycle would be based. The results of this Cycle’s assessment were integrated into the “ICF Categorical Profile” (Table 1) and the “ICF Assessment Sheet” (see Table 2).
Figure 1: ICF Categorical Profile: Illustrates the aspects of the functioning status which are relevant for this patient *ICF Qualifier 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. °CG1,2,3 mark the relation to Cycle goals 1,2,3; SG is related to Service Program Goal, G related to the Global goal.
Emotional functioning, an integral component of body functions played an important role in Ingrid’s well-being and impairments in this area were explored in the assessment. She explained that her emotions shifted daily, from highs to lows. Also her energy levels differed from day to day. Pain in her neck, she felt, contributed further to both of these feelings. The health care team readily acknowledged that her mood swings and lack of energy were a central issue that needed to be addressed for her overall well-being and for effective rehabilitation.
She wasn't interested in making new friends with others in the rehabilitation centre.
Many of Ingrid’s previously existing problems in body functions and body structures persisted into this new cycle. With respect to her injury level, she demonstrated impairments in her bladder and bowel functions, blood pressure instability, increasing spasticity, decreased involuntary movement reaction functions and reduced muscle power in her upper extremities, even in those areas which were above the level of injury.
Additionally, physical examinations revealed a persisting pressure sore and a decreased mobility in both shoulder joints.
Regarding activities and participation, Ingrid’s limitations in fine hand use, and hand and arm use, difficulties in transferring and dressing and other self-care activities left Ingrid feeling extremely dependent and constrained. To further exacerbate these feelings, her wheelchair mobility was limited to only short distances. The health team also recognized Ingrid’s difficulties through her limitations in changing body positions and maintaining a sitting position.
With regard to her involvement in social life, Ingrid felt that her contact to others was very limited. Nevertheless, she wasn’t interested in making new friends with others in the rehabilitation centre. She also had concerns regarding her future employment.
Environmental and personal factors also played a role in her functioning level. Though she had much support from her family and friends, the former she felt were at times “too much”, overwhelming her with their attention. Despite Ingrid’s worries, her employer showed an interest in having her return to her position at some undefined date in the future. Another significant concern was the lack of wheelchair access at her current flat and uncertainties about where she could and would live.
The health care team readily acknowledged that her mood swings and lack of energy were a central issue that needed to be addressed.
A number of Ingrid’s personal factors also had relevance to her emotional situation. At the time of the assessment, Ingrid’s coping strategies were not having a positive influence to her functioning level. Her level of knowledge of her disease was too few to contribute to her functioning level. Furthermore, the challenge to accept her situation, particularly being a patient and dependent to others compounded her problems. The team also recognized the importance of both remunerative employment and Mr. Dee’s overall reintegration into his community.
Table 2: ICF Assessment Sheet
Based upon Ingrid’s functioning state and her own personal aims and ideas, a number of Rehab Cycle goals were defined. As with most SCI patients, Ingrid’s Global Goal was broadly defined to achieve health maintenance and community reintegration. As a step toward this general goal in this Rehab Cycle, her Service Program Goal was defined as optimal independence in daily living.
The health care team established the following Cycle Goals (CG) whose overall aim was to support Ingrid’s independence in daily living. Each concentrated on specific aspects derived from her functioning assessment:
- Improvements in mobility
- Improvements in moving and handling objects
- Improvements in self-care
- Improvements in her emotional well-being.
The extent of the problem in each Cycle Goals was rated with an ICF qualifier. At the time of assessment, all Cycle Goals except self-care were judged to be severe problems (3 on a scale from 0 to 4); self-care was a complete problem (4 on the scale). An ICF qualifier was also used to define the goal value, that value that would indicate the degree of expected improvements. The limitations in the Cycle Goals were expected to be reduced to 1 (mild problems) and 2 (moderate problem), respectively. Facilitating factors would be supported to become moderate or complete facilitators and barriers would be reduced in impact to no barrier or only a mild barrier or even to become facilitators. Goal values can be seen in the ICF Categorical Profile.
Interventions target setting
In the next stage, intervention targets were selected for each Cycle Goal. With a focus on the theme of this case study, the targets selected for emotional well-being are highlighted here. To improve this Cycle Goal, interventions would center on targets that included:
- b126 Temperament and personality functions (e.g. optimism)
- b130 Energy and drive functions (e.g. energy level and motivation)
- b152 Emotional functions (e.g. range of emotions)
- d240 Handling stress and other psychological demands
- d750 Informal social relationships and d760 Family relationships
- e310 Support of immediate family members
- Importantly, targets were set among the relevant personal factors: acceptance and knowledge of the disease and the way of relating to the own body.
Improvements to mobility and moving and handling objects would be made through addressing targets such as pain, blood pressure function, weight maintenance function, shoulder joint mobility and stability, selected muscle power, transferring ability, minimizing involuntary movement and improving the control of voluntary movement.
Self-care would overlap with some of these targets, and additionally include dressing, washing, regulating defecation and urination, eating and drinking, caring for and looking after oneself and improving coping strategies. For each of these intervention targets, appropriate interventions needed to be selected and assigned to the rehabilitation team members.