Regarding body functions, the medical team recognized that Marco’s defecation and urination functions were completely impaired and his spinal cord and muscle functioning were both severely impaired. Regarding urination functioning, he was diagnosed with both detrusor hyperactivity and detrusor-sphincter dyssynergy (DSD), resulting in an inability to control urination. His bowel functioning lacked control and sensitivity – his doctor diagnosed spastic bowel, a condition common with upper motor neuron lesions.
Beyond these dysfunctions, Marco had also gained a lot of weight and his impairments in muscle tone- and exercise tolerance functions were moderate. At the time of the assessment, his muscle power functions were severely impaired in the lower extremity and moderately in his trunk while impairment in joint mobility was mild. Generally, based upon gains in the lumbar spine area in both motor and sensitivity functioning, Marco’s AIS score improved from the moment of the break-out of his health condition about 3 months ago from “Complete” (AIS A) to “Incomplete” (AIS C).
Marco’s own perspective was similar to the health professionals’ perspective. Since beginning steroid therapy, he had felt the need to eat more and rapidly gained twenty kilograms. While he said that he could sense his full bladder, he was not able to urinate. Furthermore, he had no sensitivity of his bowel and was not able to control defecation.
Among activities, all of these factors contributed to overall limitations in mobility and self-care. While Marco required just minimal assistance in transferring from wheelchair to toilet or bathtub, standing and walking was completely limited. Also, although he could shower, dress and care for body parts independently, it was found that he was partly limited in looking after his health.
The main limitations regarding self-care could be found in toileting: For bladder management he still was dependent on the usage of a urinary condom but required just minimal assistance in toilet usage. For bowel management Marco defecated regularly every second day. However, he needed partial assistance in the manual defecation, and sometimes he experienced situations of incontinence. The performed spinal cord independence measure (SCIM) was 47, further illustrating his extent or problems in functioning.
Regarding participation, Marco easily made new acquaintances in the rehabilitation unit. He learned to play the guitar in music therapy which he visited with another patient of the rehabilitation unit. He also played when spending his spare time with his friends, which at the same time was a great way for him to relax and to handle his worries, such as about his future working situation. So his experience of stress – one of his personal factors - was related not only to body functions and an uncertain prognosis, but also not knowing how or where he would work in the future.
Stress is really a problem for me too…also because I don’t know where I will work. And this is all related to the uncertainty of my health condition. None of the medical staff, even the doctors, can tell me whether I will always be in a wheelchair. I have a feeling no one knows what to do, so they tell me just to be patient and wait. It’s extremely frustrating.
Marco, from interview at time of assessment
The assessment also included information about environmental factors. Marco had a large circle of friends and a supportive family. However, he was living in an apartment inaccessible for a wheelchair.
He learned to play the guitar in music therapy which he visited with another patient of the rehabilitation unit.
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
In summary, Marco’s assessment proved the progress he had made up to this time point and consequently led the health care team to give an optimistic prognosis (a contrast to the uncertainty that attended his initial diagnosis). The Cycle’s goals were defined accordingly:
- Marco’s global goal would be community reintegration and this would include disease control and the prevention of secondary conditions
- The service program goal for this Rehab Cycle would be to work to achieve independence in daily living.
- To this end, four cycle goals were defined and for each, appropriate intervention targets were selected:
- Improving toileting – defection/urination functions and regulation;
- Improving mobility – muscle power/tone, exercise tolerance, walking, standing, moving around, etc;
- Increasing access to his accommodation – assistive devices and home design and acquiring a place to live;
- Defining a new vocation – remunerative employment and clarification with outside institutions.
Marco's assessment proved the progress he had made up to this time point and consequently led the health care team to give an optimistic prognosis.
Figure 2: ICF Assessment Sheet: Illustrates the patient’s (upper part) and health professional’s perspective (lower part) perspective of functioning. Intervention targets are marked within connecting lines to Cycle goal ‘Toileting’.