To identify Jason’s experience of functioning three months following the accident he was asked in detail. His experiences were entered into the ICF Assessment Sheet (Figure 1, upper part of the sheet). As a consequence of the first months of limitations in mobilization Jason felt greatly limited among aspects of his activities and participation: his dependence on others to perform greater mobility activities, the absence of the regular exercise, and the lack of sports that he was accustomed are examples of limitations that left him frustrated.
With respect to body structures and functions, he felt much improved sensitivity in his legs, but they were still “out of balance” with the right leg being almost hypersensitive compared to the left. He was also not able to flex his right foot and toes – an important action for walking.
Importantly, for the context of motivation, Jason often felt tired and unenergetic; a fact that he himself thought was related to his weight loss of 12 kilograms since the injury. Although gradual walking exercises on the parallel bars demonstrated rehabilitative improvement, it left Jason feeling conflicted.
While he had hopes of walking again and eventually playing some form of sport, he continually compared his current functional capacities to his pre-injury abilities. His present fatigue and slow functional progress left him frustrated at times, which in turn lead him to disengage from his activities and not push to his limits.
With respect to his environmental factors, Jason reported both barriers and facilitators. His home was not wheelchair accessible as it was built on a hillside and had three stories. Socially, Jason felt greatly supported by his friends who visited him often and regularly, assisting him when and where they were able. In contrast, his parent’s support was more complicated, the father being at times overly demanding and the mother too overprotective. He also felt “patronized” by some of the health care staff.
Additionally, Jason was sensitive to the “attitudes” of people in the general public, sometimes feeling observed and judged in public places. With respect to his personal factors, he felt a “practical optimism” – accepting his situation while also hoping to walk and perhaps play sports again soon (personal motives). While fundamentally facilitating, these personal factors did not at first and, more importantly, visibly translate into concrete personal goals for Jason’s short-term future, because of the discrepancy between voiced intent and actual performance during training.
Sports was my life up until the accident – handball mostly. I was training intensively, playing matches each week. I don’t care if I’m in a wheelchair; but I have to play sports again.
I feel really supported by my friends and everyone really. I think everybody helps where they can.
I’m the youngest person in the clinic. I feel like I’m being constantly mothered. This is nothing for me.
Figure 1: ICF Assessment Sheet
The examinations, tests and observations performed by the health professionals confirmed Jason’s real progress up until now. Nevertheless, there were still impairments in muscle power and endurance, joint mobility, exercise tolerance, control of movement and involuntary movement reactions. Sporadic pain in his legs, back and thorax persisted and he had continued to lose weight.
Regarding activities, Jason was initially limited and lacking exercise in changing body positions, transferring (from bed to wheelchair), caring for his lower body parts and dressing due to temporary movement restrictions as a result of post surgery healing requirements. Jason was however able to use his wheelchair and to care for his upper body parts and toilet – all significant gains both in mobility and activities. Additionally, he could stand in parallel bars and, to some degree, make first steps with assistance. The health care team also found him not looking after his health properly in terms of sticking to hospital routines and especially meals. Regarding participation, it was clear that there were concerns about remunerative employment and Jason’s ability to play sports.
Motivation, although an underlying issue for goal-setting, was not directly addressed as an intervention target in this Rehab Cycle. In the assessment, Jason’s psychologist voiced some concerns about his emotional functioning, given his possible prior diagnosis of depression and his introverted behaviour– a condition that could certainly have an impact on outcomes.
However, at this point, the team believed that Jason’s ambivalence to his situation and surroundings, expressed in feelings of frustration and desire to engage in pre-injury activities (personal motives), would gradually fade into becoming a more active coping process.
The results of the examination were rated within the ICF qualifiers and completed the ICF Assessment Sheet (Figure 1, lower part of the sheet) and the ICF Categorical Profile (Figure 2). Jason’s goal-setting took into account both his progress and improvement since the onset of the SCI along with his assessment and considered his individual perspective. He would still need further rehabilitation to improve his walking and focus on moving around in different locations.
Overall, a Global Goal for community reintegration and a Service Program Goal of increased independence were considered achievable. The three Cycle Goals would focus on the improvement of his:
- Walking ability
- Participation in sports
- Maintenance of his health
Intervention targets for walking ability and sports would focus on improving muscle power, joint mobility, exercise tolerance, control of movement and reducing pain. Activities such transferring and changing positions to the point of moving around, should also contribute to his walking abilities. To increase his participation in sports, Jason was assigned to a sports program that would begin at a low intensity level. Over the following weeks, the intensity would be increased in relation to his functioning level. Health maintenance was improved through interventions targets related to different activities in self-care: body parts care, dressing, looking after one’s health, protect the skin, emotional functioning, and weight maintenance.
Figure 2: ICF Categorical Profile