Rehabilitation incorporating walking as a goal requires both the guidance and support of the rehabilitation team and the focus and determination of the patient.
As the severity of disease and the course of rehabilitation vary with each patient, the assessment of functioning and the selection of appropriate goals, targets and interventions present a critical point of decision in each patient’s rehabilitative management. This process involves clinical reasoning, integration of findings of high-quality research, health professionals’ knowledge and experience and the patient’s needs and context for achieving the best possible outcomes.
Ideally, the selection of interventions and their targets should be supported by an evidence-based approach that takes advantage of the best available clinical research on therapies and outcomes. In this case, however, applying an evidence-based approach presented some issues, as meta-analyses of past and current clinical research offered only mixed or inconclusive findings on interventions. The limited number of strong recommendations for SCI interventions highlights the need for more quality clinical studies. The knowledge gained from new and reliable clinical studies would further optimize this process.
Simon’s case examined the recovery of walking ability in a patient with an incomplete SCI, a complex biomechanical and physiological process requiring substantial rehabilitative support. Rehabilitation incorporating walking as a goal requires both the guidance and support of the rehabilitation team and the focus and determination of the patient.
The limited number of strong recommendations for SCI interventions highlights the need for more quality clinical studies.
In Simon’s case, there is a logical progression from prior rehabilitative efforts and successes through the new Rehab Cycle and its goals and targets.
Simon’s assessment was informed by both the patient’s and healthcare professionals’ perspectives, along with relevant clinical research related to aspects and expected outcomes of rehabilitation focusing on a walking recovery. Studies have clearly shown the potential success of incomplete SCI patients improving walking ability. Simon’s rehabilitation goals were thus based data such as these along with his earlier progress. His team made an informed assumption that he could significantly improve his walking and lifting/carrying abilities.
Following the goal definition came a critical decision point: selecting interventions. Using ICF categories, specific intervention targets could be planned and implemented. The integration of information drawn from clinical studies along with the knowledge and experience of the health professionals and the patient’s own history and resources helped to determine which interventions were optimal.
This integration of all relevant data is one important aspect in rehabilitation management. While the evidence from many interventions was not strong enough to earn recommendations in the Cochrane reviews, numerous studies still suggested the benefits that SCI patients could gain through therapies such as resistance and aerobic exercises, Vojta therapy, walking exercises and physical therapy for improving joint mobility. In Simon’s case, the healthcare team considered a range of therapies that would offer him the best chances of improving his walking and handling abilities.
...while Simon's cycle goals were not quite achieved, the recovery progress that was made was real and evident in Simon's own reflections.
As Simon’s Rehab Cycle concluded, the gains that he made – along with some further challenges – were evident in the evaluation. Improvements in areas such as muscle strength, joint mobility and balance were offset by a lack of advances in touch sensitivity, exercise tolerance and control of involuntary movements.
And while Simon’s cycle goals were not quite achieved, the recovery progress that was made was real and evident in Simon’s own reflections. His initial injury, resulting in an ASIA A paralysis, improved to a grade of ASIA D. With steady gains over the course of his rehabilitation came opportunities, and with the support of his healthcare team, Simon was taking every advantage of them. Unassisted walking, riding a bike, driving and improved abilities of handling and moving objects were significant accomplishments.
This patient-specific approach (in this case framed by the Rehab Cycle) utilizing a rehabilitation management that integrates a range of inputs and factors along with the most relevant evidence base informed the key steps of Simon’s assessment. The key result is the selection of appropriate targets and interventions that lead to real rehabilitative gains for the patient.