It’s quiet, but it’s okay with my friends. We still talk over the internet and by the phone, but I can’t go out with them anymore. My friends are in Bangkok and they come like twice a year - sometimes it’s annoying for me.
Participation can be considered as both an indicator and an outcome of increased accessibility. Mr. Wun’s participation throughout the first year following his accident remained greatly restricted. His exclusion from community life was almost complete, primarily as a result of his physical confinement at home. While the use of both the internet and telephone allowed him some degree of connectivity, these were less than ideal and friends were able only twice in the previous year to arrange a visit to his home.
Also, his restrictions regarding work and employment were graded as “severe.” However, he had been able to undertake some computer-based translation from home for his former employer. Travel to a workplace still remained out of the question because of his mobility limitations and problems with transportation.
Mr. Wun’s assessment also revealed a list of ongoing primary bodily function and structure problems that led to a range of actual or potential secondary complications and also negatively impacted accessibility.
- Paralyzed respiratory muscles resulted in reduced capacity for respiration and an impaired cough; this also resulted in reduced movement of lung secretions, increasing the risk of pneumonia.
- Mr. Wun’s tracheostomy fistula (from the acute phase) still had not closed; as a result, dysphagia remained and kept him at an increased risk for both aspiration and pneumonia;
- Spasticity remained and resulted in pain, fatigue and sleep problems as well as increased risks for pressure ulcers and infections.
- Impaired urination and defecation functions.
- Impaired joint mobility and muscle power.
- Restricted mobility – transferring, moving in a wheelchair, changing body positions
Among Mr. Wun’s activities, there were limitations in mobility that ranged in classification from “severe” to “complete:” changing his body positions, hand and arm use, using the toilet, caring for and washing his body, dressing and transferring into and moving his wheelchair. Also, his ability to eat remained severely limited – a particularly difficult limitation for Mr. Wun given his love of cooking and food. There were a number of contextual factors relevant to his functioning state. Environmental factors included facilitators – his mother’s and housekeepers’ support, an adapted house, medications and assistive devices - and barriers, mainly difficulties with mobility outside the home.
The wheelchair was an old and heavy model. It presented a special circumstance, being a facilitator in that it increased Mr. Wun’s mobility to some degree, while also a barrier given its excessive weight. Importantly, there are a number of environmental factors that would require changes in public policy to make a difference at an individual patient-level.
These are highlighted in the assessment table below, and include issues such as the design and construction of buildings for public use, and adequate health systems and policies.
Mr. Wun also had a number of facilitating personal factors. He held an engineering degree from an Australian university and was considering studying law; he also accepted his situation and wasn’t concerned with how others perceived him.
His exclusion from community life was almost complete, primarily as a result of his physical confinement at home.
Figure 1: ICF Assessment Sheet
The rehabilitation team – including Mr. Wun’s physician, nurse, and physical and occupational therapists – established goals for the Rehab Cycle based upon this assessment. The focus of the Global Goal was the prevention of secondary conditions. The Service Program Goal for the one month rehabilitation period was increased independence in daily living.
Three Cycle Goals would work towards increasing independence through improvments to:
- the management/prevention of specific secondary complications.
Notably, with the exception of mobility, goals directly related to increasing accessibility were absent, despite this being a major issue in Mr. Wun’s life. Unfortunately, interventions that could be undertaken to improve his access to the environment were limited. The focus therefore remained on bodily functions and activities.
Figure 2: ICF Categorical Profile: (extraction): Illustrates the aspects of the functioning status which are relevant for this patient (Spinal Cord Injury, ASIA A Th 3). *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.