Marco’s rehabilitation phase continued over three and a half months (a relatively long period for a Rehab Cycle) during which he showed continuous improvements over the course of the interventions. Overall, his inflammatory disease improved greatly and neuromuscular functioning made gains that resulted in an improvement to incomplete paraplegia with much more preserved muscle function than at the beginning of his health condition (his classification improved to AIS D).
To evaluate his changes in his functioning statues a re-assessment of the intervention targets was performed and illustrated within the ICF Evaluation Display (Figure 4). Marco’s bowel functioning had made significant gains. By the end of the cycle, he had some bowel and anal sensitivity, a degree of control and was able to defecate independently at regular intervals. However, in some situations control of defecation was not sufficient and still lead to incontinence.
Now I can feel in my stomach when I need to go. Then I have about ten minutes to find a bathroom because of incontinence. If I’m out, I really need to rush to find a public restroom. I hope this will improve, but also think it could stay this way the rest of my life.
Marco's reflections on bowel dysfunction and interventions
Marco’s urinary functioning did not improve significantly and he remained incontinent – and accordingly discouraged. His ability to regulate urination was not helped by the urinary condom due to intermittent problems of detaching.
The urinary condom was extremely frustrating. It came off all the time – at night, when I was moving around. I tried for months and it just didn’t work. Catheterization is something I really didn’t want to do – it’s just too uncomfortable, too painful…especially multiple times a day. So I have chosen the stent, in spite of the risks. It really seemed like the best option for me.
Marco’s thoughts on treatment options for bladder dysfunction.
Marco also developed a chronic urinary tract infection (exactly when is unclear). He was instructed on monitoring his urine for blood (a sign of further complications).
Among other body functions, his muscle power improved in both the lower extremities and the trunk, and muscle tone functions improved, with fewer involuntary movements, greater control over voluntary movement. The evaluation resulted in a mild impairment of his gait patterns, caused by the still existing impairment in the muscle power functions.
Functionally, these improvements greatly increased his mobility. By the cycle’s completion, he could walk short distances with increasing dexterity (though reduced muscle power remained to some degree). Increased mobility also allowed him to better use the toilet. These improvements were affirmed by Marco’s steadily rising SCIM score, which increased from 47 at the start of the cycle to 69 due to marked improvements in mobility, bowel sphincter management and use of toilet (Figure 5).
Furthermore, sight in his left eye remained reduced and would need to be carefully monitored for signs of relapses of the inflammatory disease. Despite overall improvement, inflammation had repeatedly recurred, and doctors recommended a stronger anti-inflammatory therapy (“anti-TNF-alpha therapy”). This had associated risks of side effects that also required close monitoring. The combination of the anti-inflammatory drug along with the surgically implanted stent, put him at increased risk of infection. There was still a need for vigilance both on his part (through responsible self-care and eye checks) and his medical team (with involved specialists such as his ophthalmologist, rheumatologist and others) to monitor his condition.
It can take up to six months or so until a patient’s body accepts a stent. There’s always a chance that it will be rejected or there will be continuous infections and it will need to be removed, then there are few options left – surgically enlarging the bladder and catheterization. Marco must really be careful about recurring infections.
Marco’s doctor post-surgery
Finally, although Marco had, with the assistance of the occupational therapist and some of his friends, secured a new wheelchair accessible apartment (which alleviated some stress), his vocational outlook was still uncertain. Occupational counseling would need to continue to help him define a career path and find a job.
Overall, not all Cycle goals could be achieved; however, Marco was discharged to home. To address his remaining needs, he was assigned to an out-patient rehabilitation program.
Figure 4: ICF Evaluation Display: Illustrates the change of the functioning status over the course of the cycle *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. °1,2,3 show the relation to Cycle goals 1,2,3; SPG is related to Service Program Goal, GG related to the Global goal
Figure 5: Spinal Cord Independence Measure