For most interventions, Stefan’s nurse, physical and occupational therapist would be responsible (Figure 3). A number of issues would be addressed by his physician, in addition a psychologist would be consulted for psychological counseling and a music therapist targeted on Stefan’s resource of being musical.
Specific interventions to improve mobility were performed by both the physical and occupational therapists. These included manual therapy and muscle stretching to improve joint mobility; regular circuit training to improve muscle power functions especially in his arms with the aim of improving their supportive function; standing training to reduce the increased muscle tone functions; body balance training that would potentially work to increase his involuntary movement reaction functions and by extension his capacity to maintain a sitting position.
Transferring to and from the wheelchair - a critical skill for being independent in daily living - was addressed through instruction and repeated training. To increase his outdoor mobility, his abilities in moving the wheelchair in different locations such as streets, railway stations, trains, elevators, and the city was trained within both, individual training and group activities. These interventions also aimed to reduce time consumption by optimizing the performance of these activities.
Using public transportation is difficult for Stefan Getting in an elevator with the Swiss track is impossible since it takes too much time to maneuver and the doors close before he is completely inside. Inside the train he has no time to undock the Swiss track and take a place in the wheelchair compartment. He’s also afraid of moving the wheelchair in the train. These are just some examples of problems Stefan has with public transportation – and some of the reasons things take longer for him.
To improve Stefan’s independence in self-care, a range of attendant activities were the focus of instruction and independence/self-management training undertaken by the nurse. These included training in dressing, washing and toileting, caring for body parts, eating and looking after one’s health. Also the occupational therapist aimed to increase his compensation strategies in performing self-care activities. This should increase his independence on the one hand, and optimize the use of the available time on the other hand.
Shaving within the electric shaver is difficult since his proprioception is impaired. Stefan doesn’t know how much pressure is needed. It takes him about ten minutes to complete – much longer than an unimpaired person would require.
Stefan’s occupational therapist
The psychological counseling was intended to help improve Stefan’s assertiveness and self-confidence.
All interventions were performed individually, though a number of group activities also took place (Figure 4). These included a wheelchair club, a weekly group counseling session brunch, visits to the circus, zoos and a local beach bar. One particularly relevant intervention regarding time and timing was group trips into the city. Here participants practiced the use of public transportation along with mobility within the city. These exercises helped train and support important skills for Stefan’s future undertakings. Additionally, a group project was undertaken that helped train for planning tasks and actions, effective communication and cooperation to achieve a common goal.
Although these interventions were not focused on time and timing, each helped participants focus on a degree of efficiency both alone and as a team.
Figure 3: ICF Intervention Table* Phys: Physician, PT: Physiotherapist, OT: Occupational therapist, Psych: Psychologist
Figure 4: Schedule of the 2nd week of the rehabilitation program