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The team decided to close the initial cycle (which focused on hand recovery using a standardized treatment scheme) and open a new cycle to address both the current physical situation and Peter’s behaviour.

The Team’s Assessment

Peter’s physician and his health care team worked closely with a psychologist to carry out the assessment (see Tables 1 and 2 for detail). The inclusion of a psychologist in the team helped ensure that Peter’s behaviour was taken into account when evaluating his functioning status.

I had to use this electric wheelchair, which I couldn't really get the hang of.

With Peter’s view (i.e. the Patient’s Perspective, detailed in Table 1) a number of illuminating facts arose. His specific needs and complaints about body functions reflected those of many tetraplegic patients (pain, muscle weakness, lack of sleep, etc.). These were not exceptionally difficult to address and many of the perspectives on bodily function were well-met. This was illustrated by the fact that Peter was easily performing his physical therapy activities. His perspectives on activities and participation, however, were not so simple.

Again, here is Peter’s point of view:

You know, after this surgery, everything just seemed more difficult. I had to use this electric wheelchair, which I couldn’t really get the hang of. And I even needed more help because I couldn’t use my hand. It was all really frustrating.

I felt a bit resentful and I think I kind of took it out on the nurses and doctors.

And I felt like I was in prison. I wanted just to go home on the weekends to get away — play around a little, meet my friends, feed my cat. I really wanted more freedom. In the hospital, I found it hanging out with my new friends in the ward, but that wasn’t exactly the same as going home."

Peter, 2006

The procedure performed on Peter’s arm and hand did not present any complications.

And I felt like I was in prison. I wanted just to go home on the weekends to get away...

From the health professional’s perspective, Peter had the typical impairments and limitations of a patient with tetraplegia C6, ASIA B.

However, the psychologist made note of a number of personal factors that had a significant impact on his functioning. These included a passive lifestyle, poor compliance, and the absence of a sense of responsibility and purpose.Therefore, one activity selected — "carrying out a daily routine" — incorporating these factors was included under the health professional perspective. These and other health professional perspectives can be seen in more detail in Table 1.

Additionally, the team documented Peter’s problems based on the standardized language of the International Classification of Functioning, Disability and Health (ICF) and created a profile of Peter’s functioning status that was later used for the evaluation display (see Table 2).

Goal-Setting/Determination of Intervention Targets

Table 1: Assessment Sheet

With all of these perspectives in mind, goals were discussed amongst the team. It was believed that clear and meaningful common goals would help to increase Peter’s intrinsic motivation and foster his feeling of responsibility toward the program.

So, with Peter’s input, a 6-month global goal was established to reduce ambulant care to once daily. The first service-program goal would allow Peter to fulfill his wish and go home on weekends.

Figure 1: ICF Assessment Sheet

Figure 1: ICF Assessment Sheet

This service-program goal was of some concern as it might have compromised the potential outcomes of the surgery. It was accepted, but it was essential that the cycle goals selected involved Peter and inferred "ownership" and a shared responsibility toward the rehabilitative program.

So the service-program goal was in turn dependent upon three cycle goals which, importantly for Peter’s case, were all informed by both the patient and health professional perspectives.
This gave both parties agency in the goals themselves and in the processes leading up to them.

...the cycle goals selected involved Peter and inferred "ownership" and a shared responsibility toward the rehabilitative program.

The cycle goals included:

  • Transferring oneself: Independent transfer to his wheelchair and car within 2 weeks
  • Hand and arm use: Drinking with right arm
  • Carrying out a daily routine: Participating in all treatment sessions

Once the cycle goals were established, the team identified which intervention targets were related to the cycle goal and, once improved, should also lead to an improvement in the cycle goal. The team took into account those intervention targets that were most relevant to the cycle goal and that were modifiable. The intervention targets selected for Peter’s ability to transfer himself to his wheelchair and car, for increasing fine hand and arm use, and for carrying out a daily routine are represented above in Table 1.