The intervention targets were assigned to health professionals and interventions and entered into the ICF Intervention Table (Figure 3). The focus of Jason’s Rehab Cycle interventions was on walking and sports, the majority being undertaken by either his physical or sports therapist. This included strength and endurance training, movement exercises and repetitive training. He also began playing a number of sports appropriate to his capabilities, including archery, swimming and table tennis in the beginning.
One problem initially arose as he began playing wheelchair basketball. The therapists felt he was at risk of further injury and recommended he not play in that particular sport. Nevertheless, he continued. His doctor focused on reducing pain through medication. A psychologist supported Jason’s emotional functioning through regular counseling sessions. For his health maintenance, Jason was supported by the whole team, in particular by the nurses in caring for his body, offering regular feedback, and helping improve this target.
As the interventions began, some health care staff was surprised by Jason’s lack of motivation in a number of areas given his perspectives as the Rehab Cycle began. His interactions with staff were disinterested, noted by passive listening and a lack of eye contact. When participating in group activities, such as swimming, he would quickly lose interest and required constant attention to complete the intervention.
In working with Jason, I realized early on that I wasn’t and couldn’t reach him. He didn’t really listen to me, always responding with “yeah yeah”, kind of a typical teenager response. Motivating him was very difficult.
Recognizing and concerned about Jason’s lack of short-term goals, his physiotherapist aimed to improve his motivation by emphasizing both his accomplishments and his good prognosis for better functional outcomes, often pointing out how much better he was doing in comparison to other SCI patients. His psychologist focused on improving his communication skills during their counseling sessions, thinking it could improve his interactions with the health care staff.
However, beyond these steps, the health care team felt that Jason’s motivation would have to be to a greater part intrinsic to make a lasting impact on his rehabilitation outcomes. While his health care team understood that motivation could be neither coerced nor forced, they also felt that their patience and support was essential in indirectly improving his motivation and focusing him towards his longer-term goals.
Figure 3: ICF Intervention Table: PT: Physical Therapist, Spo: Sport Therapist, Psych: Psychologist, MD, Medical doctor
About three weeks into the Cycle, Jason’s health care team noticed a dramatic shift in Jason’s attitude towards both physical training and health behaviour. He began training on his own to such a degree that he was improving his physical abilities. In wheelchair basketball, after being allowed to play again, he trained more intensively and on equal terms with the other players. While he revealed no specifics regarding his reasons for his shift in behaviour, the health care team speculated that a number of possible factors may have played a role in increasing his motivation:
Psychological and emotional (“Individualistic”) factors - Psychologically and emotionally, Jason slowly overcame the initial motivational stalemate caused by the trauma that had distorted his emotional and thus rational connection to his pre-injury goals (e.g. sports). Over time (and with functional improvement) his awareness and acceptance of his circumstances increased (also, in part through the combination of his good prognosis and the possibility of regaining a “normal” life)
Social factors – Prior to his injury, Jason had been competitive and disciplined (as demonstrated by his sporting accomplishments). Early in rehabilitation he felt “mothered” and treated like a child, a relationship that was essentially demotivating for him. As rehabilitation progressed, communication improved between him and health care staff (perhaps impacted by his counseling, but also through increased efforts by his rehabilitation team). He was also supported by strong peer relationships with friends visiting regularly and helping him as they could. Within the clinic, Jason’s patient acquaintances improved and were discharged, setting a positive example and moving the rehabilitation phase and its outcomes into a wider perspective with his life beyond the clinical setting.
Goal-setting (combined individualistic and socio-environmental factors) - Reframing his personal goals, independent of the Cycle Goals: As stated, Jason initially compared his pre- and post-injury capacities. In summary, his own goals of “playing sports again” in the way he had prior to his injury did not seem achievable given his condition. This may have had a demotivating effect.
However, once he was allowed to actively participate in wheelchair basketball, he was able to compensate the loss of the sporting goal. This helped Jason to accepting his limitations and adapt accordingly. He redefined his own goal to “wanting to walk again to the best [of his] ability”. He thus internalized the same Cycle Goal that he initially may have perceived as imposed by his health care team. Improved communication between Jason and the health care team helped to clarify these initially conflicting goals.