As with each Rehab Cycle, the process began with an overall assessment integrating the patient and the health professional perspectives in all components of functioning and the environmental and personal factors and documenting in the ICF Assessment Sheet (Figure 2). The ICF Core Set for SCI in the early post-acute situation13 was used to guide through this assessment.
Conrad’s body functions/structures were primarily affected by his lesion at L1 and its associated conditions. Pain still occurred, in particular in relation to weather changes, and greatly affected his day-to-day activities, centered on his back, limbs and joints, but also at times extending to his pelvis and genital area. He felt that although he was eating normally, he was continuing to lose weight and at times felt unable to summon the energy needed for his exercises. The health care team documented further impairments with joint mobility, exercise tolerance and muscle power in the lower extremities, as well as protective functions of the skin and sensation related to muscle and movement function.
Among Conrad’s activities and participation, while he was able to transfer himself without difficulties, he also recognized the limits of his not being able to walk; his mobility was clearly impaired. His health care team also found that mobility and moving around using devices would be a critical target, as well as maintaining sitting and standing positions. Additionally, Conrad presented limitations in caring for body parts, looking after his health, regulating urination and defecation, and washing oneself and dressing.
Overall, Conrad’s spinal cord independence measure (SCIM) was graded at 20. Indoor and outdoor mobility was, at this point, rated a zero out of 40 possible points. There were also scores of zero, indicating complete dependence, in bowel and bladder sphincter management, and transferring from bed-to-wheelchair and from wheelchair-to-toilet/bathtub. He had better scores (~3/20) for self-care activities (feeding, bathing, dressing and grooming) and respiration (10/10).
Regarding many issues such as vocation, independent living and social security/insurance issues arose that would be needed to be addressed. Conrad himself had concerns regarding employment (“I can’t do my job anymore...”) and reduced mobility (“This will really limit what I can do in life...”). The health care team also felt that the restrictions in remunerative employment would need to be addressed. There were a number of open questions regarding this issue:
- What would happen with his planned retirement?
- Would he be able or need to return to his former job for financial reasons?
- If so, was his workplace wheelchair accessible?
- Would these benefits cover his expenses or require him to work for supplemental income?
In addition, many of Conrad’s environmental factors would need attention with respect to his re-integration to community:
- Devices to improve mobility were not sufficient
- Housing - his current residence is on a mountainside (1800m above sea level) and not wheelchair accessible and is culturally protected (limiting architectural modifications);
- Accessibility to the family restaurant (also a source of income) was limited;
- Unclear insurance situation. At present, Conrad was on sick leave and receiving 80% of his normal salary, which is not enough to live on at his (and his wife’s) current standard of living.
- Restrictions on housekeeping compensation. Not covered by accident insurance, and only very limited coverage with health insurance. This left much of the burden of housekeeping to his wife.
- Transportation costs were not covered and due to the remote terrain where their house is located, a car is a necessity and thus must be modified to allow him to drive.
- The waiting time for decisions on social security issues showed already during the first months to be lengthy and, hence, would delay payments. Alternative financing options needed to be explored.
On the other hand, Conrad continued to be sociable with many visits and much support from family and friends. He also was satisfied with the help he received from the health care staff. And there were a number of facilitating personal factors: he already had developed strategies for coping with his condition; he was motivated, athletic and hoped to be able to work and/or enjoy outdoor activities in the future.
Figure 2: ICF Assessment Sheet
Conrad’s assessment highlighted a number of areas of initial concern that included mobility and participation (including employment). Based on these assessments, multiple goals were established and documented in the ICF Categorical Profile (Figure 3).
A global goal was defined as successful community reintegration and the service program goal as the first step towards this was independence in daily living. Three cycle goals were defined based on the assessment and the relevant intervention targets were linked to each, with the overall aim of increasing independence:
- Economic self-sufficiency