Ida’s assessment, as in every Rehab Cycle, included four critical aspects: 1) Identification of patient needs and problems from the patient perspective; 2) Identification of problems within clinical examinations, tests and investigations (the health professional perspective); 3) Determination of long-term, program, and cycle goals; and 4) Identification of intervention targets for the defined cycle goals.

Ida’s body structures and functions impairment centered primarily on pain that was constant and focused on the lower back, but extended down to her feet. To assess the intensity of pain, the Visual Analog Scale (VAS)12 was applied. On the VAS scale, Ida’s rated her pain as 8 out of 10. The type of pain was qualified by the health professionals as neuropathic due to its constant and circular characteristics and quality”.

Box 2 | Measuring Pain 13

Reliable and valid measurement systems are needed to determine the effectiveness of interventions against pain. In order to assess pain in SCI patients, there are several major factors that need to be considered, including:

  • Pain quality – the Leeds Assessment of Neuropathic Signs and Symptoms defines and assesses pain qualities such as prickling, feelings of electric shocks, etc. However, there are currently no measures that distinguish neuropathic and non-neuropathic pain.
  • Pain intensity – probably the most common metric, there are a number of frequently used scales that include the Visual Analogue Scale, the Numerical Rating Scale, and the Verbal Rating Scale. These scales have demonstrated consistent psychometric value across various pain populations. The Numerical Scale utilizes a 0-10 rating, with 7-10 indicating severe pain.
  • Pain location(s) – this can complicate assessments when multiple sites are involved. One approach is to assess pain in general, though Jensen et al. note that this “oversimplifies the assessment and can interfere with determining the true effects of pain treatment” with the authors recommending assessing basic information on at least three sites. Pain is often located using human form diagrams or checklists.
  • Affective qualities of pain that include bothersomeness, fear, anger, etc. These can be assessed using the pain intensity scales mentioned above, or with more specific multiple item measures of pain affect such as the McGill Pain Questionnaire.

Reliable and valid measurement systems are needed to determine the effectiveness of interventions against pain. In order to assess pain in SCI patients, there are several major factors that need to be considered, including:

Pain quality – the Leeds Assessment of Neuropathic Signs and Symptoms defines and assesses pain qualities such as prickling, feelings of electric shocks, etc. However, there are currently no measures that distinguish neuropathic and non-neuropathic pain.

Pain intensity – probably the most common metric, there are a number of frequently used scales that include the Visual Analogue Scale, the Numerical Rating Scale, and the Verbal Rating Scale. These scales have demonstrated consistent psychometric value across various pain populations. The Numerical Scale utilizes a 0-10 rating, with 7-10 indicating severe pain.

Pain location(s) – this can complicate assessments when multiple sites are involved. One approach is to assess pain in general, though Jensen et al. note that this “oversimplifies the assessment and can interfere with determining the true effects of pain treatment” with the authors recommending assessing basic information on at least three sites. Pain is often located using human form diagrams or checklists.

Affective qualities of pain that include bothersomeness, fear, anger, etc. These can be assessed using the pain intensity scales mentioned above, or with more specific multiple item measures of pain affect such as the McGill Pain Questionnaire.

Additional impairments that were associated with pain included poor sleep quality (she would sometimes awaken due to pain), low motivation and feeling emotionally unstable. Both the patient and health professional perspectives corresponded for most of the signs and symptoms. Regarding Ida’s emotional instability, a psychological evaluation diagnosed Ida with minor clinical depression, though also noted this may be related to a pre-existing bipolar condition.

Regarding activities and participation, Ida strongly experienced limitations in carrying out her daily routine , and this in turn added both stress and in her case then worsened the pain. She also experienced transferring herself painful. Regarding her ability to drive a car, she was not able to drive due to both, the experience of pain and due to her pain medication that decreased her capacity to drive. She was however able to perform some errands using a SwissTrac which helped to increase her mobility.

However, due to her limitations in mobility, Ida continued to feel “isolated”, particularly because she was severely restricted in meeting friends and going to work. From the health professional perspective, although Ida was considered independent in her self-care, a range of limitations in daily living remained. Ida was not able to undertake complex tasks nor carry out a daily routine or perform housework without assistance or considerable more time for performing these tasks. She continued to have difficulty in activities such as transferring, and to some degree wheelchair use. She also was perceived to have difficulty handling stressful situations such as running errands and taking care of the household for her husband and family.

On the one hand, environmental facilitators relevant to Ida’s case included pain medications and anti-depressants, a house that was well adapted to her condition and level of ability, a supportive husband and a desire to re-engage in outdoor activities. Environmental barriers on the other hand included the side effects of her pain medication. Regarding personal factors, Ida had problems with her emotional functions and lacked sufficient coping strategies, as well as the fear of falling that arose since her accident.

The results of the assessment where entered into the ICF Assessment Sheet (Figure 1) and the ICF Categorical Profile (Figure 2).

Figure 1: ICF Assessment Sheet

Figure 1: ICF Assessment Sheet

Figure 2: ICF Categorical Profile

Figure 2: ICF Categorical Profile

Based on Ida’s comprehensive assessment, a Global Goal of increased participation was established that would encompass both reductions in pain and bettering her mobility. The first Service Program Goal, related to her actual in-patient rehabilitation stay, was defined as improvement of the pain management; two Cycle Goals were defined in support of the service program goal: developing coping strategies for handling stress and increasing physical mobility. The determined goals were entered into the upper part of the ICF Categorical Profile (figure 2).

Intervention targets for each of the Cycle Goals were determined and marked in the ICF Categorical Profile. Each target had been included in the assessment and was assigned a baseline value using ICF qualifiers that could be based on quantitative metrics or qualitative evaluations depending on the target. These ranged from 0 (no problem/barrier/facilitator) through 4 (complete problem/barrier/facilitator)

The rehabilitation team selected intervention targets for the two cycle goals derived from the ICF Categorical Profile as follows:

  1. Coping strategies for handling stress: energy and drive functions, sleep function, emotional function (e.g. sadness about disability), handling stress and other psychological demands, acquisition of goods and services, arts and culture, immediate family and their individual attitudes, fear of falling and coping strategies;
  2. Increasing physical mobility: muscle endurance functions, undertaking complex tasks, carrying out a daily routine, changing body positions, lying down, sitting and maintaining position, transferring, lifting/carrying objects, swimming, moving using a wheelchair, using transportation, looking after one’s health, swimming, recreation and leisure;

To address each intervention target specific interventions meant to improve their baseline assessment values or capitalize on as a facilitating factor had to be selected in the next step. Goal values were also defined based on what was considered by the team to be a realistic outcome for this Rehab Cycle.