Individuals with spinal cord injuries face extraordinary challenges beyond adapting to the physical aspects of their injuries. The overarching goal of rehabilitation has been described as reintegration into the community.1From this perspective, disability can be understood in the context of a biopsychosocial model, which includes biological, individual and social elements.2 With such a comprehensive rehabilitation objective there are not only challenges to be met regarding physical and functional limitations, but also importantly, problems to be faced in a person’s participation within his or her physical and psychosocial environment.

SCI causes tremendous social and participatory disruptions in the daily lives of those it afflicts. Community reintegration (also sometimes called community integration) is the process by which such disruptions are minimized, allowing and enhancing a patient’s return from a hospital or rehabilitation center to his or her community. This process of preparing for community integration can begin early in rehabilitation process and necessarily involves many issues, disciplines and stakeholders. Box 1 offers some discussion on how community reintegration has been described and defined. The degree of disability in most activities of daily living is significantly associated with the severity of an injury.4 However, neither the type nor the severity of an SCI is a good predictor of long-term outcome.1 The early stages of medical rehabilitation frequently focus on the improvement of injury related physical functions. Nevertheless, interventions focusing only on physical functioning would not prepare SCI patients adequately for community reintegration after they are discharged from the hospital.5 Following an extended period of hospitalization, community reintegration will present a range of obstacles for SCI patients to overcome; rehabilitation teams are needed to help them navigate these obstacles (see Box 2).4 Successful strategies that address community reintegration issues depend not only on a patient’s physical functioning, but also on many interrelated contextual facilitators and barriers.4

Box 1 | Defining Community Reintegration in Persons with Spinal Cord Injuries and other Disabilities

Community reintegration is a complex concept that has been defined as “the assumption/resumption of [a] culturally and developmentally social role.” While the WHO’s ICF 3 doesn’t specifically define community reintegration, many categories within it are relevant and useful in framing what the process involves. Of the major life areas, education, work/employment and economic life are addressed. Other important areas are community life, recreation and leisure, religion and spirituality, human rights, political life and citizenship. Five distinct domains have been described that frame the concept of community reintegration around physical independence, mobility, occupation, social integration and economic self-sufficiency.

Deficits surrounding reintegration are also not entirely easy to describe or quantify. Norms in post-industrial, multicultural societies are often elusive and unclear, covering a range of social behaviour at multiple levels. Nevertheless, for those with severe disabilities such as SCI, it is obvious that community integration is a challenge. Reintegration thus involves a multifaceted relationship of internal and external factors, barriers and opportunities. Figure 1 is a simplified model that breaks down some of the interrelated elements that can promote or hinder community reintegration:

cs08-box1 

((Legende))

Given the complexity of community reintegration, the challenge for rehabilitation teams is to offer the optimal guidance, support and training to an SCI patient that provides him or her with the best opportunity to return to and live in his or her community while minimizing the experience of disability.

Issue areas that frequently need to be considered include:46

  • House and home: How will housework, outdoor maintenance and home upkeep be undertaken?
  • Fitness: Will the patient be able to maintain and/or improve his or her physical fitness?
  • Nutrition: How will meals be prepared? How will the shopping be done?
  • Mobility: What means of transportation are available? Facilitation for driving (independent mobility)
  • Recreation: What activities are accessible? (Art and theater, games and other cultural events; athletic activities also prove particularly valuable.)

These can improve both physical fitness and self-esteem while raising society’s expectations of people with disabilities.

  • Carrying out family and domestic tasks as main occupation, selecting a trade or profession, job-hunting.
  • Interpersonal relations and sexual relationships
  • Community activities
  • Improving independence in self-care and community access
  • Facilitating equipment provision
  • Consolidation of knowledge relating to living with SCI
  • Liaison and advocacy with community services
  • Psychological support

For example, to achieve employment vocational strategies need to take into consideration existing resources, needs (including additional education and/or developing possibilities for new careers), and a patient’s own goals (which may change or develop over time). Mobility and adequate transportation can also have a significant impact on participation and recreation by increasing access to them.6 Limited community resources, on the other hand, can result in less access to medical and/or social services, potentially undermining other aspects of reintegration due to unmet needs.6

Most often, a group of specific interventions will be required to deal with the range of facets and issues that comprise community reintegration. A tailored, client-oriented approach to each patient that develops an appropriate set of interventions based on his or her needs and resources will offer the best support.

While individual living situations will vary, interventions for community reintegration will require specific multidisciplinary interventions targeting education; social support; health maintenance and pain management; and options for recreation. An approach that addresses all of these can all do much to ease the shift back to community life.6 Each patient will possess a variety of facilitating factors and barriers that can either help or hinder the transition.

Examples of facilitating factors may include:

  • Support of family and friends
  • Peer mentoring
  • Returning to a familiar community or neighborhood
  • Availability of accessible and desirable housing
  • Access to personal means of transportation
  • Community resources (including medical and social services)

While barriers that can hinder this transition include:

  • Lack of general physical accessibility of services, living arrangements, etc.
  • Low income level and high costs of services, supplies and equipment
  • Chronic pain and other health-related complications
  • Negative and limiting societal attitudes
  • Poor attitude of rehabilitation professionals

Case Study 7 introduced Martin, a 26-year old survivor of a serious motorcycle accident who was diagnosed with a spinal cord injury (ASIA A) at Th7. In the span of this study, Martin initiated his vocational integration, completing the activation phase where the first steps in defining a career and securing employment are made through enhancing motivation and trust.

This case study continues Martin’s story and aims to illustrate how his rehabilitative interventions helped facilitate his transition from the hospital back into the community and prepared him for long-term reintegration. A number of intervention strategies that focus on independent mobility, housing, recreation and leisure will be described, in addition to concluding Martin’s vocational training.