Each target’s intervention was assigned to an appropriate member of the healthcare team. In this Rehab Cycle, the intervention was assigned to Martin’s physician, physical therapist, occupational therapist, psychologist, social worker and vocational counselor. Nursing staff would play a supportive role at this stage and would not be responsible for any specific interventions.
The physical therapist focused on most of the interventions related to body function/structure and the movement Cycle Goal. Regular manual therapy helped with back and upper extremity pain. Daily endurance and circuit resistance training built exercise tolerance and muscle power in the regions above the level of injury.
To influence spasticity, hippotherapy done in the previous Rehab Cycle did not show much success. Now, aquatic physical therapy and a course of acupuncture and pain management implemented by the physician were added to the regimen. Additionally, the occupational therapist worked on activities relating to movement and mobility.
Movement reaction training both allowed Martin to maintain a sitting position and to optimize involuntary movement reactions. Wheelchair training and instruction on how to use a Swiss Track™ supported Martin in his mobility in varying locations. And lastly, a program of driver’s training including the driving test was undertaken.
...the occupational therapist worked on activities relating to movement and mobility.
While movement and mobility were fundamental to Martin’s independence, other non-medical interventions were equally vital to achieving the longer-term goal of transitioning back to his community. This would cover aspects of the other three Cycle goals that focused on vocation, recreation and independent housing and transportation.
Martin would work with his psychologist on a number of relevant personal factors. Through weekly counseling, he hoped to improve how he related to others and how he perceived and dealt with his own body. Additionally, Martin would work on building competencies in decision-making, a life skill that would have an impact on the Cycle Goals for vocation and housing, as well as in various other life areas.
Figure 3: ICF Intervention Table, Assignments for Martin’s Second Rehab-Cycle® Phys = Physician, PT = Physiotherapist, OT = Occupational Therapist, SW = Social Worker
...non-medical interventions were equally vital to achieving the longer-term goal of transitioning back to his community.
Environmental factors would be the focus of targets for independent housing and transportation. The occupational therapist together with the social worker took the lead here to find assistive devices (such as the Swiss Track™) to improve Martin’s mobility and to clarify the payment methods.
Finally, the vocational counselor continued to play a major role in preparing Martin for reintegrating into his community through the last two phases of vocational counseling. Phase 2 of vocational counseling aimed at clarifying Martin’s vocational perspectives and built on the successes of the activation phase — greater trust, increased motivation and an improved capacity for decision-making (see Case Study 7).
This second phase was divided into three components:
- An analysis of lost and existing resources — here the development of new skills may compensate for lost resources. Following Martin’s courses from the previous cycle, he enrolled in an English as a Foreign Language course as he had planned.
- Vocational and career counseling — suggesting a number of suitable professions based on individual career experience. Here, Martin’s vocational counseling continued on a weekly basis, offering him encouragement and support in discovering job possibilities. This included essay writing on what Martin considered an ideal work day.
- Knowledge transfer — transfer of specific knowledge for specific jobs and the planning of next steps. Somewhat controversially, a cognitive evaluation was given to Martin to determine what professions might suit him. This latter intervention was at Martin’s own request; he felt such a test might offer him clearer directions and possibilities.
Phase 2 built on the successes of the activation phase - greater trust, increased motivation and an improved capacity for decision-making.
However, the vocational counselor was initially reluctant to offer the evaluation, having concerns that such a test could produce negative results, hindering Martin’s progress. Nevertheless, Martin was insistent and the test was made available to him.
The third and final phase was the Integration Phase. This included a search for employment or an apprenticeship training position.
These interventions would continue for two months, concluding on Martin’s anticipated date of departure from the rehabilitation facility. The interventions would be evaluated just prior to this.
Box 3 | The Importance of Non-Medical Rehabilitative Interventions
Non-medical interventions are an essential component of the rehabilitation process aiming to reintegrate SCI patients. An individual’s independence within a community has been described as having four distinct components:
- physical functioning
- perceived control of one’s life
- psychological self-reliance
- environmental resources 58
While acute rehabilitative interventions often focus on body structures, functions and a narrow range of activities (physical functioning), these are often insufficient to prepare a patient for the challenges of returning to life in his or her community.7
Non-medical rehabilitation often focuses on and strengthens aspects of patient participation (including self-control and self-reliance) and a patient’s environmental resources. Such interventions may cover such psychosocial areas as vocation, recreation and leisure activities; opportunities for education; housing; legal rights and advocacy; adjustment issues (such as maintaining the household); interpersonal relationships (including sexuality); and psychological issues including substance abuse problems, depression and anxiety.
Non-medical interventions may begin at various times after the acute phase in a patient’s rehabilitation and may last from a few weeks to a few months.7 Community reintegration programs can do much to successfully promote a patient’s decreased levels of disability, decreased distress and increased personal control within a community.5