I don’t actually have any real problems; I’m independent, I can do anything. What we’re talking about here are problems of luxury.

Simon, five months following injury

Assessment of Simon's "problems"

Five months into Simon’s rehabilitation, a new Rehab Cycle began to focus general efforts on the recovery of walking ability. The assessment would be essential for integrating both the patient’s and the health professionals’ perspectives of the patient’s current status. These perspectives would help to define the Global, Service-Program and Cycle Goals to work towards and to establish relevant interventions along with their corresponding intervention targets.

The use of the ICF Core Set for SCI helped guide the healthcare team through the assessment. In Simon’s case, a spectrum of outstanding issues in the components of body functions, body structures, activities and participation could be identified that required attention even after five months of rehabilitation. In addition, perspectives that reflected both a great degree of success and supportive contextual factors would be considered. The ICF categorical Profile (Table 2) gives a complete overview of his functioning state at this point.

Assessment

Figure 1: ICF Categorical Profile

Figure 1: ICF Categorical Profile *ICF Qualifier range from 0 = no problem to 4 = complete problem in the components of body functions (b), body structures (s), activity and participation (d) and from -4 = complete barrier to +4 = complete facilitator in the environmental factors. In personal factors, the sign + and - indicates to what extent a determined pf has a positive or negative influence on the individual’s functioning. °C1,2,3 mark the relation to Cycle goals 1,2,3; SG is related to Service Program Goal, G related to the Global goal

Looking initially at body structures and functions, both Simon’s and the health professionals’ perspectives are complementary. There are outstanding problems with reduced muscle mass, muscle power, sensitivity, proprioception and spasticity below the level of injury. Simon also had pain and decreased mobility in the right shoulder. His gait patterns, balance and coordination of voluntary movements were impaired due to the lesion of the spinal cord.

Gait analysis identified that Simon had Duchenne limping, a disorder caused by reduced muscle power in the hip, a lack of arm swinging ability and poor reaction functions. This disorder could lead to falling when walking. Additionally, his exercise tolerance was reduced as a consequence of his impaired respiratory functions and sedentary situation following the accident.

...Simon had Duchenne limping, a disorder caused by reduced muscle power in the hip, a lack of arm swinging ability and poor reaction functions.

In the components of activities and participation the health professionals found expected limitations to walking. The assessment of mobility showed limitations regarding climbing stairs and outdoor mobility. At this time he still had to use the wheelchair to move around for distances longer than a few minutes. Driving a car was also difficult. Beside problems related to his lower extremity, Simon also showed reduced fine-hand functions and limitations in lifting and carrying objects, both of which were caused by his tetraplegia. Interestingly, Simon also felt that the lengthy time required for dressing decreased his “spontaneity.”

Simon had begun working part-time for his former employer already during his inpatient rehabilitation and hoped to return at some point to full-time work. He spent the weekends with his family and friends and intended to return to his mother’s home, where he would have some assistance with daily activities.

At the rehabilitation center, Simon was an active table tennis player and also attended cultural events with the center’s “learning-by-doing” club. The healthcare professionals recognized that many of Simon’s previous capacities in recreational activities had been severely reduced.

Lastly, there were the relevant contextual factors. Personally, he was ambitious with clear goals, enjoyed physical activity and was accepting of his disability. Environmentally, he had a supportive network, both in his family and his healthcare team. He had access to assistive devices, including a wheelchair and crutches to increase his locomotion. There also was an insurance caseworker who took care of all financial details, unburdening him of those concerns.

The result of the first step in the Rehab Cycle’s assessment is an initial “laundry list” of functional limitations, barriers and facilitating environmental and personal factors. Deciding upon which of these perspectives to address will determine the goals to be set and establish intervention targets and the corresponding interventions.