Conrad, a 57-year old Swiss border guard, sustained a spinal cord injury as a result of the surgical intervention performed to treat an abdominal aortic aneurysm.11 This occurred shortly before he was set to retire – a fact that would have serious consequences, complicating his financial outlook following rehabilitation and therefore his ability to successfully reintegrate.
At 57, Conrad had raised four children living independently with sons and daughters of their own. He now lived with his wife in an old, culturally protected house almost 2000m above sea level. Beyond his profession as a border guard, Conrad helped his wife run a good sized restaurant on the ground floor of their home. Outside of his remunerative work, he enjoys working and hunting in the natural environment, and generally loves being active outdoors. In addition, he enjoys meeting his friends and acquaintances in his valley for whom he presents a liked and respected individual within the community.
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.
Interventions were established to treat each of the intervention targets with the hope of reaching specifically defined goal values set by the health care team in the assessment. They were documented in the ICF Intervention Table (Figure 4). Conrad’s nurse, physical and occupational therapists focused on many of the activities relating to mobility and self-care. Many of the self-care interventions were based on instruction and education. Repetition and body balance training were undertaken to improve transferring and changing/maintaining positions. His physical therapist also worked to reducing pain and increasing joint mobility through thermo-therapy and movement therapy.
Conrad’s social worker was responsible for counselling, clarifying and organizing his vocational and financial perspectives. Hence, this work included a number of interventions beyond those related to the cycle goals that needed to be addressed in parallel.
I’ve always been the person to help others - now I need the help, but I feel like a burden... I now have a goal to work in the kitchen of our restaurant. I believe the more motivation you have, the better the healing...so I have to move forward. Once I get home, I’ll just have to see how it goes...
Conrad at the time of evaluation
Conrad’s interventions proceeded slowly over the four months following his admission and assessment. To evaluate the changes in his level of functioning, a re-assessment was performed; the results were entered in the ICF Evaluation Display (Figure 6). Although he achieved only one of his cycle goals (mobility), steady gains were made in many of the interventions and there were improvements that moved him towards the other two cycle goals (self-care and vocation). His SCIM score increased from 20 to 44, showing slight gains in mobility and bowel management.
For SCI patients, social workers provide critical support for a range of socioeconomic and reintegration issues that will impact the patients overall quality of life as they return to their communities. Recent efforts at utilizing and integrating aspects of the ICF as a framework for social work in rehabilitation reflect this overarching importance and the need to address a multitude of participatory, personal and environmental factors that contribute to greater independence and quality of life. This includes a wide range of responsibilities and issues (that also extend beyond the ICF) including psychosocial well-being, insurance and finance, vocation and local economics, accommodation and housing, and so forth.
Each patient will bring his or her own individual set of environmental facilitators and barriers along with participatory needs that determine which social work interventions are most necessary. Oftentimes, these occur in parallel to other interventions focusing on body structures/functions and activities and will furthermore depend upon degrees of mobility and activities. Thus, a patient’s functional state and general prognosis are related to social work interventions and goals.