Physical Therapy Case Study Spinal Cord Injury

Background and Purpose

Physical therapists require a comprehensive assessment of a patient's functioning status to address multiple problems in patients with severe conditions. The International Classification of Functioning, Disability and Health (ICF) is the universally accepted conceptual model for the description of functioning. Documentation tools have been developed based on ICF Core Sets to be used in multidisciplinary rehabilitation management and specifically by physical therapists. The purposes of this case report are: (1) to apply ICF-based documentation tools to the care of a patient with spinal cord injury and (2) to illustrate the use of ICF-based documentation tools during multidisciplinary patient management.

Case Description

The patient was a 22-year-old man with tetraplegia (C2 level) who was 5 months postinjury. The report describes the integration of the ICF-based documentation tools into the patient's examination, evaluation, prognosis, diagnosis, and intervention while he participated in a multidisciplinary rehabilitation program for 2 months.

Outcomes

The patient's comprehensive functioning status at the beginning of the program, the rehabilitation goals, the intervention plan, and his improvements in functioning following rehabilitation and the according goal achievement were illustrated with physical therapy–specific and multidisciplinary ICF-based documentation tools.

Discussion

This case report illustrates how the ICF-based documentation template for physical therapists summarizes all relevant information to aid the physical therapist's patient management and how ICF-based documentation tools for multidisciplinary care complement one another and thus can be used to enhance multidisciplinary patient management. In addition, the ICF assists in clarifying clinician roles as part of a multidisciplinary team. The case report demonstrates that the ICF can be a viable framework both for physical therapy and multidisciplinary management and for clinical documentation.

In many clinical settings, physical therapy often is one critical part of multidisciplinary rehabilitation programs that aim to enable people with health conditions to achieve and maintain optimal functioning and to encourage full participation of individuals in all aspects of life in their environment.1,2 Spinal cord injury (SCI) is an example of a condition in which patients are faced with a multitude of health-related problems with respect to body functions (physiological functions of body systems) and body structures (anatomical parts of the body) and to activities (execution of tasks or actions) and participation (involvement in life situations), and environmental factors (physical, social, and attitudinal environment in which people live and conduct their life)3 often play a key role. When multiple systems are affected, as they are in SCI, multidisciplinary approaches are important for optimal care.4 To address multiple problems, a comprehensive description of a patient's functioning status is an essential element of sound patient management.5

The International Classification of Functioning, Disability and Health (ICF)6 is the universally accepted conceptual model for the description of functioning. The ICF refers to functioning as an umbrella term for body functions and body structures and for activities and participation. Functioning and disability are considered to be the result of the interaction between a health condition and personal and environmental factors. As a classification system, the ICF provides a hierarchical organization of “descriptors” in the form of ICF categories. Thus, the ICF framework offers physical therapists and other rehabilitation professionals a common understanding and a standardized language to describe functioning.7

With the endorsement of the ICF by the American Physical Therapy Association,8 physical therapists are now faced with the challenge of concretely translating the use of ICF in their daily clinical practice. To address the needs of users, ICF-based practical tools, including the ICF Core Sets,9,10 have been developed. The ICF Core Sets provide a list of ICF categories applicable and relevant to specific health conditions. Although Brief ICF Core Sets are developed for single encounters, Comprehensive ICF Core Sets are intended for use in multidisciplinary settings.11 The ICF Core Sets serve as practical tools for the documentation and as a reference standard for the reporting of functioning.11 To report the extent of problems in specific ICF categories, ICF qualifiers can be used as a rating scale from 0 to 4, which includes the equivalent percentage values as a reference6:

  • 0—no problem (none, absent, negligible) 0%–4%

  • 1—mild problem (slight, low) 5%–24%

  • 2—moderate problem (medium, fair) 25%–49%

  • 3—severe problem (high, extreme) 50%–95%

  • 4—complete problem (total) 96%–100%

Supplementary to the ICF Core Sets, so-called ICF-based documentation tools have been developed to be used in multidisciplinary rehabilitation management.12 In addition, an ICF-based documentation template is suggested by Escorpizo et al13 (see companion perspective article in this issue) to be used specifically by physical therapists. This template is based on the Guide to Physical Therapist Practice14 (herein referred to as the Guide), the elements of which consist of examination and evaluation of the patient's level of functioning, a description of a diagnosis and prognosis, the generation of a plan of care, intervention, and re-examination. The ICF-based documentation tools for multidisciplinary management and the documentation template for physical therapists can be used to complement each other, to illustrate a patient's functioning status, and to chronicle patient management (Fig. 1).

Figure 1

Overview of the use of International Classification of Functioning, Disability and Health (ICF)-based documentation tools in patient management.

Figure 1

Overview of the use of International Classification of Functioning, Disability and Health (ICF)-based documentation tools in patient management.

The purposes of this case report are: (1) to apply the ICF-based documentation tools for physical therapy and multidisciplinary teams to the care of a patient with SCI and (2) to illustrate the use of ICF-based documentation tools during the patient's care. These documentation tools were integrated with the patient management elements described in the Guide. The patient had an incomplete cervical SCI, and our description of the multidisciplinary care begins 5 months postinjury.

Patient History

The patient was a 22-year-old man who had started his career as an online graphic designer. A diving accident resulted in a type II dens fracture of the second cervical vertebra (C2). He was treated at a local hospital and transported to an SCI center 2 days later. He was admitted to the intensive care unit and initially diagnosed with tetraplegia below C2, classified as AIS (American Spinal Injury Association [ASIA] Impairment Scale15) grade A (“no motor or sensory function is preserved below the level of injury”). Three days postinjury, surgery was performed to stabilize the fracture. A stiff collar was prescribed for the first 6 weeks following the surgery.

After the surgery, the patient was admitted to the early postacute inpatient unit of the SCI center, where a multidisciplinary rehabilitation program was initiated. In the first 2 weeks, the patient was completely dependent. He required the use of an artificial ventilator 24 hours a day, received only intravenous nutrition, and was able to move only his eyes and mouth. After 6 weeks, his movement-related functions had improved, and he required artificial ventilation only at night.

Over the next several weeks, the patient's neurological and overall functioning continued to improve. Upright positioning and graduated training activities to improve gait patterns could be initiated as tolerated by the patient. Five months after the injury, he was able to stand and to take few steps in the parallel bars. Furthermore, the patient achieved a degree of independence in the areas of self-care, respiration and sphincter management, and mobility.

This case report was undertaken 5 months following injury and 2 months before the planned discharge. At this time point, a new examination became necessary to adapt and coordinate the plan of care to account for the patient's improved functioning status that had occurred since the injury. The new examination data were used to coordinate and revise care for the remainder of the patient's stay in the rehabilitation center.

Examination

The Comprehensive ICF Core Set for SCI in the early postacute context16 was used as the basis to guide the examination. For the description of the patient's current functioning status, the responsibility to examine specific ICF categories was distributed among the physical therapist and the other rehabilitation team members. Problems experienced by the patient were assessed via interview. Afterward, tests were performed to examine each ICF category. The documentation template for physical therapists was used to document the specific tests, examinations, or observations performed by the physical therapist (Tab. 1) (see eTab

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