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.


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.


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.


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

1. World Health Organization. International classification of functioning, disability and health. Geneva: World Health Organization; 2001

2. Post MW, Kirchberger I, Scheuringer M, Wollaars MM, Geyh S. Outcome parameters in spinal cord injury research: a systematic review using the International Classification of Functioning, Disability and Health (ICF) as a reference. Spinal Cord 2010;48(7):522–8 [PubMed]

3. Wee J An international comparative study assessing impairment, activities, and participation in spinal cord injury rehabilitation – a pilot study. Asia Pac Disabil Rehabil 2004;15(2):43

4. Magasi SR, Heinemann AW, Whiteneck GG.; Quality of Life/Participation Committee. Participation following traumatic spinal cord injury: an evidence-based review for research. J Spinal Cord Med 2008;31(2):145–56 [PMC free article][PubMed]

5. Dijkers MP Individualization in quality of life measurement: instruments and approaches. Arch Phys Med Rehabil 2003;844 Suppl 2:S3–14 [PubMed]

6. Whiteneck G, Meade MA, Dijkers M, Tate DG, Bushnik T, Forchheimer MB. Environmental factors and their role in participation and life satisfaction after spinal cord injury. Arch Phys Med Rehabil 2004;85(11):1793–803 [PubMed]

7. Dijkers M Quality of life after spinal cord injury: a meta-analysis of the effects of disablement components. Spinal Cord 1997;35(12):829–40 [PubMed]

8. Harvey LA, Lin CW, Glinsky JV, De Wolf A. The effectiveness of physical interventions for people with spinal cord injuries: a systematic review. Spinal Cord 2009;47(3):184–95 [PubMed]

9. Ragnarsson KT Medical rehabilitation of people with spinal cord injury during 40 years of academic physiatric practice. Am J Phys Med Rehabil 2012;91(3):231–42 [PubMed]

10. Sipski ML, Richards JS. Spinal cord injury rehabilitation: state of the science. Am J Phys Med Rehabil 2006;85(4):310–42 [PubMed]

11. Hammell KW Exploring quality of life following high spinal cord injury: a review and critique. Spinal Cord 2004;42(9):491–502 [PubMed]

12. Whalley Hammell K Quality of life after spinal cord injury: a meta-synthesis of qualitative findings. Spinal Cord 2007;45(2):124–39 [PubMed]

13. Noreau L, Fougeyrollas P, Post M, Asano M. Participation after spinal cord injury: the evolution of conceptualization and measurement. J Neurol Phys Ther 2005;29(3):147–56 [PubMed]

14. Van Asbeck FW, Raadsen H, van de Loo ML. Social implications for persons 5–10 years after spinal cord injury. Paraplegia 1994;32(5):330–5 [PubMed]

15. Hill MR, Noonan VK, Sakakibara BM, Miller WC.; SCIRE Research Team. Quality of life instruments and definitions in individuals with spinal cord injury: a systematic review. Spinal Cord 2010;48(6):438–50 [PMC free article][PubMed]

16. Wilson JR, Hashimoto RE, Dettori JR. Spinal cord injury and quality of life: a systematic review of outcome measures. Evid Based Spine Care J 2011;2(1):37–44 [PMC free article][PubMed]

17. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003;83(8):713–21 [PubMed]

18. American Physical Therapy Association. Guide to physical therapy practice. Alexandria: American Physical Therapy Association; 2003

19. Alexander MS, Anderson KD, Biering-Sorensen F, Blight AR, Brannon R, Bryce TN, et al. Outcome measures in spinal cord injury: recent assessments and recommendations for future directions. Spinal Cord 2009;47(8):582–91 [PMC free article][PubMed]

20. Effing TW, van Meeteren NL, van Asbeck FW, Prevo AJ. Body weight-supported treadmill training in chronic incomplete spinal cord injury: a pilot study evaluating functional health status and quality of life. Spinal Cord 2006;44(5):287–96 [PubMed]

21. Hicks AL, Adams MM, Martin Ginis K, Giangregorio L, Latimer A, Phillips SM, et al. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43(5):291–98 [PubMed]

22. Hicks AL, Martin KA, Ditor DS, Latimer AE, Craven C, Bugaresti J, et al. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41(1):34–43 [PubMed]

23. Mulroy SJ, Thompson L, Kemp B, Hatchett PP, Newsam CJ, Lupold DG, et al. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Phys Ther 2011;91(3):305–24 [PubMed]

24. Heutink M, Post MWM, Bongers-Janssen HMH, Dijkstra CA, Snoek GJ, Spijkerman DCM, et al. The CONECSI trial: results of a randomized controlled trial of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain after spinal cord injury. Pain 2012;153(1):120–8 [PubMed]

25. Geyh S, Nick E, Stirnimann D, Ehrat S, Muller R, Michel F. Biopsychosocial outcomes in individuals with and without spinal cord injury: a Swiss comparative study. Spinal Cord 2012;50(8):614–22 [PubMed]

26. Dorsett P, Geraghty T. Health-related outcomes of people with spinal cord injury – a 10 year longitudinal study. Spinal Cord 2008;46(5):386–91 [PubMed]

27. Mathew KM, Ravichandran G, May K, Morsley K. The biopsychosocial model and spinal cord injury. Spinal Cord 2001;39(12):644–9 [PubMed]

28. Escorpizo R, Stucki G, Cieza A, Davis K, Stumbo T, Riddle DL. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther 2010;90(7):1053–63 [PubMed]

29. Rauch A, Escorpizo R, Riddle DL, Eriks-Hoogland I, Stucki G, Cieza A. Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management. Phys Ther 2010;90(7):1039–52 [PubMed]

30. Herrmann KH, Kirchberger I, Stucki G, Cieza A. The comprehensive ICF core sets for spinal cord injury from the perspective of physical therapists: a worldwide validation study using the Delphi technique. Spinal Cord 2011;49(4):502–14 [PubMed]

31. Mulroy SJ, Winstein CJ, Kulig K, Beneck GJ, Fowler EG, DeMuth SK, et al. Secondary mediation and regression analyses of the PTClinResNet database: determining causal relationships among the International Classification of Functioning, Disability and Health levels for four physical therapy intervention trials. Phys Ther 2011;91(12):1766–79 [PubMed]

32. Cieza A, Kirchberger I, Biering-Sorensen F, Baumberger M, Charlifue S, Post MW, et al. ICF core sets for individuals with spinal cord injury in the long-term context. Spinal Cord 2010;48(4):305–12 [PubMed]

33. Vocaturo LC Psychological adjustment to spinal cord injury. In: Sisto SA, Druin E, Sliwinski M. Spinal cord injuries. Management and rehabilitation. St. Louis: Mosby Elsevier; 2009, 104–120

34. Catz A, Itzkovich M. Spinal Cord Independence Measure: comprehensive ability rating scale for the spinal cord lesion patient. J Rehabil Res Dev 2007;44(1):65–8 [PubMed]

35. Ullrich PM, Spungen AM, Atkinson D, Bombardier CH, Chen Y, Erosa NA, et al. Activity and participation after spinal cord injury: state-of-the-art report. J Rehabil Res Dev 2012;49(1):155–74 [PubMed]

36. Natale A, Taylor S, LaBarbera J, Bensimon L, McDowell S, Mumma SL, et al. SCIRehab Project series: the physical therapy taxonomy. J Spinal Cord Med 2009;32(3):270–82 [PMC free article][PubMed]

37. Silver J, Ljungberg I, Libin A, Groah S. Barriers for individuals with spinal cord injury returning to the community: a preliminary classification. Disabil Health J 2012;5(3):190–6 [PubMed]

38. Piskur B, Daniels R, Jongmans MJ, Ketelaar M, Smeets RJ, Norton M, et al. Participation and social participation: are they distinct concepts? Clin Rehabil 2014;28(30):211–20 [PubMed]

39. Taylor-Schroeder S, LaBarbera J, McDowell S, Zanca JM, Natale A, Mumma S, et al. The SCIRehab project: treatment time spent in SCI rehabilitation. Physical therapy treatment time during inpatient spinal cord injury rehabilitation. J Spinal Cord Med 2011;34(2):149–61 [PMC free article][PubMed]

40. Whiteneck G, Gassaway J, Dijkers M, Backus D, Charlifue S, Chen D, et al. The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med 2011;34(2):133–48 [PMC free article][PubMed]

41. National Spinal Cord Injury Statistical Center. Annual report for the Spinal Cord Injury Model Systems 2010. Birmingham: University of Alabama; 2011

42. Whiteneck GG, Gassaway J, Dijkers MP, Lammertse DP, Hammond F, Heinemann AW, et al. Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab Study. Arch Phys Med Rehabil 2011;92(3):361–8 [PubMed]

43. Hammell KR Spinal cord injury rehabilitation research: patient priorities, current deficiencies and potential directions. Disabil Rehabil 2010;32(14):1209–18 [PubMed]

44. Kennedy P, Sherlock O, McClelland M, Short D, Royle J, Wilson C. A multi-centre study of the community needs of people with spinal cord injuries: the first 18 months. Spinal Cord 2010;48(1):15–20 [PubMed]

45. Van Leeuwen CM, Kraaijeveld S, Lindeman E, Post MW. Associations between psychological factors and quality of life ratings in persons with spinal cord injury: a systematic review. Spinal Cord 2012;50(3):174–87 [PubMed]

46. Sand A, Karlberg I, Kreuter M. Spinal cord injured persons' conceptions of hospital care, rehabilitation, and a new life situation. Scand J Occup Ther 2006;13(3):183–92 [PubMed]

47. Kerstin W, Gabriele B, Richard L. What promotes physical activity after spinal cord injury? An interview study from a patient perspective. Disabil Rehabil 2006;28(8):481–8 [PubMed]

48. Papadimitriou C ‘It was hard but you did it’: the co-production of ‘work’ in a clinical setting among spinal cord injured adults and their physical therapists. Disabil Rehabil 2008;30(5):365–74 [PubMed]

49. Westerkam D, Saunders LL, Krause JS. Association of spasticity and life satisfaction after spinal cord injury. Spinal Cord 2011;49(9):990–4 [PMC free article][PubMed]

50. Donnelly C, Eng JJ. Pain following spinal cord injury: the impact on community reintegration. Spinal Cord 2005;43(5):278–82 [PMC free article][PubMed]

51. Putzke JD, Richards JS, Hicken BL, DeVivo MJ. Interference due to pain following spinal cord injury: important predictors and impact on quality of life. Pain 2002;100(3):231–42 [PubMed]

52. Lund ML, Nordlund A, Bernspang B, Lexell J. Perceived participation and problems in participation are determinants of life satisfaction in people with spinal cord injury. Disabil Rehabil 2007;29(18):1417–22 [PubMed]

0 thoughts on “Physical Therapy Case Study Spinal Cord Injury”


Leave a Comment

Your email address will not be published. Required fields are marked *