Discussion

Health maintenance is a critical factor that essentially contributes to the quality of life of patients suffering from spinal cord injuries. While health care professionals can do much to influence an individual’s health maintenance through interventions such as routine clinical monitoring, the patient’s own health behavior is equally important, if not more so.³⁶

Such health behavior may be understood as having two essential components — risk behavior and protective behavior, each of which may be present or absent to varying degrees in each individual.³⁷  Under ideal rehabilitative circumstances, the former would be minimized and the latter maximized. However, promoting health behavior that contributes to health maintenance may face challenges in every patient and the final responsibility for engaging in these health behaviors ultimately lie with the patient him- or herself.

Pressure ulcers, an always serious and potentially life-threatening SCI complication, offer one good example of a secondary health condition that is significantly dependent upon an individual’s health behavior. Risk behaviors such as smoking can increase the chances of developing ulcers; accordingly, protective factors include leading a healthy lifestyle, and proper nutrition can minimize the risks.³⁸

Monica’s case confronting pressure ulcers offers an instructive example of the challenges faced by health care professionals when focusing on health maintenance by implementing preventive strategies, including the strengthening of health behavior.

Although her surgery and the treatment of her existing ulcer were successful, the health team believed that Monica was not “taking ownership” of her condition and rehabilitation.

This could be seen at the start of the Rehab Cycle in the assessment phase. Monica’s perspective lies primarily in restrictions in her body functions, activities and participation; the health professional perspective added the problems she faced regarding health behavior and subsequently health maintenance.

In general, improvements in her health behavior were disappointing. Given her addiction to cigarettes, an unwillingness to give up smoking and an overall limitation in looking after her health, Monica tended toward the high risk, low protective behavior category.

Her health care team, including the physician, felt that low levels of disease acceptance, self-responsibility and health behavior in general were significant contributing personal factors that put her at risk for developing pressure ulcers. The team had a feeling they would be seeing Monica again. Her physician describes the situation from her perspective:

Recurring pressure ulcers could certainly be one symptom that suggests a lack of acceptance of the patient’s paralysis. Although she had formulated her goal as “going home with a completely healed ulcer,” to reach this there would be certain preconditions. And I know that for someone having her life experience, psychological counseling is a difficult precondition. When I consider her biography and her case overall, I think she’ll likely return at some point with another ulcer. I really see psycho-therapeutic counseling as one important possibility that will help her develop behaviors that promote “looking after herself.”
                 
In considering her case, the team agreed that the Rehab Cycle might have proceeded slightly differently to achieve better results. Monica’s assessment by her health care professionals included limitations in looking after her health in addition to the personal factors (in this case barriers) of low disease acceptance, self-responsibility and health behavior. These elements played a significant role in Monica’s failing to achieve her targets.

In retrospect, her medical team felt that they would have liked to focus greater attention on aspects of “looking after her health.” Had Monica remained at the rehabilitation center, this would have been undertaken. Specifically, Monica’s involvement in the goal-setting phase would have been greater.

There would have also been serious consideration of setting looking after her health as an overarching program goal rather than a specific cycle goal. Here, the cycle goals would have hopefully achieved increased health prevention behavior.

Intervention targets would have included the health behavior-focused factors mentioned above along with more time and energy to support and strengthen Monica’s responsibility and management of her own health. This, in turn, would have contributed greatly to preventing future ulcerations. Thus, in the unfortunate event of a return visit, Monica’s Rehab Cycle will be sure to take a slightly different path. more