Chapter 1: Introduction

INTRODUCTION

Damage to the spinal cord can have profound and global effects. Paralysis of voluntary musculature can lead to reduced mobility and impairment of vocational, avocational, and self-care abilities. Spinal cord injury (SCI) can also affect the functioning of the sensory, respiratory, cardiovascular, gastrointestinal, genitourinary, and integumentary systems. A host of debilitating and potentially life-threatening secondary conditions can result.

The psychosocial sequelae of spinal cord injury are equally important. Bodily changes, impaired mobility, functional dependence, altered sexual functioning, and incontinence all constitute seemingly overwhelming losses with which people with spinal cord injuries must come to terms. Moreover, these problems can interfere with the social roles and activities that are central in each person's life and identity. Finally, spinal cord injuries cause previously “normal” people to become “disabled” and thus become subject to society's prejudices regarding people with disabilities.

The physical sequelae of damage to the spinal cord vary widely, depending on the level and completeness of the lesion. Regardless of injury severity, it is possible to return to a healthy, fulfilling, and productive life. Achieving this outcome, however, can be a monumental task. It may seem daunting to the health professional unfamiliar with spinal cord injuries. With such a broad array of physical and psychosocial problems that can result from spinal cord injury, where should the health-care team focus its attention? The rehabilitation process following spinal cord injury can be better understood using a conceptual framework of functioning, disability, and health.

FUNCTIONING, DISABILITY, AND HEALTH

In the past, various models were proposed to conceptualize disability and the disablement process. Each model presented a different understanding of the nature of disability and the factors that affect it. In addition, the various models contained conflicting terminology. The lack of consensus on a conceptual framework and terminology related to disability interfered with communication in clinical and research contexts.¹ In 2001, the member states of the United Nations adopted the International Classification of Functioning, Disability and Health (ICF) to provide a standard language and framework for descriptions of health and health-related states.² The ICF, now used widely around the world,^3,4 can enhance communication across disciplines, settings, and national boundaries.^4-8

In contrast to earlier models, the ICF emphasizes health and functioning rather than disability. It is based on a biopsychosocial model in which functioning and disability reflect an interaction among health conditions (disorders, diseases, injuries, etc.) and contextual (environmental and personal) factors (Fig. 1-1). Functioning occurs at the level of the body or body part (body functions and structures), the whole person (activity), and the whole person in a social context (participation).² The term disability refers to dysfunction at any of these levels: impairment in body function or structure, activity limitation, or participation restriction.² Table 1-1 presents the ICF terminology.