[Implementation of the ICD-ICF model in rehabilitation medicine: presentation of a clinical case in neuromotor rehabilitation]

We present the clinical case of a 17-year-old boy who, after an auto-motorbike collision, suffered of bilateral condylar atlo-occipital dislocation with blood in the medullary canal and contusion of the CI-C3 spinal cord, hemothorax and pneumothorax, multiple costal fractures, fractures processes transverse Ll and right iliac wing and displaced fracture of the middle third of the right femur. In the emergency phase the patient, who was in a coma GCS: 3/15, was immediately intubated and taken to the Emergency Department and subsequently to Intensive Care Unit. He was also immediately subjected to chest drainage, reduction of femoral fracture and placement of external fixator and tracheostomy. Upon stabilization of the clinical picture, the patient was subjected to occipital-cervical stabilization with plates and screws and reduction of the fracture of the right femur with an intramedullary rod. Then the patient in hemodynamically stable and in alert condition, in spontaneous breath, was discharged and transferred to our Operative Unit of Intensive Neurorehabilitation.
At the entrance, the doctor's evaluation, with the whole multidisciplinary team, enabled to identify the ICD-9 and ICF codes that best described the severity of the clinical picture: the patient showed tetraplegia, dysphonia and dysphagia, bearing a tracheal cannula in breath spontaneous with 02 supplementation, sequelae of multiple costal fractures and right femur, totally dependent on ADL. The rehabilitation intervention was aimed at promoting motor recovery in the 4 limbs, recovery of standing and walking, acquisition of ability to control daily life activities (ADL), recovery of physiological swallowing and removal of the tracheostomy tube. After long and slow physiotherapeutic training, the patient recovered the active motility at the crural and brachial level mainly at the proximal level, which however is not effective for ADL recovery. On the other hand, speech therapy allowed the passage to oral feeding and removal of the tracheostomy tube. Upon discharge, the re-evaluation of the ICF codes identified at the entrance indicated an improvement in the strength of the trunk muscles (b7305) with the possibility of performing transfers with assistance (d420), of dysphonia (b320) and of swallowing (b510) which led to the removal of the PEG and the tracheostomy tube; unfortunately severe deficiency of the muscular force at the distal brachial and crural level (6730, b7304) persists with severe disability in the activities of daily life (d455, d4551, d465, d429, d230).