2019 Volume 4 Article ID: 20190001
Background: We report the changes in the health condition after using a service dog of a person with a complete C5 spinal cord injury (SCI). Case: A 48-year-old married man began using a service dog after suffering a complete C5 SCI. We conducted a semi-structured interview based on the International Classification of Functioning, Disability, and Health (ICF) rehabilitation sets to describe the change in the participant’s experience after using a service dog. The interview was converted into written form, and information regarding the changes in the participant’s health condition was extracted. These data were categorized by similarity and then classified by the ICF conceptual framework. Discussion: The participant experienced multiple changes in his health condition after using a service dog. These included the following factors from the ICF – “Body Function” category: “increased vitality and motivation,” “emergence of self-affirmation,” and “physical improvement.” Health changes form the “Activities and Participation” category included: “emergence of new roles,” “increased resilience,” “expansion of moving area,” “acquisition of activities incorporated with a service dog assist,” “emergence of autonomous health management,” “expansion of relation with other people,” and “expansion of social activity.” The participant experienced “reduction of psychological barriers,” categorized under “Personal Factor,” and “expansion of support environment,” categorized under “Environmental Factor.”
Spinal cord injuries (SCI) often result in complete or incomplete paresis in the chronic phase.1) Patients with thoracic or lumbar SCI are able to propel a wheelchair, accomplish independent activities of daily living (ADL), and participate in social undertakings because their upper limbs remain functional.1) However, patients with high cervical SCI, affecting at C5 and above, need a caregiver to perform almost all their ADLs because they cannot perform tenodesis wrist actions. Consequently, social participation in such patients is severely restricted.2) Although previous studies have reported that various kinds of devices and orthoses allow patients with high cervical SCI to improve their level of social participation, their involvement in society is still largely limited.3,4)
Nonetheless, several reports have shown that service dogs can assist with bodily functions, improve the psychological well-being of disabled people, and eventually enhance social participation.5,6,7,8,9,10,11,12,13) Fairman and Huebner reported that service dogs could help with a user’s ADL and reduce the time of care.6) Other studies have reported that service dogs can assist with propelling a wheelchair and can pick up dropped items from the floor.7,8,9,10) Allen and Blascovich11) conducted a randomized controlled trial on participants with severe chronic ambulatory disabilities and showed that the group with service dogs had a higher rate of school attendance and/or part-time employment than those without service dogs. Regarding personal factors, Collins et al.12) reported that service dog users tended to have higher self-esteem. Camp13) conducted semi-structured interviews and showed that service dogs gave users greater self-confidence. Shintani et al.14) conducted a case–control study between service dog users and non-users and concluded that service dog users had fewer psychological burdens and a higher quality of life than non-users did. Regarding environmental factors, Eddy et al.15) and Mader et al.16) compared disabled people with and without service dogs and showed that passers-by tended to offer help more often when the disabled person had a service dog.
For patients with high cervical SCI, however, taking care of a service dog is difficult. As far as we know, there has been no report showing the adaptation of a service dog to a patient with complete C5 SCI. Therefore, we conducted a qualitative case study to describe the experience of a patient with complete quadriplegia who used a service dog. We believe that this will provide new insight into the adaptation and dissemination of service dogs. The purpose of this narrative-based qualitative case study was to clarify, by applying the International Classification of Functioning, Disability and Health (ICF)17) framework, the changes in the health condition in a person with complete C5 SCI after using a service dog.
The participant was a 48-year-old married man.
History of InjuryIn 2009, the participant had a complete C5 SCI after a fall at work. On the same day, he underwent an anterior cervical fusion procedure. In 2010, he underwent cystostomy and was discharged home.
Body FunctionThe participant’s Zancolli classification18) was C5A, and his American Spinal Injury Association classification19) was A.
Service DogThree years after his SCI, the participant began using a service dog (a 7-year-old female Labrador retriever) that was trained by the Japan Service Dog Association and certified by the Japanese Government (Fig. 1).
The service dog, a 7-year-old female Labrador retriever, was trained by the Japan Service Dog Association. The dog needs to wear a vest labelled “service dog“ that shows certification by the Japanese Government. Dogs wearing this vest have a right to access public spaces by the Act on Assistance Dogs for Persons with Physical Disabilities established in 2002 in Japan.
This was a qualitative single case study
Method of Data CollectionIn July 2017, we conducted a semi-structured interview based on ICF rehabilitation sets20,21) to determine the participant’s experiences regarding the changes in his health condition after using a service dog. The semi-structured interview lasted for about 3 h and was conducted by the first and the second authors at the participant’s home. The participant could freely express the changes in his experience before and after using a service dog. When the participant reported any changes, the researchers asked in-depth questions about what changes had occurred. The participant’s wife also attended the interview and confirmed the facts.
Because the aim of this qualitative study was to clarify the change of health condition defined by the ICF after using a service dog, the semi-structured interview needed to be based on the ICF evaluation. The original ICF evaluation17) contains more than 1450 categories and is therefore impractical to use in a clinical setting. The ICF Research Branch proposed the use of parsimonious core sets which are feasible for routine use and ensure data comparability.22) To evaluate SCI patients, ICF core sets for longitudinal spinal cord injury have been proposed,23) but the comprehensive core sets for SCI still include numerous categories and are hard to use in an interview setting, and the brief core sets do not contain categories regarding social participation. In contrast, the ICF rehabilitation sets contain 9 body function categories and 21 activities and participation categories, including social participation.20,21) These 30 sets present a reference framework for harmonizing existing information on disability across general and clinical populations.20,21) For these reasons, the use of the ICF rehabilitation sets for the basis of the interview was deemed to be appropriate for this qualitative study.
The Method of Data TreatmentThe interview was recorded and converted into written form. The transcript was read carefully, and all quotes regarding the participant’s experience with changes in his health condition were extracted as the data for this study. The data were coded to express the changes that were recognized by the participant (without changing the original meaning of the quotes) and were categorized as changes in the content. Furthermore, the categories were summarized by similarity and classified into larger categories of changes in the participant’s experience. To ensure reliability and validity, the work of generalization, coding, and categorization was regularly discussed with a study collaborator who had extensive experience in qualitative research; she confirmed that the original meanings were preserved. Finally, the categories were applied to the ICF framework to show how the change in experience after using a service dog affected the participant’s overall health condition.
Ethical ConsiderationsThis study was approved by the Ethics Committee of Yawata Medical Center in Ishikawa, Japan. Before conducting the interview, the participant was advised by the authors regarding the protection of personal information; he thereafter completed a written consent form.
The participant experienced multiple changes in his health condition after using a service dog. Table 1 provides a summary of these changes.
| Change in content | Classification of change in content | ICF classification |
| Structural planning for care needs | Increased vitality and motivation | Body functions |
| Focusing on next behavior | ||
| Improvement of motivation | ||
| Establishment of action | ||
| Joy brought by a service dog | Emergence of self-affirmation | |
| Real feeling of benefit | ||
| Distraction from the sense of pain | Improvement of physical function | |
| Increased endurance | ||
| Improvement of joint movement | ||
| Improvement of muscle power | ||
| Motivation to take care of the service dog |
Emergence of new roles | Activities and participation |
| Management of the service dog | ||
| Getting new means to relieve stress | Increased resilience | |
| Reduced depression | ||
| Accepting failures | ||
| Increase of carry-on items | Expansion of moving area | |
| Help of a service dog to pick up dropped items | ||
| Dressing incorporated with a service dog assist | Acquisition of activities incorporated with a service dog assist | |
| Eating incorporated with a service dog assist | ||
| Avoiding staying up late | Emergence of autonomous health management | |
| Spontaneously getting up in the morning | ||
| Aiding other people by listening | Expansion of relation with other people | |
| Communication facilitation | ||
| Consideration of other people | ||
| Buffer of emotional conflict | ||
| Acquiring jobs | Expansion of social activity | |
| Remunerative employment | ||
| Volunteer work | ||
| Leisure activity | ||
| Reduction of psychological barrier for asking other people for help | Reduction of psychological barrier | Personal factors |
| Expansion of support environment due to visualization of disability |
Expansion of support environment | Environmental factors |
| Assistance from public service providers |
Before the participant began using a service dog, he was obliged to multitask because he could not distinguish between what he could do by himself and what he could request others to do for him. The obligation of multitasking hindered his focus on doing the next activity and caused psychological fatigue that decreased his vitality and motivation.
“When I wanted to go outside, I had to do many things like sitting up, dressing, and transferring to a wheelchair. In addition to these bodily activities, I needed to plan what I should bring, and was obliged to think about how to solve the problems that might happen outside. For example, when I wanted to go shopping, I needed to take my purse, but where should I put it? I had to carry and bring home the purchased items. I needed to pay for the items. How could I do this? I needed to think about numerous procedures, and that made me feel exhausted. Eventually, my motivation and energy shrank.”
After using a service dog, the participant could clarify what he could do by himself and what the service dog could do for him. In this way, he experienced “structural planning for care needs” by distinguishing his specific care needs, and this helped him to focus on his task, which improved his motivation to establish actions.
“It is clear where I should put my purse because my dog can take it from my bag. I can focus on where I put my purse, and then I feel I can take another item and so on. This is how my motivation increased.”
Previously, the participant had a feeling of resignation because he could not solve any of the problems he encountered, but when he used a service dog, he felt joy when the service dog performed tasks at his command. He felt the benefits the service dog brought to him, and eventually, he experienced “emergence of self-affirmation.”
“When I encountered unexpected troubles, I did not wonder what to do; I commanded my service dog to solve my problems and she did! Of course, sometimes she could not do it well, but unexpectedly, many times she could do it. I really feel the benefit of a service dog. These experiences have brought me great joy and confidence.”
“Improvement of physical function”The participant initially stayed in bed almost all day, and tended to focus on neurogenic pain in his whole body. However, after using a service dog, playing with and taking care of the dog became a new means to distract him from his pain. Initially, he had needed to take a break every 15 min when he was out in a car, but after using the dog, he had many opportunities to go outside and was able to remain sitting longer. Consequently, he became able to continuously ride in a car for 5 h without taking a rest, and that meant he experienced “increased endurance.” He had to brush the service dog and pull her leash many times a day, and these movements made him feel that his joint movement and muscle power improved.
“I tended to concentrate on the pain in my whole body when I did not have a service dog, because I had nothing to do. There was nothing to distract me from the pain. But now, I have many chances to distract myself from pain when I play with the dog. Also, I have a lot of chances to take care of the dog like brushing her hair and pulling the leash that is attached to my wheelchair. These movements have improved my joint movement and muscle strength.”
“Emergence of new roles”The participant previously had no roles in daily life, but he gained motivation to take care of the dog after he became a service dog user. Consequently, he experienced the “emergence of new roles.”
“Increased resilience”Before using a service dog, the participant’s means of stress relief were going outside with his family and surfing the internet. After using a service dog, he was able to relieve stress by commanding his service dog and going shopping with the dog. The participant felt relief because the dog could retrieve the items he dropped on the floor. He could accept the dog’s failures because he knew it was a dog (not a person). The participant felt he could try again when he was accompanied by the dog, and, consequently, he experienced less depression and had “increased resilience.”
“For example, when I dropped something and asked a family member for help, sometimes I was told to wait a minute. But I waited a long time, and finally, I was stressed out and got irritated with my family. But when using a service dog, the dog retrieved it and if the dog could not do it, I could accept that because it was a dog, not a person! It is obvious that a dog sometimes fails to do what I command. When something gets on my nerves a bit, I do not have to become depressed or irritated with my family because the dog can help me.”
“Expansion of moving area”Previously, the participant had no opportunities to go outside alone, because he could not take many items with him and he could not pick up dropped items without the help of a caregiver. But after using a service dog, the participant could carry many items with him when he went outside because the service dog could take out his purse, cell phone, and other items from the bag attached to the front of the wheelchair (Fig. 2). Furthermore, the service dog could help him to pick up his dropped items. He experienced “expansion of moving area” by carrying many items with him when he went outside.
The participant could carry many items with him when he went outside because the service dog could take out his purse, cell phone, and other items from the bag attached to the front of the wheelchair. The photographs show the service dog taking out the participant’s purse from the bag (A) and passing it to him (B).
Originally, the participant needed caregivers to do all his ADLs, such as dressing and eating. However, when he got his service dog, the dog helped him put on and take off his coat and mufflers by pulling the sleeves of the coat or the tip of his muffler, so he could control his temperature without needing help from caregivers. When he wanted to eat or drink, the dog helped him by taking eating utensils or a bottle out of his bag. Thus, the participant could carry out ADLs with the help of the service dog.
“Emergence of autonomous health management”Before getting the service dog, the participant could not go to bed or get up without help from his wife. However, after getting the service dog, he can avoid staying up late at night and can spontaneously get up early in the morning because he needs to walk the service dog in the morning. The participant experienced the “emergence of autonomous health management.”
“Expansion of relation with other people”The participant used to have very few chances to go outside and had little opportunity to speak with other people. However, since obtaining the service dog, he often goes outside and has many opportunities to speak with people with disabilities, and he has been able to help them by listening to their difficulty and problems. Words like “pretty” and “good girl” in reference to the service dog became an icebreaker to start conversations with strangers, and the participant experienced improved communication by having the service dog. He began to be considerate of the hair the dog shed and people’s allergies to dogs when he moved about with the service dog. When an emotional conflict arose in a conversation with his wife, he was able to look at the service dog and communicate with his wife as if the service dog was speaking on his behalf, like a ventriloquist’s dummy. In this way, he gained the ability to better resolve emotional conflicts he had with his wife.
“When I speak with strangers, the conversation starts with light words such as ‘pretty’ or ‘good girl,’ referring to the service dog. These words are the best icebreaker, and I can easily speak with them. I also have had many chances to listen to people with disabilities, and I feel, somehow, that my listening attitude helps those with disabilities.”
“I need to be considerate of other people when I move about with the service dog because I need to clean up the hair the dog sheds, and some people might have an allergy or be afraid of dogs, so I always think about the other passengers when I ride on a train or bus.”
“When I get angry with my wife and want to say something to her, I speak to the dog first, and my wife also speaks to the dog first. This conversation style of integrating the dog when speaking with my wife lightens the emotional conflict, and we eventually become calm.”
“Expansion of social activity”The participant initially had no job, but since starting to use a service dog, on the recommendation of his friends and the media, he has been paid to lecture about his experiences and opinions regarding physical disabilities and barrier-free concepts. He has lectured 15 to 20 times a year and has earned money. He has engaged in volunteer activities such as lecturing in a primary school and negotiating with the administration. Before using a service dog, the participant enjoyed no leisure activities, but he began to participate in leisure activities when he traveled alone by plane, accompanied by his service dog.
“Reduction of psychological barrier”The participant felt reluctant to ask other people for help discarding the urine in his urine drainage bag because he had a restless feeling when there were only two people in a closed, narrow restroom. He felt that his psychological barrier was reduced when his service dog accompanied him, and he felt better able to ask strangers to help care for him.
“When I need to discard the urine in my urine bag, of course, I need to ask for help from other people, but it was not easy. I felt awkward when I was with an unknown caregiver in a narrow, closed restroom. I was sure the caregiver also felt the same way as me. But the presence of the dog makes us feel relaxed in a restroom. I feel that my psychological barrier to asking for help from other people is reduced when I am with my dog.”
“Expansion of support environment”When the participant went out with his service dog, he found that strangers often offered him help. He experienced more friendly offers to help him when he was going out with his service dog than without. After using a service dog, he had many more chances to go outside, and he received assistance from public service providers such as pushing him up a slope and pushing his wheelchair up a ramp when he was having difficulty in public spaces. Because the service dog made his disability more visible, he experienced “expansion of support environment.”
“When I am with my service dog, people notice me, talk to me, and smile, and their friendly attitudes also make it easy to ask them to help me. For example, when I am in a trouble with my service dog and begin looking around restlessly, passersby or public service providers immediately notice me and help me. The dog is a sign. It is obvious I have many more chances to be helped by other people when I am with my service dog than without.”
Adding a service dog was an environmental factor that caused changes in all components of the ICF, and the participant experienced an improved health condition (Fig. 3).
ICF framework after adding a service dog in the environmental factors. All the components in the ICF changed, and the participant’s health condition improved.
ICF, International Classification of Functioning, Disability, and Health.
In this qualitative study, we report on an individual with a complete C5 SCI who used a service dog and experienced improvements in all the components of the ICF. This qualitative study is the first to show improvements in the health condition of an individual with high cervical SCI who used a service dog.
Regarding changes in body function after using a service dog, we identified improvements in the areas of “increased vitality and motivation” and “emergence of self-affirmation.” Allen and Blascovich showed that service dog users had improved psychological well-being and internal locus of control.11) By evaluating the Rosenberg Self-Esteem scale24) and the UCLA Loneliness Scale,25)Collins et al.12) reported that service dog users had higher self-esteem and fewer feelings of loneliness than non-users. However, none of these previous studies conducted a qualitative analysis to show why the individuals had an improved internal locus of control, greater self-esteem, and fewer feelings of loneliness. In the current qualitative study, we demonstrated that the participant was able to clarify what the service dog could do for him and what caregivers should help him with. We also showed that structural planning for his care needs helped him to focus on his next behavior, and this brought him “increased vitality and motivation.” Regarding the change in emotional function, the participant experienced emergence of self-efficacy and self-affirmation. The act of commanding and taking care of a service dog might lead to increased self-esteem and improved emotional function. Previous studies did not show whether a service dog could affect pain or muscle and joint functions. This qualitative study showed that commanding and focusing on a service dog might distract an individual from pain, and taking care of the dog improved the participant’s endurance and muscle and joint functions. These findings indicate that a service dog may be able to improve the body functions of their owners in several ways.
Regarding changes in activities and participation, our study found improvements in the area of “emergence of new roles,” “increased resilience,” “expansion of moving area,” “acquisition of activities incorporated with a service dog assist,” “emergence of autonomous health management,” “expansion of relation with other people” and “expansion of social activity.” Previous studies reported that service dog users could expand their activities by using the assistance of their service dog to pick up dropped items from the floor.7,8) Hubert et al. showed that service dogs assisted with propelling manual wheelchairs and expanded the users’ activities and the area in which they could move.7) Our study showed that the service dog could not only pick up dropped items from the floor but also take items like self-help tools, a purse, and a cell phone out of the user’s bag. The assistance of a service dog in taking items out of a bag can potentially expand the user’s activities because the user can carry many items when going out. Although previous studies did not research the effect of a service dog on coping with stress, our study indicated that the service dog created more opportunities to go outside and go shopping. These became new stress coping measures for the user. In addition to these stress coping measures, the participant in our study said that he could accept the dog’s failures because he knew it was a dog (not a person), and he felt he could try again when he was accompanied by the dog. These feelings might have increased his resilience to cope with stresses and deal with the problems he needed to solve. Previous studies showed that service dog users improved their community integration and employment status.11) However, there has been no study to investigate whether service dogs have an effect on expanding relationships with other people. Our study suggested that the service dog expanded the participant’s relationships with other people by becoming a communication facilitator and buffering emotional conflict. This study also showed that the participant became considerate of other people after he used a service dog because he needed to be careful of the hair the dog shed and other people’s dog allergies when he moved about with his dog. These benefits brought by the service dog might have expanded his relationships with other people.
Regarding changes in personal factors, the participant experienced a “reduction of psychological barrier.” Previous studies have shown improvement in the psychological well-being of service dog users,11,12) but no studies have investigated changes in personal factors. The participant in our study felt relaxed when accompanied by his service dog because the presence of the dog reduced the psychological barrier to asking other people for help.
Regarding changes in environmental factors, the participant experienced more interactions with other people, and public service providers offered to help him more often when he was going out with his service dog. Eddy et al.15) and Mader et al.16) reported that social acknowledgments were substantially more frequent when a service dog was present. Furthermore, the tendency of able-bodied people to ignore and avoid the disabled person was reduced. Their conclusions are in concordance with our findings that a service dog draws attention to a user’s disability in an amicable way. Ultimately, a service dog leads other people to offer more help and expands the user’s support environment.
Study LimitationsThere are some limitations in this study, mainly resulting from the qualitative single case study design. First, there is a need to recruit many participants and confirm the saturation of categories to determine whether the conclusions reached have generalizability to other high cervical SCI cases. Second, the participant’s experiences prior to having a service dog might be subject to recall bias, because the participant was interviewed after he had used a service dog. To minimize recall bias, we confirmed the participant’s experiences before and after using a service dog with his wife; however, conducting interviews before using a service dog is recommended. Third, because the results came from an interview based on the ICF rehabilitation sets, the participant might have experienced other changes not included in the ICF rehabilitation sets. The addition of other ICF categories in line with the study purpose is recommended.
The authors have no conflicts of interest directly relevant to the content of this article.
