Introduction
About half of all spinal cord injuries (SCIs) happen at the cervical level. SCI may result from trauma, disease, or degeneration. The average age at which clients experience SCI is around 40 years old [1]. Functional impairments due to SCI are highly variable and may impact a person’s capacity to engage in activities of daily living (ADL) and social participation [2]. Persons with cervical SCI need the most extensive care among those with SCI and even the most basic ADL tasks become a challenge for them. It can render the individual dependent upon assistance in many areas of daily living [3]. ADLs that are challenged in a person with a cervical SCI include fundamental skills, such as grooming/personal hygiene, dressing, toileting, functional mobility, and eating [4]. Even though SCI seriously impresses all aspects of occupational performance, occupational therapy frequently focuses on supporting clients to regain the abilities necessary for independence in ADLs [5].
Occupational-based models help occupational therapists work on the activity and participation of individuals with SCI. Among these models, the model of human occupation (MOHO), developed by Kielhofner in the 2017s, is an occupation-centered model widely used by occupational therapists around the world [6, 7]. The MOHO is a conceptual framework that addresses how and why we engage in meaningful daily activities, which are called occupations [8]. In MOHO, the elements related to the person are volition, habituation, and performance capacity; these elements interact with the surrounding environment to produce occupational performance [9]. To view the components of this model and their definitions, refer to Table 1.


The MOHO examines the mental dimensions of SCI, which leads to a decrease in the individual’s volition, interests, and values in performing ADLs [6, 10]. Considering that individuals with cervical SCI cannot fully perform their ADLs due to volition and performance capacity deficits and feel that they are not competent in performing these tasks, the MOHO is a suitable model for dealing with the challenges of ADLs compared to other occupational therapy models.
This study aims to formulate ADL problems in a case with cervical SCI with clinical reasoning based on the MOHO as a conceptual framework.

Patient Description
Ali (pseudonym to protect the privacy of the client) is a 26-year-old man who was diagnosed with incomplete cervical SCI. He could sit independently, spherical volar grip, full range of motion in the shoulders and elbows, and control of urine and feces, but he did not have the ability to stand and gait. Ali depends on a wheelchair for mobility. Before this accident, Ali lived alone at home and did all the household chores alone. He worked in an auto spare parts shop and job responsibilities included moving boxes, accounting, and reception. He currently lives with his sister. 

Concepts of MOHO
Before this, the client’s ADLs were completely carried out by his caregivers, and he had not received any explanation or training during occupational therapy sessions regarding the necessity of performing these activities independently. The last column of Table 1 presents the individualized application of the MOHO in this client. In the following, the concepts of this model are explained for the case presented above.

Volition
Cervical SCI affects his volition and motivation and impresses his capacity to engage in ADLs. The psychological effects of SCI, such as depression and anxiety, and a decrease in sense of control over his body, lead to a reduction in volition, a feeling of helplessness, and a dwindling in self-efficacy [11]. Volition in MOHO includes personal causation, value and interest [6].

Personal causations
Personal causation is the perception of his competence and effectiveness in performing ADLs. It is related to the concept of self-efficacy, which plays a crucial role in motivating and participating in performing ADL and in his ability to influence the environment or achieve goals for cervical SCI [12]. 

Values and interests
One of the goals of rehabilitation is to perform ADLs that align with personal values and interests. Because he cannot pursue occupations that were once integral to his identity, he reevaluates and detects his values and interests with the help of the occupational therapist. This process results in more focus on values such as independence in doing ADLs for living alone in a house and social communication [6, 13].

Habituation
Habituation describes the patterns and routines influenced by context, the environment, roles, and habits. He must adapt his habits and roles to accommodate limitations to recognize meaningful habits [6, 14, 15]. The habituation concept in MOHO contains two elements of habits and internalized roles [12].

Habits
Cervical SCI usually disrupts previous habits due to the physical restrictions imposed by the injury. In this client, ADLs which were once performed automatically, now require conscious effort and planning, for example, using adaptive tools for feeding and grooming, and continuous monitoring of body skin to prevent bedsores [16].

Internalized roles
Cervical SCI profoundly affects his roles, functions, and consequently social participation. By internalizing the roles, he develops an identity for himself. In the family role, he is unable to transfer and leave the house to do shopping, and he needs his sister’s help to do ADLs. In an employee’s role at work, it is difficult to go to work and perform tasks, such as accounting [3, 17].

Performance capacities
Performance capacity is the capability to do things, incorporating the person’s objective physical and mental elements, and their subjective experiences before, during, and after performing an occupation. A person’s physical and mental abilities are factors that affect the performance capacity. He must modify one or more aspects of his volition and habituation to adapt to long-term impairments in his performance capacity. Weak trunk control in a sitting position, reduced breathing capacity, and disturbances in some movements of the upper limbs have caused problems in the independent performance of ADL. Psychological adjustment to cope with anxiety and depression gives him the necessary preparation to adapt to new conditions and perform ADLs in an atypical form [18].

Environment
From the MOHO perspective, occupational behavior is largely influenced by the environment. The environment affects motivation, organization, and occupational performance. Background elements such as physical, social, cultural, political, and economic aspects constitute an environment. According to the MOHO, a person’s environment and internal characteristics are interconnected and affect their occupational behavior [19]. 
For him with cervical SCI, the environment has a crucial role in facilitating or impeding his occupational performance and participation. Because he is recovering at home, family and home are the main environments for him, therefore his main challenges are in performing ADLs in this environment. These challenges include the lack of proper access to the necessary equipment, such as a reacher, grab bar, or universal cuff to perform ADLs [6, 14].

Intervention 
How an individual completes an occupation inside the environment can be observed in three mutually interdependent levels of occupational participation, occupational performance and occupational skills.
The first rehabilitation focus for the client was to identify personal meaningful and achievable goals related to ADLs to enhance occupational participation, including eating with a spoon, grooming with a razor and brushing teeth, dressing and undressing, and functional mobility, such as in-bed mobility and wheelchair mobility independently. We provided opportunities for the client to experience success in small tasks, and gradually increased complexity to reinforce a sense of competence and personal causation. He stated his values and interests to identify occupations that are meaningful and valuable for these activities. Social communication with his friends was very significant to him. The client was guided to establish a scheduled time for skill acquisition and practicing ADLs. To achieve occupational performance, he identified and strengthened existing positive habits for instance brushing his teeth after every meal, shaving his face daily and eating with a spoon. We discussed the client’s roles before and after the injury and helped him explore new roles he can adopt that align with his current capabilities. The integration of routine occupational therapy exercises with ADLs to enhance strength, coordination, and functional mobility of muscles led to an increase in self-confidence in performing these activities independently. The living environment was assessed and modifications were recommended to enhance accessibility and safety [6, 14, 20].

Discussion
This study was conducted to investigate challenges related to volition, habituation, performance capacity and environmental influences that hindered Ali’s participation in ADLs, and by solving these challenges, he could improve his performance in these tasks.
There is not much evidence of the use of MOHO and its tools as a basis for clinical interventions in SCI. The study conducted by Jo showed that using the interaction between humans and the environment for environmental modification increased the time used in occupational participation and competence to perform occupations in people with disability. By applying MOHO theory to evaluate and modify one’s home environment and activity performance, the researchers can comprehend the lifestyle of clients and suggest opportunities to actively participate in ADLs. Adapting MOHO theory to enhance activity participation will contribute to enhancing the quality of occupational therapy services in community settings [6]. In the other study, a scoping review explored the connection between volition as a person’s motivation to engage in activities and participation among adults with acquired disabilities, such as SCI. The review found that acquired disabilities impact both volition and participation and that a positive relationship was found between the two [21]. A study conducted by Guidetti emphasized new client-centered ADL intervention based on the MOHO for persons with stroke. Its intervention empowered stroke survivors by focusing on their personal experiences and promoting their autonomy in ADLs. The results emphasized the significance of a holistic and individualized approach to rehabilitation, to improve the quality of life (QoL) for individuals recovering from stroke [22].
In the present study, with special attention to psychological issues in this client, good treatment results were obtained. As we know psychosocial support is necessary to manage challenges related to independence in ADL in cervical SCI [20]. The most basic ADLs are complicated for a person with cervical SCI, and it makes them dependent on assistance in many areas [23]. Occupational therapy’s role is to modify social and living environments and regain crucial and meaningful roles and abilities. When few significant improvements exist in cervical SCI rehabilitation, the client with cervical SCI may discouraged or give up [17]. Thus, by highlighting functional skills and emphasizing on client’s physical, social, emotional, sensory, and cognitive abilities, we promote their self-esteem and self-efficacy.
According to the concepts mentioned above, and the therapeutic outcomes of this treatment, the MOHO is based on a general systems theoretical framework in which the human was conceptualized to be an open system. The volitional, habituation, performance capacity, and environmental components of the human system contribute to the overall dynamic of the system, resulting in the emergence of thoughts, feelings, and actions that constitute occupational adaptation. In this view, therapeutic intervention is directed toward the alteration of any of the four components, leading to the re-organization of the entire system, MOHO provides a framework for understanding and solving ADL challenges in clients with cervical SCI and emphasizes the role of occupation in maintaining health and well-being and the impact of a person’s capacity to participate in ADLs in cervical SCI [20, 24].
We can use the MOHO theory to assess the degree of independence in daily activities to provide opportunities for them to actively participate in ADLs. Therefore, it can be argued that occupational therapists should implement the MOHO-based intervention to improve clients’ ADL performance and QoL.

Conclusion
MOHO-based interventions focusing on the client’s volition, habituation, and performance capacity and emphasizing physical aspects, and psychological and social dimensions in the rehabilitation process, led to substantial improvements in ADL skills, such as dressing, grooming, feeding, and transferring independently.

Limitations
In this study, specific tools of MOHO were not used, because the researcher did not have access to these tools during the implementation of the intervention.

Ethical Considerations
Compliance with ethical guidelines
This study was done with the informed consent of the client.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization: Maryam Derakhshanfar and Samaneh Karamali Esmaeili; Methodology: Mayam Derakhshanfar; Writing, review and editing: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the patient for his collaboration on this project

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