The case was referred to HCML by joint instruction one month after the client had been injured. The accident involved a motorbike colliding with the client whilst he was out walking in a park with his family.
The client sustained multiple injuries which left him with a fractured eye socket, laceration to the nostril and head, psychological trauma, and resulted in a left leg trans-tibial amputation.
Prior to case management, the client had been undergoing regular physiotherapy, orthopaedic intervention and had been fitted with a prosthesis through the NHS, just under 4 weeks after the accident.
At this point the client was able to move around using crutches for 1-2 minutes at a time, so it was clear that with the right support, the rehabilitation potential for the client would be significant.
Immediate needs assessment
The accident had extensive practical and emotional impacts on the client and the family, and presented a huge change in family dynamics.
The nature of his injuries meant the client needed far more assistance post-accident, and as the eldest of 4 young children, the shift in care meant the need for increased support from parents and a change in family priorities.
Prior to the incident the client’s parents had both worked part time. At the time of the immediate needs assessment (INA), the client’s mother had given up work to enable her to look after the client full time. His father suffered substantial psychological distress because of his son’s accident and was unable to continue working. The change in family circumstances impacted the client’s siblings psychologically too, where one sibling presented with psychosomatic symptoms of leg pain and saying they were unable to walk properly.
The practical implications for the family were vast. As the client was wheelchair bound, their family home was not suitable. The property had step access to most of the downstairs rooms, but as it was a rental property, the potential for adaptations was limited. The client’s bedroom was located up two flights of stairs, so it was necessary for the family to turn the dining room into a bedroom.
The parents had to help with all activities of daily living, from enabling their son’s access in and around the house by physically carrying him, as well as assisting with bathing and other personal care.
Outside the house, installing ramp access was challenging as the main entrance opened directly onto the pavement, adjacent to a busy main road. As a family they were now unable to go out together in the car as it was too small for the wheelchair.
Above all, was the huge impact it had on the client’s life. Prior to the accident, he was extremely active and took part in multiple sporting activities including gymnastics at a regional competition level.
The rehabilitation case manager identified several priorities during the immediate needs assessment (INA):
- Sourcing a suitable everyday prosthesis
- Housing assessment for necessary adaptations
- School environment assessment to ensure access and procedures in place for potential pain/mobility issues
- Dietetics assessment to review and adapt diet accordingly to support energy required to mobilise with a prosthesis
- Psychological support for the whole family
- Support for family to purchase a vehicle with space for a wheelchair
Recommendations & goal setting
It was important that the rehabilitation programme was designed to help the client work towards the goals that were most important to him, whilst also taking into account the families wishes, their circumstances and the practicalities of different rehabilitation interventions.
The client wanted to:
- move around independently
- go back to school
- be able to play with friends
- continue attending sports clubs and practice.
The rehabilitation case manager worked closely with the family to understand what support they felt they needed and to manage expectations about their son’s rehabilitation programme. They were concerned about their son’s accessibility around the house in a wheelchair and wanted to ensure adaptations were made to support their son immediately and to address his needs in the longer term. They were also keen to ensure their son had the most suitable prosthetic as they were determined that he still have the same opportunities as other children his age.
Short term goals included moving around the house without assistance, being able to sleep in his own bedroom upstairs again, getting outside and walking with a frame or crutches, and reducing his psychological symptoms as well as those of the rest of the family.
Longer term goals were:
- a return to full time education
- to return to all pre-injury sporting hobbies including gymnastics, trampolining, swimming, dancing and riding his mountain bike.
The HCML rehabilitation case manager worked with a range of NHS and private practitioners to deliver the rehabilitation programme. A priority was to work with an occupational therapist to provide temporary ramp access to the house and a lightweight wheelchair which allowed the client to move around the ground floor of their family home independently.
In the meantime, the rehabilitation case manager arranged physiotherapy and supported the client to use their prosthesis, and within 3 months of receiving it, the client had progressed to wearing the prosthesis for up to six hours a day, without using any kind of crutch. Later, as a result of the rehabilitation manager’s knowledge and understanding of the market, a high activity blade was sourced to help the client progress with their sporting pursuits.
The rehabilitation case manager also liaised with a dietician to review and discuss the client’s goals to create a meal plan that would sustain the energy levels required for the client and be easy to follow to successfully undertake the rehabilitation programme that would enable him to achieve those goals.
With the client keen to get back to school, the rehabilitation case manager worked with the Special Education Needs Coordinator (SENCo) at his school and occupational therapist to assess the school environment and put in place measures to support the client’s return. These included ramp entry, a phased return to PE to safeguard against further injury and creating a ‘safe space’ for the client to go if he felt he needed to.
The family were extremely supportive of the rehabilitation package, engaging with the rehabilitation case manager from the outset, and were willing to help in any way possible. Understanding the significant impact the incident had on all family members, the rehabilitation case manager recognised that relevant psychological interventions were needed to enable the family to maintain this strong level of support for the client and each other. This included a referral to the Child and Adolescent Mental Health Services (CAMHS) for the client’s siblings.
Incredibly, the client was able to return to gymnastics just four months after the accident, which was one of his main goals. Although movement was still slightly restricted in that he was unable to run up to the springboard, having been fitted with a prosthesis just 3 months earlier, he was able to perform routines on the bars, floor, beam and rings.
It was around this time that the client returned to school – only four months after the accident – and this would have been sooner had it not been for Covid-19 restrictions.
Just eight months after the accident, the client had returned to all his sporting hobbies, using his high activity blade for the majority of activity, enabling him to move freely across various terrains.
The client continued to work with the physiotherapist recommended by the rehabilitation case manager and at 10 months post-accident, he took part in a fundraising event with the physiotherapist to raise funds for a cerebral palsy charity. The client helped raise £19k by running 1 mile, doing 30 squats, 30 sit ups and 30 press ups, everyday for one month.
The client reported that he felt his overall recovery was 80-85%, just 11 months after the accident.
A year after the accident, with advice from the rehabilitation case manager, the family moved into a suitable family home which allowed the client ease of access when using his wheelchair.
By 16 months post-injury, the client was wearing his prosthesis up to 10 hours a day and was unrestricted in any activity he chose to take part in, including gymnastics, rugby, mixed martial arts and football.
The client is now a keen fundraiser, and has attended charity events for The LimbBo Foundation, a charity that supports children with a limb difference and their families.
Given the timeframes and what has been achieved, the client has demonstrated an exceptional recovery. The knowledge and advocacy of the rehabilitation case manager in putting in place the relevant interventions and their understanding of family needs, together with the client’s motivation and drive to achieve their goals, enabled a recovery that exceeded all expectations.
Moving forward, the client is considering exploring the possibility of training to become a Paralympian.