Amputee’s determination to succeed after catastrophic motorcycle injury

The client sustained significant injuries following an accident where a motor vehicle collided with him whilst he was riding his motorcycle. This included a significant ankle fracture, as well as bilateral shoulder and upper back pain, and resulting psychological symptoms.

Over a period of 4 years, the client underwent an open reduction internal fixation (ORIF) procedure, a form of open surgery, to repair the bone in his left leg. Despite the surgery and postoperative walking boot to assist functional recovery, the client developed a contracture in his left foot which resulted in him being unable to move or use his left foot at all. The client experienced severe pain in his foot, with the slightest touch causing intense pain. Nearly 2 years after the accident, the client was diagnosed with complex regional pain syndrome.

This poorly understood condition meant that the client was seen by multiple specialists, and treatment included residential rehabilitation at the Royal Hospital for Rheumatic Diseases. He also trialled a spinal cord stimulator, however, none of the interventions provided any significant relief in symptoms.

As a result, the client elected to undergo amputation a little over 3 years after the initial accident.

His case was referred to HCML approximately 3 ½ years after the accident.

Immediate needs assessment

Within 2 weeks of referral the HCML Rehabilitation Case Manager conducted an immediate needs assessment (INA).

The accident had had a huge impact on the client’s ability to move around and therefore on his lifestyle. The client was restricted to using a wheelchair as there had been no prosthesis provided. Despite support from his parents, the family home was unsuitable for wheelchair access and they were opposed to significant adaptations such as permanent ramps and stair lifts. This made it extremely difficult for the client to adjust to home life.

Prior to injury, the client had been extremely active, so the accident had a huge impact on the way he lived his life. Pre-accident he was a keen sportsman, taking part in multiple sporting activities such as football, cross-country running, mountain biking, mixed martial arts, and was a regular at the gym. The accident cut him off significantly from his social life.

In addition to this, the client was unable to return to his previous employment as a gardener and doorman.

Not being able to participate in the social and vocational activities he had pre-accident had a huge impact on the client’s wellbeing. Of significant concern were issues around acceptance and body image, with the client experiencing anxiety and depression as characterised by adjustment disorder.

A further challenge was the client’s previous negative experiences and perception of clinical specialists, as the pain he experienced had not been reduced nor his function increased in the past 4 years.

Recommendations & goal setting

The client wanted to achieve independence with his mobility and be able to complete basic activities of daily living. It was important for him to be able to start taking part again in the sporting activities he’s previously enjoyed and successfully reduce the pain he was experiencing to a manageable level.

The HCML Rehabilitation Case Manager worked with the client to establish a clear set of goals.

Short-term goals included:

  • to walk for 15 minutes per day using an NHS prosthesis
  • to find a more suitable private prosthesis
  • to trial and purchase a running blade
  • to return to sleeping in his bedroom upstairs within 6 months
  • to shower independently within 6 months
  • to access all areas of his family home (with suitable equipment / adaptations)
  • to return to pre-accident hobbies, and
  • to return to riding a motorcycle.

Long-term goals included:

  • to return to employment as a gardener
  • to return to being independent
  • to return to his pre-accident hobbies such as football, running, mountain biking and mixed martial arts, and
  • to be able to live independently in the future.

Interventions

The recommendations from the INA formed the basis of the client’s bespoke rehabilitation plan to achieve the set goals and included:

  • a private occupational therapy assessment to provide suitable adaptations to the family home within the parameters set by his parents
  • a private prosthetic assessment at PACE Rehabilitation which resulted in the client receiving an everyday prosthesis and a running blade
  • psychological support
  • physiotherapy for upper body strength
  • a taxi account to ensure the client was able to attend medical appointments
  • funding for personal training / gym instructor course
  • funding for motorcycle adaptations including push button gear change system.

As the client progressed through his rehabilitation programme, the HCML Rehabilitation Case Manager adapted and expanded upon the programme as necessary.

A major barrier to the client’s progress was the pain he experienced in his residual limb, compounded by neuropathic pain and phantom limb pain. This was continually fluctuating and despite improvements in function was setting him back in his recovery.

The HCML Case Manager researched and arranged a variety of interventions to help with pain management. The client had private reviews with a pain management consultant, plus a consultant in rehabilitation medicine to improve his skills in managing his own pain. In addition to this, the Case Manager utilised his strong links with orthopaedic provides and organised neuromotus therapy, a relatively new and innovative form of therapy which aims to reduce phantom limb pain through augmented reality software.

In addition, to further reduce pain levels, the Case Manager arranged Lignocaine infusions alongside the other pain management therapies.

As part of his ongoing case management, the client also underwent private procedures for surgical revision to the stump to reduce secondary problems as a result of amputation. Further treatments to increase comfort included laser hair removal to improve skin condition and reduce irritation and cyst removal.

Alongside these, the HCML Case Manager worked with the client on functional rehabilitation to increase the client’s mobility and also start working towards a return to social and working life.

Having a strong programme of rehabilitation has enabled the client to achieve some truly amazing goals, but it has not been without its challenges. The programme has really motivated the client and his determination to succeed has led to pushing himself with, as he describes it, an “all or nothing” approach. This sometimes has the effect of him achieving major goals, but then being wheelchair bound for a number of days afterwards and unable to wear his prosthesis because skin breakdowns and fatigue.

It’s an ongoing process where the HCML Case Manager has to work with specialists to educate the client in ‘pacing’ activity and managing his expectations so that recovery continues to progress smoothly.

In addition, managing the client’s sporadic sleep pattern has proved challenging. This sometimes leads to missing medication and not taking it regularly which has an impact on pain management. The HCML Case Manager continues to work with the client on this too.

Outcomes

Just 6 months post amputation, the client was using his prosthesis throughout the day without use of crutches, and returned to sleeping upstairs in his own room.

Within 8 months of starting his rehab programme with HCML, the client began to ride his mountain again, managing 1.5 miles at a time. Within the next 2 months he was attending the gym 3 times a week and took part in multiple sporting sessions including football, climbing wall, running and snowboarding – all with his prosthesis which he was able to sustain for around 45 minutes.

18 months after his amputation, the client climbed Scarfell Pike, England’s highest mountain at 978m, which took him 6 hours. At this point he was also able to jog for 5-10 minutes on his running blade.

Just one month later, the client climbed Ben Nevis, the UK’s highest mountain at 1,345m.

With the support of the HCML Rehabilitation Case Manager, the client is overcoming adjustment disorder and the resulting psychological symptoms he was experiencing, to making marked improvements in function and harnessing great self-belief. The client’s ultimate goal is to become a Paralympian, which, 3 years ago, would not have been deemed possible. His journey continues.