Catastrophic amputee and brain injury case supersedes expectations

Referral

The client incurred extensive injuries following an accident where a motor vehicle collided with him whilst he was riding his motorcycle.

His injuries included:

  • right leg transfemoral amputation
  • infection to the residual limb
  • extensive diffuse axonal brain injury (DAI) and subdural hygromas
  • left brachial plexus injury, resulting in left upper limb hemiplegia
  • fractured right pelvic ring
  • fractured right acetabulum
  • dislocated right hip
  • fractured left tibial plateau
  • left knee ligament damage
  • dislocated left elbow
  • dislocated left shoulder
  • grade 3 splenic laceration
  • fractured proximal phalanx of the left foot
  • fracture of first left rib
  • bruised lungs
  • psychological symptoms.

The HCML rehabilitation case manager was appointed 5 months after the accident. At this point the client was an inpatient at a neurological rehabilitation hospital ward where he’d received physiotherapy and psychotherapy.

The consultant advised that it would be unlikely that he would ever be able to carry out any day to day activities independently. Due to the client’s left arm hemiplegia, the consultants eventually offered amputation as an option (declined by the client).

The client had not returned home since the accident. This had a huge impact on family dynamics, with the added pressure of Covid-19 restrictions which meant his family couldn’t visit as often as they’d wanted.

Immediate needs assessment

The immediate needs assessment (INA) was conducted within a week of the case being referred to HCML.

Given his extensive injuries, the client’s mobility was significantly affected. He had been provided with a locked knee prosthesis, but was struggling to use this due to limited neuromuscular control around the left hip and pelvis, socket discomfort and physical / cognitive fatigue. This meant he was mainly wheelchair bound.

The client had also lost the use of his left arm, feeling no sensation or ability to initiate any kind of active movement.

The physical impact of his injuries meant the family home was now unsuitable for him to move back to. With limited space downstairs, narrow doorways, no bathroom facilities on the ground floor and ramp access restrictions, the home was not wheelchair accessible. In addition, the client’s use of a wheelchair meant the family car was no longer fit for purpose.

With a full time job, the client’s wife was not in a position to provide the all day care her husband required in the initial stages of his rehabilitation.

The client’s traumatic brain injury had a profound effect on his relationships, particularly with his wife, as it had triggered personality changes including things like understanding humour. It had also caused impaired memory, poor concentration and attention, as well as affecting his speech and executive functioning.

The psychological effects of the accident were far reaching, from the client experiencing psychological trauma to his wife and children having suffered ongoing and substantial psychological distress as they came to terms with the incident and the way in which it had affected their relationship with their husband/father.

The accident completely changed their lives. The client had always been extremely active and took part in multiple sporting activities on a regular basis including running, circuit training, karate, open water swimming, cycling, as well as Latin and Ballroom dancing with his wife.

Recommendations & goal setting

The HCML rehabilitation case manager identified several priorities the client’s rehabilitation programme would need to address:

  • Initial requirement for adequate lightweight prosthesis.
  • Move the client to a specialist residential rehabilitation unit which would provide intensive support in physiotherapy, occupational therapy, neuro-psychotherapy, hydrotherapy and use of prosthetics and Neuromotus (a new innovative technology that allows clients to control limbs using augmented reality).
  • A housing assessment to be conducted.
  • A driving assessment.
  • Psychological support for the whole family.

The family were keen to support the recommendations. They also wanted to ensure any adaptations needed for the house would not alter the feel of it being a ‘home’ and make it too clinical.

Most important for the client was to:

  • Return to independent mobility and complete basics activities of daily living including dressing, showering and meal preparation.
  • Return to the gym, swimming and sports clubs.
  • Return to driving.

The rehabilitation case manager worked with the client and the family to establish clear goals and a rehabilitation programme that would enable the client to work towards achieving independence.

A long term goal was to return to employment. Prior to the accident, the client had been an HGV driver. Returning to this vocation would be ambitious due to his injuries and the resulting restrictions they caused, but by addressing short term goals he would see tangible improvements that would sustain motivation.

These included:

  • Finding a suitable property upon discharge.
  • To be able to complete personal hygiene tasks independently and prepare a basic meal and drinks by the time he returned home.
  • To be able to use the stairs at home with prosthesis and single quad stick.
  • To be able to walk outside for 5 minutes using his prosthesis and single quad stick.
  • To be able to go into the local community using his powered wheelchair.

Interventions

Less than 3 weeks following the appointment of the HCML case manager, the client was transferred from NHS care to a specialist residential rehabilitation unit where he spent 20 weeks.

He received a range of NHS and private equipment and adaptations to assist his function including 2 new protheses, a water activity limb, 2 wheelchairs for inside and outside mobility, a powered wheelchair plus various adaptations to his home to enable access.

The case manager maintained regular contact with both NHS and private practitioners and equipment providers to ensure the client received the most suitable equipment. A significant challenge was that the client required multiple socket changes due to the residual limb undergoing changes in shape and volume during postoperative recovery. These fluctuations were in part due to the distribution of pressure between the client’s residual limb and prothesis, which meant ongoing assessment and revision surgery to alleviate pain and correct balance in his right residuum was required.

In addition to this, his left arm remained flail with a complete lack of mobility and sensation, which meant the client had to fit his prosthesis using one hand. As a result, the case manager organised for an osseointegration assessment to address continued socket and functionality difficulties.

The client’s brain injury was another significant obstacle in enabling him to fit and use his prothesis effectively, as it had affected his thought processing and memory, which made it difficult for him to learn and remember new techniques, including using his prosthetics.

Despite the family difficulties at the outset due to the nature of the injuries, the rehabilitation programme and interventions led by the case manager were very well received by the client and his family, and enabled the family to maintain a good relationship. This included organising psychological support for the whole family and putting them in contact with their local Headway branch.

They were extremely supportive of the rehabilitation programme, engaged and willing to help in any way they could.

Outcomes

In the 4 months the client spent at the specialist residential rehabilitation unit, he achieved a number of functional goals including:

  • swim 20 lengths of the pool unaided
  • walk 10 metres unaided
  • walk 1 kilometre outside with use of his single quad stick
  • able to get up off the floor independently
  • walk up and down a flight of stairs using his prothesis, and
  • complete activities of daily living independently.

In just 5 months of starting his rehabilitation programme with HCML, the client took a driving assessment, and with some vehicle adaptations, was deemed fit to drive. HCML facilitated wheelchair accessible vehicle demonstrations and the client began driving unrestricted just 14 months after the start of his rehabilitation programme.

Meanwhile, the case manager worked with the family and other professionals to source a suitable new home for the client and family.

A few days before Christmas, approximately 13 months after the accident, the client was able to move into his new home with his wife and children.

14 months after the accident, the client walked outside for ¾ of a mile, which took him 1 hour and 19 minutes. This was an amazing achievement, given that the consultant at the beginning of the process had advised that the client might only be able to wear a prothesis for 2-4 hours a day due to nerve damage and only use it to transfer in the house. Just 2 months after starting the rehabilitation programme, the consultant stated that the client’s progress measured by the SIGAM scale was much more than they’d initially thought possible.

Back at home, HCML assisted the client with further interventions including neuro occupational therapy, neuro psychotherapy and physiotherapy. The case manager arranged for the client to receive a MyoPro orthotic device to help restore the function in his left arm and continued to facilitate the possibility of osseointegration for his left residuum.

In 14 months of referral to HCML, the client:

  • has returned to driving using a wheelchair accessible vehicle
  • uses a prosthesis and single quad stick to walk up to 1 mile at a time
  • is able to independently access the local community with his mobility scooter
  • can easily move around his home with his prosthesis or wheelchair
  • has returned to swimming 2-3 times per week, including open water swimming training
  • completes ongoing rehabilitation exercises at home and in the gym
  • is able to complete all activities of daily living independently
  • is able to manage his cognitive and vestibular deficits such as fatigue, impaired memory, reduced concentration, word finding and planning
  • is about to start rehabilitation using MyoPro orthosis to increase function in his left arm, and
  • is awaiting further diagnostics to see if osseointegration is a possibility.

Given his initial prognosis from consultants, the client has demonstrated an exceptional recovery within a relatively short period of time. Having superseded NHS expectations, he continues to improve and is committed to ongoing rehabilitation, so further recovery can be achieved. His determination, positive attitude, drive and adherence to his rehabilitation programme has meant he has achieved what was initially thought impossible.

Testimonial

Andrew was involved in a catastrophic road traffic accident where he was knocked off his motorbike on his way home from work.  This resulted in multiple injuries including an above knee amputation, brachial plexus injury, traumatic brain injury along with a pelvic fracture which required a pelvic ring repair, broken ribs, splenic damage, Horner’s syndrome, dislocated elbow and shoulder and other minor injuries.  We instructed a legal team to help us to deal with this. The legal team recommended that we enlist the help of an experienced case manager, who specialised in dealing with this type of case and who would liaise with solicitors of both parties; they recommended Jason. 

Right from the beginning Jason has been professional, easy to talk to, knowledgeable and efficient.  He has helped to guide us through a very complex process and suggest relevant interventions on the way through. 

Andrew was away from home for over a year, and I was diagnosed with PTSD and signed off work for approximately 5 months.  To add to this, we were hit with the Covid pandemic which added further issues.  We also had to move due to the original house not being suitable for Andrew’s needs.

Jason has and continues to be supportive of our families’ needs, not just Andrew.

Initially I had at least weekly calls with Jason who was on hand to offer advice and support.  He listened to issues and was and still is always a great ‘ear’ who offers practical and emotional support.  As time went on, he spoke and continues to speak regularly to Andrew, to check how he is doing and to chase up anything requested.

We have been very grateful for Jason’s commitment to us and to our case, he appears to genuinely care; Not being involved with life changing injuries before meant that we had little knowledge of what to do. Luckily Jason had a lot of knowledge about this type of thing and many contacts, so he is able to be our guide who has offered assistance in arranging meetings with relevant people, suggesting ideas of things that may be helpful, supporting with issues along the way.   He has communicated with various third parties on our behalf including rehabilitation specialists, physiotherapists, hospitals, prosthetists, wheelchair providers, solicitors, Motability (WAV) providers, occupational therapists, psychotherapists, swimming rehab and others.  He has been very efficient at keeping us up to date at every step on our way and is always reliable; if you ask him to do something you can consider it done.

Without Jason’s support I believe our case would be several months behind where it is now, and the stress levels would have been even higher.

Rehabilitation client’s wife.

Jason is our Amputee Clinical Lead and will be joining the client in a 5km charity walk this June. They will be raising money for the Richard Whitehead Foundation at the Run with Rich event. If you’d like to support them, please donate to help raise money for this worthy cause.