Encouraging reengagement with rehabilitation

Referral

The client was riding his motorbike when he was hit by another vehicle, which left him with severe injuries to his left leg, wounds to both arms and right leg, femoral fracturing to his right leg, and a head injury.

At the point at which his case was referred to HCML via joint instruction, the client had undergone a below the knee amputation, and was suffering with lower back pain and psychological trauma.

The referral to HCML came 10 months after the accident, due to the case having been previously handled by another case management company, where the relationship had broken down.

As a result, it was critical that the HCML rehabilitation case manager build a good relationship with the client to gain his trust and confidence, make up for lost rehabilitation time and ensure the client’s recovery journey got back on track.

Immediate needs assessment

The client’s injuries had a profound effect on family life. He lived with his father at the time of the accident, who was unable to provide the support the client needed following the incident. This meant the client had to move in with his partner and two young children for her to provide support.

Prior to the accident, the client was an active and hands on individual, enjoying fishing and fixing cars, motorbikes and quad bikes, as well as spending time socialising with friends and looking after his young family.

Through the immediate needs assessment (INA), the rehabilitation case manager identified a significant number of areas that needed to be addressed, including:

Mobility: the client was still largely dependent on wheelchair use, and only able to use his prosthesis with walking aids for a maximum of 10-15 minutes.

Access: moving around the home was a challenge. The only way the client could use the stairs was by manoeuvring himself using his arms and bottom. Steps in the garden meant this was also inaccessible.

Pain: 10 months after the accident, the client was still experiencing pain in his right thigh and phantom limb pain in his left residual limb, which stopped him from being able to move around more easily.

Day to day activities: the client’s partner had to support with general activities of daily living, including cooking, household chores and parental responsibility.

Weight: the client’s weight had significantly increased since the accident and was within 5kg of being too heavy to use his Proflex prosthesis. This presented barriers to his prosthetic rehabilitation and overall general health. It also contributed to ongoing back pain.

Psychological state: the client’s psychological wellbeing was continuing to deteriorate, with his reduced parenting abilities being a significant contributing factor. Low mood and symptoms of anxiety and depression had led to poor engagement with rehabilitation on occasions. Increased feelings of anger led to some anti-social behavioural issue. He experienced regular nightmares and flashbacks throughout the night, which had led to insomnia and also impacted on mood.

Work: the client had not been able to return to his role as a warehouse operative.

Recommendations & goal setting

The client’s goals were to return to:

  • independent mobility
  • undertaking everyday activities independently
  • taking care of his children
  • socialising and hobbies such as fishing
  • riding his motorbike
  • work.

To work towards achieving this level of independence, the rehabilitation case manager would need to motivate the client to reengage with rehabilitation and encourage him to persevere and take the necessary steps that would lead to achieving these longer-term goals.

For example, the client’s diet was very poor, and he was not aware of the affect it could have on his progress and recovery, from residual limb volume and socket fitting to functional rehabilitation.

Through conducting the INA the rehabilitation case manager identified several priorities including:

  • providing a new everyday prosthesis and water activity limb, combined with intense functional rehabilitation activity
  • conducting a housing assessment with an occupational therapist to identify ramp access and adaptive equipment requirements
  • dietetics assessment
  • psychological/psychiatric support
  • nursery care for their children to allow some respite for client and partner.

What was initially a challenging situation was managed sensitively, as a result of the rehabilitation case manager’s frank conversations with the client about what he could expect if he didn’t engage with rehabilitation.

Having developed a mutual understanding, they agreed a series of specific short-term goals that would enable the client to work towards his desired outcomes. These were:

  • to mobilise inside his home with his prosthetic limb without the use of a walking stick within 6 months
  • to walk with his prosthetic outside of the house with the use of a walking stick within 6 months
  • to be able to get around the garden using his prosthesis and walk sticks to navigate stepped access within 6 months
  • to report reduced anxiety and that his frequent nightmares and flashbacks were reduced to once per week
  • to take a family break at a suitable location with disabled access.

Interventions

It became clear early on that the client preferred face to face contact with the rehabilitation case manager, as the frequency and quality of his progress updates over the phone were not as effective as in person. The case manager adapted his communication, holding regular face to face reviews.

The rehabilitation programme incorporated a range of NHS and private practitioners, who the case manager coordinated and maintained regular contact with. His strong relationship with a prosthetics provider, meant that within 6 months, the client had undergone a trial of three microprocessor feet (which mimic natural ankle function and movement) which had a dramatic improvement on his overall attitude and adherence to his personal rehabilitation programme.

In addition to trialling the microprocessor feet and increasing his usage of a prosthesis, the client was also given a mobility scooter which enabled him to return to walking the dog, again boosting his overall mood as his independence began to increase.

The rehabilitation case manager also facilitated a family break in the UK and was involved in supporting the client along with his legal representative to purchase a new family home and make the relevant adaptations prior to moving.

The client also underwent regular reviews with a dietitian to ensure there would be no problems with prosthesis fitting.

To improve pain management, the case manager coordinated private treatment for the client to undergo a private popliteal sciatic nerve block with a local anaesthetic, plus trigger point injections in the vastus medialis and vastus lateralis muscles under ultrasound guidance. This helped reduce the client’s overall pain and assisted with increasing his function.

To address the client’s significant psychological and psychiatric symptoms because of the accident, the case manager coordinated a comprehensive range of psychological treatments including cognitive behavioural therapy (CBT), eye movement desensitisation and reprocessing therapy (EMDR) and medication reviews.

Outcomes

In just two months of commencing his rehabilitation programme with HCML, the client was wearing his prosthesis for up to eight hours per day and was able to walk outside for up to 20 minutes aided by a walking stick.

After five months, he was walking around his home using his prosthesis unaided and was able to access the garden independently. He was also better managing his diet, making better choices with what he ate and swapping out unhealthy options for lower fat/sugar options.

At eight months, the client and his family were able to take a weeklong break in the UK. He had also returned to riding a three-wheeled motorcycle which increased his overall independence and subsequently reduced his psychological symptoms of anxiety and anger.

Further to psychological treatment the client also reported a vast reduction in nightmares and flashbacks, which enhanced his quality of sleep.

At this point, the client was only using his walking stick for approximately 5% of the time and was wearing his EmPower microprocessor prosthesis for the majority of the time. With hugely increased confidence in his ability, he was now able to take his children to the park independently, walking on average for about 25 minutes.

One year after he’d begun his rehabilitation programme with HCML, the client had returned to completing all his activities of daily living. His reported pain had reduced from 8/10 on the Visual Analogue Scale (VAS) to 1-2/10.

The client and his family were very pleased and supportive of the rehabilitation package developed by the HCML rehabilitation case manager. As function began to increase, the client became a lot more engaged in his rehabilitation, particularly during the microprocessor foot trial.

Testimonial

This was a particularly tricky case for a young man who suffered a below knee amputation in a motorcycle accident. The legal teams agreed that the client would benefit from the involvement of a case manager experienced in supporting amputees. The HCML rehabilitation case manager was selected because of his expertise, and he was instructed on a joint basis under The Rehabilitation Code due to ongoing liability enquiries. He made a difference immediately making a number of recommendations within his INA which could be implemented quickly covering a range of therapeutic options including private prosthetic rehabilitation, physiotherapy, psychology, OT, services support and more general, practical recommendations that assisted the client and his young family adjust to the changes they faced. The HCML case manager worked well with the legal teams, was incredibly knowledge and always approachable, likewise he built a good rapport with our client which was key to success of the rehabilitation.

Personal Injury Solicitor