The Art and Science of Case Managing Rehabilitation after Brain Injury

building the rehabilitation team, balancing aspirations and goals with assessment of rehabilitation potential toward meaningful outcomes

​Brain injury rehabilitation is a broad church – part science, part art and certainly a very individual experience every time.
 
Many variables influence potential, progress and outcomes for each person engaging with rehabilitation. Factors such as; pre-injury abilities, age at injury, individuality, drive, motivation, general health, stamina, support, environment as well as the exact nature of the injury and time elapsed since injury alongside symptoms and impairments.
 
Then there is the science and current understanding of the brain, how it works, how it repairs and how it responds short, medium and long term after injury. This is set alongside ever-developing understanding of how exactly treatments and therapies impact (even where we ‘know’ that they do), what the dosage of therapy should be and how to maximise the benefits in each case. It is therefore impossible to pinpoint and prescribe an exact pathway or specific treatments based on a diagnosis, scan or symptomatic picture.
 
Good case-managed brain injury rehabilitation is therefore an approach and not a recipe or set prescription. It begins with a curious, observant and enquiring mindset, the building of rapport such that clear and open communication can occur, and ideally access to the client’s history and useful information on progress and issues to date (although the level of information available can be variable).
 
The aim of the initial case management assessment – within which I include meeting the client and family but also gathering and analysing information from other sources directly and indirectly – is to build a picture of breadth, depth and colour as to each individual client and their unique presentation in the context of their own lives. A truly deep understanding of each client will continue to develop as the case manager and client work together identifying aspirations and goals and this is central. The case manager then builds and manages the active rehabilitation whilst aiming to hold the position of neutral and deep understanding alongside concurrent monitoring of progress.
 
A multidisciplinary approach to rehabilitation will most usually be required and depending on a range of circumstances and the stage of recovery may consist of statutory provision, private provision or a mixture. The exact requirements in terms of the makeup of the rehab MDT around the individual may vary according to need. 
 
Case management aims to ensure an integrated and collaborative approach, within which good communication is central. I know from decades of my own experience that there is nothing more professionally satisfying than to be part of a rehabilitation team which is able to plan and work seamlessly and where there can be healthy debate and open exploration of all issues and ideas and thus arguably better rehabilitation effectiveness. This struck me again very recently during supervision when a case manager on my team shared her professional satisfaction to have built a team around one particular client. The team were working together so well that previous significant barriers to progress had dissolved and positive change was now very evident and building on itself, as it so often does when the client and family see meaningful progress and feel greater levels of trust and rapport with a team who ‘speak with one voice’.
 
A word here about experience within the rehabilitation team. Knowledge and experience in the field are of course important but it is worthy of note that in brain injury rehabilitation, each clinician's experience and knowledge is shaped by the clients they have worked with. This is interesting because it means that the person who on paper may have the least experience within the team, may actually have experience of something particularly useful in a specific case that their more experienced peers have not yet encountered. Of course, the more years of brain injury rehab experience a team member has the more likely it is that they have encountered a wider range of impacts from these injuries, but I and my colleagues across the UK and beyond never cease to share tales of new experiences – it is something that unites the professional brain injury rehab community, a certain delight in being surprised by new issues, challenges and goals!
 
So, whilst it is important that the overall MDT is able to draw on its expertise and experience of rehabilitating brain injury survivors, that can arise from combined experience across the team and the savvy case manager can weigh this alongside finding the ‘right fit’ in terms of communication styles, approach and personality when considering the components of the team. A demonstrably curious, creative thinking, collaborative and reflective therapist who could work well with a particular client and their team might be a good choice even if their CV is not peppered with brain injury experience.
 
So now let us turn to thinking about how far each client may be able to progress, what of their goals and aspirations are they likely to realise? How does the rehabilitation team assess and address this? Does potential change over time? Conversations of “rehabilitation potential” are often held with clients and families by the rehabilitation team, these conversations are important. The phrase is sometimes unpopular with rehabilitation professionals as it can be seen as limiting, however it is now widely used and in the context of personal injury litigation in particular it can be a helpful shorthand to indicate to everyone involved how far the MDT feel they can take the client through the rehabilitation process that they can offer (intentional emphasis).
 
In my experience these conversations often begin when the client is receiving rehabilitation from statutory services who are working toward discharge or a slower stream rehab scenario, often this is about managing expectations for those reaching their potential within that particular service (again, emphasis intended). It is not uncommon at this stage for clients and families to suggest they are being written-off. They see potential but feel the message they hear is the reverse. Disagreements can ensue.
 
This can be challenging - clinicians don't want to give what is sometimes referred to as ‘false-hope’, yet I've never in my 30-plus years in this field met a therapist that didn't want their patients to achieve the best possible results. I have however observed many differences of opinion between families and treating professionals, between professionals themselves and between predictions and actual eventual results.
 
Given the vast array of factors we have yet to fully understand that I refer to above, but which in combination give rise to the variety and individuality of each post-injury presentation and progress afterward, it must be the case that predictions of rehabilitation potential - from professionals and non-professionals - are hypotheses.
 
It is perfectly possible to hold many and opposing hypotheses at one time. Hypotheses offer a way to identify each 'best guess' based on the information and understanding that is available. Once proposed, the function of the hypothesis is to act as a statement of a possible outcome which can then be tested to see if it can be supported or not and in so doing more information is gathered which can assist in revising hypotheses / predictions to fit the individual and their circumstances.
 
Presenting hypotheses gives a clear, inclusive and non-confrontational way to discuss differences of opinion with client and family and also across the MDT. In effect, it is face-saving if outcomes are not what any hypothesiser suggested, this can be important in maintaining relationships, trust and rapport. It allows everyone involved to feel heard and that their thoughts and observations have been considered. Even more importantly it allows goals and treatment plans to be built around testing the hypotheses that have evolved and the client is less likely to miss out on opportunities to improve, and where progress is not made as hoped for it facilitates healthier conversations and supports adjustment (in a way that may not happen if the client and family remain at odds with treating professionals because they don't feel heard).
 
The art and science of rehabilitation that the case manager facilitates will be different each time – as individual as each client, and yet within the rehabilitation there will be similarities and themes that repeat across the world of brain injury rehabilitation. Crafting rehabilitation for each client will be a mix of many aspects, crossing boundaries, services and approaches which must be balanced and mixed for optimal impact. Key aspects will include the makeup of the MDT, client-led goal setting and inclusive open-minded conversations about potential with feedback linked to active monitoring of outcomes.    
 
 
Vicki Gilman MSc MCSP
BABICM Chair
Case Manager at Social Return
Neurophysiotherapist