CPD: Rehabilitation following left brachial plexus trauma

An insurance-funded vocational case manager was able to help an employee back to work following a motorcycle accident

Anne Harriss and Su Chantry assess the role of an insurance-funded vocational case manager in developing a post-discharge rehabilitation care package for a lorry driver who sustained serious injuries in a motorcycle collision.

Motorcycles are a common form of transport; their riders are more vulnerable than those of users of other motor vehicles in the event of a road traffic accident and may sustain life-changing injuries.

This article features Arthur, a 28-year-old lorry driver, who sustained serious injuries as a result of a collision whilst travelling to work by motorcycle. It focuses on his injuries and the involvement of an insurance-funded vocational case manager (VCM) who developed a post-discharge rehabilitation care package.

The Case Management Society UK state on its website that: “(Vocational) case management is a collaborative process which: assesses, plans, implements, co-ordinates, monitors and evaluates the options and services required to meet an individual’s health, social care, educational and employment needs, using communication and available resources to promote quality cost effective outcomes”. (Case Management Society UK)

All VCMs supporting clients covered by a personal injury claim must follow a strict rehabilitation code in the same way as OH nurses must practice in compliance with their NMC code of practice (Case Management Society UK, 2015).

A variety of healthcare professionals practice as VCMs, including physiotherapists, occupational therapists and nurses. There are similarities between the roles of VCMs and occupational health nurses (OHN), as they all develop rehabilitation strategies and work should be a health outcome.

There may be opportunities for multi-professional working where a VCM service user is employed by an organisation providing an OH service. Arthur’s employer did not provide an OH service; had it done so, his VCM may have taken the opportunity to liaise with it to discuss and collaborate on interventions to promote a return to work. Such a strategy would have been undertaken as part of an insurance-funded recovery strategy. This article provides an insight into their role and an overview of how Arthur’s VCM coordinated his post-discharge care.

Arthur sustained multiple life-threatening injuries including left brachial plexus damage resulting from complete post-ganglionic evulsion of the spinal nerves C6, C7, C8 and T1 originating from a combination of cervical and thoracic vertebrae. Other injuries included a left scapula fracture, acute changes to his thoracic vertebrae and laceration to his right thigh. A further complication was the development of pulmonary emboli.

The day after his accident, Arthur was transferred from the hospital that gave initial emergency care to a specialist hospital for exploration and repair of his brachial plexus injuries. It was this injury that had serious implications for his future long-term recovery and return to gainful employment. This element of his injuries will be the focus this article.
Although not life-threatening, there were long-term implications to the damage he sustained to his brachial plexus. Arthur experienced long-term disabilities due to the effects on the musculature of his left shoulder, elbow, wrist and hand.

Anatomy

The brachial plexus consists of five nerves, each originating from the spinal cord and incorporating the four lower cervical nerves (C5-C8) and the nerve originating at T1. These nerves control the muscles of the shoulder, elbow, wrist and hand, as well as providing sensation in the arm. Although some brachial plexus injuries are minor and will completely recover within several weeks, more severe injuries such as those sustained by Arthur cause long-term disabilities.

The position of the arm at the point of impact influenced Arthur’s resulting injury and determined the levels involved (Park and others, 2017). Should the arm be held in a neutral position at the side, a C8-T1 injury is usual. However, should the arm be abducted, as was the case for Arthur, C7 is also commonly involved. In his case there was involvement of all the spinal nerves from C6 down to T1.

Brachial plexus trauma may lead to a range of symptoms including:

  • Swelling around the shoulder;
  • Neck and shoulder pain;
  • Paraesthesia and weakness in the arm; and
  • Horner’s syndrome which is characterized by ptosis (a drooping eyelid), miosis (pupil constriction) enophthalmos (posterior displacement of the eyeball within the orbit) and anhidrosis (decreased sweating).

Arthur suffered from each of these, but the most disabling for him was severe neck and shoulder pain coupled with weakness and paraesthesia of his left arm. As effective and timely rehabilitation strategies play an important role in reducing disability in adult trauma, the VCM remained aware of the range of the options for specialist surgical repair, which included nerve transfers.

The National Institute for Health and Care Excellence (NICE) recommends that phrenic nerve transfer may be considered as a treatment option. Other options include nerve grafting, muscle transfers and neurolysis of scar tissue around the brachial plexus. In some patients phrenic nerve transfer has shown to be useful in the recovery of arm function (Sakellariou and others, 2014).

There is very little information about long-term functional and quality-of-life outcomes. Patients with brachial plexus injuries are often severely disabled and treatment options are limited. The team responsible for the Arthur’s care decided the specific surgical intervention and hospital care; the role of the VCM was to then plan and co-ordinate ongoing support from appropriate therapists such as occupational and physiotherapists. This ongoing support was funded by his insurance settlement.

A subsequent CT scan confirmed pulmonary emboli and these were treated with anticoagulants. After two weeks of acute treatment, Arthur was discharged home with one follow-up appointment for rehabilitation in the hand clinic of his local hospital. A successful brachial repair using phrenic nerve transfer was the surgical treatment of choice but this intervention was postponed until he had completed the anticoagulant therapy required to treat his pulmonary embolus.

Although able to drive his car, his injuries precluded him from his usual work tasks, which involved driving and maintaining large plant and vehicles. The vocational assessor was of the opinion that, given the current effects of his brachial plexus injury with an anticipated restricted prognosis, it was unlikely he would be able to work as a quarry driver in either the short or long term. The substantial and long-term effects of his injuries on his ability to perform normal daily activities were congruent with the definition of having a disability under the Equality Act 2010.

Arthur’s recovery was hampered by his ongoing low mood, lack of motivation, social isolation and reliance on family members for assistance. His ability to perform many activities of daily living, particularly those requiring fine motor movements, remained static, neither improving nor deteriorating, and he was unable to return to work in his role as a quarry driver.

A number of issues relating to Arthur’s condition affecting his upper and lower body and mobility were noted as being pertinent in promoting his recovery, in particular those relating to him undertaking activities of daily living. These included:

Upper body

  • Arthur was right arm dominant.
  • Right arm – he had a full range of extension movement and power.
  • Left arm – he had no extension movement or power.
  • Paraesthesia in his left arm/hand.
  • Numbness left arm/hand with no grip in his left hand.
  • Atrophy of the musculature of his left arm.
  • Swelling of his left upper arm and within his armpit.
  • Crushing and burning pain that he described as being at five on a 10-point pain scale.
  • Significant left sided neck discomfort.

Lower body

  • Right knee flexion – he experienced some pain from scar tissue restriction.
  • Right leg wound – this was healing well.

Physical mobility

Before his accident, Arthur had been independently mobile with no medical history of note. Following his accident, Arthur was unable to achieve high-level physical activities such as running. His limited neck flexion and rotation required him to rotate his whole body in order to look sideways to the left.

The range of movements of his left arm and hand was compromised and he was unable to push up from left side. Although able to use the stairs at home he reported being unable to climb steps or a ladder with implications in regards to his full recovery and a return to the work place.

Arthur’s upper body injuries affected the function of his left hand and arm, leaving him unable to perform tasks involving grip or manual dexterity. This resulted in him requiring assistance with activities of daily living including dressing. His wife was keen to contribute to his recovery and was able to help him with the passive exercises for his fingers, hand, wrist, elbow and shoulder.

These exercises had been prescribed during his one attendance at the NHS hand clinic. Despite this treatment there was obvious atrophy of the musculature of his left arm. Furthermore, Arthur was no longer attending the local gym, an activity he had previously enjoyed, and he noted that he was experiencing social isolation.

Arthur’s VCM arranged for him to be referred to a physiotherapist for assessment and treatment with a short-term aim of maintaining an optimal range of passive movements in his left arm. A further referral to an occupational therapist explored all options available regarding practical support for his upper limb restrictions. At this juncture, whether he would experience a return to independent upper limb mobility was unclear. All available options to promote physical mobility, rehabilitation and quality of life were explored in a measured and realistic manner.

A focused vocational rehabilitation programme was developed addressing both his physical and mental wellbeing. From a psychological perspective, acceptance of his current disability was essential and it was decided that he would benefit from cognitive behavioral therapy that was arranged with and delivered by a chartered clinical psychologist.

Therapeutic goals incorporating physiotherapy and occupational therapy were the primary treatments choices to promote his physical health. His mobility needs were addressed in terms of optimising his general physical fitness and upper body strength. His quality of life depended on him engaging in vocational activities choices of which were significantly restricted due to his physical impairments.

The impact on his ability to undertake activities of daily living meant that he would be covered by requirements of the Equality Act 2010. Unfortunately, the long-term effects of Arthur’s injuries were significant. Despite the involvement of physical and occupational therapists, it had not been possible to recommend what could be considered to be reasonable adjustments to his role or work equipment.

This precluded his continuing employment as a quarry driver. Consequently, goals were set with a focus on new vocational options. It was noted that he had significantly reduced left upper limb function, was living with daily pain and was struggling to mitigate the impact of these on activities of daily living. He was largely dependent on the support of wife and parents; he indicated his enthusiasm to becoming more independent and looked forward to returning to an employed role in the future.

The Department for Work and Pensions reports on the employment rates of disabled people by impairment. According to its Labour Force Survey, disabled people are now more likely to be employed than they were in 2002, but disabled people still remain significantly less likely to be in employment than those without disabilities (Department for Work and Pensions, 2014).

The Papworth Trust (2016) in its report Disability in the United Kingdom states that a key reason for the low employment rate of people with disabilities is the fact that one in six of those who became disabled whilst in work lose their employment during the first year of becoming disabled (Papworth Trust, 2016). Once employment is lost it becomes increasingly difficult to return to the workplace.

VCMs can provide support and guidance with specific focus on employability options. There was no OH service provided by Arthur’s employer and therefore his VCM explored alternative roles with his employer. Although left with limited use of his left arm and hand, Arthur was able to fulfil the requirement of roles not involving driving heavy vehicles.

Redeployment is considered a reasonable adjustment under the Equality Act 2010. There are benefits for the individual to return to work and supporting disabled people to stay economically active is also good for business. The benefit of retaining an experienced, skilled employee with an acquired impairment is greater than the costs and efforts associated with recruiting and training new staff.

The costs of making reasonable adjustments to accommodate disabled employees are often lower than recruiting and training a replacement. The post of weigh-bridge operator was available and the assessment undertaken by the VCM confirmed that Arthur would be able to fulfil that role which required:

  • Checking and logging visitors and drivers’ details as they enter and exit the site;
  • Weighing lorries on their entry and exit to the site;
  • Completing inspection sheets;
  • Updating records on computer systems; and
  • Undertaking administrative tasks such as taking telephone enquiries.

Given Arthur’s significant disabilities in relation to upper limb dexterity and functional ability, the VCM accessed the written advice that was available from the Health and Safety Executive. His line manager also accessed this information. The HSE provides advice aimed at supporting managers to assist workers with disabling conditions to return to work Such advice can form part of a basic early intervention programme when seeking employment.

The VCM had an overriding duty to the court. Their report provided truthful, impartial and independent opinions. The court will discount the evidence of one who is, or is seen to be, partisan. The legal representatives advocated for Arthur, this was not the role of the VCM. Moving away from the medical rehabilitation model and focusing on his functional abilities assisted in progressing Arthur’s case to an optimum outcome.

At the time of writing, Arthur was being considered for employment as a weigh-bridge operator. The VCM had provided an independent expert opinion in accordance with the legal instructions given and in the form of a report for consideration by a court of law. It liaised with his employer and advised it of the financial and advisory support available from Access to Work to facilitate Arthur’s redeployment into this role.

For Arthur, returning to the workplace environment was a major life achievement following such catastrophic injuries.

Su Chantry BSc Hons, SCPHN (OH), DipHE, RGN Queens Nurse is occupational health manager at Williams Grand Prix Engineering and senior vocational case manager at CCMS Ltd. Anne Harriss MSc, BEd, OHNC, RSCPHN(OH), CMIOSH, FRCN, Hon FFOM, Queens Nurse is professor in occupational health and course director, London South Bank University

References
Case Management Society UK (2015), “The 2015 Rehabilitation Code”. Available from: https://www.cmsuk.org/files/CMSUK%20General/REHAB%20CODE%20in%20full.pdf
Department for Work and Pensions (2014), “Disability Facts and Figures”. London, Department for Work and Pensions. Available from: https://www.gov.uk/government/publications/disability-facts-and-figures/disability-facts-and-figures
Hye Ran Park et al. (2017), “Brachial Plexus Injury in Adults.” The Nerve 3 (1) 1-11. Available from: https://doi.org/10.21129/nerve.2017.3.1.1
Papworth Trust (2016), “Disability in the United Kingdom 2016: Facts and Figures.” Papworth: Papworth Trust. Available from: http://www.papworthtrust.org.uk/sites/default/files/Disability%20Facts%20and%20Figures%202016.pdf
Park, HR et al. (2017), “Brachial Plexus Injury in Adults.” The Nerve. 3 (1) 1-11. Available from: https://doi.org/10.21129/nerve.2017.3.1.1
Sakellariou, VI et al. (2014), “Treatment Options for Brachial Plexus Injuries.” Orthopedics. Volume 2014 (2014), Article ID 314137, 10 pages. Available from: http://dx.doi.org/10.1155/2014/314137

 

 

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