Neuro Rehabilitation: Sam’s Story

In September 2024, Sam experienced a sudden and severe onset of headache and vomiting, which marked the beginning of a prolonged and complex inpatient journey across several acute hospitals. He was initially admitted to Bournemouth Hospital before being transferred to Southampton, then Dorchester Hospital, where scans confirmed a right pontine cerebral haemorrhage, and later onward to Poole. Despite having no prior history of hypertension or ongoing medical needs, Sam was found to be hypertensive and was commenced on medication to stabilise his blood pressure. His acute phase was medically complex; he required nasogastric feeding due to swallowing difficulties and persistent indigestion, and further assessment by the Gastroenterology team identified a benign oesophageal stricture and oesophagitis, resulting in several endoscopic dilatations. His inpatient pathway included transfer to Portland Ward at Poole Hospital in December 2024. By May 2025, Sam was clinically stable and his rehabilitation potential had been recognised, contributing positively to his recovery, however discharge home was not deemed appropriate at that time. Church Road Brain Injury Service was therefore identified for a period of specialist, intensive rehabilitation, where he remained until October 2025.

On admission to Church Road, Sam presented with significant functional limitations. He was a full time wheelchair user whose mobility was heavily restricted by a Holmes tremor, which worsened markedly with fatigue. His transfers required the use of a Re-turn, and he relied on staff support for personal care, particularly for washing areas he could not reach and managing toileting and hygiene. Although dependent physically, he demonstrated strong insight, good memory, and an ability to self initiate, meaning his cognitive functioning did not present barriers to rehabilitation. His medication continued to be administered fully by staff three to four times per day. There were no behavioural concerns, and his main emotional vulnerability related to frustration when fatigue or tremor interfered with his progress. Overall, his risk profile remained low, with the main challenges centred around pacing, motivation, and balancing activity with adequate rest.

Sam engaged actively with a multidisciplinary programme that combined daily rehabilitation support with structured physiotherapy, neuro occupational therapy, and weekly neuropsychology sessions. His tremor and fatigue meant he required careful pacing, but he consistently demonstrated resilience and commitment. A key component of his wider rehabilitation included visiting an external provider for weekly exoskeleton based gait sessions, typically lasting one to two hours, which contributed significantly to improvements in stamina, strength, and postural control. The therapy team at Church Road held weekly MDT meetings to evaluate progress, with care plans and goals tailored and modified in response to Sam’s rate of improvement and changing needs. 

Over time, Sam’s functional abilities improved considerably. His transfers progressed from requiring a Re turn to completing pivot and step transfers with assistance of one. His fatigue became more manageable as he learned to balance activity and rest effectively. His personal care also improved, with greater independence achieved in washing, dressing, and toileting, though supervision remained appropriate for safety. Sam’s meal preparation skills developed steadily, he initially needed support to participate, he ultimately became able to prepare his own breakfast and light lunches independently. He accessed the fridge and cupboards without assistance and safely placed pizzas into the oven, requiring only support for removing hot items. Weekly neuropsychology sessions helped stabilise emotional regulation and reduce frustration, resulting in notable improvement in his overall wellbeing.

As Sam approached discharge, the multidisciplinary team carried out home visits and coordinated minor adaptations to ensure the environment would meet his needs safely. A six week transitional plan was implemented, it included two hours of occupational therapy and two hours of physiotherapy per week through the rehabilitation team. After this transition period, Sam transferred to the ABIRS community brain injury team for continued rehabilitation support. His support package reduced significantly during his placement at Church Road, he entered the service with twelve hours of one to one support per day alongside a twelve-week therapy assessment block, and by discharge this reduced to eight hours per day, continuing to decrease as he approached his return home. Once in the community, his long-term package was minimal, one hour per visit, three times per week, with family support and assistance at other times representing a substantial reduction in dependency. Throughout the placement, there were no unplanned hospital admissions, and all outcome measures, including goals and OT data, reflected consistent and clinically meaningful progress.

During his rehabilitation, Sam was also assessed for Deep Brain Stimulation (DBS) as a potential intervention for managing his Holmes tremor. Following review by specialist neurology services, the procedure was approved and scheduled for May 2026, with the expectation that it may further improve his functional ability, stability, and quality of life.

Sam has now returned home to his family and continues to progress well. He maintains purposeful daily routines, engages in community activities, and enjoys family life with a significantly reduced care package. Reflecting on his rehabilitation journey, Sam and his family shared the following feedback: 

“We, as a family, just want to emphasise that my time at Church Road was great. The staff there were really supportive, kind and helpful. The Rehabilitation team were amazing. They really kick‑started my rehabilitation and kept pushing me on… I would definitely recommend Church Road! Thank you again. Sam xx”

Sam’s case highlights the value of specialist step down neuro rehabilitation in preventing long term residential placement, reducing care needs, supporting safe discharge pathways, and ensuring sustainable, community based independence. His story represents the strong alignment between specialist neuro rehabilitation services and commissioning priorities focused on prevention, independence, and long term outcomes.