Developing Mental Toughness

Here are a couple of case study vignettes. This is what gets me out of bed in the morning. I would be interested in what you thought about this aspect of your practice.

Last week I was referred 2 very different people, yet both were on struggle street with their injuries and perceived futures. One was a younger person that significant foot, tibia and knee injuries due to a mechanical accident. After 18 months of surgeries (foot reconstruction, tibial fixation - internal and external, skin flaps and grafts, ACL cleanup) he presented on two crutches, not wearing a shoe, foot NWB and pretty much blue and sweaty. He had constant pain, was online gaming pretty much all day, went to bed around 2-3 am (still gaming) and got up at noon. He didn't sleep well, ate minimally and lived with a family that was not his own. He had completely exhausted all his WC medical benefits ($150K). He had been referred six weeks prior by his surgeon but had avoided attending because he didn't' think there was much point.

The other person was an older female shearer that had tangoed with a 90kg ewe and was kicked back into a slipway gate, striking her shoulder and causing her arm to instantly feel paralysed. Her employer said they didn't believe in WC and wouldn't be lodging a claim on her behalf. She had to fight to achieve her rights to a WC claim, but by this time 5 months had passed and with no wages had been evicted from her house, lost her drivers licence (unable to pay) and her vehicle was repossessed. A stranger had offered her accommodation, but she lived 120kms from us, which meant a day bus trip both ways. Living rural and remote can mean accessing services is a challenge! On our first appointment, she was crying before I had even asked her my first question. She hadn't washed under her arm for a month due to pain and she held her arm across her stomach, elbow at 90 degrees. Her HADS - Depression subscale was 18 and HADS - Anxiety subscale 20 ( > 11 clinically significant).

How would you assist these people? Do you think we have an intervention role at this stage, or should we send them off for 'psychological' management before commencing 'physical' management? My experience is that following an appropriate screening examination, we can provide these people with practical guidelines and develop a plan going forward. Providing clear direction, education and physical boundaries relax their minds, opens up positive opportunities and invariably there are significant physical and correspondingly psychological gains over the next few weeks.

Key issues for the young man, from my perspective, were lack/fear of weight bearing, poor sleep routine & hygiene, lack of self-worth. We discussed the benefits of making some changes and how this could occur. After a week, he is weight bearing walking with one crutch (and two shoes), completing a range of WB exercises, and on an exercise bike for 15 -20 minutes daily. He is using a combination of breathing exercises and CBT, to wind back his bedtime and his sleep latency has gone from over an hour to 20 minutes (normal). He sleeps soundly, wakes still later than ideal, but is working on developing a regular waking time and is refreshed. His foot is pink, with minimal pain and nil sweating. I have suggested he contribute to mealtime preparations and eat at the kitchen table with the family instead of the sofa (said this was always necessary to elevate his now non-painful foot) to increase social interaction and +ve feeling from contribution to others. He is positive about the changes he has made and the effect this is having on his leg.

I explained to the lady that her neurological and isometric testing was normal, so the parathesia and weakness were due to guarding, disuse and myofascial pain (trigger points). I indicated the muscles that were causing her pain and showed her how to massage them. I started her on elastic assisted exercises with an emphasis on shoulder stability and controlled movement and emphasised she had food (wages) + shelter, a normal shoulder that was just weak and lived in a great place. I have seen her three times so far, tissues are still exchanged but she restarted walking herself, pain is minimal and accepted as a temporary flare following her exercises and she can raise her arm to flexion 120, and 140 with minimal assistance. She will do well, she is tough and on the right path.

I feel very privileged to have been given the skills to assist these people to move from a place of confusion and darkness towards one in which they smile and again enjoy the life that is around them to be lived. I find it fascinating how structure, exercise, support and education, can assist people to overcome some significant problems.

I have included a pic of awesome list of attributes, commonly found in mentally resilience people and encourage you to share and foster these with your clients. If you would like to share your thoughts or other strategies to develop resilience in our clients please do in the comments or on our FB page.