The Challenge

Roger was discharged from inpatient MDT rehabilitation in 2023 to his terraced house on a busy main road in Stockport. He had made significant progress in hospital, but he still experienced dysregulated behaviour and an antalgic gait, and his walking remained slow and unsteady. He could climb and descend stairs independently with caution, and used a walking frame outside if supervised over short distances. He had a leg length discrepancy but refused orthotic support, and his only footwear was a well-worn pair of slippers, which he considered perfectly adequate.

Roger found it difficult to accept support workers, experiencing their presence as an invasion of his personal space, which could trigger his dysregulated behaviours. Yet he was not safe to be in the community unsupervised. The result was a stalemate: support was arranged only on an ad hoc agency basis, and Roger rarely left his home other than for hospital visits.

When Jacqueline first assessed Roger, she identified clear potential for further improvement and used her experience to negotiate carefully with him, giving him space when needed and building treatment around his terms. Roger had a martial arts background and was knowledgeable about movement, but struggled to isolate and sequence movement in a way that enabled him to stand symmetrically and shift his weight to step effectively.

Within sessions, Roger could demonstrate change. However, Jacqueline could see no carryover into his everyday gait pattern outside the clinical context. Rather than accept this as the limit of what was possible, she reconsidered her approach entirely.

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Our Approach

Jacqueline sourced a local martial arts instructor willing to work with Roger one-to-one alongside physiotherapy input. He had personal experience of managing dysregulated behaviour through previous life experiences, and access to a spacious, well-equipped studio – albeit on the third floor of an industrial warehouse, reached by a safe but noisy and rickety lift, in a building shared with several other businesses and a steady flow of unfamiliar people.

This mattered because Roger did not manage novel situations well and was prone to rumination; preoccupation with these thoughts measurably worsened his walking and increased his falls risk. The plan therefore had to manage several compounding sources of risk and unpredictability at once:

• Unsettled, often wet and windy Manchester weather
• A home on a busy A road, next to traffic lights
• Negotiating both his home environment and an unfamiliar industrial warehouse
• Different taxis, drivers and vehicle layouts on every journey

Jacqueline negotiated with the case manager to escort Roger to sessions by taxi herself and arranged an initial six-week taster course of 30-minute sessions. Throughout, she continuously and dynamically risk-assessed every likely trigger: environmental factors such as banging doors and exhaust fumes, briefing the taxi firm on safe collection and drop-off given Roger’s busy home location, and meeting the instructor in advance to align on aims, expectations, and how to respond if Roger’s behaviour escalated. For the first visit, she also brought in a second SP Therapy Services physiotherapist as additional escort support, to maximise safety while the plan was tested for the first time.

The first session was a success. Roger’s behaviour remained regulated throughout, and he said afterwards that he had enjoyed it and was looking forward to more – it gave him a sense of purpose in his week.

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The Outcomes

Weeks 1–6: Building routine and trust

The first block was about attendance and familiarity – essential for anyone with a brain injury, and a genuine challenge in an unfamiliar community setting. There were no significant incidents, but Jacqueline continued to observe closely, refining her list of behavioural triggers and noting the impact of cognitive load on Roger’s walking pattern throughout.

Weeks 7–12: Carryover begins

A second six-week block was authorised once Roger’s progress became clear within sessions. By working with movement patterns already familiar to him from martial arts, Jacqueline helped him move more automatically, with smoother, better-coordinated movement. He began providing himself with feedback and correction as his understanding grew. He still relied on Jacqueline’s support in the taxi home, where he was often reflective and self-critical, needing encouragement to recognise the physical gains he was making.

Direct physical progress followed: his stamina in sessions improved and, critically, this began to carry over outside the studio, as he started voluntarily leaving his walking frame behind on the 40-metre walk back down the corridor. On the return taxi journeys, his mood visibly improved, and he began initiating conversation about local landmarks, though his interpretation of other drivers’ behaviour could still trigger a dysregulated reaction that Jacqueline managed in the moment.

Months 4–12: Sustaining progress through service-design problem solving

A rolling six-week authorisation followed as Roger continued to progress – but new challenges emerged.

• Darker winter evenings were approaching, after a run of sessions that had, unusually for the North West, all taken place in daylight and dry weather.
• The full round trip – escorted taxi travel both ways plus the session itself – was taking three and a half hours per visit, a significant demand on Jacqueline’s caseload as a part-time physiotherapist.
• Early conversations with his case manager about directly employing a dedicated support worker had begun but had identified that this would take months to arrange.

Recognising that consistency and repetition were what would sustain Roger’s progress, Jacqueline handed day-to-day delivery of the sessions to an SP Therapy Services colleague for three months. Jacqueline remained Roger’s key contact and physiotherapist in the MDT, enabling her to balance his ongoing needs with the needs of her wider caseload. This handover also gave her the opportunity to refine the trigger list and supporting paperwork in preparation for the incoming support worker.

Throughout this period, Roger continued to build skills in negotiating everyday physical obstacles – his home’s worn stone step, a congested pavement on a busy main road, getting in and out of different taxis, and the warehouse yard, lift and corridor, all in changing light and weather. His confidence in managing these tasks grew visibly.

Within sessions, the speed and complexity of the demands placed on his balance increased week on week. On one occasion, he mistimed a movement and fell to the mat – then bounced straight back up, pointed at Jacqueline, and said: “She has always been frightened of me falling, but what she didn’t know was I know how to fall and how to get up!”

His walking down the corridor afterwards continued to improve in speed and stride length, even while Jacqueline carried his walking frame for him.

In total, Jacqueline and the SP Therapy Services team supported Roger to attend sessions consistently for 12 months. Once a dedicated support worker was finally in place, the team handed over day-to-day attendance, enabling Roger to attend two sessions a week independently – a level of confidence and skill in community participation that would have been unthinkable at referral.

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Key Success Factors

Treating risk as something to manage, not avoid: Rather than ruling out a community-based, novel intervention because of Roger’s dysregulated behaviour, Jacqueline built a continuously updated risk assessment around it – covering travel, environment, personnel and the activity itself – so that an apparently unconventional plan could be delivered safely.

Finding the right specialist partnership: Sourcing a martial arts instructor with direct personal experience of managing dysregulated behaviour meant Roger’s engagement, not just his movement, was understood and planned for.

Working with what motivates the client: By building rehabilitation around movement patterns from Roger’s own martial arts background, Jacqueline tapped into automatic, intrinsically motivating movement rather than asking him to relearn from scratch.

Service-design flexibility under real-world constraints: When caseload pressures and the slow pace of finding a dedicated support worker threatened continuity, the team restructured delivery – handing over day-to-day sessions while retaining clinical oversight – rather than letting progress stall.

Persistence and clinical advocacy: At the point where conventional treatment showed no functional carryover, Jacqueline didn’t conclude the case had reached its ceiling. She redesigned the approach – and kept redesigning it as new obstacles appeared over the following year.

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Key Outcomes

• Sustained engagement in a novel, community-based intervention for 12 months, with dysregulated behaviour successfully managed throughout
• Voluntary discontinuation of the walking frame over short distances, with clear carryover from session-based gains into everyday mobility
• Improved stamina, coordination and confidence in negotiating real-world obstacles – steps, pavements, taxis, lifts and corridors – across changing weather and light conditions
• Reduced rumination and dysregulated responses to novel situations over time, supported by a continuously refined, individualised risk and trigger plan
• A successful transition from physiotherapist-escorted sessions to independent attendance, supported by a dedicated support worker, at two sessions per week
• A flexible service delivery model that maintained consistency and clinical oversight despite competing caseload demands.

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The Value of Risk-Led, Creative Rehabilitation

Roger’s case shows what becomes possible when a stalled rehabilitation plan is treated as a problem to be redesigned rather than a ceiling to be accepted. The breakthrough did not come from a new exercise or technique, but from rethinking the entire context of treatment: a different setting, a different professional partnership, and a meticulously managed approach to risk that made an otherwise unworkable plan safe to deliver.

Twelve months on, Roger had moved from a housebound life punctuated only by hospital visits to confident, independent attendance at twice-weekly community sessions – a result built not on a single intervention, but on sustained clinical judgement, creative problem-solving, and a willingness to keep adapting the plan as new challenges emerged.

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About Jacqueline

Jacqueline is a talented physiotherapist with a genuine passion for what she does – an exceptional advocate for her clients’ physical health and wellbeing, and a truly collaborative team member.

Outside of her SP Therapy Services t-shirt, Jacqueline is a dedicated mum of two, and is the Practice’s resident fashionista with a love of colour and sparkle.