Journal of Rehabilitation Medicine 51-4inkOmslag | Page 58

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therapist to correlate information on the achie-
vement of specific milestones to therapy effects
recorded in the Treatment Evaluation Guide
(TEG) (see below) and to the possible occurrence
of complications. Table I presents an overview
of the AAIG.
Treatment Guide (TG)
Fig. 2. Four basic elements of PROMETHEUS.
Patient Assessment Guide (PAG)
In addition to a description/classification of fracture(s), this
guide consists of a set of patient profile descriptors that have
been reported in the clinical literature as being potentially use-
ful in predicting treatment progress and outcome of individual
patients during fracture rehabilitation (12–14, 16). In effect, the
guide serves to establish a patient profile, focusing on characte-
ristics promoting or limiting fracture healing, therapy outcome
and the occurrence or non-occurrence of complications during
fracture healing. The PAG helps to draw clinical conclusions
on: (i) the post-rehabilitation activity level to be expected, thus
guiding the selection of attainable aims; (ii) therapy intensity;
and (iii) the risk of complications occurring during the recovery
process. Checking each PAG item results in a patient profile.
The PAG is depicted in Fig. S1 1 .
Aftercare Aims Identification Guide (AAIG)
The AAIG helps to classify patient-defined treatment aims at
the activity level (therapy milestones) aimed for during the
recovery process. The classification embodies 5 areas of the
ICF classification: mobility, self-care, domestic life, major life
areas, and social and civic life. The early rehabilitation phase,
which primarily aims at stance and ambulation, is subdivided
into several sub-phases, of arbitrary length, i.e. with a certain
bandwidth, during which weight-bearing on the fractured leg
is gradually increased, with a simultaneous decrease in the use
of mobilization-supporting aids, such as hydrotherapy, bars or
crutches. The change from one sub-phase to the next is gradual
and depends on the effectiveness with which the activity is per-
formed by the patient, based on criteria defined in the protocol.
Once a therapy milestone has been reached, it is marked and
time-stamped in the AAIG, thus providing an overview of the
progress of weight-bearing at the activity level and the progress
of the patient’s functional activities. This also enables the
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The TG (Fig. S2) aids in designing the treatment
plan, i.e. selecting the means necessary to attain
the treatment aims (at all 3 ICF levels) and the
appropriate dosage of each of these means. In the
early post-surgery rehabilitation phase, i.e. until
the time when full weight may be borne by the pa-
tient, the patients’ treatment aims at the function/
impairment and activity levels are, in general,
similar for fractures of the pelvis and the acetabu-
lum and other fractures of the lower extremities.
At the function level, these rehabilitation aims
are: control of oedema and hydrops, improvement
of circulation, maintenance or improvement of
mobility of the joint and the adjacent joints, as
well as improvement of muscle function, endu-
rance, and coordination. (See also Fig. S2 “select
means”). Aims at the activity level are: performing all transfers
necessary, maintaining stance, walking with and without aids,
dressing and grooming. The purpose is to have the patient fun-
ctioning independently (preferably without compensations) as
soon as possible. The generic protocol designates the activities
of “stance”, “walking”, and “transfers” as “milestones” (see also
the AAIG in Fig. 2), because they have an inherent relationship
to the load-bearing capacity of the fracture and can be translated
into objectively quantifiable data representing the increase in the
patient’s weight-bearing tolerance.
Treatment Evaluation Guide (TEG)
Ideally, the increase in load-bearing by the fracture takes place
in parallel with fracture healing. In order to approximate this
condition, the gradual increase in weight borne by the fracture
is guided by the concurrent clinical symptoms. These symp-
toms are used to evaluate the progress during the rehabilitation
treatment, based on the patient’s clinical manifestations and
reactions to the therapy provided, as well as on the early signs
or occurrence of possible complications that may necessitate
adjustment of the therapy regime. The aim is to assess whether
the therapy dosage is within the optimal therapeutic bandwidth
throughout the aftercare process. The TEG screens for the pos-
sible effects of weight-bearing and for possible complications,
using a number of clinical criteria and/or phenomena, i.e. pain
(or changes in pain), temperature, erythema, oedema, hydrops,
neurovascular signs, clinical control of bone alignment, in-
stability, clinical weight-bearing capacity, control of adjacent
soft tissue and control of mobility of adjacent joints, wounds,
the patient’s therapy compliance, and changes in medication.
Furthermore, if complications, such as infection, neurovascular
issues, complex regional pain syndrome, failure of the osteo-
synthesis, and delayed union or non-union, occur, these have to
be evaluated and graded by the rehabilitation physician or the
surgeon in charge. Depending on the outcome of this evaluation,
a decision is made to continue the current therapy regime, to
adjust it, or to consult a medical specialist.