Journal of Rehabilitation Medicine 51-4inkOmslag | Page 59
Permissive weight-bearing in surgically treated fractures
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Table I. An overview of the aftercare aims identification guide
Rehabilitation milestones Progression
Mobility Level of performance
Activity
Symmetrical
standing with
Wheelchair support
Symmetrical
standing without Performing in
One leg stand
support
standing position 1 be > 10 s
Standing
Wheelchair Walking between Two crutches
bars
2-point gait
Two crutches
4-point gait
Two walking
sticks
1 walking Without
stick
support
Walking
Walking uphill/downhill
Moving objects
Walking over uneven surface
Walking stairs
Achieved
Running, climbing, jumping
Full bed mobility
Sitting transfers (low level)
Standing transfer (high level)
Car transfer
Moving indoors in adapted environment
Moving indoors in non-adapted
environment
Performing in standing position
Picking up an object from the floor
Cycling (road safety)
Using public transport
Driving vehicle
Self-care
Washing oneself
Care of body parts
Going to the toilet
Dressing/undressing oneself
Putting shoes on/off
Drinking independently
Eating independently
Domestic life
Shopping
Preparing meals
Washing and drying clothes
Cleaning house
Operating household equipment
Storage of daily amenities
Removal of waste
Gardening
Major life areas, Resuming training
social and civic Resuming work
life
Starting/resuming social life
Visiting
Going out
Permissive weight-bearing
Permissive weight-bearing is operationalized in daily practice
as follows: first, a patient profile is established by completing
the PAG ( Fig. S1 1 ). This results in a comprehensive overview
of patient and lesion characteristics that need to be taken into
account when setting up a personalized rehabilitation treatment
plan. Complications are gauged/inventoried in order to be able
to adequately adjust the treatment plan when complications
occur. Subsequently, the TG ( Fig. S2 1 ) assists the therapist in
choosing the appropriate means and training intensities/dosages
for setting up the aforementioned personalized training plan.
During the actual treatment phase, a gradual progression
in functional activities guided by the subjective experience
(pain and confidence to bear weight) and by objective clinical
symptoms of the patient occurring during the process of rehabi-
litation. Symptoms such as the evolution of signs of inflamma-
tion, neuro-vascular status, weight-bearing tolerance, possible
changes in alignment of the affected side of the body, quality
and function of the soft tissue and involved joints.
The progression in functional activities is determined on the
basis of the quality of the performance of a functional activity
and is established in milestones to be achieved at activity level
within the ICF areas: mobility, self-care, household, participa-
tion, and transport (Table I).
The therapy progress is determined not by the degree of
loading the affected side of the body in kg or in percentage
of bodyweight, because that, as discussed earlier, is an unrea-
listic representation of reality. When applying the permissive
weight-bearing method, conscious choices are made to assess
the maximum weight-bearing capacity of the fixed fracture and
the damaged soft tissue. Within this process, we strive towards
allowing the patient to apply the activities (formulated in the
request for help (see Table I: aftercare aims identification guide))
with normal/optimal motor skills as quickly as possible. If
necessary, these activities may be supported with walking aids
and orthoses. The quality of the performance of the activity and
safety (e.g. preventing stumbling) are leading in this approach.
Progress is determined by the quality with which the activity is
carried out and is recorded in the list with therapy milestones
(see Table I) based on decreasing the use of walking aids. These
walking aids contribute to the quality of the gait pattern and to
safety, and may possibly compensate for a certain limitation
in the patient’s conditional capacities, such as reduced muscle
strength, stability or postural balance reactions. The milestone
is reached only if the gait pattern is executed optimally, i.e.
resembling normal gait as closely as possible, and can be
performed independently and safely by the patient. In case of
delayed recovery or permanent impairment (due to, for example,
complications during rehabilitation), a choice must be made
for the best possible gait pattern, optimal for each individual
patient. It should include the following aspects:
• Safety: reducing the risk of falls.
• Distance: achieving a functional walking distance for the
patient.
• Speed: achieving an acceptable functional walking speed.
• Prevention: the chosen strategy with regard to the gait pattern
must be a sustainable solution to compensate for the possible
physical restrictions and fit the mental and physical capacity
of the patient. The aim is to reduce the risk of injury due to,
for example, overload.
• Variability: the patient is able to adapt his/her gait to the
environmental conditions given.
• Visual acceptable: the gait pattern looks acceptable for the
patient.
J Rehabil Med 51, 2019