Journal of Rehabilitation Medicine 51-4inkOmslag | Page 59

Permissive weight-bearing in surgically treated fractures 293 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