Abstract
This document is part of the “Care Pathways in Physical and Rehabilitation Medicine” series developed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Physical and Rehabilitation Medicine Federation (Fedmer). For a given patient profile, each concise document describes the patient’s needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with acute proximal humeral fracture requiring shoulder hemi-arthroplasty are classified into four care sequences and two clinical categories, both of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO’s International Classification of Functioning, Disability and Health) that may influence patient needs.
Résumé
Le présent document fait partie d’une série de documents élaborés par la Société française de médecine physique et de réadaptation (Sofmer) et la Fédération française de médecine physique et de réadaptation (Fedmer). Ces documents décrivent, pour une typologie de patients, les besoins, les objectifs d’une prise en charge en médecine physique et de réadaptation (MPR), les moyens humains et matériels à mettre en œuvre, leur chronologie, ainsi que les principaux résultats attendus. Le « parcours de soins en MPR » est un document court, qui doit permettre au lecteur (médecin, décideur, administratif, homme de loi ou de finance) de comprendre rapidement les besoins des patients et l’offre de soins afin de le guider pour l’organisation et la tarification de ces activités. Les patients présentant une fracture de l’extrémité supérieure de l’humérus et traités par prothèse humérale sont ainsi présentés en quatre périodes et deux catégories cliniques, chacune étant traitée selon les six même paramètres tenant compte, selon la Classification internationale du fonctionnement, des facteurs personnels et environnementaux pouvant influencer les besoins.
1
English version
This document is part of the “Care Pathways in Physical and Rehabilitation Medicine” series developed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Physical and Rehabilitation Medicine Federation (Fedmer). The objective is to inform future discussions on pricing for follow-up and rehabilitation care activities by suggesting procedures that complement the fee-for-service approach. For a given patient profile, each document provides an overview of the patient’s needs, the care objectives in physical and rehabilitation medicine (PRM) and the required human and material resources. The first “Care Pathways in PRM” documents are now available on the Sofmer’s website ( www.sofmer.com ) and have been published in the medical literature . The documents are deliberately concise, so that they are easy to read and apply. They are based on the opinion of the contributing expert group, following an analysis of the regulations, legislation and guidelines in force in France , a literature review and validation by the Sofmer’s Scientific Board.
However, each document in the “Care Pathways in PRM” series is much more than a simple tool that can be used when discussing pricing: it also helps us to define the true content of our fields of expertise in physical and rehabilitation medicine. For each condition, patients are first grouped into the main categories as a function of the severity of their disability. Each category is then subdivided according to the International Classification of Functioning, Disability and Health (i.e. as a function of the various personal or environmental parameters likely to influence execution of the “optimum” care pathway).
Patients having undergone shoulder hemi-arthroplasty for proximal humeral fracture are classified into four care sequences and two categories that take account of personal and environmental factors.
1.1
Target population
Patients having undergone shoulder hemi-arthroplasty after a proximal humeral fracture.
1.2
The care sequences
1.2.1
Principles
The time line for post-surgical care is related to the patient’s health status prior to the trauma, other comorbidities prior to surgery (e.g. trauma-associated lesions), the time required for bone consolidation, the surgical technique and the implants used.
The organizational procedures for post-surgical care take account of the patient’s health status and sanitary/social environment.
The care pathway described here corresponds to the most commonly encountered situations.
1.2.2
Categories and phases
One can define two categories and four phases:
- •
category 1: one impairment;
- •
category 2: several impairments.
Each category can be divided into six subcategories:
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a: impairment with no additional barriers;
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b: a requirement for material adaptation of the patient’s environment;
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c: an inappropriate or inadequate medical care network;
- •
d: social difficulties;
- •
e: career plans;
- •
f: associated medical conditions with a functional impact.
1.3
Category 1: one impairment
1.3.1
Impairment with no additional barriers (1.a)
1.3.1.1
The preoperative phase (1.a.1)
In the context of trauma, this phase (which is generally an integral part of care pathways that subsequent involve surgery) is often quite short and is conditioned by the patient’s clinical status. In most cases, it is performed by the surgical team in an orthopaedic unit.
However, there are still a number of objectives – although the latter may be difficult to set up or perform:
- •
provide information on the post-surgical follow-up as part of a collaborative project between the surgeon and the PRM specialist;
- •
perform an analytical preoperative assessment and evaluate socioprofessional conditions, in order to determine a functional prognosis and guide future referrals;
- •
propose referral for postoperative rehabilitation and functional retraining.
1.3.1.2
Phase 1. Rehabilitation between postoperative weeks 1 and 4, when the patient’s arm is immobilized (1.a.2)
1.3.1.2.1
Objectives
The objectives are: pain relief, application and adjustment of the sling, maintenance of elbow, wrist and fingers mobility, adaptation for activities of daily living.
1.3.1.2.2
Resources
The resources used are as follows:
- •
in the surgical department – immediate postoperative care:
- ∘
check-up for massage/physical therapy (MP), plus daily MP,
- ∘
an assessment or consultation with a PRM specialist (recommended for complex clinical or environmental situations);
- ∘
- •
following discharge from the surgical department. Outpatient care:
- ∘
MP two to three times a week for 4 weeks,
- ∘
an MP assessment before and after the series,
- ∘
consultation with the surgeon at postoperative week 4.
- ∘
1.3.1.3
Phase 2. Between postoperative weeks 4 and 6 (with consolidation of the tuberosities at week 6) (1.a.3)
1.3.1.3.1
Objectives
Recovery of passive shoulder mobility, pain relief.
1.3.1.3.2
Resources
The outpatient care is as follows:
- •
MP five times a week (or daily) for 2 weeks;
- •
an MP assessment before and after the series of sessions;
- •
a consultation with the PRM specialist between postoperative weeks 4 and 6 (recommended in complex clinical or environmental situations or if the patient’s conditions worsens).
1.3.1.4
Phase 3. From postoperative week 7 (after consolidation of the tuberosities) to postoperative week 12 (on an indicative basis) (1.a.4)
1.3.1.4.1
Objectives
Removal of the sling, recovery of active shoulder mobility and recovery of arm function in activities of daily living.
1.3.1.4.2
Resources
The outpatient care is as follows:
- •
MP five times a week for 6 to 8 weeks;
- •
an MP assessment before and after the series of sessions;
- •
a consultation with the PRM specialist at postoperative week 12;
- •
continuation of physical therapy three times a week, as long as the patient continues to improve.
The MP sessions should be discontinued when PRM consultations 4 to 6 weeks apart do not evidence any further improvement in the patient’s condition.
In the most common situations, there is no need to continue the PRM and MP care for more than 6 months after surgery.
1.3.2
A requirement for material adaptation of the patient’s environment (1.b)
In certain situations, architectural aspects of the domestic environment prevent an immediate discharge to home: there may be a need for around a month’s hospitalization in a general post-treatment care facility, after which time the patient is transferred to a PRM care facility specializing in the locomotor system.
1.3.3
An inappropriate or inadequate medical care network (1.c)
When patients are far away from care facilities (i.e. poor access to MP) or are unable to receive intensive (daily) MP, there may be a need for around a month’s hospitalisation in a general post-treatment care facility, after which time the patient is transferred to a PRM facility specializing in the locomotor system. Alternatively, treatment in a PRM care facility can be envisaged from phase 2 onwards.
1.3.4
Social difficulties (1.d)
In the event of social isolation, there may be a requirement for around a month’s hospitalisation in a general post-treatment care facility, after which time the patient is transferred to a PRM care facility specializing in the locomotor system.
1.3.5
Work-related plans (1.e)
This situation is very rarely envisaged.
1.3.5.1
Objectives
Appropriate muscle strengthening, physical activity training, an ergotherapy assessment and modification of the working environment (if required) for a young working patient.
In this context, the PRM consultation at week 12 is very useful for setting these objectives and for planning and managing referrals.
1.3.5.2
Resources
Ideally partial hospitalisation in a PRM care facility specializing in the locomotor system for about 6 weeks, together with MP and occupational therapy (amongst other procedures).
1.3.6
Associated medical conditions with a functional impact (1.f)
Some postoperative medical complications (pain intensification, complex regional pain syndrome, limited range of joint motion, functional limitation, sepsis, hematoma, lack of wound healing, etc.) may prompt transfer to a PRM care facility specializing in the locomotor system for 4 to 8 weeks of intensive, multidisciplinary care.
1.4
Category 2: several impairments
Populations mainly concerned are patients with a history of other arthroplasties, rheumatoid arthritis, poor cardiorespiratory function, hemiplegia, poliomyelitis, Parkinson’s disease, dementia, etc.
1.4.1
Impairments with no additional difficulties (2.a)
1.4.1.1
The preoperative phase (when possible) (2.a.1)
1.4.1.1.1
Objectives
Provision of information on postoperative follow-up, as part of a collaborative project with the surgeon.
An overall preoperative clinical evaluation, in order to prevent certain complications or the aggravation of symptoms (notably neurological symptoms, such as muscle tone disorders).
1.4.1.1.2
Resources
A consultation with a PRM specialist is recommended, as part of a collaborative project with the surgeon:
- •
an analytical and functional preoperative assessment;
- •
evaluation of the socioprofessional context;
- •
suggestions for referral for postoperative rehabilitation.
1.4.1.2
Phase 1. Rehabilitation between postoperative weeks 1 and 4, when the patient’s arm is immobilized (2.a.2)
1.4.1.2.1
Objectives
Pain relief, application and adjustment of the sling, maintenance of elbow, wrist and finger mobility, adaptation for activities of daily living.
An assessment of the patient’s clinical status, plus treatment of the associated medical conditions.
1.4.1.2.2
Resources
The resources used are as follows:
- •
in the surgical department – immediate postoperative care:
- ∘
a PRM consultation, as part of a collaborative project with the surgeon:
- –
analysis of the need for retraining and rehabilitation,
- –
decision on referrals for rehabilitation care,
- –
prescription of the rehabilitation care;
- –
- ∘
an MP assessment and daily MP;
- ∘
- •
following discharge from the surgical department: in most cases, there is a need for about a month’s full-time hospitalization in a general post-treatment care facility, after which time the patient is transferred to a PRM care facility specializing in the locomotor system.
1.4.1.3
Phase 2. Between postoperative weeks 4 and 6 (with consolidation of the tuberosities at week 6) (2.a.3)
1.4.1.3.1
Objectives
Recovery of passive shoulder mobility, pain relief.
An assessment of the patient’s clinical status and treatment of the associated medical conditions.
1.4.1.3.2
Resources
The resources used are as follows:
- •
full-time hospitalization in a PRM care facility specializing in the locomotor system, in most cases:
- ∘
at least two rehabilitation sessions and at least 2 hours a day (shared among the various rehabilitation professionals);
- ∘
- •
a PRM/rehabilitation assessment, plus interdisciplinary coordination.
1.4.1.4
Phase 3. From postoperative week 7 (after consolidation of the tuberosities) to postoperative week 12 (on an indicative basis) (2.a.4)
1.4.1.4.1
Objectives
Removal of the sling, recovery of active shoulder mobility, recovery of arm function in activities of daily living.
The patient remains in a PRM care facility until he/she becomes independent in activities of daily living.
The care procedure can then be modified if allowed by the patient’s personnel, sanitary and social environment.
1.4.1.4.2
Resources
The patient undergoes:
- •
partial hospitalization in a PRM care facility specializing in the locomotor system as long as pain is poorly relieved or there is shoulder stiffness and muscle impairment, and if:
- ∘
more than one type of rehabilitation is required and at least two daily rehabilitation sessions are essential for functional optimization,
- ∘
PRM and rehabilitation assessments, plus interdisciplinary coordination,
- ∘
rehabilitation for at least 2 hours a day.
Depending on the patient’s status, these care procedures can be continued beyond week 12 (on an indicative basis) and the care procedures can be modified.
- ∘
- •
outpatient care:
- ∘
if the analytical and functional assessment is positive:
- –
MP five times a week (or daily) for 4 to 6 weeks,
- –
an MP assessment before and after the series of sessions,
- –
a PRM consultation 4 months after surgery,
- –
continuation of physical therapy three times a week, as long as the patient continues to improve;
- –
- ∘
the MP sessions should be discontinued when PRM consultations 4 to 6 weeks apart do not evidence any further improvement in the patient’s condition;
- ∘
in most situations, there is no need to pursue the PRM and MP care for more than 6 months after surgery.
- ∘
1.4.2
A requirement for material adaptation of the patient’s environment (2.b)
Full-time hospitalization in a PRM care facility specializing in the locomotor system until the patient becomes independent in activities of daily living (until postoperative week 9 or 10, on an indicative basis).
1.4.3
An inappropriate or inadequate medical care network (2.c)
Full-time hospitalization in a PRM care facility specializing in the locomotor system until the patient becomes independent in activities of daily living and as long as his/her condition continues to improve (until postoperative week 12, on an indicative basis).
1.4.4
Social difficulties (2.d)
Some cases may additionally require hospitalization in a general post-treatment care facility or a post-treatment care facility specializing in elderly patients with several comorbidities and a risk of dependence, prior to discharge to home (community-based post-treatment care).
1.4.5
Work-related plans (2.e)
This situation is very rarely envisaged.
If the patient wishes to continue working, 4 to 6 weeks’ partial hospitalization in a PRM care facility specializing in the locomotor system after postoperative month 4 (on an indicative basis) is often necessary, especially when prompted by the patient’s initial status or other medical conditions.
In this context, the PRM consultation at week 12 is very useful for setting these objectives and planning referrals if the care has been provided on an outpatient basis.
1.4.6
Associated medical conditions with a functional impact (2.f)
Some medical situations may prompt transfer to PRM care facility specializing in the locomotor system, prior to discharge to home. Other situations may require a change in the patient’s life plan, with either an initial stay in a post-treatment care facility specializing in elderly patients with several comorbidities and a risk of dependence or the provision of community-based, multidisciplinary care.
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