Abstract
This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. “Care pathways in PRM” is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after knee ligament surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients’ needs, in accordance with the International Classification of Functioning (WHO).
Résumé
Le présent document fait partie d’une série de documents élaborés par la Société française (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 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 après ligamentoplastie de genou sont ainsi présentés en quatre périodes et deux catégories cliniques 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 a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). The objective is to provide arguments for discussing the future pricing of the activity in follow-up rehabilitation health care facilities, by proposing other approaches, complementary to the activity-based pricing. These documents called “care pathways in PRM” globally describe: the needs of various types of patients, objectives of PRM care while suggesting what human and material resources need to be implemented. They are voluntarily short in order to be useful, concise and practical. These pathways are based on the opinion of the authors after analysis of the official French rules and recommendations and of the literature , validated by the SOFMER.
However, this “care pathway” document is more than just a mere tool for activity based-pricing, it helps defining the real PRM fields of competencies. For each kind of pathology covered, patients are primarily classified into main categories according to their impairments’ severity, and then each category is declined according to the International Classification of Functioning (ICF) while taking into account the various personal or environmental parameters that could influence the outcomes of an “optimum” clinical care pathway.
Patients after knee ligament surgery are classified into four care sequences and two clinical categories, while taking into account personal and environmental factors that could influence patients’ needs.
1.1
Target population
Patients who underwent planned knee ligament surgery: anterior cruciate ligament (ACL) reconstruction and/or posterior cruciate ligament (PCL) reconstruction, with or without associated injuries and regardless of the surgical technique or type of graft used.
1.2
Care pathway process
1.2.1
Principles
The agenda for postoperative care is directly related to the patient’s preoperative health status, the required delay for tendon healing and the surgical technique. Care organization modalities take into account the patient’s status, sanitary and social environment.
This 4-sequences pathway fits the most common clinical situations.
1.2.2
Stage 0 – preoperative care
1.2.2.1
Objectives
Preserve or recover knee range of motion (ROM), warrant proper muscle trophicity, inform and educate the patient on self-mobilization, static muscle strengthening as well as walking with assistive aids before surgery.
1.2.2.2
Means
Consultations with the PRM physician in the framework of a collaborative project with the surgeon:
- •
preoperative functional and analytic assessment:
- •
evaluating the patient’s socioprofessional context;
- •
prescribing ambulatory physical therapy (PT) sessions:
- ∘
preparing for the surgery with educational training that includes four to six physical therapy sessions,
- ∘
or joint ROM recovery when necessary with three physical therapy sessions per week during 4 weeks;
- ∘
- •
proposal for postoperative rehabilitation care orientation.
1.2.3
Stage 1 – up to 8 weeks post-surgery (necessary delay for proper graft fixation): physical therapy and rehabilitation to daily living activities
1.2.3.1
Objectives
Pain management, inflammation decrease, restore knee mobility in flexion and extension, restore enough muscle strength to get single-stance standing with the knee locked in extension and unlocked, get walking abilities without any assistive aids or limping, going up and down stairs, getting back to crouching as well as cycling. Getting back to biking and swimming. Getting back to work depending on professional settings. Getting back to driving.
1.2.3.2
Means
1.2.3.2.1
In the acute care unit – immediate postoperative care
Consultation by the PRM physician according to the collaborative project defined in partnership with the surgeon:
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to analyze the patient’s PRM needs;
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to decide where the PRM care will take place and orientate the patient;
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to prescribe rehabilitation sessions;
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to prepare the patient’s return home if possible.
Physical therapy assessment and continuing the physical therapy sessions initiated in the surgical unit.
1.2.3.2.2
Postoperative follow-up care
1.2.3.2.2.1
Impairment without any other disorder
Impairment without any other disorder, pain is managed, the patient is self-ruling and understands the risks inherent to this period (according to each situation a knee brace for immobilization might be necessary), the patient’s social and sanitary environment is adequate.
Outpatient care:
- •
physical therapy sessions three to five times a week during 6 weeks;
- •
physical therapy assessment at the beginning and the end of the series;
- •
PRM consultation between week 3 and week 5 post-surgery.
1.2.3.2.2.2
Existence of medical complications
Existence of medical complications, pre-existing pathologies, unmanaged pain, the patient is compromising the ligament healing process or the patient’s social and sanitary environment is inadequate.
Inpatient or outpatient (“hôpital de jour” [HDJ]) stays in a PRM care unit:
- •
at least two daily rehabilitation sessions for at least 2 hours a day with different rehabilitation professionals;
- •
medical assessment by PRM physician and rehabilitation therapists + multidisciplinary coordination.
According to the patient’s status, this period can be extended beyond 8 weeks and the type of PRM facility can be adjusted and changed.
1.2.4
Stage 2 from week 9 to week 12 post-surgery (approximately) – effort training
1.2.4.1
Objectives
Painless knee, mobility in flexion and extension, stability, enough strength to put loading on the operated limb with knee flexed on stable and unstable planes, as well as performing a clear and ample jump. Getting back to adapted activities (biking on flat surfaces and up a hill, 15 to 25 km once a week, crawling with or without palms, walking without getting tired), no running before 4 months post-surgery. Getting back to work. Helping the patient to wean off the orthotic device, restoring active mobility of the shoulder without resistance training, restoring upper limb function in daily life activities.
1.2.4.2
Means
1.2.4.2.1
Impairment without any additional difficulty
Impairment without any additional difficulty, the clinical evolution is favorable (painless and mobile knee); the patient’s sanitary and social environment is adequate:
Outpatient care:
- •
physical therapy once to twice a week during 6 weeks;
- •
physical therapist assessment at the beginning and end of the series;
- •
PRM consultation at month 3 or month 4 post-surgery;
- •
postoperative isokinetic assessment (recommended) 4 months post-surgery.
1.2.4.2.2
Existence of medical complications
Existence of medical complications, pre-existing pathologies, limited mobility or the patient’s sanitary and social environment is inadequate.
Outpatient follow-up care (HDJ) in a PRM unit, exceptionally inpatient stay:
- •
several rehabilitation professionals are needed and at least two sessions of daily rehabilitation training are essential to optimize functional recovery;
- •
assessment by PRM physicians and rehabilitation therapists + multidisciplinary coordination;
- •
rehabilitation training at least 2 hours a day.
This period usually lasts between 3 to 4 weeks.
1.2.4.2.3
If the environment does not permit proper and specific athletic rehabilitation training
If the environment does not permit proper and specific athletic rehabilitation training in good conditions, it could be done in outpatient care in a PRM unit (benefits of having the adequate rehabilitation equipment) during 2 to 3 weeks.
According to the patient’s health status, this period can be extended and the type of PRM facility can be changed.
1.2.4.2.4
In some demanding work and social situations
In some demanding work and social situations, the multidisciplinary PRM facility is the most adapted to fit the patient’s needs.
1.2.5
Stage 3 from week 13 post-surgery: sport rehabilitation training
1.2.5.1
Objectives
Muscle strengthening and effort training (professional gestures, leisure and sport activities – knee is stabilized after 6 to 12 months), getting the patient to crouch down almost completely, normal running and aerobic capacities allowing for long-term efforts, authorization to get back to work (at risk work conditions) as well as returning to pivoting sports after month 7.
1.2.5.2
Means
Outpatient care:
- •
physical therapy once to twice a week;
- •
physical therapy assessment at the beginning and end of the serie;
- •
PRM consultation at the end of month 4 and month 6;
- •
isokinetic evaluation at the end of month 6 recommended).
In most common clinical situations, there is no use to go on PRM and PT care over 6 months post-surgery. In case of an abnormal delay for functional restoration, another consultation with isokinetic evaluation may be required.
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