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 rotator cuff tear 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 (ICF) (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 chirurgie de la coiffe des rotateurs 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 analyse 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 rotator cuff 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 shoulder rotator cuff tear surgery; curative or palliative surgery as the tear is restorable or not.
1.2
Care pathway process
Principles:
- •
the agenda for postoperative care is directly related to the patient’s preoperative health status, required delay for tendon healing and surgical technique;
- •
care organization modalities take into account patient’s status, sanitary and social environment.
This four sequences pathway fits the most common clinical situations.
1.3
Stage 0 – preoperative care
1.3.1
Objectives
Preserve or recover shoulder range of motion (ROM), warrant proper muscle trophicity, educate the patient on self-mobilization, active stabilization of the humeral head and decrease impingement to allow unrestricted passage of the rotator cuff under the coraco-acromial arch before surgery.
1.3.2
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 socio-professional context;
- •
prescribing ambulatory physical therapy (PT) sessions:
- ∘
preparing for surgery with educational training that includes four to six physical therapy sessions,
- ∘
or joint ROM recovery when necessary (adhesive capsulitis with rotator cuff injury), three physical therapy sessions per week during a few weeks to a few months;
- ∘
- •
proposition for postoperative rehabilitation care orientation.
1.4
Stage 1 – up to six weeks post-surgery (necessary delay for proper tendon healing)
1.4.1
Objectives
Pain management, installing and adapting the orthotic device, restore passive shoulder mobility according to the surgeon’s instructions and restarting muscle activity to avoid stiffness.
1.4.2
Means
1.4.2.1
In the acute care unit (MCO) – immediate postoperative surgery
Consultation by the PRM physician according to the collaborative project defined in partnership with the surgeon:
- •
to analyze the patient’s PRM needs;
- •
to decide where the PRM care will take place and orientate the patient;
- •
to prescribe rehabilitation sessions;
- •
to prepare the patient’s return home if possible.
Physical therapy assessment and continuing the physical therapy sessions initiated in the surgical unit.
1.4.2.2
Postoperative follow-up care
1.4.2.2.1
Impairment without any other disorder
Pain is under control, the patient is self-ruling with the orthotic device and understands the risks during this period and the patient’s social and sanitary environment is adequate:
Outpatient care:
- •
physical therapy sessions three to five times a week during six weeks;
- •
physical therapy assessment at the beginning and the end of the serie;
- •
PRM consultation six weeks after surgery.
1.4.2.2.2
Existence of medical complications, pre-existing pathologies
No decreased pain, the patient is compromising the 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 two hours a day with rehabilitation professionals;
- •
medical assessment by PRM physicians and rehabilitation professionals plus multidisciplinary coordination.
According to the patient’s status, this period can be extended beyond six weeks and the type of PRM facility can be changed.
1.5
Stage 2 from week 7 to week 12 post-surgery (approximately)
1.5.1
Objectives
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.
1.5.2
Means
1.5.2.1
Impairment without any additional difficulty
The clinical evolution is favorable (painless and mobile shoulder); the patient’s sanitary and social environment is adequate.
Outpatient care:
- •
physical therapy three to five times a week/six weeks;
- •
physical therapy assessment at the beginning and end of the serie;
- •
PRM consultation at week 12 post-surgery.
1.5.2.2
Existence of medical complications, pre-existing pathologies
No decreased pain, limited mobility or the patient’s sanitary and social environment is inadequate.
Outpatient follow-up care (HDJ) in a PRM unit, exceptionally inpatient stay:
- •
more than one rehabilitation professional is needed and at least two sessions of daily rehabilitation training are essential to optimize functional recovery;
- •
assessment by PRM physician and rehabilitation therapists plus multidisciplinary coordination;
- •
rehabilitation training at least two hours a day.
This period usually lasts between three to four weeks.
According to the patient’s health status, this stage can be extended and the type of PRM facility can be changed.
1.5.2.3
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.
1.6
Stage 3 from week 13 post-surgery (approximately)
1.6.1
Objectives
Muscle strengthening and effort training (professional gestures, leisure activities).
1.6.2
Means
Outpatient care:
- •
physical therapy two to four times 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.
In most common clinical situations, there is no use to go on PRM and PT care over six months post-surgery.
1.7
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
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