Physical and rehabilitation medicine (PRM) care pathways: “Stroke patients”




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 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. Stroke patients are divided into four categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.


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 AVC sont ainsi divisés en quatre catégories selon la sévérité des déficiences, chacun étant traité selon les six mêmes 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 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” 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.


For stroke, we decided to first start with Medical Information Systems Program (PMSI) types defined for stroke patients in acute units but the four main severity categories derived from each homogenous group of patients did not seem to match the severity categories that are relevant in PRM care. But really the classification of these patients according to PMSI categories is done afterwards and is not based on precise criteria, even medical information department physicians are aware of that fact.


We propose four different care pathways for stroke patients. These take into account the severity of the impairments, functional prognosis and contextual factors according to the ICF model:



  • •

    category 1: only one type of impairment, independent walking, no need for ecological evaluation: e.g. arm paralysis (brachiofacial motor impairment), isolated language disorder without any comprehension disorders (pure motor aphasia), vision disorder (homonymous lateral hemianopsia), isolated and incomplete sensitivity disorders (mild thalamic ataxia);


  • •

    category 2: several impairments (e.g. complete hemiplegia and/or aphasia and/or spatial disorientation and/or transitory swallowing disorders) or motor deficit of the lower limb preventing the patient from walking, there is a potential for recovery and a probable independence project. This concerns unilateral strokes;


  • •

    category 3: several impairments with at least some cognitive disorders (memory, language or executive functions disorders) and/or behavioral disorders, limited recovery potential, partial or impossible independence project. This concerns total, bilateral or multiple strokes;


  • •

    category 4: extremely severe accident; multiple associated impairments (massive paralysis, awakening and communication disorders, respiratory deficiency), no independence project can be possible. These clinical states included Locked-in syndromes (LIS) and vegetative or minimally responsive states (EVC-EPR) secondary to bi-hemisphere or brainstem strokes.



Each category of patients will be analyzed according to complex individual or environmental parameters each requiring specific competencies, sometimes only additional time in an appropriate structure all leading to higher costs for which indicators will be necessary in the future PMSI system: home adaptation or environment adaptation (solely equipment-related); inadequate or insufficient medical network; social and psychosocial difficulties; associated medical or psychiatric pathologies with a functional impact.


Thus, each category can be analyzed according to six situations:



  • •

    impairments without any added difficulty;


  • •

    need to adapt the environment (equipment related only);


  • •

    inadequate or insufficient medical network;


  • •

    social and psychosocial difficulties;


  • •

    associated medical pathologies having a functional impact;


  • •

    associated psychiatric pathologies having a functional impact.



1.1


Category 1


Only one type of impairment, independent walking, and no need for an environmental evaluation: e.g. arm paralysis (brachiofacial motor impairment), isolated language disorder without any comprehension disorders (pure motor aphasia), vision disorder (homonymous lateral hemianopsia), isolated and incomplete sensitivity disorders (mild thalamic ataxia);


1.1.1


Impairments with no added difficulty


1.1.1.1


In the neurovascular unit (NVU)


Objectives:



  • •

    recommendation on the patient’s orientation and PRM needs;


  • •

    prescription for future rehabilitation care;


  • •

    evaluation by the relevant therapists and onset of rehabilitation;


  • •

    preparing the patient for discharge.



Means:



  • •

    one consultation by the PRM physician;


  • •

    daily physiotherapy, speech therapy and occupational therapy according to the patients’ needs.



1.1.1.2


Discharge home





With private practice rehabilitation




  • Possible if only 1 rehabilitation professional is necessary (physical therapist, speech therapist, vision therapist)



  • Rehabilitation three to five times a week



  • Evaluation by the therapists after 3 months



  • Duration of the rehabilitation: 1 to 3 months



  • PRM consultation after 3 months with a thorough assessment and according to the patient’s needs



  • Depending on the PRM assessment rehabilitation may be continued



  • Transfer the continuing care to the patient’s family physician



With PRM outpatient care (“hôpital de jour” [HDJ])




  • If more than 1 type of rehabilitation is necessary (physical therapist + occupational therapist, occupational therapist + speech therapist)



  • Rehabilitation frequency: three to five times a week in HDJ alone or associating HDJ + private practice



  • Duration: 1 month



  • Assessment upon discharge from the PRM unit with evaluation by the physician and the therapists; complete synthesis provided after discharge



  • Extended rehabilitation care: private practice if needed, two to three times a week during 2 to 6 months



  • PRM evaluation at the end of the program and transfer of the continuing care to the patient’s family physician




1.1.2


Need to adapt to the environment (equipement-related only)


This situation should not exist by definition since patients have a slight impairment and are independent for walking.


1.1.3


Inadequate or insufficient medical network


The lack of PRM outpatient care can result in prolonging the patients’ inpatient hospital stay in the acute unit (MCO) or transferring them to a PRM-follow-up rehabilitation (SSR) center in case of isolated yet severe language disorders.


1.1.4


Social and psychosocial difficulties


Inpatient hospitalization in SSR units, specialized or not (neurological PRM or elderly care for patients with several associated pathologies) 1


1 This refers to French care facilities organization: most of the PRM facilities are included in the “Soins de suite et de Réadaptation” (SSR) dedicated to patients needs after care in “acute units”. See description in Ref. .

.


We need to find social dimension indicators to estimate the cost of the hospital stay.


The duration depends on resolving social issues.


1.1.5


Associated medical pathologies having a functional impact


Inpatient hospital stay in SSR centers, specialized or not according to the patient’s needs.


Probable duration: 1 to 2 months then discharged home with or without PRM outpatient care (see above).


1.1.6


Associated psychiatric pathologies having a functional impact


Necessary psychiatric evaluation in the NVU; SSR inpatient hospital stay with psychiatric and psychologist or post-psychiatric unit with PRM care; duration of care according to psychiatric needs; discharge home with support care from local psychiatric care units and eventual additional support in PRM outpatient HDJ (see above).


In all cases, we recommend to plan a PRM consultation 3 to 6 months after the initial stroke to conduct a neuropsychological assessment, evaluate rehabilitation needs and verify the feasibility and adequacy of the patient’s social and professional project.


1.2


Category 2


Several impairments (e.g. complete hemiplegia and/or aphasia and/or spatial disorientation and/or transitory swallowing disorders) or motor impairment of the lower limb preventing the patient from walking, there is a potential for recovery and defining a probable independence project. This concerns unilateral strokes (e.g. complete hemiplegia and/or aphasia and/or spatial disorientation and/or transitory swallowing disorders).


1.2.1


Impairments without any added difficulty


1.2.1.1


In the neurovascular unit (NVU)


Objectives:



  • •

    recommendation on the patient’s orientation and PRM needs;


  • •

    prescription for future rehabilitation care;


  • •

    evaluation by the relevant therapists and onset of rehabilitation;


  • •

    possible implementation of early treatments for complications (spasticity).



Means:



  • •

    consultation with the PRM physician;


  • •

    daily physical therapy, speech therapy and occupational therapy sessions, according to the patient’s needs.



1.2.1.2


Followed by an hospitalization in a neurological PRM-SSR unit


Objectives:



  • •

    prepare the patient’s return home;


  • •

    screening for and treating medical complications;


  • •

    intensive rehabilitation for optimizing recovery and helping the patient adapt to impairments and limitations of remaining activities.



Duration: 1 to 4 months.


Daily clinical monitoring and specialized nursing care several times a day.


Psychological support for patients and their family.


Need for specialized social services, home visits by the team.


Need for a specialized PRM technical platform (human and material resources):



  • •

    daily rehabilitation with several health care professionals ≥ at 2 hours per day (physical therapist, speech therapist, occupational therapist, neuropsychologist, even psychomotor therapist);


  • •

    specific needs for neuro-orthopedic treatments (mainly spasticity treatments), neuropsychology, neuro-urology and assistive devices and orthotics;


  • •

    rehabilitation and movement evaluation equipment available in any specialized neurological PRM-SSR structure.



1.2.1.3


Then the patient returns home


The rehabilitation process continues according to patient’s needs:



  • •

    first option: PRM outpatient care (HDJ):



    • ∘

      objectives: continuing to optimize patient’s recovery and daily independence, follow-up on specific treatments (spasticity, pain), adapted driving, return to work, effort training exercises…,


    • ∘

      needs: rehabilitation competencies not available in private practice settings or requiring several of these competencies and coordination of the rehabilitation project,


    • ∘

      example of patients: persons with a professional activity, hemiplegia with sensitive or cognitive impairments,


    • ∘

      frequency: three to five times a week during 1 to 3 months, either in outpatient care or associating HDJ + private practice rehabilitation (physiotherapy and speech therapy), then private practice rehabilitation. Patients are taught and encouraged to engage in physical self-maintenance;



  • •

    second option: mobile rehabilitation team or home care rehabilitation assists the patient at home;


  • •

    or finally third option: private healthcare rehabilitation professionals assisting the patient at home when needs can be met by private practice healthcare professionals (physical therapy and speech therapy);


  • •

    most time, the duration of the motor rehabilitation will be less than 12 months (three times a week) but can sometimes be longer according to patients’ specific needs (e.g. delayed recovery, severe spasticity, orthopedic disorders); aphasia rehabilitation (two to three times a week) often requires up to 2 years. Patients are taught and encouraged to engage in physical self-maintenance.



1.2.1.4


PRM consultations follow-up after inpatient or outpatient care


One to 3 months systematically after discharge according to the patient’s needs. Structures providing this specialized outpatient care on the long term must be identified with their specific means.


1.2.2


Necessity to adapt the patient’s environment (equipment-related)


Same process as Section 1.2.1 , the time needed to work on adapting the patient’s home environment or moving house can lengthen the stay in a specialized SSR unit or transferring to another polyvalent SSR unit depending on the resources available.


1.2.3


Inadequate or insufficient medical network


The lack of adapted medical and rehabilitation care lengthens the stay in a specialized SSR unit or requires transferring the patient to another unit depending on available regional resources.


1.2.4


Social and psychosocial difficulties


Same process as Section 1.2.2 .


We need to identify social dimension indicators to estimate the cost of stay.


There is a dire need for specialized housing structures for vulnerable patients with motor or cognitive impairments.


The time needed to overcome these social problems might require an inpatient stay in a polyvalent SSR center, according to regional care resources. But in some cases, it could be enough to have the patient stay in a hotel-type structure with social services and rehabilitation care ensured by private practitioner (this type of structure needs to be created!).


When there is no social support, and according to patients’ age, they might be discharged to nursing homes or housing services for people with disabilities.


1.2.5


Associated medical pathologies with a functional impact


According to the severity of the medical pathologies, the PRM program will be implemented differently:



  • •

    same process as Section 1.2.1 : 1 to 3 additional months within the neurological PRM-SSR unit might be necessary, daily duration of the rehabilitation is lower but there is a higher cost in specialized medical consultations, examinations and treatments; then discharge home with the same process described in Section 1.2.1 ;


  • •

    or discharge SSR care unit specialized in elderly care according to the patient’s age and previous health status;


  • •

    or another type of specialized SSR structure according to the patient’s needs.



1.2.6


Psychiatric pathologies with a functional impact


Psychiatric evaluation in the NVU.


Hospitalization in a neurological PRM-SSR center with psychiatrist and psychologist consultations or discharge to a psychiatric care unit with involvement from the multidisciplinary PRM team; duration of stay will be based on the patient’s psychiatric needs; discharge home is possible with support from local psychiatric care structures eventually reinforced by outpatient PRM care (HDJ) (Section 1.2.1 ).


1.2.7


In all cases (Sections 1.2.1–1.2.6 )


PRM assessment between Month 6 and 12 post-stroke.


Beyond 2 years: multidisciplinary assessment in PRM outpatient or inpatient care units; further rehabilitation, prescriptions of assistive devices and medications…


1.3


Category 3


Several impairments with at least some cognitive disorders (memory, language or executive functions disorders) and/or behavioral disorders, limited recovery potential, limited or impossible independence project. This concerns total, bilateral or multiple strokes.


1.3.1


Impairments without any added difficulty


1.3.1.1


In the neurovascular unit (NVU)


Objectives:



  • •

    determining the patient’s orientation according to the SOFMER SFNV SFG recommendations ;


  • •

    evaluating the patient’s physical medicine and rehabilitation needs;


  • •

    prescription of future rehabilitation care;


  • •

    evaluations by the relevant therapists and onset of rehabilitation care;


  • •

    implementing early treatments for complications (spasticity).



Means:



  • •

    consultation with the PRM physician or geriatrist;


  • •

    daily physical therapy, speech therapy and occupational therapy sessions, according to the patient’s needs.



1.3.1.2


Hospitalization in neurological PRM-SSR structures (for patients whose needs and health status justify inpatient hospitalization in these units)


Objectives:



  • •

    preparing the patient’s life project and discharge (direct return home or after transitory housing; orientation in Medical Housing Units [“Foyer d’accueil médicalisé”, FAM], Specialized Housing Units [“Maison d’Accueil specialisé, MAS] or nursing home for dependent elderly patients [Établissement pour personnes agées dépendantes, EHPAD] according to the patient’s age);


  • •

    screening for and treating medical complications; nursing and feeding; specific needs for patients who underwent decompressive craniectomy;


  • •

    intensive rehabilitation training to optimize recovery and to adapt to impairments and limited activities.



Duration: 2 to 6 months.


Daily medical monitoring specialized nursing care several times a day.


Psychological support for patients and their family.


Need for specialized social services, home visits by the PRM team.


Need for a specialized PRM technical platform (human and material resources):



  • •

    daily rehabilitation with several health care professionals ≥ at 2 hours per day (physical therapist, speech therapist, occupational therapist, neuropsychologist, even psychomotor therapist);


  • •

    specific neuro-orthopedic needs (specially spasticity treatments), neuropsychology, neuro-urology, assistive devices and orthotics;


  • •

    rehabilitation and movement evaluation equipment available in any specialized neurological PRM-SSR structure.



1.3.2


Then discharge home when possible


Then discharge home when possible:



  • •

    role of medicosocial support services for disabled adults (“Service d’accompagnement médicosocial pour adulte handicapé”, SAMSAH), home nursing care (“Service de soins infirmiers à domicile”, SSIAD), rehabilitation home care; the patient’s family physician has an important coordinating role to play;


  • •

    home rehabilitation care provided by private practitioners. When patients’ needs (…) can be fulfilled by private practitioners (physiotherapy and speech therapy). The duration of motor rehabilitation is usually ≤ 1 year but it can be longer according to specific needs (e.g. delayed recovery, severe spasticity, orthopedic disorders); aphasia rehabilitation (two to three times a week) often requires up to 2 years.



1.3.2.1


PRM follow-up


The PRM follow-up is as follows:



  • •

    consultations: systematically 1 to 3 months after hospital discharge then according to patient’s needs. Structures providing this specialized long-term outpatient care must be identified with specific means;


  • •

    outpatient day care (HDJ) or 1-week inpatient hospital care in a PRM unit for assessments of specific treatments;


  • •

    beyond 2 years post-stroke: multidisciplinary PRM assessments in outpatient day care or 1-week hospital stay; possible additional rehabilitation, prescription of assistive devices and medications. Need for respite hospital stays in polyvalent or specialized SSR structures.



1.3.3


Necessity to adapt the patient’s environment (equipment-related)


Same process as Section 1.3.1 , the time needed to work on adapting the patient’s home environment or moving house can lengthen the stay in a specialized SSR unit or might require transferring the patient to another polyvalent SSR unit depending on the resources available.


1.3.4


Inadequate or insufficient medical network


The lack of adapted medical and rehabilitation care lengthens the stay in a specialized SSR structure or requires transferring the patient to another polyvalent SSR structure depending on the resources available.


1.3.5


Social and psychosocial difficulties


Need for institutionalization: the case must be quickly submitted to the Departmental House for Disabled Persons (“Maisons départementales pour personnes handicapées”, MDPH) for an orientation advice.


We need to identify social dimension indicators to estimate the patient’s stay.


There is a dire need for specialized housing structures for vulnerable patients with motor or cognitive impairments.


The time needed to overcome these social problems might require a hospital stay in a polyvalent SSR structure according to the available local resources available.


1.3.6


Associated medical pathologies with a functional impact


According to the severity of the medical pathologies, the PRM program will be implemented differently:


Same process as Section 1.3.1 : 1 to 3 additional months within the neurological PRM-SSR unit might be necessary, daily duration of the rehabilitation is lower but there is a higher cost due to specialized medical consultations, examinations and treatments; then, the same process described in Section 1.3.1 is implemented for the patient’s discharge home.


Inpatient stay in a SSR structure for elderly patients according to age and previous health status.


1.3.7


Associated psychiatric pathologies with a functional impact


Institutionalization will most probably be necessary.


Hospitalization in a SSR structure will need to be supported by psychiatric care follow-up.


1.3.8


In all cases (Sections 1.3.1–1.3.6 )


PRM consultation: for complete assessment between Month 6 and 12 post-stroke.


1.4


Category 4


Extremely severe accident with multiple associated impairments (massive paralysis, awakening and communication disorders, respiratory deficiency), no independence project can be possible. These clinical states include locked-in syndromes (LIS) and vegetative or minimally conscious states secondary to bi-hemisphere or brainstem strokes.


1.4.1


Impairments without any added difficulty (highly unlikely)


1.4.1.1


In the neurovascular unit (NVU)


Objectives:



  • •

    defining the patient’s orientation according to the SOFMER SFNV SFG recommendations ;


  • •

    evaluating the patient’s physical medicine and rehabilitation needs;


  • •

    prescription of future rehabilitation care;


  • •

    evaluation by the relevant therapists and onset of rehabilitation care;


  • •

    implementing early treatments for complications (spasticity).



Means:



  • •

    PRM and/or geriatric consultation;


  • •

    daily physical therapy, possible speech therapy (locked-in-syndrome).



1.4.1.2


Ideally patient is transferred to a post-intensive care rehabilitation structure


Objectives: ensure medical care while preserving the patients functional chances and preparing their orientation of care according to their health progression.


Determining elements for the orientation: cognitive state; respiratory impairments (need for tracheotomy, intermittent assisted breathing), severe swallowing disorders (enteral feeding by surgical gastrostomy or jejunostomy).


Two main categories:



  • •

    locked-in syndrome (LIS);


  • •

    vegetative or minimally conscious states.



Locked-in syndrome :


Transfer to a specialized PRM extended care structure. The objectives are:



  • •

    preparing the patient’s life project and discharge: in the best of cases, the patient will return home directly after hospitalization or after staying in a transitory structure; if not, orientation to an institution (FAM, MAS or EHPAD according to the patient’s age);


  • •

    screening for and treating medical complications; nursing and feeding; respiratory function, tracheotomy; urinary functions…


  • •

    intensive rehabilitation training for maximum recovery and rehabilitation to adapt to impairments and limited activities.



Duration: 6 to 12 months.


Daily medical monitoring specialized nursing care several times a day (tracheotomy, gastrostomy, nursing…).


Psychological support for patients and their family.


Need for specialized social service, home visits by the team.


Need for a specialized PRM technical platform (human and material resources):



  • •

    daily rehabilitation with several health care professionals 1 to 2 hours per day (physical therapist, speech therapist, occupational therapist);


  • •

    specific needs in domotics, assisted communication, neuro-orthopedic needs (specially spasticity treatments), neuro-urology;


  • •

    rehabilitation and movement evaluation equipment available in any specialized neurological PRM-SSR structure.



Minimally conscious or vegetative states :



  • •

    transfer to a specialized SSR unit;


  • •

    indeterminate duration of stay, expect in rare cases, there is no project to get back home;


  • •

    regular medical monitoring, specialized nursing care several times a day (tracheotomy, gastrostomy, nursing…);


  • •

    psychological support for patients and their family;


  • •

    need for a specialized PRM platform: (human and equipment resources):



    • ∘

      daily rehabilitation courses with several actors around 1 h/day (physiotherapist, eventually occupational therapist),


    • ∘

      specific needs in neuro-orthopedics (specially spasticity treatments), neuro-urology.




The severity of the impairments takes away some relevance in the different categories.


1.4.2


Need to adapt the environment (domotics-home automation)


In the best of cases, it should be a minimum: for LIS patients, environment control, man-machine interface, domotics, electric wheelchair with chin or palpebral command, complete home automation.


1.4.3


Inadequate or insufficient medical network


It is the rule, an eventual return home can only be envisioned for LIS patients with proper home care support, which is poorly developed right now.


1.4.4


Social and psychosocial difficulties


Not enough structures can welcome patients with these affections, with tracheotomy or even intermittent assisted ventilation.


1.4.5


Associated medical pathologies


According to the severity of medical complications, the cost is higher in specialized medical consultations, gestures and treatments.


Orientation to a long-term care unit specialized in elderly patients with multiple medical pathologies, according to the patient’s age and previous health status.


1.4.6


Associated psychiatric pathologies


For LIS patients, there is the need for psychiatric follow-up and support.




2


Version française


Le présent document fait partie des documents élaborés par la Société française (Sofmer) et la fédération française de médecine physique et de réadaptation (Fedmer) dont l’objectif est d’apporter des arguments dans les discussions concernant la future tarification à l’activité en structures de soins de suite et de réadaptation (SRR), en proposant d’autres modes d’approche, complémentaires de la tarification à l’acte. Ces documents appelés « parcours de soins en MPR » décrivent globalement : les besoins des patients par typologies, les objectifs d’un parcours de soins en MPR et proposent les moyens humains et matériels à mettre en œuvre. Ils sont volontairement courts pour être aisément lus et utilisables. Ils s’appuient sur l’avis du groupe d’expert signataire après analyse des textes règlementaires et recommandations en vigueur en France et de la littérature , validés par la Sofmer.


Pour autant, le parcours de soins n’est pas qu’un simple outil pouvant être utile à la tarification, il est bien plus que cela : il participe à définir le véritable contenu des champs de compétence de notre spécialité. Pour chaque pathologie abordée, les patients sont d’abord groupés en grandes catégories selon la sévérité de leurs déficiences, puis chaque catégorie est déclinée selon la classification internationale du fonctionnement, en fonction de différents paramètres personnels ou environnementaux susceptibles d’influencer la réalisation du parcours de base « optimum ».


Pour les AVC, il avait été envisagé de partir des typologies PMSI des AVC en secteur aigu mais les quatre grandes catégories de gravité qui sont effectuées à partir de chaque groupe homogène de malades ne semblent pas correspondre à des catégories de gravité pertinentes en MPR et, surtout, le classement des patients dans ces catégories PMSI est réalisé, a posteriori, et n’est pas basé, aux yeux mêmes des médecins DIM, sur des critères précis.


Nous proposons quatre parcours de soins différents pour les patients atteint d’AVC. Ceux-ci tiennent compte de la sévérité des déficiences, du pronostic fonctionnel et des facteurs contextuels selon le modèle de la classification internationale du fonctionnement :



  • •

    catégorie 1 : une seule déficience, autonomie de marche, pas de besoin d’évaluation écologique: paralysie d’un bras (déficit moteur brachiofacial), trouble du langage isolé sans trouble de compréhension (aphasie motrice pure), trouble de la vision (hémianopsie latérale homonyme), trouble isolé et incomplet de la sensibilité (ataxie thalamique discrète)… ;


  • •

    catégorie 2 : plusieurs déficiences (hémiplégie complète et/ou aphasie et/ou négligence spatiale et/ou troubles de déglutition transitoires…) ou déficit moteur du membre inférieur interdisant la marche, potentiel de récupération, projet d’autonomie probable. Il s’agit d’AVC unilatéral ;


  • •

    catégorie 3 : plusieurs déficiences dont au moins des troubles des fonctions cognitives (troubles de mémoire, du langage ou des fonctions exécutives) et/ou troubles du comportement, potentiel de récupération limité, projet d’autonomie partielle ou impossible. Il s’agit d’AVC hémisphériques totaux, bilatéraux ou multiples ;


  • •

    catégorie 4 : accident gravissime ; multiples déficiences associées (paralysies massives, troubles de l’éveil et de la communication, déficience respiratoire), aucun projet d’autonomie envisageable. Il s’agit d’états cliniques de locked-in-syndrome et d’état végétatifs ou paucirelationnels (EVC-EPR) secondaires à des AVC bi-hémisphériques ou du tronc cérébral.



Chaque catégorie de patients sera analysée selon des paramètres personnels ou environnementaux de complexité qui justifieront des compétences spécifiques, parfois seulement du temps supplémentaire, entraîneront des surcoûts et pour lesquels des indicateurs seront nécessaires dans le futur programme de médicalisation des systèmes d’information (PMSI) : nécessité d’adaptation (purement matérielle) de l’environnement ; inadaptation ou insuffisance du réseau médical et paramédical ; difficultés sociales et psychosociales ; pathologies médicales associées ayant une incidence fonctionnelle ; pathologies psychiatriques associées ayant une incidence fonctionnelle.


Ainsi, chaque catégorie peut être déclinée de six façons :



  • •

    déficiences sans difficulté ajoutée ;


  • •

    nécessité d’adaptation (purement matérielle) de l’environnement ;


  • •

    inadaptation ou insuffisance du réseau médical ;


  • •

    difficultés sociales et psychosociales ;


  • •

    pathologies médicales associées ayant une incidence fonctionnelle ;


  • •

    pathologies psychiatriques associées ayant une incidence fonctionnelle.



2.1


Catégorie 1


Une seule déficience, autonomie de marche, pas de besoin d’évaluation écologique : paralysie d’un bras (déficit moteur brachiofacial), trouble du langage isolé sans trouble de compréhension (aphasie motrice pure), trouble de la vision (hémianopsie latérale homonyme), trouble isolé et incomplet de la sensibilité (ataxie thalamique discrète)…


2.1.1


Déficiences sans difficulté ajoutée


2.1.1.1


En unité neurovasculaire (UNV)


Objectifs :



  • •

    avis d’orientation et sur les besoins de rééducation et réadaptation ;


  • •

    prescription de la rééducation ultérieure ;


  • •

    bilan par les rééducateurs concernés et rééducation ;


  • •

    préparation du retour domicile.



Moyens :



  • •

    une consultation par le médecin MPR ;


  • •

    kinésithérapie, orthophonie et ergothérapie quotidiennes, selon besoins.



2.1.1.2


Retour au domicile





Avec rééducation en secteur libéral




  • Possible si 1 seul rééducateur nécessaire (kinésithérapeute, orthophoniste, orthoptiste)



  • Rééducation 3 à 5 fois par semaine



  • Bilan par le rééducateur à 3 mois



  • Durée de la rééducation : 1 à 3 mois



  • Consultation bilan MPR à 3 mois selon besoin



  • Éventuelle poursuite de la rééducation selon bilan



  • Relais de la suite des soins par le médecin traitant



Avec hôpital de jour (HDJ) de MPR




  • Si plus d’un type de rééducation est nécessaire (kinésithérapie + ergothérapie, ergothérapie + orthophonie) ou rééducation longue et spécialisée



  • Fréquence de la rééducation : 3 à 5 semaine en HDJ seule ou HDJ + libéral



  • Durée : 1 mois



  • Bilan de sortie par le médecin MPR et les rééducateurs ; synthèse de fin d’HDJ



  • Suite de rééducation : en libéral selon besoin, 2 à 3 par semaine pendant 2 à 6 mois



  • Bilan MPR de fin de programme et relais de la suite des soins par médecin traitant


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Apr 23, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Physical and rehabilitation medicine (PRM) care pathways: “Stroke patients”

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