Proefschrift

Chapter 5 58 Treatment Guide (TG) The TG (Figure 5.4) aids in designing the treatment plan, i.e. selecting the means necessary to attain the treatment aims (at all three ICF levels) and the appropriate dosage of each of these means. In the early post-surgery rehabilitation phase, i.e. until the time when full weight may be borne by the patient, the patients’ treatment aims at the function/impairment and activity levels are, in general, similar for fractures of the pelvis and the acetabulum and other fractures of the lower extremities. At the function level, these rehabilitation aims are: control of edema and hydrops, improvement of circulation, maintenance or improvement of mobility of the joint and the adjacent joints, as well as improvement of muscle function, endurance, and coordination. (See also Figure 5.4 “select means”). Aims at the activity level are: performing all transfers necessary, maintaining stance, walking with and without aids, dressing and grooming. The purpose is to have the patient functioning independently (preferably without compensations) as soon as possible. The generic protocol designates the activities of “stance”, “walking”, and “transfers” as “milestones” (see also the AAIG in Figure 5.2), because they have an inherent relationship to the load bearing capacity of the fracture and can be translated into objectively quantifiable data representing the increase in the patient’s weight bearing tolerance. Treatment Evaluation Guide (TEG) Ideally, the increase in load bearing by the fracture takes place in parallel to fracture healing. In order to approximate this condition, the gradual increase in weight borne by the fracture is guided by the concurrent clinical symptoms. These symptoms are used to evaluate the progress during the rehabilitation treatment, based on the patient’s clinical manifestations and reactions to the therapy provided, as well as on the early signs or occurrence of possible complications that may necessitate adjustment of the therapy regime. The aim is to assess whether the therapy dosage is within the optimal therapeutic bandwidth throughout the aftercare process. The TEG screens for the possible effects of weight bearing and for possible complications, using a number of clinical criteria and/or phenomena, i.e. pain (or changes in pain), temperature, erythema, edema, hydrops, neurovascular signs, clinical control of bone alignment, instability, clinical weight bearing capacity, control of adjacent soft tissue and control of mobility of adjacent joints, wounds, the patient’s therapy compliance, and changes in medication. Furthermore, if complications such as infection, neurovascular issues, complex regional pain syndrome, failure of the osteosynthesis, and delayed union or non-union occur, these have to be evaluated and graded by the rehabilitation physician or the surgeon in charge. Depending on the outcome of this evaluation, a decision is made to continue the current therapy regime, to adjust it or to consult a medical specialist.

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