Journal of Rehabilitation Medicine 51-4inkOmslag | Page 57

Permissive weight-bearing in surgically treated fractures
both rehabilitation training and daily activities. Despite
this fairly ill-defined terminology, few complications
due to overloading seem to occur in clinical practice.
Nevertheless, both overloading and underloading may
lead to a more complicated and extended recovery.
A schematic overview of the consequences of lo-
ading for the consolidation process is depicted in Fig.
1. Weight-bearing is necessary to elicit micro-move-
ments between adjacent bony fracture components,
stimulating biological processes that enhance fracture
consolidation, and to minimize the negative effects of
immobilization (8, 9).
To optimize rapid clinical recovery and the restoration
of function and functionality, it may be useful to apply a
treatment protocol that is near the upper boundary of the
therapeutic bandwidth, yet safe enough to avoid overlo-
ading. However, no clear evidence on the location of this
upper boundary is known from the literature. Therapy
dosage in the early aftercare treatment of fractures is,
to a large extent, determined by the load-bearing ca-
pacity of the bone, which, in turn, depends on the type
of fracture, the bone quality, the soft-tissue quality, the
stabilizing effects of the surrounding soft-tissue cuff,
the stabilization method used (plaster/nail/plate) as
well as the mechanical load-bearing capacity, and the
point of application and direction of the forces relative
to the line(s) of fracture (10, 11). However, functional
outcome after fracture rehabilitation depends not only
291
on mechanical stability, but also on an intricate complex
of bio-psycho-social processes, involving physical tissue
damage characteristics of the bone and other surroun-
ding soft tissue, existing co-morbidities, and patients’
age, sex, physical and mental condition, as well as
their cognitive abilities and coping styles (12–14). In
International Classification of Functioning, Disability
and Health (ICF) terms (15), this means that aftercare
treatment should focus not only on the patients’ functio-
ning, but also on their activity and participation levels.
To date, the literature has reported no comprehensive,
ICF-based protocol for the aftercare of patients with a
surgically treated fracture that systematically addresses
patient’s aftercare assessment, selection and provision
of aftercare modalities, monitoring of therapy intensity,
and evaluation of aftercare.
The aim of the present paper is to describe a compre-
hensive protocol for permissive weight-bearing (PWB)
during allied health therapy and to report on both the
time to full weight-bearing and the number of compli-
cations in patients with surgically treated fractures of
the pelvis and lower extremities who undergo PWB.
PATIENTS AND METHODS
Basic elements of the protocol
Since PWB was implemented at our rehabilitation centre from
2003, and has been standard care since 2005, much experience
has been gained in surgically treated trauma
patients with (peri)- or intra-articular fractures
of the pelvis and lower extremities. During
this period, the research group has developed
a PROtocol for permissive weight-bearing
during allied health (paraMEdical in Dutch)
THerapy and Evaluation of surgically treated
fractUreS (acronym: PROMETHEUS) of the
pelvis and lower extremities, which consists
of 4 basic elements, viz. a patient assessment
guide, an aftercare aims identification guide,
a treatment guide, and a treatment evaluation
guide. Fig. 2 shows a schematic representa-
tion of the use of the PROMETHEUS pro-
tocol. The fracture aftercare process starts
by assessing the patient’s profile. Next, the
generic and patient-specific treatment aims
are identified, which, when combined, lead
to the aftercare treatment aims. These aims
are then compared with the patient’s profile
descriptors, which, together with potential
predictors of the outcome of the aftercare of
the surgically treated fracture, may indicate:
(i) the feasibility of the aftercare treatment
aims, (ii) the estimated time frame in which
the aims may be reached; and (iii) the in-
tensity/dosage/weight-bearing needed to
achieve the aims. Treatment progress and
possible complications are assessed using the
treatment evaluation guide, and may lead to
alteration/adjustment of the treatment plan.
Fig. 1. Schematic overview of the consequences of loading in the consolidation process.
J Rehabil Med 51, 2019