Interdisziplinäre Beurteilungskriterien für die Rehabilitation nach Verletzungen an der unteren Extremität: Ein funktionsbasierter Return-to-Activity Algorithmus^[*]

Zusammenfassung

Hintergrund: Bei der Nachbehandlung von Patienten mit Verletzungen an der unteren Extremität findet ein Paradigmenwechsel statt: rein zeitbasierte Nachbehandlungskonzepte treten immer mehr in den Hintergrund und werden zunehmend durch funktionsbasierte Konzepte ersetzt.

Methodik: Es wird ein funktionsbasierter Return-to-Activity Algorithmus vorgestellt, der sich an einer Leveleinteilung (I-IV) orientiert. Jedem Level ist zunächst ein qualitativer und ein entsprechender quantitativer Test zugeordnet. Innerhalb des zu testenden Levels muss immer zunächst der qualitative Test bestanden werden bevor der Patient den zugeordneten quantitativen Test durchführen darf. Beide Tests müssen erfolgreich absolviert worden sein um das jeweils nächste Level zu erreichen. Das Beurteilungskriterium für die erfolgreiche Absolvierung jedes Levels ist immer der qualitative bzw. quantitative Vergleich mit der nicht betroffenen Extremität. Die Level sind stufenweise mit aufsteigender motorisch-funktioneller Anforderung aufgebaut und erfordern im Level I sagittale Stabilität ohne Impacts, im Level II dynamische Stabilität in der Sagittalebene, im Level III zusätzlich dynamische Stabilität in der Frontalebene und im Level IV multidirektionale dynamische Stabilität. Der zeitliche Aufwand für die Testung der einzelnen Levels beträgt nicht länger als 5 Minuten. Der Return-to-Activity Algorithmus wird am Beispiel eines Profifußballers beschrieben. Nach einer Knieverletzung wurde dieser mit einer VKB-Rekonstruktion (Patellasehne) und einer Teilmeniskusentfernung (lateral und medial) arthroskopisch versorgt.

Ergebnisse: Der Sportler konnte am Ende der Rehabilitation jedes Level erfolgreich absolvieren. Die Gesamtdauer der Rehabilitation betrug 203 Tage. Das erste komplette Training mit der Mannschaft bestritt er nach 222 Tagen. Der Spieler wurde 247 Tage nach seiner Verletzung erstmals wieder bei einem Fußballspiel über die volle Spielzeit eingesetzt.

Diskussion: Der Return-to-Activity Algorithmus hilft, den funktionellen Status nach einer Verletzung oder einer Operation zu evaluieren und ist in der Lage Defizite oder Asymmetrien aufzudecken die ein Risiko für eine Re-Verletzung darstellen. Ein individuelles funktionsbasiertes Vorgehen hilft, die Belastung spezifisch zu dosieren und den richtigen Zeitpunkt für die weitgehend risikoarme Rückkehr zum Sport zu bestimmen.

Abstract

Background: In the treatment of patients with lower extremity injuries, a paradigm shift is taking place: Time-dependent concepts are increasingly being replaced by function-based concepts.

Methods: A function-based return-to-activity algorithm is presented which contains a level classification (I-IV). Qualitative and subsequent quantitative tests are assigned to every level. Within each level, first the respective qualitative test has to be passed before patients are allowed to perform the corresponding quantitative test. Criteria for success are qualitative and quantitative comparisons with the unaffected side. Before entering the next level, both tests have to be successfully passed. The levels are ordered according to increasing demands on the loco-motor system. These demands are adequate stability without impact interaction in sagittal plane for level I, followed by dynamic stability demands for level II. Impacts in frontal plane are added for level III and finally multidirectional impacts have to be compensated at level IV. The time expenditure per level is no more than 5 minutes. The case of a professional soccer player will serve to exemplify the return-to-activity algorithm. Following a knee injury, he underwent arthroscopy with ACL reconstruction (patellar tendon) and a partial meniscectomy (lateral and medial).

Results: The athlete was able to successfully pass each level and finished his rehabilitation 203 days post injury. He returned to the team training 221 days post injury. 247 days post injury, the athlete completed his first game.

Conclusion: The return-to-activity algorithm is able to support the evaluation of the functional status of the loco-motor system after injury or surgery and is furthermore capable of uncovering deficits or asymmetries, which are a proven risk for re-injury. This function-oriented individual approach is able to adequately dose the therapeutic efforts on an individual basis. With this approach, the right timing for a safe return to sports activities can be detected with high certainty.

Schlüsselwörter

Rehabilitation - untere Extremität - Zurück zum Sport - Entscheidungshilfe

Key words

rehabilitation - lower extremity - back to sports - aid to decision-making

^* Erstveröffentlichung in: Sportverl Sportschad 2016; 30: 38–49

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