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Effects of Immobilization and Deconditioning

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Presentation on theme: "Effects of Immobilization and Deconditioning"— Presentation transcript:

1 Effects of Immobilization and Deconditioning
William McKinley MD

2 Case: PM&R Consult 47 yo male, T-3 ASIA A EXAM: MVA, DOI 6 weeks ago
ROS: Pain, poor sleep, bowel accidents, night-time bladder incont, dizzy when OOB Bladder Rx: IC cc/day Meds: perc, SQ hep, docusate, supp’s prn EXAM: Ht 5’6”, weight 105lbs VS: 90/55, 100.9, 105, 26 Labile, tearful, NAD Basilar rales Tachy Rt hand numbness Leg atrophy w/ swelling Lt thigh, Rt knee Dec ROM bil. ADF, + Thomas test Sacral pressure ulcer (stage 3)

3 Problem list and management strategies?

4 “Anyone who lives a sedentary life and does not exercise, even if he eats good foods and takes care of himself according to proper medical principles, all his days will be painful ones and his strength shall wane”

5 Immobilization & Deconditioning
Immobilization – physical restriction of movement to body or a body segment Deconditioning – decreased functional capacity of multiple organ systems Severity is dependent on degree & duration of immobility Disuse causes: Impairment (organ system) Disability (decline of function) The goal of rehabilitation is to restore & maximize function!

6 Clinical Immobility 20% of rehab admissions are 2nd to “deconditioning” Patients & Situations at risk for prolonged immobilization / bed rest: Chronically ill, aged, disabled Paralysis (SCI, Stroke, BI/coma, NMD) LBP Post operatively / complications Polytrauma, CAD, Obstetrical comp’s

7 Organs Systems affected with prolonged debilitation (Space program – “effects of immobilization and weightlessness”) Cardiovascular Respiratory Muscular Skeletal Joint & CTD Gastrointestinal Genitourinary Integumentary Endocrine Neurological Psychological

8 Cardiovascular areas affected
Heart Blood vessels (tone) Fluid balance Venous thrombosis

9 CV: Heart Increased heart rate (resting tachycardia)
HR rises 0.5 bpm/day over first several weeks Exaggerated with exercise (even trivial exertion) Angina, decreased LV-EDV Decreased stroke volume – 15% in 2 weeks Cardiac Output remains largely unchanged Cardiac muscle mass may decrease

10 CV: Blood Vessels Blood pools in the legs
Blood vessels may lose their ability to constrict in response to postural change Decreased venous return Stroke volume Blood pressure ORTHOSTASIS! Rx: early mobilization, isometric LE exercise, positioning/gradual tilting, TEDs, fluids, meds

11 CV: Fluid Balance Prolonged recumbence leads to volume loss
Shifts 700cc to thorax, increased CO by 25% Gradual diuresis (protein loss) Decreased plasma volume –10-15%, Hct may increase, then fall as RBC mass decreases

12 CV: Venous Thrombosis (DVT)
“Virchow’s Triad” – stasis, hypercoagulability, vessel trauma (risk factors for Thrombosis) “high risk” patients – see next slides Venous stasis 2nd to decreased blood flow, Inc viscosity hypercoagulability, increased blood fibrinogen Location: calf veins highest risk, 20% propagate to popliteal, 50% of popliteal will embolize (PE) Rx: SCD’s, ambulation, TED, SQ prophylaxis

13 Identifying High Risk for DVT
Standardized Risk assessment (See next slide) Then stratify as follows: Low Risk: < 2 factors Moderate Risk: 2-4 risk factors High Risk: > 5 risk factors OR TKR/THR OR Fracture of hip, femur, or tib-fib

14 Risk Factors: Age 40-60 years Severe COPD
Age > 60 (count as 2 factors) History of DVT or PE (count as 5 factors) Malignancy Obesity (>120 % of IBW) Immobilization (>72hrs) Major Surgery Paralysis Trauma Severe COPD Pregnancy, or post partum < 1 month Severe sepsis Hypercoagulable state Nephrotic Syndrome Leg ulcers, edema, or stasis History of MI, CHF, Stroke, IBD

15 Respiratory Potential decrease in lung volumes (2nd to muscle weakness, positioning/restriction) Vital capacity TLC Residual volume Expiratory reserve Functional residual capacity A-V shunting Increased respiratory rate

16 Resp (cont) Dec cough (abdominal weakness, decreased ciliary action)
Pneumonia, Atelectasis Hypostatic (posterior, LLL) Aspiration (RLL) Rx: early mob, position changes, chest PT, incentive spirometry, asst cough, fluids, meds

17 Muscle Progressive decrease in muscle strength / endurance
Strength declines 1-3%/day 10-20% per week (plateaus at 25-40% in 3-5 wks) Greater in antigravity muscles (quadriceps, back extensors, plantarflexors) Type 1 (slow twitch, oxidative) muscles Fatigability Decreased ATP & glucose stores and ability to use fatty acids

18 Muscle (cont) Decrease in muscle mass & tension
Decreased fiber diameter (decreased myofibrils & xsec area) Muscle atrophy / wasting 2nd to decreased muscle synthesis 3%/day (decreased fiber size, not #) Body Composition changes Decreased lean body mass (up to 3%) Increased body fat (up to 12%)

19 Muscle (cont) Prevention/Treatment
daily isometric contractions can prevent deterioration Note: it may take 2-3 times longer to “regain” lost muscle mass & strength 20-30% of maximal contraction for several seconds 50% maximal contraction for 1 second FES

20 Soft Tissues Contracture – decreased PROM of joint (2nd to joint, Conn Tissue or muscle shortening) one of the “most” function-limiting complications With immobility, collagen develops CROSS-LINKS and becomes less flexible Joint – synovial tightening Conn tissue - Loose turns to dense Muscle - decreased sarcomeres muscles (especially 2-joint), tendons, ligaments may become involved

21 Contractures Risk factors for contractures:
Positioning Pain Local trauma, DJD Infection, Poor circulation Edema Amputation (BKA: knee & hip, AKA: hip) Muscle imbalance Paralysis/weakness (esp 2 joint muscles) Spasticity Muscles most affected: hip flexors, hands, gastroc, shoulder abd/IR’s

22 Contractures (cont) Contracture prevention Bed positioning
Ext of neck, hips, knee…, ankle neutral, ”functional” hand position BID range of motion exercises (terminal, sustained) Standing, early mob & ambulation CPM for TKA Splinting – static, serial casts Heat (40-43 degrees) Surgery (capsular release, tenotomy, tendon transfer / lengthening) Nerve & MP blocks

23 Ligaments and Tendons The PARRALEL arrangement of type 1 collagen is crucial for their function With immobility (and lack of “stress”), new fibers may be laid down OBLIQELY causing decreased strength and elasticity Water and GAG content of the tissues decreased with disuse Rx: periodic longitudinal stress can prevent deterioration

24 Bone “Wolff’s Law” – buildup or breakdown of bone is proportionate to the forces being applied (weight-bearing, muscle forces, gravity) When forces are not applied - it rapidly resorbs Osteoporosis! – peaks at 4-6 weeks Bone density decreases 40% after 12 weeks (accelerated in SCI) (xray not sensitive until 35-50% bone loss) Increased osteoclastic activity Decreased rate of bone formation The WEIGHT_BEARING bones are the first to lose mass (first few days) Vertebral columns lose up to 50% Can lead to fracture, even with minor trauma Prevention: weight-bearing & muscle contractions

25 Bone (cont) Immobility Hypercalcemia may occur 2-4 weeks after onset
Symptoms: N/V, abd pain, lethargy, muscle weakness Treatment: hydration and lasix diuresis, mobilization Heterotopic Ossification In either neurological, osseous or muscular trauma

26 Joints Cartilage degeneration (proteoglycan diminishes)
Synovial atrophy & fatty infiltrate Underlying bone degeneration Benign joint effusions may occur spontaneously in SCI Contractures

27 Gastrointestinal Decreased fluid intake, appetite
Increased transit time in esophagus, stomach Reduced small bowel motility (2nd to increased adrenergic activity) Constipation Rx: bowel meds, fluids, mob, fiber-rich diet (fruits, veg), avoid narcotics

28 Genitourinary Diuresis (2nd to fluid re-mobilization)
Difficulty voiding (due to postioning) UTI’s Calculus formation (10-15%), hypercalciuria (esp SCI, Fxs) Rx: mob, fluids, upright positioning, d/c catheters

29 Skin Pressure ulcers Risks: positioning, decreased tissue mass, poor skin care/incontinence, shear Sites: sacrum, heels, ischium, occiput, trochanter Rx: prevention! turning/positioning/seating, inspection (hands-on), skin hygiene Edema – may predispose to cellulitis Subcutaneous bursitis (due to pressure) Rx: NSAID, steroid injection)

30 Endocrine Impaired glucose tolerance
hyperinsulinemia Muscles develop insulin resistance Altered regulation of Parathyroid, Thyroid, adrenal, pituitary, growth hormones, androgens and plasma renin activity Altered circadian rhythm Altered temperature and sweating response

31 Metabolic Urinary loss of:
Nitrogen – (begins day 5-6, peaks at 2 weeks) Calcium – (begins day 2-3, peaks at 4-6 weeks) Phosphorus Reversible post mobilization

32 Neurological Compression neuropathies Decreased coordination / balance
Ulnar (at the elbow) Peroneal (fibular head) Decreased coordination / balance Decreased visual acuity

33 Psychological Sensory deprivation (“ICU psychosis”)
decreased attention span, awareness, coordination, increased Depression, labiality, anxiety Sleep disturbance Increased auditory threshold Decreased pain threshold

34 Summary of Preventative Treatments
Early mobilization Strengthening ROM Maintain skin integrity DVT prophylaxis Pain management Psychological assessment / treatment Aggressive Respiratory management B/B assessment & care




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