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Effects of Immobilization and Deconditioning William McKinley MD.

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Presentation on theme: "Effects of Immobilization and Deconditioning William McKinley MD."— Presentation transcript:

1 Effects of Immobilization and Deconditioning William McKinley MD

2 Case: PM&R Consult 47 yo male, T-3 ASIA A 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, supps prn EXAM: Ht 56, 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 2 nd 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 comps

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) Virchows Triad – stasis, hypercoagulability, vessel trauma (risk factors for Thrombosis) high risk patients – see next slides –Venous stasis 2 nd 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: SCDs, 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 Age years –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 Risk Factors:

15 Respiratory Potential decrease in lung volumes (2 nd 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 2 nd 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 (2 nd 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/IRs

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 Wolffs 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 (2 nd to increased adrenergic activity) Constipation Rx: bowel meds, fluids, mob, fiber-rich diet (fruits, veg), avoid narcotics

28 Genitourinary Diuresis (2 nd to fluid re-mobilization) Difficulty voiding (due to postioning) UTIs 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 –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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