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