Effects of Immobilization and Deconditioning

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Effects of Immobilization and Deconditioning

• William McKinley MD

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Case PMR 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 2000cc/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)

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Problem list and management strategies?
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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
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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!

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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 comps

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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

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Cardiovascular areas affected

• Heart
• Blood vessels (tone)
• Fluid balance
• Venous thrombosis

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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

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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

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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

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CV Venous Thrombosis (DVT)

• Virchows 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 SCDs, ambulation, TED, SQ prophylaxis

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Identifying High Risk for DVT

• Standardized Risk assessment (See next slide)
• Then stratify as follows
• Low Risk lt 2 factors
• Moderate Risk 2-4 risk factors
• High Risk gt 5 risk factors OR TKR/THR OR
  Fracture of hip, femur, or tib-fib

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Risk Factors

• Age 40-60 years
• Age gt 60 (count as 2 factors)
• History of DVT or PE
• (count as 5 factors)
• Malignancy
• Obesity (gt120 of IBW)
• Immobilization (gt72hrs)
• Major Surgery
• Paralysis
• Trauma

• Severe COPD
• Pregnancy, or post partum lt 1 month
• Severe sepsis
• Hypercoagulable state
• Nephrotic Syndrome
• Leg ulcers, edema, or stasis
• History of MI, CHF, Stroke, IBD

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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Joints

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

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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

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Genitourinary

• Diuresis (2nd 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

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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)

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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

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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

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Neurological

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

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Psychological

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

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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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