Effects of Immobilization

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Effects of Immobilization and

Deconditioning

William McKinley MD


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Case: PM&RConsult

47 yo male, T-3 ASIA A

MVA, DOI 6 weeks ago

ROS:

Pain, poor sleep, bowelaccidents, night-time bladderincont, 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 sedentarylife and does not exercise, even if

he eats good foods and takes careof himself according to proper

medical principles, all his days

will be painful ones and hisstrength shall wane


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Immobilization &

Deconditioning Immobilization physical restriction of movement

to body or a body segment

Deconditioning decreased functional capacity ofmultiple organ systems

Severity is dependent on degree & duration ofimmobility

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 prolongedimmobilization / 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 andweightlessness)

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, increasedCO 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 topopliteal, 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: < 2 factors

Moderate Risk: 2-4 risk factors

High Risk: > 5 risk factors OR TKR/THR OR Fractureof hip, femur, or tib-fib


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Age 40-60 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:


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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 fattyacids


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Muscle (cont) Decrease in muscle mass & tension

Decreased fiber diameter (decreased myofibrils & xsec

area) Muscle atrophy / wasting 2nd to decreased musclesynthesis

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 lostmuscle 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 developsCROSS-LINKS and becomes less flexible

Joint synovial tighteningConn tissue - Loose turns to dense

Muscle - decreased sarcomeres

muscles (especially 2-joint), tendons, ligaments may becomeinvolved


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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 handposition

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 ofstress), new fibersmay be laid down OBLIQELY causing decreasedstrength and elasticity

Water and GAG content of the tissues decreased

with disuse

Rx: periodic longitudinal stress can preventdeterioration


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Bone

Wolffs Law buildup or breakdown of bone isproportionate 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/ccatheters


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Skin Pressure ulcers

Risks: positioning, decreased tissue mass, poor skincare/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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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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Effects of Immobilization

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