Effects of Immobilization and

Deconditioning
William McKinley MD
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 + 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)



Problem list and management
strategies?



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
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!
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

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


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
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
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
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

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:
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
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
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


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%)

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
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

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


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
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
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
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

Joints
Cartilage degeneration (proteoglycan diminishes)
Synovial atrophy & fatty infiltrate
Underlying bone degeneration

Benign joint effusions may occur spontaneously in
SCI

Contractures

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
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
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)

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
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
Neurological
Compression neuropathies
Ulnar (at the elbow)
Peroneal (fibular head)

Decreased coordination / balance

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

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