Download - Effects of Immobilization
-
8/8/2019 Effects of Immobilization
1/37
Effects of Immobilization and
Deconditioning
William McKinley MD
-
8/8/2019 Effects of Immobilization
2/37
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)
-
8/8/2019 Effects of Immobilization
3/37
Problem list and management
strategies?
-
8/8/2019 Effects of Immobilization
4/37
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
-
8/8/2019 Effects of Immobilization
5/37
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!
-
8/8/2019 Effects of Immobilization
6/37
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
-
8/8/2019 Effects of Immobilization
7/37
Organs Systems affected with
prolonged debilitation
(Space program effects of immobilization andweightlessness)
Cardiovascular Respiratory
Muscular
Skeletal
Joint & CTD
Gastrointestinal
Genitourinary Integumentary
Endocrine
Neurological
Psychological
-
8/8/2019 Effects of Immobilization
8/37
Cardiovascular areas affected
Heart Blood vessels (tone)
Fluid balance
Venous thrombosis
-
8/8/2019 Effects of Immobilization
9/37
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
-
8/8/2019 Effects of Immobilization
10/37
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
-
8/8/2019 Effects of Immobilization
11/37
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
-
8/8/2019 Effects of Immobilization
12/37
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
-
8/8/2019 Effects of Immobilization
13/37
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
-
8/8/2019 Effects of Immobilization
14/37
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:
-
8/8/2019 Effects of Immobilization
15/37
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
-
8/8/2019 Effects of Immobilization
16/37
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
-
8/8/2019 Effects of Immobilization
17/37
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
-
8/8/2019 Effects of Immobilization
18/37
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%)
-
8/8/2019 Effects of Immobilization
19/37
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
-
8/8/2019 Effects of Immobilization
20/37
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
-
8/8/2019 Effects of Immobilization
21/37
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
-
8/8/2019 Effects of Immobilization
22/37
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
-
8/8/2019 Effects of Immobilization
23/37
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
-
8/8/2019 Effects of Immobilization
24/37
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
-
8/8/2019 Effects of Immobilization
25/37
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
-
8/8/2019 Effects of Immobilization
26/37
Joints Cartilage degeneration (proteoglycan diminishes)
Synovial atrophy & fatty infiltrate
Underlying bone degeneration
Benign joint effusions may occur spontaneously in
SCI
Contractures
-
8/8/2019 Effects of Immobilization
27/37
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
-
8/8/2019 Effects of Immobilization
28/37
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
-
8/8/2019 Effects of Immobilization
29/37
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)
-
8/8/2019 Effects of Immobilization
30/37
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
-
8/8/2019 Effects of Immobilization
31/37
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
-
8/8/2019 Effects of Immobilization
32/37
Neurological Compression neuropathies
Ulnar (at the elbow)
Peroneal (fibular head)
Decreased coordination / balance
Decreased visual acuity
-
8/8/2019 Effects of Immobilization
33/37
-
8/8/2019 Effects of Immobilization
34/37
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
-
8/8/2019 Effects of Immobilization
35/37
-
8/8/2019 Effects of Immobilization
36/37
-
8/8/2019 Effects of Immobilization
37/37