Transcript Effects of Immobilization - VCU Physical Medicine

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,
supp’s prn
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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)
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 2nd to
“deconditioning”
• Patients & Situations at risk for prolonged
immobilization / bed rest:
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Chronically ill, aged, disabled
Paralysis (SCI, Stroke, BI/coma, NMD)
LBP
Post operatively / complications
Polytrauma, CAD, Obstetrical comp’s
Organs Systems affected with
prolonged debilitation
(Space program – “effects of immobilization and
weightlessness”)
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Cardiovascular
Respiratory
Muscular
Skeletal
Joint & CTD
Gastrointestinal
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Genitourinary
Integumentary
Endocrine
Neurological
Psychological
Cardiovascular areas affected
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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)
• “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
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
Risk Factors:
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Age 40-60 years
– Age > 60 (count as 2 factors)
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History of DVT or PE
– (count as 5 factors)
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Malignancy
Obesity (>120 % of IBW)
Immobilization (>72hrs)
Major Surgery
Paralysis
Trauma
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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
Respiratory
• Potential decrease in lung volumes (2nd to
muscle weakness, positioning/restriction)
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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 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%)
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 (2nd to
joint, Conn Tissue or muscle shortening)
– one of the “most” function-limiting complications
• With immobility, collagen develops CROSSLINKS 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
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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
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
• “Wolff’s Law” – buildup or breakdown of bone is
proportionate to the forces being applied (weightbearing, 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 (2nd to increased
adrenergic activity)
• Constipation
• Rx: bowel meds, fluids, mob, fiber-rich diet
(fruits, veg), avoid narcotics
Genitourinary
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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
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
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Depression, labiality, anxiety
Sleep disturbance
Increased auditory threshold
Decreased pain threshold
Summary of Preventative
Treatments
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Early mobilization
Strengthening
ROM
Maintain skin integrity
DVT prophylaxis
Pain management
Psychological assessment / treatment
Aggressive Respiratory management
B/B assessment & care