Transcript IMMOBILIZATION

IMMOBILIZATION
IS THE PHYSICAL RESTRICTION OF MOVEMENT
INVOLVING
A BODY SEGMENT
OR
THE ENTIRE BODY
PROLONGED STAYS IN
RECUMBENT POSITION (E.G.
CHRONIC LOW BACK PAIN),
OR SITTING POSITION (E.G.
WHEEL CHAIR SITTING)
CRITICAL ILLNESS
REQUIRING BED REST, E.G.:
AFTER ACUTE MYOCARD
INFARCTION
CARDIAC DYSRHYTMIA
SEPTIC SHOCK
NEUROMUSCULOSKELETAL
DISORDERS AND INJURIES, E.G.:
PARALYSIS DUE TO STROKE OR
SPINAL CORD INJURY
ORTHOPEDIC CASTS, BODY JACKETS,
AND SPLINTS, USUALLY AFTER
TRAUMA OR FRACTURE
IMMOBILIZATION
IMMOBILIZATION DUE TO
PROLONGED BED REST
DECONDITIONING
REDUCED FUNCTIONAL CAPACITY
OF MULTIPLE BODY SYSTEM
ESPECIALLY THE
MUSCULOSKELETAL SYSTEM
LEADS TO FUTHER INACTIVITY AND
PERPETUATES THE VICIOUS CYCLE
DECONDITIONING
THE SEVERITY OF THE DECONDITIONING IS DEPENDENT ON THE
DEGREE AND DURATION OF IMMOBILIZATION
THE
PREVENTION
OF
IMMOBILIZATION
IS
MUCH
COSTEFFECTIVE AND IS PREFERABLE TO TREATMENT
MORE
THE ADVERSE CLINICAL MANISFESTATIONS OF
PROLONGED IMMOBILZATION
1. CONTRACTURE
• IS THE LACK OF FULL ACTIVE OR PASSIVE RANGE OF MOTION
(ROM) DUE TO A JOINT, SOFT TISSUE, OR MUSCLE LIMITATION
• CONDITIONS PRODUCING LIMITED JOINT ROM:
1. PAIN (E.G. TRAUMA, INFLAMMATION, INFECTION, JOINT
DEGENERATION, ISCHEMIA, AND HEMORRHAGE)
2. MUSCLE IMBALANCE (E.G. PARALYSIS AND SPASTICITY)
3. CAPSULAR OR PERIARTICULAR TISSUE FOBROSIS
4. PRIMARY MUSCLE DAMAGE (E.G. POLYMYOSITIS, MUSCULAR
DYSTROPHY)
5. MECHANICAL FACTORS (E.G. IMPROPER BED POSITIONING,
CASTING/ SPLINTING IN FORESHORTENED POSITION)
CONTRACTURE…
THE MUSCLE FIBRES & CONNECTIVE TISSUE
IN SHORTENED POSTION (3 – 5 DAYS)
↓
CONTRACTION OF COLLAGEN FIBERS DECREASE IN MUSCLE FIBERS
↓
≥ 3 WEEKS
THE LOOSE OF CONNECTIVE TISSUE IN MUSCLES & AROUND JOINT 
DENSE CONNECTIVE TISSUE
↓
CONTRACTURE MOST COMMONLY AT:
LOWER LIMB ( BIARTICULAR MUSCLE) IN THE HIPS, KNEES, ANKLES
UPPER LIMB : THE SHOULDER, ELBOWS,WRISTS, FINGERS
CONTRACTURE…
PREVENTION:
- PROPER POSITIONING
(USING PILLOWS, TROCHANTER ROLLS, HAND ROLLS, RESTING SPLINTS)
- ACTIVE/PASSIVE ROM EXERCISE
- EARLY MOBILIZATION AND AMBULATION
2. MUSCLE WEAKNESS AND ATROPHY
• SEEN IN THE ANTIGRAVITY MUSCLES OF THE LOWER
LIMBS
• TOTAL INACTIVITY  ↓ISOMETRIC MUSCLE STRENGTH:
10-20%/WEEK (1-3%/DAY)
50% IN 2- 5 WEEKS
• STREGTH THAT LOST IN1 WEEK MAY TAKE 4 WEEKS FOR
REGAIN EVEN WITH MAXIMAL STREGTHENING PROGRAM
MUSCLE WEAKNESS AND ATROPHY…
PREVENTION:
• MUSCLE MUST EXERT 20-30% OF ITS MAXIMAL CAPACITY FOR
SEVERAL SECOND EACH DAY
• MUSCLE EXERTION AT 50% MAXIMUM CAPACITY ( 1 SEC/DAY) 
MORE EFFECTIVE
• NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) FOR
DENERVATED MUSCLE
• PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION
3. DISUSE OSTEOPOROSIS
IMMOBILIZATION
↓
LACK OF STIMULUS
(E.G. WEIGHT BEARING, GRAVITY, AND MUSCLE ACTIVITY)
↓
↑URINARY EXCRETION OF CALCIUM & HYDROXYPROLINE
↑ EXCRETION OF THE CALCIUM IN THE STOOL
↓
INCREASED OF BONE RESORPTION
↓
LOST OF THE BONE DENSITY
↓
DISUSE OSTEOPOROSIS
DISUSE OSTEOPOROSIS…
• MORE MARKED IN SUBPERIOSTEAL REGION
• INITIALLY INVOLVES THE CANCELLOUS BONE AT THE
METAPHYSIS & EPIPHYSIS EXTENDS TO DIAPHYSIS
• ↓ BONE DENSITY :
 40-45% AFTER 12 WEEKS OF BED REST
> 50% AFTER 13TH WEEKS
• SENSITIVE TO MINOR TRAUMA  FRACTURE
DISUSE OSTEOPOROSIS…
PREVENTION:
•WEIGHT BEARING STANDING
•STANDING FRAME OR TILT TABLE  IF UNABLE TO STAND
UNSUPPORTED :
 30 DEGREE 1 MINUTE
 ↑10 DEGREES EVERY 3-5 DAYS
 UNTIL 70 DEGREES (30 MINUTES)
 STANDING IN PARALLEL BAR
 AMBULATION
•GENERAL EXERCISE PROGRAM (STRENGTHENING, ENDURANCE,
COORDINATION, ADL)
1. ORTHOSTATIC (POSTURAL) HYPOTENSION
• IS DUE TO THE IMPAIRED ABILITY OF THE CIRCULATORY SYSTEM
TO ADJUST TO THE UPRIGHT POSITION
• AS THE PERSON STANDS  BLOOD POOLS IN THE LOWER LIMBS
CAUSING AN IMMEDIATE DROP IN VENOUS RETURN  ↓ STROKE
VOLUME &↓ CARDIAC OUTPUT
NORMALLY: IMMEDIATE VASOCONSTRICTION AND ↑ HEART
RATE (HR)& SYSTOLIC BLOOD PRESSURE (SBP)
IN PROLONGED BED REST: LOSE THIS ADAPTATION :
TINGLING, BURNING IN THE LOWER LIMBS, DIZZINESS,
LIGHTHEADEDNESS, FAINTING, VERTIGO, ↑ HR (> 20
X/MINUTE), ↓ SBP (> 20 mmHg), ↓ PULSE PRESSURE
ORTHOSTATIC (POSTURAL) HYPOTENSION…
TREATMENT:
•
EARLY MOBILIZATION (ROM EXERCISES, STRENGTHENING EXC., AMBULATION,
CALISTHENICS)
•
ABDOMINAL STRENGTHENING AND ISOTONIC-ISOMETRIC EXERCISE OF THE
LEGS ( TO REVERSE VENOUS STASIS AND POOLING)
•
PROVIDING THE WHEELCHAIR WITH ELEVATING LEG RESTS AND RECLINING
BACK
•
TILT TABLE (GRADUAL TILT UP TO 70 DEGREES F0R 20 MINUTES)
•
BANDAGE WRAPS, FULL LENGTH ELASTIC STOCKINGS, ABDOMINAL BINDERS
•
SYMPATHOMIMETIC PRESSOR AGENTS
•
MINERALOCORTICOID  TO MAINTAIN BP < ADEQUATE SALT & FLUID INTAKE TO
PREVENT FURTHER BLOOD VOLUME CONTRACTION AND WORSENING
HYPOTENSION
2. CHANGES DUE TO CARDIAC DECONDITIONING
AT REST:
 ↑RESTING HR
 ↓ RESTING STROKE VOLUME  RELATED TO ↓ BLOOD
VOLUME
 ↓ CARDIAC SIZE
 ↓ LEFT VENTRICULAR & DIASTOLIC VOLUME
 REMAINS UNCHANGED : RESTING SYSTOLIC & MEAN BP, O2
UPTAKE AT REST, ARTERIOVENOUS O2 DIFFERENCE
2. CHANGES DUE TO CARDIAC
DECONDITIONING
WITH EXERCISE:
 ↑HR RESPONSE TO SUBMAXIMAL EXERCISE (MAXIMAL HR REMAINS
UNCHANGED OR SLIGHTLY ↑)
 ↓STROKE VOLUME AT SUBMAXIMAL & MAXIMAL EXERCISE
 ↑ CO
 ↓ MAXIMUM O2 UPTAKE (VO2 MAX)
 ARTERIOVENOUS O2 DIFFERENCE AT SUBMAXIMAL EXERCISE
3. CHANGED IN FLUID BALANCE
IN THE RECUMBENT POSITION:
 ↑ CO
 ↑ CARDIAC WORK
 SHIFT OF 700 ML OF BLOOD VOLUME TO THE THORAX
 DELAYED SHIFT OF EXTRAVASCULAR FLUID INTO THE CIRCULATION
 COMPENSATORY DIURESIS ( ↓PLASMA VOLUME WITH SUBSEQUENT
LOSS OF PLASMA MINERAL AND PROTEIN  ↓HYDROSTATIC BP, ↓ ADH
CHANGED IN FLUID BALANCE…
TREATMENT:
ISOTONIC EXERCISE IS ALMOST TWICE AS EFFECTIVE AS ISOMETRIC
EXERCISE IN PREVENTING PLASMA VOLUME REDUCTION
3. VENOUS THROMBOEMBOLISM
• DUE TO VENOUS STASIS INCREASED BLOOD VICOSITY AND
HYPERCOAGULABILITY (↓ PLASMA VOLUME, RED BLOOD MASS
UNCHANGED)
• PREVENTIVE:
 ACTIVE EXERCISE (E.G. CALF OR ANKLE PUMPING EXERCISE AND
WALING
 ELASTIC STOCKINGS (KNEE OR THIGH HIGH)/ ELASTIC WRAPS
 LOW MOLECULAR/UNFRACTIONED HEPARIN
 PROPER POSITIONING (LEGS ELEVATED)
RESPIRATORY CHANGES…
BED REST
↓
↓ ROM OF THE COSTOVERTEBRAL & COSTOCHONDRAL JOINT
↓
↓ CHEST EXCURSION
↓
MECHANICAL RESTRICTION OF BREATHING
↓
RAPID, SHALLOW BREATHING
↓
↓ PULMONARY FUNCTION PARAMETERS (↓ TIDAL VOLUME, MINUTE
VOLUME, VITAL CAPACITY, MAXIMUM VOLUNTARY VENTILATION)
RESPIRATORY CHANGES…
IN THE SUPINE POSITION:
THE MUCOCILIARY MECHANISM INEFFECTIVE IN CLEARING SECRETIONS
↓
MUCUS SECRETIONS ACCUMULATE IN THE DEPENDENT RESPIRATORY SEGMENT
(POSTERIOR SEGMENT)
↓
IN THE NON DEPENDENT RESPIRATORY SEGMENTS ( ANTERIOR SEGMENT) DRY
RESPIRATORY CHANGES…
IN THE SUPINE POSITION:
THE CILIARY MALFUNCTION
WEAKNESS OF THE ABDOMINAL MUSCLES
↓
IMPAIRED COUGH
RESPIRATORY CHANGES…
IN THE SUPINE POSITION:
THE DEPENDENT RESPIRATORY SEGMENT BECOME POORLY VENTILATED &
OVERPERFUSED
↓
REGIONAL CHANGES IN THE VENTILATION-PERFUSION RATIO
↓
SIGNIFICANT ARTERIOVENOUS SHUNTING
↓
LOWER ARTERIAL OXIGENATION
↓
IF METABOLIC DEMAND IS INCREASED
↓
HYPOXIA
↓
ATELECTASIS & HYPOSTATIC PNEUMONIA
RESPIRATORY CHANGES…
PREVENTION:
• EARLY MOBILIZATION
• FREQUENT CHANGE IN POSITION
• CHEST PHYSICAL THERAPY ( DEEP BREATHING, INCENTIVE
SPIROMETRY, ASSISTED COUGH, AND/OR CHEST PERCUSSION
AND VIBRATTION)
• ADEQUATE PULMONARY HYGIENE
SKIN CHANGES …
• PRESSURE ULCERS
• DEPENDENT EDEMA  PREDISPOSE TO CELLULITIS
(PREVENTION: ADEQUATE MOBILIZATION AND ELEVATION, USE
OF STOCKING/ GLOVES, PRESSURE GRADIENT COMPRESSION,
AND MASSAGE)
• SUBCUTANEOUS BURSITIS (B ECAUSE OF EXCESSIVE PRESSURE
ON THE BURSAE (USUALLY PREPATELLAR OR ELBOW BURSAE) 
PREVENTION: NSAID, PERCUTANEOUS DRAINAGE,
CORTICOSTEROID INJECTIONS, SURGERY IN REFRACTORY CASE)
GASTROINTESTINAL CHANGES…
•
↓ APPETITE
•
↓ GASTRIC SECRETION
•
ATROPHY OF INTESTINAL MUCOSA AND GLANDS
•
SLOWER RATE OF ABSORPTION
•
DISTATE FOR PROTEIN RICH FOOD ( LEADS TO NUTRITIONAL HYPOPROTEINEMIA)
•
REDUCING OF DESIRE TO DEFECATE
•
CONSTIPATION DUE TO DECREASED GASTRIC AND INTESTINAL MOTILITY 
AGGRAVATED BY THE LOSS OF PLASMA VOLUME AND DEHYDRATION
 TREATMENT  LAXATIVES, ENEMAS, MANUAL EXTRACTION, OR SURGICAL
 PREVENTION  ADEQUATE FLUID INTAKE & FIBER RICH DIET, USE
SOFTENERS AND BULK FORMING AGENT, AVOIDANCE OF NARCOTICS, LIMITED
USE OF HYPEROSMOTIC (E.G. GLYCERIN) OR PERISTALTIS-STIMULATING (E.G.
BISACODYL) SUPPOSITORIES COMBINED WITH REGULARLY-TIMED BOWEL
PROGRAM
GENITOURINARY CHANGES…
• INCREASED DIURESIS AND MINERAL SECRETION
• URINARY STAGNATION & HYPERCALCIURIA  STONE
FORMATION
• URINARY TRACT INFECTION
• DECREASED GLOMERULAR FILTRATION RATE AND DECREASED
ABILITY TO CONCENTRATE URINE
• DECREASED OF SPERMATOGENESIS AND ANDROGENESIS
GENITOURINARY CHANGES…
PREVENTION :
•
ADEQUATE FLUID INTAKE
•
USE OF THE UPRIGHT POSITION FOR VOIDING
•
STRICT AVOIDANCE OF BLADDER CONTAMINATION DURING
INSTRUMENTATION
•
PATIENT WITH HIGH POST VOID RESIDUAL  CONDOM
CATHETERIZATION OR INTERMITTENT CATHETERIZAT ION
•
FOR UTI  ANTIBIOTICS , ACIDIFICATION ( VITAMIN C) TO PREVENT THE
GROWTH OF PROTEUS ORGANISM, URINARY ANTISEPTICS
•
HIGH RISK OF STONE FORMATION  UREASE INHIBITOR
•
TREATMENT FOR STONE FORMATION  SURGICAL REMOVAL OR
LITHOTRIPSY
METABOLIC & NUTRITIONAL CHANGES…
• ↓ LEAN BODY MASS
• ↑ BODY FAT
• DISSORDER OF NITROGEN BALANCE
• MINERAL & ELECTROLYTES LOSSES
• HYPERCALCEMIA DUE TO IMMOBILIZATION  ASSOCIATED WITH
OSTEOPOROSIS  ESPECIALLY IN ADULT MALES WITH
TRAUMATIC INJURY  TREATMENT : ADEQUATE CALCIUM
EXCREATION THROUGH HYDRATION (SALINE 0,9% OR 0,45 %)
AND DIURESIS WITH FUROSEMIDE
ENDOCRINE CHANGES…
•
DUE TO ALTERED RESPONSIVENESS OF HORMONES AND ENZYMES :
•
GLUCOSE INTOLERANCE (NOTED 8 WEEKS AFTER IMMOBILITY )
 DUE TO REDUCED INSULIN-BINDING SITES DECREASED
SENSITIVITY OF PERIPHERAL MUSCLE TO CIRCULATING INSULIN)
 IMPROVED BY ISOTONIC EXERCISES OF THE LARGE MUSCLE
GROUPS IN THE LEGS
•
ALTERED CIRCADIAN RHYTHM
•
ALTERED TEMPERATURE AND SWEATING RESPONSES
•
ALTERED REGULATION OF PARATHYROID HORMONE (PTH), THYROID
HORMONE,, ANDROGENS , ADRENAL HORMONES, PITUITARY
HORMONES, GROWTH HORMONES AND PLASMA RENIN ACTIVITY
NEUROLOGICAL, EMOTIONAL, AND
INTELLECTUAL CHANGES …
•
THE EFFECTS OF SENSORY DEPRIVATION ( ↓ ATTENTION SPAN, CONFUSION AND
DISORIENTATION TO TIME AND SPACE, ↓ HAND – TO – EYE COORDINATION)
•
↓ INTELLECTUAL CAPACITY
•
EMOTIONAL & BEHAVIORAL DISTURBANCES (ANXIETY, DEPRESSION, AUTONOMIC
LABILITY, RESTLESNESS, ↓ PAIN TOLERANCE, IRRITABILITY, HOSTILITY, INSOMNIA,
AND LACK OF MOTIVATION)
•
↑ AUDITORY THRESHOLD
•
↓ VISUAL ACUITY
•
IMPAIRED BALANCE AND COORDINATION (PROBALY DUE TO NEURAL FACTORS
RATHER THAN MUSCLE WEAKNESS)
•
COMPRESSIONS NEUROPATHIES
NEUROLOGICAL, EMOTIONAL, AND
INTELLECTUAL CHANGES …
PREVENTION:
• ENCOURAGING THE PATIENT TO INTERACT WITH STAFF, OTHER
PATIENTS, AND FAMILY MEMBERS
• RECREATIONAL THERAPY FOR PSYCHOSOCIAL INTERAGRATION,
RESOCIALIZATION, AND ADJUSTMENT TO INDEPENDENT
FUNCTIONING
• NERVE COMPRESSION CAN BE PREVENTED BY PROPER
POSITIONING TO RELIEVE PRESSURE FROM THE NERVE
REFFERENCE
PRACTICAL MANUAL OF PHYSICAL MEDICINE AND
REHABILITATION: DIAGNOSTICS, THERAPEUTICS AND
BASIC PROBLEMS, JACKSON TAN, MOSBY, 1998