DECONDITIONING SYNDROME BY BED REST

NURYANI SIDARTA

AIM

• TO KNOW AND UNDERSTAND THE COMPLICATION OF BED REST

• TO PREVENT THE COMPLICATION OF BED REST

• TO KNOW THE PATHOLOGICAL CONDITION THAT MAY INDUCE DECONDITIONING SYNDROME

INTRODUCTION

• BED REST HAS BEEN ROUTINELY AND OFTEN CASUALLY PRESCRIBED, DURING A PERIOD OF INJURY AND RECOVERY.

• CAUSES A GENERALIZED DECONDITIONING OF THE HEALTY SUBJECT INAL, INVOLVING MOST OF THE PHYSIOLOGICAL SYSTEMS OF THE BODY, INCLUDING THE CARDIOVASCULAR, PULMONARY, GASTROINTESTINAL, HORMONAL, AND SKELETAL SYSTEMS.

DECONDITIONING

AS REDUCED CAPACITY OF THE MUSCULOSKELETAL AND OTHER BODY

SYSTEMS (DeLisa)

DECONDITIONING

THE MULTIPLE CHANGES IN ORGAN SYSTEM PHYSIOLOGY THAT ARE INDUCED BY

INACTIVITY AND REVERSED BY ACTIVITY

IMMOBILITY

MUSCULOSKELETALMUSCULOSKELETAL

CARDIOVASCULAR

CARDIOVASCULAR

SKINSKIN

NEUROLOGICALEMOTIONAL

NEUROLOGICALEMOTIONAL

GASTOINTESTINAL

GASTOINTESTINAL

GENITOURINARYGENITO

URINARY

RESPIRATORYRESPIRATORY

ENDOCRINEENDOCRINEBODY COMPOSITION

BODY COMPOSITION

CARDIOVASCULAR SYSTEM

CARDIAC :↓ STROKE VOLUME

↑ HEART RATE↓ CARDIAC OUTPUT

↓ VO2 MAX

CARDIAC :↓ STROKE VOLUME

↑ HEART RATE↓ CARDIAC OUTPUT

↓ VO2 MAX

CARDIOVASCULAR

CARDIOVASCULAR

NEUROVASCULAR:•ORTHOSTATIC INTOLERANCE

NEUROVASCULAR:•ORTHOSTATIC INTOLERANCE

FLUID BALANCE:• ↓ PLASMA VOLUME

•↓ TOTAL BODY VOLUME•↓ RED BLOOD CELL MASS

FLUID BALANCE:• ↓ PLASMA VOLUME

•↓ TOTAL BODY VOLUME•↓ RED BLOOD CELL MASS

BLOOD COAGULATION:• ↓ CALF BLOOD FLOW•↑ VENOUS THROMBOSIS•↑ BLOOD FIBRINOGEN

BLOOD COAGULATION:• ↓ CALF BLOOD FLOW•↑ VENOUS THROMBOSIS•↑ BLOOD FIBRINOGEN

CARDIO SYSTEMCARDIO SYSTEM

STROKE VOLUME ↓ 30%STROKE VOLUME ↓ 30%

HR ↑ ½ BEAT/MIN/DAY FRO 3-4 WKHR ↑ ½ BEAT/MIN/DAY FRO 3-4 WK

CARDIAC OUTPUT UNCHANGED OR SLIGHTLY DECREASED

CARDIAC OUTPUT UNCHANGED OR SLIGHTLY DECREASED

MAXIMUM OXYGEN CONSUMPTIONDECREASED UP TO 28%

MAXIMUM OXYGEN CONSUMPTIONDECREASED UP TO 28%

ORTHOSTATIC HYPOTENSION

VAS CULAR

SYSTE M

VAS CULAR

SYSTE M

↓ BLOOD FLOW IN MUSCLE DUE TO ↓MUSCULAR PUMPING

↓ BLOOD FLOW IN MUSCLE DUE TO ↓MUSCULAR PUMPING

↑ BLOOD VISCOSITY RESULTED FROM INCREASED HT AND BLOOD VISCOSITY

INCREASED PLATELET ADHESIVENESSINCREASED PLATELET ADHESIVENESS

INCREASED FIBRINOGEN LEVEL

INCREASED RISK FOR DVT AND PULMONARY EMBOLISMINCREASED RISK FOR DVT AND PULMONARY EMBOLISM

TILTING TABLE

• ↑FORCED VITAL CAPACITY•↑ TOTAL LUNG CAPACITY

(SLIGHT)•RESIDUAL VOLUME

UNCHANGED•↑ RESPIRATORY RATE•VITAL CAPACITY

UNCHANGED•FUNCTIONAL RESIDUAL CAPACITY UNCHANGED•PULMONARY EMBOLISM

(POSSIBLE)

• ↑FORCED VITAL CAPACITY•↑ TOTAL LUNG CAPACITY

(SLIGHT)•RESIDUAL VOLUME

UNCHANGED•↑ RESPIRATORY RATE•VITAL CAPACITY

UNCHANGED•FUNCTIONAL RESIDUAL CAPACITY UNCHANGED•PULMONARY EMBOLISM

(POSSIBLE)

RESPIRATORYRESPIRATORY

TREATMENTTREATMENT

• EARLY MOBILIZATION• FREQUENT POSITION CHANGES• INCENTIVE SPIROMETRY• DEEP BREATHING• ADEQUATE HYDRATION• GOOD DENTAL CARE• CHEST PERCUSSION WITH POSTURAL DRAINAGE• ANTIOBIOTIC

• EARLY MOBILIZATION• FREQUENT POSITION CHANGES• INCENTIVE SPIROMETRY• DEEP BREATHING• ADEQUATE HYDRATION• GOOD DENTAL CARE• CHEST PERCUSSION WITH POSTURAL DRAINAGE• ANTIOBIOTIC

MUSCLES :•ATROPHY

DECR STRENGTHDECR ENDURANCE•CONTRACTURE

•DECREASED STRENGTHOF TENDON & LIG

MUSCLES :•ATROPHY

DECR STRENGTHDECR ENDURANCE•CONTRACTURE

•DECREASED STRENGTHOF TENDON & LIG

BONE :OSTEOPOROSIS

BONE :OSTEOPOROSIS JOINTS:

•CARTILAGE- DEGENERATION

•FIBROFATTY TISSUE INFILTRATION

•SYNOVIAL ATROPHYANKYLOSIS

CONTRACTURE SEQUELAE

HIP JOINT FLEXION COMPENSATORY LORDOSIS, KNEE FLEXION, SHORT STEPS

HIP JOINT FLEXION COMPENSATORY LORDOSIS, KNEE FLEXION, SHORT STEPS

HIP JOINT EXT ROTATION EXCESSIVE STRESS ON MEDIAL KNEE LIG.HIP JOINT EXT ROTATION EXCESSIVE STRESS ON MEDIAL KNEE LIG.

ANKLE PLANTAR FLEXION GENU RECURVATUM ABSENCE OF HEEL STRIKEANKLE PLANTAR FLEXION GENU RECURVATUM ABSENCE OF HEEL STRIKE

SHOULDER FLEXION, ADDUCTION CAN NOT REACH BACK POCKET, COMB HAIRAND INTERNAL ROTATION OR REACH ABOVE SHOULDER LEVEL

SHOULDER FLEXION, ADDUCTION CAN NOT REACH BACK POCKET, COMB HAIRAND INTERNAL ROTATION OR REACH ABOVE SHOULDER LEVEL

WRIST & FINGER FLEXION WEAKEND GRIP CANNOT OPEN HAND TO GRASPWRIST & FINGER FLEXION WEAKEND GRIP CANNOT OPEN HAND TO GRASP

DECREAESED MUSCLE STRENGTH

• STRENGTH DECREASES BY 0.5-1.7%/DAY• MUELLER : 1.0-1.5% OF ISOMETRIC STRENGTH

PER DAY OF BED REST OVER 2 WEEKS• STRENGTH LOSS GENERALLY GREATED IN LEGS

THAN ARMS• ANTIGRAVITY MUSCLES LOSS MORE

STRENGTH

TENDON AND LIGAMENTSTENDON AND LIGAMENTS

• DECREASED TENSILE STRENGTH• INCREASED COLLAGEN TURN OVER• DECREASED COLLAGE MASS• HISTOLOGIC CHANGES :

1. LONGITUDINAL STRESS TO CONNECTIVE TISSUES FOSTERS PARALLEL LIGAMENT OF FIBERS

2. WITH BED REST, NEWLY FORMED COLLAGEN IS LAID DOWN IN HAPHAZARD ARRANGEMENT

CALCIUM METABOLISM

• MAINTENANCE OF A SKELETON CAPABLE OF RESISTING THE MECHANICAL FORCES APPLIED DURING ACTIVITY IS DEPENDENT ON THE INTTERMITTEN APPLICATION OF THESE SOME FORCES.

• WHEN STRESS IS APPLIED TO A BONE, AS IN NORMAL ACTIVITY OR EXERCISE, THE STRAIN IS SENSED, WITH SUBSEQUENT CHANGES IN OSTEOCLAST AND OSTEOBLAST CELLULAR ACTIVITY.

• MAINTENANCE OF A SKELETON CAPABLE OF RESISTING THE MECHANICAL FORCES APPLIED DURING ACTIVITY IS DEPENDENT ON THE INTTERMITTEN APPLICATION OF THESE SOME FORCES.

• WHEN STRESS IS APPLIED TO A BONE, AS IN NORMAL ACTIVITY OR EXERCISE, THE STRAIN IS SENSED, WITH SUBSEQUENT CHANGES IN OSTEOCLAST AND OSTEOBLAST CELLULAR ACTIVITY.

• IF NO FORCE IS APPLIED TO THE SKELETON, EITHER BECAUSE OF PLASTER IMMOBILIZATION, STRICT BED REST, PARALYSIS, OR WEIGHTLESSNESS OF SPACE FLIGHT, BONE MINERAL IS LOSS BECAUSE THE RATE OF BONE FORMATION FALLS BELOW THE RATE OF BONE MINERAL ABSORPTION.

STUDIES*

• URINARY CALCIUM INCREASED AT A RATE OF 12% PER WEEK

• LOSSES OF TOTAL BODY CALCIUM IN URINE, SWEAT, AND FECES AVERAGED 0.5% PER MONTHS

• PARALLEL LOSSES IN PHOSPHORUS AND HYDROYPROLINE.

PREVENTION & TREATMENT

• RELATIVELY INTENSE EXERCISE (ISOTONIC & ISOKINETIC) IN BED HELP MAINTAIN MUSCLE STRENGTH

• DAILY ROM EXERCISE OF MUSCLES DELAYS ATROPHY

• EARLY MOBILIZATION AND WEIGHT BEARING ACTIVITY

BODY COMPOSITION, METABOLISM, NUTRITION

•↓ LEAN BODY MASS•↑ BODY FAT•NITROGEN LOSS• CALCIUM LOSS•PHOSPHORUS LOSS•SULFUR LOSS•POTASSIUM LOSS

ALTERED CIRCADIAN RHYTYMALTERED CIRCADIAN RHYTYM

ALTERED TEMPERATURE AND SWEATING RESPONSE

ALTERED TEMPERATURE AND SWEATING RESPONSE

ALTERED REGULATION OF HORMON:PARATHYROID, ADRENAL, ANDROGEN,

THYROID

ALTERED REGULATION OF HORMON:PARATHYROID, ADRENAL, ANDROGEN,

THYROID

IMPAIRED GLUCOSE TOLERANCEIMPAIRED GLUCOSE TOLERANCE

IMPAIRED GLUCOSE TOLERANCE

• BECAUSE OF INACTIVITY, MUSCLE DEVELOPS INSULIN RESISTANCE THAT MAKE REDUCTION IN PERIPHERAL GLUCOSE UPTAKE WHICH CAUSED HYPERGLYCEMIA FOLLOWED BY HYPERINSULINEMIA

• OCCURS AS SOON AS 3 DAYS AFTER BEDREST• DECREASE 20-50% BY 14 DAYS

GENITOURINARY

↑ MINERAL EXCRETION↑ MINERAL EXCRETION

↑ POSTVOIDRESIDUALVOLUME

↑ POSTVOIDRESIDUALVOLUME

↑ URINARY TRACT

INFECTION

↑ URINARY TRACT

INFECTION↑ OVERFLOW

INCONTINENCE↑ OVERFLOW

INCONTINENCE

↓ ABILITY TOCONCENTRATE

URINE

↓ ABILITY TOCONCENTRATE

URINE

↓ GFR↓ GFR

↑ CALCULUSFORMATION↑ CALCULUSFORMATION

GASTROINTESTINAL

↓ FLUID INTAKE↓ FLUID INTAKE

↓ APPETITE↓ APPETITE

↓ BOWELMOBILITY↓ BOWELMOBILITY

↓ GASTRIC SECRETION

↓ GASTRIC SECRETION

CONSTIPATIONCONSTIPATION

GI ATLERATIONS• DECREASED TRANSIT TIME• SLOWED BY UP TO 66% IN LYING POSITION

COMPARED WITH STANDING• INCREASED GASTRIC ACIDITY BECAUSE OF

ACTIVATION OF THE SYMPATHETIC SYSTEM INHIBITION OF GASTRIC BICARBONATE SECRETION.

• STOOL CALCIUM LEVEL INCREASED FROM A MEAN OF 797-911 MG PER DAY WITH BED REST

• INTESTINAL ABSORPTION DECREASED FROM 31% WITH BED REST

PREVENTION & TREATMENT

• USE TOILET OR BEDSIDE COMMODE WHEN POSSIBLE INSTEAD OF BED PAN

• ENCOURAGE EARLY MOBILIZATION• USE HIGH FIBER DIET OR FIBER SUPPLEMENTATION• ENSURE ADEQUATE FLUID INTAKE• DECREASE CONSTIPATING MEDICATIONS SUCH AS

NARCOTICS• CONSIDER STOOL SOFTENERS• GLYCERIN ENEMA DAILY AS NEEDED• LAXATIVES (IF NEEDED)

SENSORY DEPRIVATION (ATTENTION SPAN, TIME AWARENESS, HAND TO EYE COORDINATION, DEPRESSION,

ANXIETY)↓ BALANCE

↓ COORDINATION↓ VISUAL ACUITY

↑ AUDITORY THRESHOLD

NEUROLOGICAL, EMOTIONAL

TREATMENT

• STOP MEDICATIONS THAT MAY CAUSE CHANGES IN MENTAL STATUS

• FREQUENTLY ORIENT PATIENT TO TIME AND PLACE

• ENCOURAGE VISITS FROM FAMILY AND FRIENDS

• ENCOURAGE GROUP ACTIVITIES• KEEP PATIENT HEARING AIDS AND GLASSES

EASILY AVAILABLE

PRESSURE ULCER

PRESSURE ULCER

SKIN

SKIN

EDEMAEDEMA

SUBCUTANEOUS

BURSITIS

SUBCUTANEOUS

BURSITIS

INTRINSIC:• ABN SKIN SENSATION•ABN MENTAL STATUS •ALTERED CONCIOUSNESS

•ADVANCED AGE•↑LOCAL TISSUE METABOLIC RATE

•PREVIOUS PRESSURE SORE•MUSCLE AND SKIN ATROPHY

•SCARS•EDEMA

•MALNUTRISI & ANEMIA•OBESITY•INFECTION

INTRINSIC:• ABN SKIN SENSATION•ABN MENTAL STATUS •ALTERED CONCIOUSNESS

•ADVANCED AGE•↑LOCAL TISSUE METABOLIC RATE

•PREVIOUS PRESSURE SORE•MUSCLE AND SKIN ATROPHY

•SCARS•EDEMA

•MALNUTRISI & ANEMIA•OBESITY•INFECTION

EXTRINSIC :• DURATION OF PRESSURE•SKIN MACERATION

EXTRINSIC :• DURATION OF PRESSURE•SKIN MACERATION

PREVENTION PRESSURE ULCERPREVENTION PRESSURE ULCER

• PROPER TURNING• PRESSURE RELIEVING BED• PROPER SKIN CARE & TOILETING• PROPER SEATING• PROPER NUTRITION• SKIN CARE PROCEDURE

PRESSURE ULCER• ULCUS DECUBITUS• TERM “DECUBITUS” IS DERIVED FROM LATIN

MEANING “LYING DOWN”• CAN RESULT FROM ANY PROLONGED,

UNCHANGED POSITION• ARE CLINICAL MANIFESTATION OF LOCAL TISSUE

DEATH AND CATABOLISM• FOUND MOST FREQUENTLY OVER BONY

PROMINENCE EXPOSED TO COMPRESSING SURFACES

EPIDEMIOLOGY

• 7.7% OF HOSPITALIZED PATIENTS DEVELOP PRESSURE ULCER WITHIN 21 DAYS OF ADMISSION

• ORTHOPEDIC & GERIATRIC : 24%• SCI : 24-59%

ETIOLOGIC FACTORSETIOLOGIC FACTORS

PRESSURE:•DURATION•INTENSITY

PRESSURE:•DURATION•INTENSITY

SHEAR:•POOR SITTING

POSITION•POOR BED POS•SPASTICITY•SLIDING

INSTEAD OF LIFTING PS

WHEN TRANSFER

SHEAR:•POOR SITTING

POSITION•POOR BED POS•SPASTICITY•SLIDING

INSTEAD OF LIFTING PS

WHEN TRANSFER

FRICTION :• SKIN TEAR•SKIN

ABRASION

FRICTION :• SKIN TEAR•SKIN

ABRASION

SECONDARY FACTORS :• MOBILITY•NUTRION•AGE

•MOISTURE/INCONTINENCE• DIABETES•SMOKING•FEBRIS•IMPAIRED

MENTAL STATUS

SECONDARY FACTORS :• MOBILITY•NUTRION•AGE

•MOISTURE/INCONTINENCE• DIABETES•SMOKING•FEBRIS•IMPAIRED

MENTAL STATUS

SIX BASIC CONDITION

• SEDENTARY LIFE STYLE• REST BY MEDICAL/SURGICAL ILLNESS• MEDICAL/CAREGIVER NEGLECT WITH PATIENT

RESTRICTED FROM MOBILITY• IMMOBILISATION BODY/PART OF BODY BY

CAST/BRACE (AFTER TRAUMA)• DISUSE BY NEUROMUSCULAR DISORDER

(PARALYSIS)• DISUSE BY WEIGHT

ULCUS GRADE 1

ULCUS GRADE 2

ULCUS GRADE 3

ULCUS GRADE 4

PRIMARY PREVENTION

• INDICATES AREA OF HIGH RISK IN SITTING, SUPINE, AND SIDE-LYING POSITIONS

• AVOID SLIDING PATIENT’S BODY ACROSS SURFACES

• PATIENT SHOULD BE REPOSITIONED EVERY 2 HOURS

• INSPECT AND ASSESS SKIN WITH EACH TURNING

• SUPPORT SURFACES

WOUND MANAGEMENT PRIORITIES

• REDUCE OR ELIMINATE CAUSATIVE FACTORS• PROVIDE SYSTEMIC SUPPORT FOR WOUND

HEALING• INITIATE APPROPRIATE THERAPY• EDUCATION

SYSTEMIC SUPPORT

• TISSUE PERFUSION AND OXYGENATION• NUTRITIONAL AND FLUID SUPPORT:

1. ALBUMIN2. ZINC : PROTEIN SYNTESIS & REPAIR

3. VIT C : COLLAGEN SYNTHESIS• CONTROL OF SYSTEMIC CONDITIONS AFFECTING

WOUND HEALING

SYSTEMIC CONDITIONS

• DIABETES MELLITUS• HEMATOPOIETIC ABNORMALITIES

• IMMUNOSUPRESSION• RENAL FAILURE

INITIATE APPOPRIATE THERAPY

• DEBRIDEMENT• IDENTIFY AND ELIMINATE INFECTION• MAINTAIN MOIST WOUND SURFACE• PROVIDE THERMAL INSULATION• PROTECT HEALING WOUND

THANK YOU