IMMOBILI

ZATIO

N

IMMOBILI

ZATIO

N

SUSANTI DHARM

MIK

A, DR. S

PKFR

SISTEM

DERM

ATOMUSKULO

SKELETA

L

FAKULT

AS KEDOKTERAN U

NISBA 2

012

IMMOBILIZATION

IS THE PHYSICAL RESTRICTION OF MOVEMENT INVOLVING

A BODY SEGMENT OR

THE ENTIRE BODY

DECONDITIONING

THE SEVERITY OF THE DECONDITIONING IS

DEPENDENT ON THE DEGREE AND DURATION OF

IMMOBILIZATION

THE PREVENTION OF IMMOBILIZATION IS MUCH

MORE COSTEFFECTIVE AND IS PREFERABLE TO

TREATMENT

THE ADVERSE CLINICAL MANISFESTATIONS OF PROLONGED IMMOBILZATION

I. MUSCULO

SKELETA

L

CHANGES

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)

II. C

ARDIOVA

SCULAR

CHANGES

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 OUTPUTNORMALLY: 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)

III. R

ESPIRAT

ORY

CHANGES

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

IV. S

KIN C

HANGES

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)

V. GASTR

OINTE

STINAL

CHANGES

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

VI. GENIT

OURINARY

CHANGES

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

VII. M

ETABOLIC

&

NUTRIT

IONAL C

HANGES

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

VIII. E

NDOCRINE

CHANGES

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

IX. N

EUROLOGIC

AL,

EMOTIONAL,

AND

INTE

LLECTU

AL CHANGES

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