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IMMOBILITY &

SKELETAL MUSCLE
Disuse atrophy :alteration of muscle cell
homeostasis in response to muscle
inactivity.
Lower limbs > Upper limbs

Main contributor to muscle


atrophy: muscle protein
synthesis is significantly
reduced
10 days: 50% muscle weight loss.

14 days: 50% of the baseline level of


SKELETAL MUSCLE
Loss of strength: a consequence
of muscle atrophy

10% to 15% loss of strength


per week

35-50% over 5 weeks


SKELETAL MUSCLE
Loss of endurance

1. Decreases energy storage


of glycogen and ATP
2. Causes a reduction of
oxidative enzymes
3. Reduces mitochondrial
function and
microvascular circulation,
muscle metabolic activity,
strength, and endurance.
PREVENTION & TREATMENT
STRATEGI
ES
Prescribe Progressive
resistive exercises and
activity programs.

Quickly recognize the side


effects of inactivity

Use a combination of two or


three specific exercises, such
as flexibility exercise, exercise
for strength, and exercise for
Functionally remobilize the patient as
endurance and fitness.
quickly as possible
PREVENTION & TREATMENT
LEXIBILITY EXERCISE
Stretching:
maintenance of
normal muscle
function
Daily stretching of a
muscle for a half
hour can prevent the
loss of sarcomeres in
series of the
immobilized muscle
PREVENTION & TREATMENT
RENGTHENING EXERCISE
Resumption of normal
activities

Prescription of
resistance exercise
Daily muscle
contraction at 30% to
50% of one repetition
maximal strength for 2
to 5 minutes, 3x a
week, should suffice to
PREVENTION & TREATMENT
TRENGTHENING EXERCISE

Electrical
Stimulation
3 sessions per day
for 30 minutes, using
rectangular biphasic
pulse stimulation
-useful for
astronauts
PREVENTION & TREATMENT
Treatment
Prescription :intensity,
frequency, duration, & goal.
1 repetition maximum for each muscle
group.
Select initial and later intensity of 50%
to 80% of that maximum.
Repetition is performed 10 to 15 times,
2x per session for each muscle group,
3x per week.
Include the large muscle groups of the
lower
Focusand
on upper limbs and, if indicated,
antigravity muscles.
back and abdominal muscles.
Reestablish the new one-repetition maximum, as
well the intensity and duration after 2 to 3 weeks
CONNECTIVE TISSUE CHANGES & JOINT
CONTRACTURE
Joint contractures:
pathologic changes in the
joint & adjacent tissue
and immobility imposed
by pathology or some
other extrinsic factors.

Single factor that


contributes most
frequently: lack of joint
mobilization
Reduction the
throughout of resting
full flexing
allowable range and capsular
muscle length or
soft-tissue tightness with
resultant fixed joint
contracture
CONNECTIVE TISSUE CHANGES & JOINT
CONTRACTURE
Anatomical Classification of Contractures
Type of Causes
Contracture
Arthrogenic Cartilage damage, joint incongruency (e.g., congenital
deformities), inflammation, trauma, degenerative joint disease,
infection, immobilization
Synovial and fibrofatty tissue proliferation (e.g., inflammation)
pain, effusion
Capsular fibrosis (e.g., trauma, inflammation, immobilization)
Soft and Periarticular soft tissue (e.g., trauma, inflammation,
dense tissue immobilization)
Skin, subcutaneous tissue (e.g., trauma, burns, infection, systemic
sclerosis)
Tendon and ligaments (e.g., tendinitis, bursitis, ligamentous tear
and fibrosis)
Myogenic Trauma (e.g., bleeding, edema, immobilization)
Intrinsic, Inflammation (e.g., myositis, polymyositis)
structural Degenerative changes (e.g., muscular dystrophy)
Ischemic (e.g., diabetes, peripheral vascular disease,
compartment syndrome)
Extrinsic Spasticity (e.g., strokes, multiple sclerosis, spinal cord injuries and
other upper motor neuron diseases)
yogenic Contracture
Shortening of resting muscle
length that is due to intrinsic
or extrinsic causes, limiting full
ROM and causing abnormal
positioning of the limbs or
body
Dx: Careful PE (evaluation of
active and passive ROM)
Muscular dystrophy
:intrinsic degenerative
process in the muscle.
Histology: muscle fiber loss,
segmental necrosis, and
The replacement
increased amountsofof functional
lipocytes muscle fibers with
collagen and fatty tissue in concert with chronically
and fibrosis.
shortened resting muscle length results in contracture
yogenic Contracture
Extrinsic myogenic contracture:
MC type occurring after multiple
injuries and chronic illness
Therapeutic approach: identify the
cause

If a paralyzed muscle cannot


provide adequate resistance to its
antagonist muscle across a joint,
then the stronger muscle will
eventually become shortened.
E.g.: shortened triceps surae seen
in persons with chronic peroneal
nerve palsy or in patients with
plantar-flexor spasticity.
throgenic Contracture
Pathologic processes involving
joint components, such as
degeneration of cartilage,
congenital incongruency of
joint surfaces, or synovial
inflammation, can lead to
capsular tightness and
fibrosis.

Synovial inflammation and


effusion are accompanied by
pain that predisposes to
limited joint motion, leading
Management
Mild contracture: stretching
for 20 to 30 min
Severe contractures:
Prolonged stretches of 30
minutes or more combined
with appropriate positioning
and splinting.
More successful when used
with the application of heat to
the musculotendinous
junction or joint capsule.
(Ultrasound).
Heating of the tissue to 40 C
to 43 C will increase the
viscous properties of
connective tissue and
Management
Dynamic splinting :
provides tension in
the desired
direction

Hand and arm:


allows a measure
of function while
providing stretch.

Continuous passive
mobilization (CPM)
device.
DISUSE
OSTEOPOROSIS
Maintenance of skeletal mass
depends largely on
mechanical loading applied to
bone by tendon pull and the
force of gravity.

Bone mass will increase with


repeated loading stresses
and will decrease with the
absence of muscle activity
or with the elimination of
Immobilization
gravity or immobility
primarily decreases bone
formation, specifically in the
zones of high turnover rate
(primary spongiosa).
SISTANCE EXERCISES FOR OSTEOPOROSIS
Resistive exercise can
increase bone mass.

Significant correlation
between muscle strength
and bone mineral density.

Reduced back extensor


muscle strength is
associated with a higher
incidence of vertebral
fractures
YPICAL PRESCRIPTION
Progressive resistive strengthening exercise training for back
extensors, hip extensors and abductors, and shoulder girdle
muscles
Posture training and ambulation
Avoidance of flexion exercise of lumbar spine or high-impact
exercises (e.g., jogging, step aerobics), especially when
CARDIOVASCULAR

3 weeks of bed rest:


VO2max 25%,
Individuals with an
inactive lifestyle and a low
level of fitness are more
prone to develop
coronary artery disease
and are at a higher risk
of suffering myocardial
infarction and death
IMPAIRED CARDIOVASCULAR
PERFORMANCE & FITNESS
reduced physical
activity and fitness is
associated with a
twofold increase in risk
of cardiovascular
mortality and
Increase in physical
morbidity
activity and mobility,
on the other hand,
increases
cardiovascular
performance
IMPAIRED CARDIOVASCULAR
PERFORMANCE & FITNESS
physical activity and
appropriate diet can
reduce risk of type 2
diabetes development by
58%
30 min per day or 3 to4
hours per week of
exercise
Physical activity and
exercise (even of
moderate intensity) have
a beneficial effect on the
other cardiovascular risk
factors such as
RESPIRATORY
Balance between
perfusion and
ventilation is altered
during recumbency .

Upright to supine:
2% vital capacity,
7% total lung
capacity
19% residual vol
30% functional
residual capacity
RESPIRATORY
Clearance of secretions :
difficult in a recumbent
position.

The dependent (posterior)


lobes accumulate more
secretions, whereas the upper
parts (i.e., anterior) become
dry, rendering the ciliary lining
ineffective for clearing
secretions and allowing
secretions to pool in the lower
bronchial tree.
GENITOURINARY

bladder or renal
stones and UTI
MC struvite and
carbonate (15%
-30%)
Bacterial growth &
decrease the
efficacy of
standard
antimicrobial
treatment.
GENITOURINARY
Treatment:
1. Prevention (adequate fluid intake )
2. Scrupulous avoidance of bladder
contamination during instrumentation.
3.Acidification of the urine through the
use of vitamin C, or a urease inhibitor
for stone formers.
4. Surgical removal or the use of
ultrasonic lithotripsy.
5. Appropriate ABx (urine GS/CS)
6. After stroke or spinal cord injury,
removal of the Foley catheter and
initiation of voiding trails should
GASTROINTESTINAL
Passage of food: slower
Gastric acidity: higher in the
supine position
Constipation common
complication
1. Immobility causes increased
adrenergic activity, which
inhibits peristalsis and causes
sphincter contraction .
2. The use of a bedpan for fecal
elimination places the patient
in a nonphysiological position,
and the desire to defecate is
reduced by social
GASTROINTESTINAL

Prevention:
1.Fiber-rich diet
2.Stool softeners
and bulk-
forming agent
3.Use of narcotic
agents should
be limited
NERVOUS SYSTEM
Restlessness, anxiety, decreased pain
tolerance, irritability, hostility, insomnia,
and depression may occur during 2 weeks
of recumbency and social isolation.
Judgment, problem solving and learning
ability, psychomotor skills, and memory all
may be impaired.

Treatment:
1. Group therapy sessions,
2. Attention to socialization,
encouragement of family interaction
and avocational pursuits during
Keep Moving