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IMMOBILIZATION

IMMOBILIZATION. SUSANTI DHARMMIKA, dr. SpKFR SISTEM DERMATOMUSKULOSKELETAL FAKULTAS KEDOKTERAN UNISBA 2012. IMMOBILIZATION. IS THE PHYSICAL RESTRICTION OF MOVEMENT INVOLVING A BODY SEGMENT OR THE ENTIRE BODY. DECONDITIONING.

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IMMOBILIZATION

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  1. IMMOBILIZATION SUSANTI DHARMMIKA, dr. SpKFR SISTEM DERMATOMUSKULOSKELETAL FAKULTAS KEDOKTERAN UNISBA 2012

  2. IMMOBILIZATION IS THE PHYSICAL RESTRICTION OF MOVEMENT INVOLVING A BODY SEGMENT OR THE ENTIRE BODY

  3. 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

  4. THE ADVERSE CLINICAL MANISFESTATIONS OF PROLONGED IMMOBILZATION

  5. I. MUSCULOSKELETAL CHANGES

  6. 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: • PAIN (E.G. TRAUMA, INFLAMMATION, INFECTION, JOINT DEGENERATION, ISCHEMIA, AND HEMORRHAGE) • MUSCLE IMBALANCE (E.G. PARALYSIS AND SPASTICITY) • CAPSULAR OR PERIARTICULAR TISSUE FOBROSIS • PRIMARY MUSCLE DAMAGE (E.G. POLYMYOSITIS, MUSCULAR DYSTROPHY) • MECHANICAL FACTORS (E.G. IMPROPER BED POSITIONING, CASTING/ SPLINTING IN FORESHORTENED POSITION)

  7. 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

  8. CONTRACTURE… • PREVENTION: • - PROPER POSITIONING • (USING PILLOWS, TROCHANTER ROLLS, HAND ROLLS, RESTING SPLINTS) • - ACTIVE/PASSIVE ROM EXERCISE • - EARLY MOBILIZATION AND AMBULATION

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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)

  14. II. CARDIOVASCULAR CHANGES

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. CHANGED IN FLUID BALANCE… • TREATMENT: • ISOTONIC EXERCISE IS ALMOST TWICE AS EFFECTIVE AS ISOMETRIC • EXERCISE IN PREVENTING PLASMA VOLUME REDUCTION

  21. 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)

  22. III. RESPIRATORY CHANGES

  23. 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)

  24. 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

  25. RESPIRATORY CHANGES… • IN THE SUPINE POSITION: • THE CILIARY MALFUNCTION • WEAKNESS OF THE ABDOMINAL MUSCLES • ↓ • IMPAIRED COUGH

  26. 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

  27. 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

  28. IV. SKIN CHANGES

  29. 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)

  30. V. GASTROINTESTINAL CHANGES

  31. 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

  32. VI. GENITOURINARY CHANGES

  33. 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

  34. 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

  35. VII. METABOLIC & NUTRITIONAL CHANGES

  36. 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

  37. VIII. ENDOCRINE CHANGES

  38. 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

  39. IX. NEUROLOGICAL, EMOTIONAL, AND INTELLECTUAL CHANGES

  40. 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

  41. 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

  42. REFFERENCE • PRACTICAL MANUAL OF PHYSICAL MEDICINE AND REHABILITATION: DIAGNOSTICS, THERAPEUTICS AND BASIC PROBLEMS, JACKSON TAN, MOSBY, 1998

  43. THANKYOU

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