At the end of this module, you will be able to;

5.1. Describe the importance of initiating physical activity and exercise in stroke recovery

5.2. Principles of post-stroke exercises

5.3. Type of exercises we should promote and its frequency

5.4. Motivators and barriers to continue exercises

5.1. The importance of initiating physical activities and exercise as early as possible

In Module 4, we saw the brain’s recovery attempts after a stroke. We can help the brain in its rewiring process by initiating physical activities as early as possible. Physical activities bring a multitude of benefits not only moving arms and legs. The main advantages of early physical activities can be appreciated by reading this post: Detrimental effects of prolonged bed rest.

The main disadvantages of prolonged bed rest are as follows (source: The statement from the American Heart Association and the American Stroke Association).

• Losing muscle strength quickly
• Increased sodium and potassium loss through increased amounts of urine
• Decreasing immunity
• Losing heart muscle strength
• Increased risk of difficulty in moving limbs
• The difficulty of sitting and standing

Moreover, we cannot ignore that the physical activity also boosts self-confidence and psycho-social wellbeing.

The difference between the physical activities and exercise

We need to acknowledge the difference between physical activity and exercise at the very beginning. The term, physical activity, refers to any movement of the body and limbs that result in energy expenditure. The word, exercise, refers to a subset of physical activities that are planned, structured, and repetitive and are done with the aim of improving physical fitness (The American Heart and Stroke Association).

5.2. Principles of post-stroke physical activities and exercise

Research shows that we need to adhere the following principles for the maximum results.

• Early mobility
• Consistency of physical activities and exercise should be consistent and repetitive
• Repetitiveness

Early mobility: How early?

The American Heart Association and the American Stroke Association says the affected individual if they do not have medical or physical contraindications as certified by the physician, needs to sit on the bed within 24 hours after a stroke. This is because early mobility improves brain changes. You can read more about this topic here: “Early mobility improves recovery after stroke”.

Consistency and repetitiveness

• According to the American Heart Association and the American Stroke Association, physical activities is only effective if it is done consistently. This has been recognized as a formidable challenge for stroke survivors and stroke carers.
• Repetitive practice is the key: The US post-stroke rehab fact sheet equates this to a type of practice when one should do when playing the piano or pitching a baseball.
• The intensity of the exercises;

Exercise after stroke: http://hwcdn.libsyn.com/p/b/a/3/ba31d6360e144222/Zzz2.pdf?c_id=72611270&cs_id=72611270&expiration=1600313974&hwt=7ddf8d0963b4ee002d822d6d207dbf2f

exercises recommendations rational; https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000022

5.3. Types of physical activities and exercise we should promote

Pre-requisites

Before embarking on an exercise program, a qualified health professional should screen and prescribe a suitable exercising program. This would be a challenge.

The Heart and Stroke Foundation outlines four types of exercises for stroke recovery. Those are as follows;

• Endurance (aerobic)
• Strength
• Balance
• Stretching

Exercises after stroke: An excellent but simple resource guide from the Stroke Foundation, New Zealand

It is rare to find online materials without copyright. However, I found an excellent open-access resource published by Margot Andrew, Margaret Hoessly, and Kate Hedges. It is under the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Physical activities and exercise, and wellness videos for people with mobility challenges

A team of physiotherapists and occupational therapists from the University Health Network have published a list of exercises and wellness videos for people with mobility challenges. It includes an excellent collection of YouTube video clips. Here are some relevant ones. One should keep in mind that these resources do not replace the exercise regimen prescribed by your healthcare professional.

Three-part series of the “it’s Your Choice” project:

• Part I: An intro and disclaimer: https://www.youtube.com/watch?v=kpTHDR5k-cY
• Part II: The warm-up: https://www.youtube.com/watch?v=XPmUqiTBEpU
• Part III: Strength, balance, and aerobic exercises: https://www.youtube.com/watch?v=Qh94WI9Ecoc

Video exercises for those living with weaker one side

• Easy leg exercises: https://www.youtube.com/watch?v=-rwby0zA6Vs
• Hand exercises: https://www.youtube.com/watch?v=i0JYsLyJEnE
• Core exercises: https://www.youtube.com/watch?v=dGBqTLtdVuA
• Arm exercises: https://www.youtube.com/watch?v=kuuGlz_ddOM

How frequently one should do the rehab exercises?

How frequently one should engage in rehab exercises to gain a desirable effect? Janice Eng, a UBC physiotherapist has responded to this question. More specifically, the question was this:

How many upper limb reps per day can positively change the brain after stroke?

Quoting findings from other researchers (Nudo et al. 1996; Murata et al. 2007), she said it would be between 600- 1000 successful reach and grasp repetitions per day. The successful means if there are droppings it would not count. These findings were based on the research work of monkey brains after a stroke lesion to the motor cortex. The research has shown the hand representation in the undamaged primary motor cortex has regained. That is pretty impressive. The improvements have even progressed to precision finger grips.

Does this happen even in the best rehab centers? you can guess. It is not. Not even close to it. Catherine Lang and her team found it was about 32 per session (day). Later research that analyzed metadata showed the more the better.

5.4.Motivators and barriers to physical activities and exercise

Once started, the biggest barrier to better results is to maintain consistency. The barriers can be grouped into patient-related and environmental barriers, and lack of resources. The American Heart and Stroke associations detail out these barriers.

Barriers

Motivators

• Providing psychological and social support
• Accessibility to trained personnel
• Establishing group classes
• Desire to achieve life goals

A stroke may either weaken vision or completely shut it off. And, those who are aged may have lower vision due to age. This is another barrier to improve communication of the stroke survivors as well as those already visually impaired.

Because of this, they are unable to socialize with their friends, read news, learn or engage in compatible jobs.

What if they have a method that it reads the computer screen? These are “screen readers”.

These are available, but expensive.

How about if you have it free?

Yes, while I was searching for that kind of facility, I found one: nvaccess.

A free screen reader: nv (non-visual) desktop access

According to their website, in 2006, Michael Curran began to develop a screen reader that could be run on Windows. Later, James Teh joined him. These two blind men founded this non-profit organization: NVDA (non-visual desktop access. Now, volunteers from all over the world have translated this into more than 55 languages and won multiple awards.

This is open-source software. What does that mean? it means that anyone can download the code free and those with knowledge can improve it further for use.

Introduction

In Module 4, we discussed the brain’s recovery attempts after a stroke. However hard the brain attempts reverting to its pre-stroke functional level, it cannot regain everything lost; some of them will, however, reappear with time – mostly within the first six months post-stroke. Regaining the lost functions with time follows a non-linear trajectory as we learned in module 4. The rest will persist – as deficits – sometimes permanently.

And, new health problems such as pain and depression will also arise.

This module will look at the pre-stroke functions that may lose – called deficits hereafter – and the new health problems that are likely to develop. At the end of this module, you will be able to describe what those are and explain its relationship with the stroke attack.

The deficits directly related to the damaged brain locations.

5.1. Deficits that occur due to the Frontal lobe damage

When the ischemic stroke attacks occur due to a block in the middle cerebral artery, one of the commonest sites, cells of the motor homunculus dies. As a result, it will not be able to do its job; sending commands to muscles that move body parts starting from the eyelid, facial and mouth muscles, arm, and leg. As we now know that mostly, but not always, a stroke strikes one side of the brain, the deficit appears on the opposite side of the body. Depending on the extent of the damage, deficits can range from mild weakness to complete paralysis of one side of the body. Consequently, those affected will face the following difficulties.

• Movement difficulties
• Swallowing difficulties
• Speech difficulties

Movement difficulties

Movement problems are one of the most visible deficits that occur due to a stroke. The deficit could range from mild weakness to complete paralysis of one side of the body – from one side of the face, mouth, arm, or leg. For example, if the weakness is on the right side, the damage is on the left precentral gyrus in the brain and vice versa.

If the parietal lobe involves, the movement difficulties that may arise from the Frontal lobe damage, it can result in difficulties in maintaining posture and balance also. In a combination with these difficulties, walking becomes the greatest challenge.

Swallowing difficulties

This is also a common as well as serious problem since the affected individual can get choked with food.

Speech difficulties

The speech difficulties that occur due to the Frontal lobe damage will be discussed under 5.4. – language deficits.

5.2. Deficits that occur due to the Parietal lobe damage

Sensory disturbances

When the Parietal lobe’s post-central gyrus is affected, the affected person cannot feel touch, pain, as well as temperature. Following are the difficulties they face.

• Inability to feel touch, pain, and temperature
• inability to sense how the body is positioned
• Inability to recognize objects that they are holding
• Pain, numbness, and altered – tingling or tickling – sensation on the affected side, arm, or leg
• neuropathic pain – due to damage to the thalamus
• The heaviness of the affected arm or leg

5.3. Deficits that occur due to the Temporal lobe damage

The prominent deficit due to the Temporal lobe damage is to verbalizing thoughts through either speaking or writing. This occurs due to the damage in the Wernicke’s area of the lobe.

5.4. Language deficits (impairments)

Language deficits range from mild impairment to complete loss. The nature of deficit/s depends on the damaged area/s. The common language deficits are Broca’s aphasia, Wernicke’s aphasia, etc.

Broca’s aphasia

As the name itself implies, this language deficit results from the death of neurons in Broca’s area that situates on the Frontal lobe. It impairs expression either by speaking or writing; hence the name, “expressive aphasia”. However, if the Wernicke’s area is not affected, they can understand concepts but are unable to formulate grammatically correct sentences according to the National Institute of Neurological Disorders and Stroke.

Wernicke’s aphasia

As its name implies, this language deficit results from the death of neurons in the Wernicke’s area that situates in the Temporal lobe. In this type, those affected cannot understand the concepts, which others express either by writing or talking. Their communication is incoherent. The National Institute of Neurological Disorders and Stroke says that their expressions, although grammatically correct, have no meaning.

Speech problems

• Loss of expressing thoughts and feelings: they lose the ability to translate their thoughts and feelings into speech or writing language
• Difficulty in understanding spoken or written language and incoherent speech; they can make grammatically correct sentences but no meaning.
• Some can have the above difficulties together.

5.4. Mental, psychological, and cognitive deficits

After a stroke, a range of mental, psychological, and cognitive deficits may persist after initial recovery. It includes the following elements;

Difficulties in thinking and memory

• Deficits in short-term memory
• Difficulty in following instructions (apraxia)
• Loss of ability to respond to objects or sensory stimuli on the affected side

Emotional problems

• Fear, anxiety, sadness, anger, frustration
• Personality changes

5.5. Loss of bladder and bowel control

Another distressing problem is the loss of bladder control. However, the good news is that it can successfully be managed with proper knowledge and an easily acquired skill set. This will be discussed in a later module.

5.6. Pain

Researchers report pain as one of the commonest but under-recognized post-stroke problems. Those who live with a stroke report pain referring to any part of the body from head to toe.

Pain’s origin seems to be manifold; it can occur due to a stroke damage to the Parietal lobe, brain structures deep inside the brain – thalamus and pons, and due to “frozen” joints.

Pain as a result of “frozen” joints

The National Institute of Neurological Disorders and Stroke describes this pain occurs due to the non-use of joints for some time. This non-use leads to freezing tendons, ligaments, and muscles that assist in moving that particular joint.

Neuropathic pain

According to the experts in this field, those who experience this type of pain describe it as using these words: lacerating, aching, freezing, burning, and squeezing. They also may complain of pain even to just touching.

Although less common, this type of pain occurs as a result of the damage to structures deep inside the brain such as the thalamus and pons. Therefore, it is also called “thalamic pain syndrome”. Our sensory information from body parts to the brain transmit via the thalamus.

Spasticity-related pain

After a stroke, some develop spasticity in which the affected exhibit uncontrolled exaggerated movements. Experts say that two-third of them complain of pain and the majority of those who do not develop spasticity do not complain of pain.

Shoulder pain

Research reveals that shoulder pain is a common problem after stroke and may occur due to more than one reason including muscle weakness around the shoulder joint; however, pain most often appears with the development of spasticity. Prevention is the key. Experts advocate beginning physiotherapy “as soon as the patient is medically stable”.

This is only an introduction.

Please help us to fill the gaps in this post; add yours in the comments section.

Module 1 for stroke carers introduces what the word – stroke – refers to, what happens in a stroke event, types of stroke, and who are at risk.

Learning objectives:

At the end of this module, you will be able to answer the following questions if someone asks.

1.1. What is a stroke?

1.2. What happens in a stroke?

1.3. How does a stroke occur?: Types of stroke

1.4. What is a “mini-stroke”?

1.5. Who are at risk?

1.1. What is a stroke?

The term, “stroke” is a broad one; a more recent definition from the American Heart Association/ Stroke Association advocates use this term to cover cell death that occurs in the brain, spinal cord, and retina attributable to the interruption to the blood supply. According to this definition, the presence of symptoms or signs of more than 24 hours is not essential to use the term. And, on the other hand, the presence of reversible stroke-like symptoms more than 24 hours due to edema without interruption to the blood supply does not qualify for a stroke.

However, “Stroke” is a disease of the brain, not of the heart. Many believe, incorrectly, that it is a type of heart disease. Since it occurs suddenly, some call it a “brain attack”. Health professionals name the condition as “cerebrovascular disease”.

Stroke is the second leading cause of death and the third leading cause of disability in the world. As much as 70 percent of stroke events are thought to occur in low-middle income countries. On average, a stroke occurs 15 years earlier among people living in those countries. During the past four decades, stroke incidence among low-middle income countries has doubled while it has halved in high-income countries¹.

A stroke occurs as a result of brain cell death due to an interruption of blood supply to a part/s of the brain. We will discuss this in module 2. 

Stroke warning signs are easy to detect. The common ones are drooping one eyelid, inability or difficulty of raising one or both arms, and slurred speech; there are more. We will discuss these in module 3.

However, a stroke can also occur without any observable changes.

Stroke results in a range of disabilities of the affected person and at least half of these disabilities persist permanently for life, if not treated early. It exerts an enormous burden not only on the person affected but the whole family, and the society. We will discuss various kinds of disabilities in detail and what we can do to rehabilitate those in Part II of this course. 

1.2. What happens in a stroke?

A stroke cuts off blood supply to a part of the brain. (You can learn more about the brain by joining the “journeys to the brain” series). Within minutes, the neuron cells in the affected area begin to die at a rate of 32,000 per each passing second. In terms of minutes, the number amounts to about two million neuron cells per minute².

The only way to save the rest of the cells threatened with death is to restore the interrupted blood supply as soon as possible. This can only be done in a hospital with adequate facilities.

1.3. Types of stroke

A stroke usually occurs either due to a block in a supply route or a burst of the supply route’s wall.

1.3.1. Ischemic stroke

Ischemic stroke occurs due to a block by a blood clot inside the supply route. The extent of the damage depends on where the clot clogs the blood supply system inside the brain. If a clot is a bigger one, it clogs a larger artery and blocks the blood supply to a larger area of the brain. If the clot is a smaller one, it may travel as far higher up as possible until it clogs a smaller branch of a smaller artery.

How a blood clot forms

A roughened wall of an artery triggers blood clot formation. The roughening begins with fat deposition at one place of the wall. Then, it hardens with calcium and cholesterol deposits. The process continues slowly but surely forming a plaque there. This thickening narrows the lumen and roughens the surface. Plaque build-up can occur anywhere; however, strokes are commonly associated with plaque build-up in the neck vessels – carotid arteries as shown in Figure 1. 

The following video clip from the British Heart Foundation explains simply how arterial thickening occurs and the factors that facilitate the process.

A clot can even originate inside the heart particularly among those with heart problems and travel into the brain.

In the US, about 80 percent of all strokes are in this nature according to the National Institute of Neurological Disorders and Stroke³. In low-middle income countries, this percentage is about 66 percent¹.

1.3.2. Hemorrhagic stroke

When a stroke occurs due to a burst of the vessel wall, we call it a “hemorrhagic stroke” (Figure 2). As a result, blood seeps out of the vessel, and oxygen and food supply to neurons interrupt. The bleeding exerts pressure on the area causing more damage.

However, there is another 5-10 percent of people who develop a stroke due to an unknown reason⁴.

1.4. What is a “mini-stroke” TIA (Transient Ischemic Attack)?

In this situation, the stroke signs and symptoms last less than 24 hours; most often, less than an hour. Hence, it is also called “Transient Ischemic Attack” (TIA). What happens here is that the clot that blocks the supply route disappears after a brief time.

However, it is a dire warning; it will certainly return as a full-blown stroke, often within the first week after the TIA, if not treated⁵.

Therefore, a mini-stroke should also be considered as a medical emergency.

In the following video clip, Professor Peter Rothwell explains why we should a mini-stroke also as a medical emergency.

However, if the effects last more than 24 hours, it is considered a stroke. Ideally, anyone who experience a mini-stroke should not drive or operate a machinery for a month. In some countries it is the law.

1.5. Who are at high-risk?

Some are at higher risk for stroke. We can reduce the risk by modifying some risk factors while others are non-modifiable. The source of the following list is the National Institute of Neurological Disorders and Stroke³.

Non-modifiable risk factors

• Age: The risk doubles every passing decade from 55 to 85. However, it can also occur in childhood⁶.
• Sex: Men are at higher risk in young and middle age. In older ages, however, the risk is equal.
• Ethnicity: some ethnic groups are at higher risk; for example, African-Americans and Hispanics experience stroke events more than Caucasians.
• Family history

Modifiable risk factors

There are some risk factors that we can reduce the risk. Those are as follows;

• High Blood Pressure: This is one of the most potent risk factors we can easily modify.
• Diabetes
• High cholesterol
• Cigarette smoking: This raises the ischemic stroke risk by two-fold and hemorrhagic stroke risk by four-fold.
• Physical inactivity and obesity

References

1. Johnson, W., Onuma, O., Owolabi, M. & Sachdev, S. Stroke (2016): a global response is needed. Bulletin of the World Health Organization 94, 634–634A, https://doi.org/10.2471/BLT.16.181636.
2. Jeffrey L. Saver (2006): “Time is Brain”: Quantified; Stroke Journal. 2006;37(1): 263-266.
3. National Institute of Neurological Disorders and Stroke (NINDS): Basic facts: preventing stroke; NIH; 2020. Accessed on September 16, 2020.
4. Donkor E.S. (2018): Stroke in the 21st Century; Stroke Res Treat.: published online.
5. British Medical Best Practice; accessed on September 20, 2020.
6. Vrudhula A, Zhao J, Liu RToo Young to Have a Stroke?—a Global Health CrisisStroke and Vascular Neurology 2019;4:doi: 10.1136/svn-2019-00029.

Have you thought about this? About the detrimental effects of prolonged bed rest? This post is about that.

A little bit of history about bed rest research

Researchers say that bed rest was considered as a treatment strategy in the 19th century. This view was beginning to change at the turning to the 20th century.

In 1947, Dr. R.A.J. Asher wrote an article to the British Medical Journal about “Dangers of going to bed”. His article was meant for physicians: ” we should think twice before ordering our patients to bed and realize that beneath the comfort of blanket there lurks a host of formidable dangers”.

Since then, more evidence has been accumulating. In 1999, a group of researchers reviewed 39-bed rest trials published in The Lancet. The conclusion: bed rest did not improve the outcome significantly; rather they reported nine situations with worsening outcomes.

However, the campaign is ongoing. For example, if you visit the website of the American Academy of Nursing, you can read the “Don’t Statement”:

Don’t Statement

In fact, The problem has received attention from several countries. It has led to a campaign named, “End PJ paralysis”.

End PJ (Pyjama) paralysis

End PJ paralysis is a global movement: https://endpjparalysis.org/

The following is a poster that is aimed at addressing this problem. We can find a series of similar educational tools to reduce the detrimental effects of prolonged bed rest.

Let us dive into our bodies to find out what happens when we take prolonged bed rest.

What happens inside our body during a prolonged bed rest?

All our body mechanisms are set to function best when standing upright – and, to sleep only about eight hours. If we prolong our bed rest time for more than 24 hours, the body begins to re-set all the systems to face the new challenges. Certainly, it will. And, it will result in a series of detrimental effects of prolonged bed rest.

Let us jump into this journey of exploring the “detrimental effects of prolonged bed rest”.

Prolonged bed rest’s detrimental effects on the heart and our blood circulation

In an upright position, most of our blood circulates below the heart level. Veins bring up the returning blood with all waste products produced by cells including carbon dioxide. The valves in veins and muscles support veins to do the job.

In contrast, in a lying down position, blood slowly moves to the abdomen, lower back, and lungs from the legs. The new situation exerts pressure on the heart. To relieve the pressure, the body initiates mechanisms to remove a certain amount of water from our blood through kidneys. The aim is to reduce the burden – preload – on heart output. Not only that, but the prolonged bed rest also reduces red blood cell mass too to reduce our blood’s oxygen-carrying capacity.

If the bed rest continues as long as 6 weeks, research has shown that the heart muscles can get atrophied. If the bed rest continues for 20 days, the heart output can reduce by 25 percent according to Kristin J. Stumpfle and Daniel G. Drury.

These adjustments cause problems; one is to increase the resting heart rate; another is the postural hypotension in which we feel dizzy when we attempt to either sit on the bed or stand. It can occur even after 24 hours of strict bed rest.

Another interesting adjustment occurs in our venous blood collection system. It begins to pool blood at our deep veins. As a result, the risk of developing blood clots increases leading to deep vein thrombosis. And, the formed blood clots can dislodge, travel all the way up to lungs, and stuck there. This can result in pulmonary embolism, always a fatal situation.

Prolonged bed rest’s detrimental effects on our muscles

Very much similar to the heart and blood circulation mechanism, our muscles also work best when we stand upright against gravity. In a prolonged bed rest, with time, they begin to shorten and then remove some of its muscle fibers. It invariably loses muscle mass and subsequently its strength. Research shows that we can lose muscle strength by 6 – 40 percent within 4 – 6 weeks of complete bed rest. More recently, a group of researchers from Johns Hopkins found that each passing day in the ICU lowers muscle strength by 3- 11 percent a day over the ensuing months and may even extend to years.

As expected the most affected muscles are the ones that work against gravity”: The “anti-gravity” muscles. Those are the muscles that help to raise the foot at the ankle joint (plantar flexors), those in the thighs and arms (quadriceps and hamstrings), those in the buttocks, calves, lower back, abdomen, and the neck. In some muscles such as those in calves, thighs, and feet, we can readily see the wasting; however, in other muscles, we cannot readily see. Research shows that the process of wasting begins as early as on the fifth day and reaches its peak in the second week of bed rest.

Effects on joints

Muscles are attached to joints through tendons and ligaments. And, joints are covered by some cartilage. Because of non-use, fibers in tendons and ligaments become shortened. Surrounding connecting tissues turn rigid due to the addition of collagen. The result? the development of almost permanent contractures that freeze joint movements. Research shows that the appearance of collagen fiber can be observed as early as on the sixth day of complete bed rest.

These changes occur in all joints. But, it is most pronounced in the hip, knee, and ankle joints.

Effects on bones

As in every part of our body, bones also respond negatively to bed rest. It begins to weaken with time; its building block – calcium – starts appearing in our urine within a few days of bed rest. It also increases the risk of forming kidney stones and urine infections. To make matters worse, calcium absorption in the intestine also decreases.

Research reveals that the bones in our legs and lower back are the worst affected.

Effects on the kidneys and bladder

Due to non-use of bones, its building block, calcium, beings to drain into urine. During the process, the chances of forming stones inside kidneys and the bladder rises. Furthermore, due to urine rentioninside the bladder the chances of urine infection als rises.

Effects on the skin

The effects of prolonged bed rest on the skin particularly the skin over bony prominence are two-fold; shear and friction damage the superficial parts of the skin while the pressure interrupts the deep tissue functions. It includes underlying muscles too.

Prolonged bed rest due to the pressure it exerts on the skin over bony prominences occludes the smallest blood carriers – capillaries – blocking the blood supply to the skin and its surrounding tissues. This sudden attack deprives living cells of oxygen and nutrient supply. The situation will lead to cell death.

Experts say that the critical duration of pressure that requires developing a pressure injury can vary from 30 minutes to 4 hours. This variation depends on underlying diseases that affect small blood supply vessels including the smallest – capillaries.

Shearing, in addition to the direct external pressure, contributes to skin damage. Shearing refers to lateral displacement of the skin due to traction over the surface. Moreover, moisture too worsens the situation by softening the skin layers.

Not only the external pressure, but shearing and friction on the skin damage the skin also. It deprives the skin cells and underlying tissues of its oxygen and nutrition for their survival, It can result in devastating bedsore. Once the process sets in, it can become a slippery slope. The most common 5 sites that pressure ulcers occur are the heel, ankle, bony prominences over the sides of the hip, sacral area, and skin over the sitting bones in the buttocks.

In fact, the detrimental effects of prolonged bed rest manifest all over the body.