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”:
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.
Global stroke care begs urgent attention, particularly in low-middle income countries. Every year, about 15 million face a stroke event in the world. Of them, about 5 million die while another 5 million become disable permanently. Almost 70 percent of stroke events occur in low-middle income countries. Alarmingly, while the new cases per 100,000 declined by half in high-income countries during the past decade, it doubled in low-middle income countries (Johnson et al., 2016).
More importantly, stroke occurs mostly at peak of one’s life.
Although vast improvements have occurred in stroke care in the world during the past decade,, these advances have not reached to low-middle income countries.
However, according to Walter Johnson and his colleagues, significant differences between high-income and low-middle income countries exist; that more stroke due to bleeding in low-middle income countries than high-income countries (34 percent versus 9 percent); that more survivors in low-middle income countries die within 3 years than high-income countries (84 percent versus 16 percent).
Surely the quality of care should also be remarkably different. For example, the absence of CT scan facility to differentiate strokes due to bleeding from a blood clot affect the intervention strategy.
A well coordinated global action is necessary as highlighted by the WHO experts.
How early someone who experienced a stroke event needs to sit on the bed if the individual has no either medical reasons not do so or severe disability?
It needs to be done as early as possible, even within 24 hours after a stroke for better recovery, according to the American Heart Association and the American Stroke Association.
However, sitting on the bed has to be followed up with intermittent standing and later with well-coordinated therapeutic exercise sessions.
This recommendation appears in their detailed statement published in the Stroke journal in 2014. It is because research shows early mobility improves chances of earlier walking ability and functional recovery.
The above findings came from a powerful randomized controlled study.
About the study
A research team compared assigned 71 stroke patients to two groups. Their mean age was 74.7. Their blood pressure, heart rate, oxygen saturation, and temperature were monitored. Among those who were safer to sit, one group received the usual standard care. and, the other group were mobilised early with a follow-up of intensive moblisation at regular inervals. Then their performance was compared on one primary outcome: the number of days required to walk 50 meters unassisted. They found that the intervention group returned to unassisted walking significantly faster than the standard intervention group (p=0.032; 3.5 median days versus 7 median days). Moreover, the other functional outcomes as measured by the Barthel index was better at 3 months in the intervention group.
The above study appeared in the Stroke journal in 2010.
However, there is a catch here. Starting physical activities early alone is not enough; it needs to be done consistently according to the above statement. This is the most difficult part.
Exercise and physical activities become effective if those are done consistently.Stroke Journal, 2014
Challenges in implementing these findings
Research reveals that although many who experience a stroke event can do exercises, they choose not to do. As a result, with time, not only their ability to walk but the ability to carry out daily activities also declines. This is because, with time, their heart-lung fitness too deteriorates.
Many factors contribute to this unfortunate situation; lack of knowledge, system inefficiency, and inadequate emphasis by healthcare professionals are the main reasons.
How to improve early mobility after a stroke
The experts recommend starting a planned exercise program as soon as the person is medically stable. The following are the specific recommendations from the American Health and Stroke associations;
The goal here is to regain or exceed pre-stroke level activity level as soon as and as much as possible. This should be started at the hospital and continued at home once discharged. The continuity is the key here for the success.
The critical principles here are;
- Maintaining the progressive task difficulty
- Functional practice
- Inclusion of aerobic (heart-lung) and strengthening exercises
The modes of adhering to above principles are;
- Treadmill exercises: Research has shown that aerobic treadmill exercise as early as within 6 days up to 6 months after stroke improves heart-lung fitness and walking distance.
- Cycling ergo-meter
- Recumbent stepper
- Chest-deep water
- Functional exercises
It is critical for the patient to develop the skills and confidence for eventual self-management of physical activity and an exercise training program.
It is critical for the patient to develop the skills and confidence for self-management of physical activity and an exercise training program.Stroke Journal, 2014: The statement from the American Heart and Stroke Associations
Experts recommend everyone to undergo graded exercise testing with ECG monitoring prior to the start of a graded exercise program. However, if the physician decides that screening for fitness is not possible due to lack of facilities, they further suggest not delaying the exercising but to tailor a program in order to suit the patient’s capability.
Due to lack of accessibility to graded exercise testing with ECG monitoring facility, experts recommend use of near-best simple test – “six minutes walk test”.
It is so critical to start a movement as early as possible; that is the key message here. For those who cannot do the exercise ECG testing, that should not be an excuse for exercise program; the recommendation is to initiate a lower-intensity one.
Whenever the prescribed exercise ECG testing is not done, a lower-intensity exercise program should be started.Stroke journal, 2014; the statement from the American Heart and Stroke Associations
The American Heart Association and the American Medical Association recommend that we should self-monitor blood pressure. They say the activity has a “high potential to improve the diagnosis and management of high blood pressure”.
This recommendation appeared in the Journal of Circulation published on June 22, 2020.
Why do they say that?
It is simply because that the place where we take the reading matters.
Yes, the place matters; when we measure blood pressure at a healthcare center, the reading is likely to be higher than the actual. This is called “white-coat syndrome”.
This is so significant; as a result, the American Heart Association and the American Medical Association issued a joint statement in this regard. This post is about that.
This statement says that “out-of-office high blood pressure is associated with a higher risk for heart problems independent of office-measured blood pressure readings”.
It further says this: “Self-measured BP monitoring has a high potential for improving the diagnosis and management of hypertension in the United States
How to measure blood pressure accurately at home
You can follow this free online course to learn how to measure your blood pressure accurately. This is an initiative of the Pan American Health Organization joined by the World Hypertension League, the Lancet Commission on Hypertension Group and Hypertension Canada, and Resolve to Save Lives, academically developed by a group of highly qualified experts recognized worldwide.
According to Dr. Norm Campbell, the Emeritus Professor at the University of Calgary, It is recommended to re-train all healthcare professionals on how to measure blood pressure every six months. This is based on the evidence that up to 50 percent of readings are potentially misclassified as either having high blood pressure or normal blood pressure.
Five steps that we should follow while measuring blood pressure
- Select a validated automated or semi-automated device
- Select the right cuff-size for the person being measured; it comes in three sizes: small, medium, and large.
- Prepare the person being measured; e.g. pain, anxiety, and stress elevate the normal blood pressure temporarily; And smoking, chewing tobacco, tea, and coffee also elevate blood pressure and it will come back to normal after 30 minutes of stopping those.
- Measure the blood pressure: Should sit comfortably 5 minutes immediately before the measurement. Both – who measures and who being measured should not be talking. The environment should not be too cold or too hot for the person being measured. Should be seated with back support and the arm should be bare. The cuff should be at the level of the heart. The legs should not be crossed. The feet should be flat on the floor. The cuff should not be too tight or too loose. A couple of fingers should be able to insert between the cuff and the arm. Measure the blood pressure: If this is the first time, repeat the measurement in the other arm. If one arm’s reading is higher, wait one minute, repeat it again at the same arm. And wait another 1 minute, get the third reading. the higher reading should be used as the correct one. If the first reading is higher than the next second and third readings, the first reading should be discarded and the other two readings should be averaged.
- Record the readings: The final two readings, arm, cuff size, heart rate, age, gender, date, and the use of any anti-high blood pressure medications
Workplace wellness programs not only detect those at risk of getting a stroke and coronary heart disease but prevent occurrence also. Overall, these interventions promote general well-being.
As a general measure, the strategy is one of the cost-effective interventions of health promotion.
Employees spend most of their time in the workplace throughout the most productive period of their lives. Carrying out wellness programs yield many dividends not only to themselves but employers and society at large also. The program managers too can save their valuable time, money, and limited resources because the workplaces gather apparently healthier individuals into one place.
Therefore, well-known advocacy organizations promote employee wellness programs. The American Heart Association is one of them.
Return – on-investment is very high
The benefits of workplace wellness programs do not limit to stroke or coronary heart disease prevention. Research shows that the return-on-investment on workplace wellness programs is very high. Just consider one facet of workplace wellness programs – weight reduction.
A group of researchers, quoting other researches wrote in their article that workplace weight management programs aimed at achieving 5 percent weight reduction would reduce annual medical cost and absenteeism costs by 90 $ per overweight employee.
Components of a workplace wellness program
A workplace wellness program usually employs a multi-modal strategy. These are as follows:
1. Screening for risk factors, interventions, and follow-up
As highlighted in the Geoffrey Rose seminal paper on “sick individuals and sick populations”, screening for risk factors bring many advantages;
- The screening easily attracts both employees, employers, as we ll as health professionals.
- The follow-up actions and results are quick because those who are at risk can be sent for immediate intervention.
- The motivation levels among all stakeholders are high and hence lifestyle modifications for them could potentially be successful.
Screening for weight, aerobic fitness levels, tobacco use, dietary habits, blood pressure, blood sugar, heart health, and lipid profile is the most common screening activities. These tests are done at the worksite. The findings are used to assess current and future risk levels for non-communicable diseases, particularly for coronary heart disease, diabetes, and cancer.
Health screening is always coupled with relevant referrals for further assessments, follow-ups, and medical interventions.
An example framework for a workplace wellness program
Following is a conceptual framework that I created to implement a workplace wellness program in Sri Lanka in 2015. This program is continuing to date and we, as a group, presented some of its findings as a poster at the 2016 Sri Lanka Medical Association Annual sessions.
Behavior change interventions
These interventions are aimed at everyone regardless of their individual risk status. It may consist of include interactive health education sessions, individual or group counseling sessions, promotive educational materials – electronic or otherwise, and creating supportive environments to sustain behavior changes. Supportive environments can be created by ways of providing incentives – financial or otherwise, formulating policies such as healthy food policy, etc.
Do health promotion at workplace work?
The policy statement from the American Heart Association
In June 2020, The Lancet Neurology published a very important Declaration proclaimed by the World Stroke Organization (WSO) on stroke and dementia.
The WSO predicts that by 2050, about 200 million stroke survivors will be in the world. And because of the close link between stroke and dementia, we could expect about 106 million living with dementia; and, thereafter, each year, we may encounter over 30 million new stroke patients.
The most notable statement, to me, in their declaration, is this:
Rather than finding why they say this, I focus my attention on what they propose to do.
Let us find out what they have to say about this.
First of all, it is worthwhile to note that they recommend a common prevention strategy for both stroke and dementia because both problems share the same risk factors.
And, these risk factors contribute not only to stroke and dementia but other leading non-communicable diseases also.
What are those?
- Elevated blood pressure
- Abnormal blood lipid levels
- Physical inactivity
- Salt and sugar
- Unhealthy diet
As we can see that the above risk factors fall into two broad categories;
- Biological (elevated blood pressure and abnormal lipid levels)
- Behavioral or lifestyle; however, behavioral risk factors in turn contribute to elevated blood pressure and abnormal lipid levels.
Now let us look at what the World Stroke Organization (WSO) suggests doing differently to address those risk factors.
A paradigm shift:
Abandoning graded risk categorization and adoption of a risk continuum scale
The first is that their appeal for a paradigm shift of risk classification; they recommend abandoning mild, moderate, and high-risk categorization for heart and stroke problems; instead re-framing stroke risk along a continuum.
Population-wide prevention strategies
They underscore the need of adopting a population-wide approach to reduce the negative impact of behavioral (lifestyle) risk factors. Quite correctly, they also emphasize the need for integrating into the WHO HEARTS initiative, and the establishments and programs at all levels, global, national, and local.
Individual level interventions
Of course, individual interventions – screening for risk behaviors – also necessary; more specifically, poor diet, physical inactivity, alcohol use, and smoking and biological risk factors – elevated blood pressure and abnormal lipid profiles.
The WSO has introduced a free stroke riskometer app to aid this intervention strategy.
Combining community interventions with medicines and behavioral interventions for people at risk of stroke
They highlight five lifestyle risk factors (smoking, physical activity, diet, alcohol consumption, weight) based on evidence.
The WSO suggests several evidence-based implementation strategies. These are as follows;
- Using community health workers serving in other community health programs: They bring forward a meta-analysis of 16 RCTs as supportive evidence.
- Combining medical (medications for blood pressure and lipid level screening, medication for the needy) interventions with lifestyle modifications
- Integrating stroke and dementia strategies with WHO HEARTS Initiative
- Imposing taxes on unhealthy food, tobacco, and smoking and dedicate the revenue to prevention, screening, and treatment interventions.
The 2015 published Cochrane review (1) found only five studies that evaluated community walking sessions for people living a stroke. And, they concluded that the quality of evidence of these studies was very low. Furthermore, only 266 individuals had been involved in all five studies and two of the programs “mimicked” community programs.
Walking certainly improves walking ability and speed after a stroke event; the activity itself brings a multitude of benefits not only economically but socially also.
I could not find any reviews published after 2015.
- Barclay RE, Stevenson TJ, Poluha W, Ripat J, Nett C, Srikesavan CS. Interventions for improving community ambulation in individuals with stroke. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010200. DOI: 10.1002/14651858.CD010200.pub2.
“This arm’s numbness may last a few minutes and then go away. I will see the doctor tomorrow”.
Does this sentence sound familiar to you?
It seems to be a common conversation starter in the event of a stroke event if it begins at home or in the vicinity of loved ones.
In contrast, if it occurs in the vicinity of your co-workers or some not so close to you, the conversation starter seems to be much different. It may be like this: ” there is something wrong here. You need to see the doctor now”.
Can you believe that?
When a stroke occurs to someone in the vicinity of their loved ones, unknowingly they may delay calling for an ambulance when compared to situations when it occurs in front of strangers or not so close to people such as co-workers.
What a paradox!
In a way, it makes sense.
The unknown bystanders to the incident will certainly call an ambulance right away while the loved ones are still contemplating.
So, it is not enough knowing what F.A.S.T. – the acronym to recognize early stages of a stroke – refers to.
We need to act upon it by dialing for an ambulance.
There is a golden hour. The treatment outcome becomes excellent if someone received the clot-buster drug within the first hour of stroke onset. You can read more about that through this link: https://www.strokecarer.com/best-practices-3-remember-the-golden-hour/.
How do we know this for sure? Or is this just a speculation?
A group of US researchers uncovered this intriguing phenomenon. They mapped how closely-knit the social networks of 175 stroke patients who arrived for hospital emergency care. Using Burt’s social capital concept, they quantified it.
They empirically demonstrated that stroke patients with a very close-knit social network arrived at the hospital later than those with a larger social network. And, closer to the tightness of the network larger the delay occurred.
Another very interesting finding was that this association did not change by sex, education status, the median income of the network or the severity of symptoms.
The researchers have documented some of the conversations that occurred between the stroke patients and the family members before they arrived late to the hospital. Find out whether some of the conversations seem familiar to you.
“No, you just wait. I will just go see my doctor in the morning”.
“There is no anything to be concerned about because it will last few minutes and go away”.
As opposed to the above conversations, when someone with F.A.S.T. symptoms with unknown people or not very closely-knit ones, the conversations may be as follows:
“Something is wrong with you. You need to go to the doctor”.
Few startling statistics
In their introduction to the paper, they highlight the following surprising statistics:
Every year in the US as many as 70 % of stroke patients arrive for emergency care six hours after its onset!
Not only that, 70 % of strokes occur at home.
Do you see how important their research project is?
In the event of a stroke, every second counts because each passing second kills about 32,000 neurons in the brain. You can read more about that through this link: https://www.strokecarer.com/journeys-to-the-brain-7-time-is-brain/.
And, moreover, successful treatment requires someone with stroke symptoms reach a hospital with treatment facilities within six hours of the onset of symptoms.
Have you ever thought about it?
You can read the full paper published in Nature Communications by clicking this link: https://www.nature.com/articles/s41467-019-09073-5.
What do we know about urine incontinence?
- Pelvic floor exercises prevent and reduce urine incontinence.
- The available evidence for effective interventions to reduce the toll of urine incontinence among stroke survivors is inadequate.
I am a fan of Cochrane reviews. Just in case, if you are not aware of Cochrane reviews, it is a global repository of high-quality reviews of research published across the globe on specific health problems people face. They do not entertain commercial or any other sort of conflicted funding. Most countries own their own Cochrane review centres.
On behalf of the 2019 world continence week which falls between June 17 – 23, Cochrane published a summary of reviews they published about the effectiveness of interventions on urine incontinence. This post is about that.
Following are their summaries;
1. Do pelvic floor exercises prevent/reduce incontinence?
For those who are not familiar with pelvic floor exercises, you can read about this through this post link. This is a common dilemma among front line healthcare providers. Cochrane reviewers reached the following conclusions after reviewing 31 studies involving 1817 women from 14 countries.
The authors of this study concluded that when compared to no treatment, women with stress incontinence if they practice these type of exercises are eight times more likely to report continence! This is a pretty amazing result, right?
Those who are interested in the complete report can read through this link:https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005654.pub4/full
2. Treating incontinence after a stroke in adults
This is again a very important and critical study; unlike in the previous case, the authors of this study concluded that the existing evidence was inadequate. If you are a caregiver, you may be dealing with your loved one’s incontinence problem with adult briefs (diapers) and pull-ups most of the time; sometimes with catheters too. They reached this conclusion and highlighted its evidence gap after reviewing 20 studies which involved as many as 1338 adults with urinary incontinence one month after a stroke event.
Those who are interested in reading their full paper can access the paper through this link: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004462.pub4/full
In one of my previous posts, I highlighted that urine incontinence is the leading cause to seek residential care in Canada and the US. In spite of its prime significance, you can see how little we know about its management.
According to a Canadian Continence Foundation report, published in December 2014, urinary incontinence leads among other reasons to seek a bed in residential care both in the US and in Canada. The report further claims that as many as 3.5 million Canadians experience some form of incontinence – either urinary, fecal or both.
Keep in mind that not all people acknowledge the existence of this problem due to the embarrassment of divulging that sort of information to a researcher – an outsider.
Because those with incontinence spend more time in clinics and hospitals, family caregivers spend innumerable numbers of their productive hours in clinics.
And, we know that due to the ageing of the population – an unavoidable phenomenon – this the negative impact of the problem grows exponentially.
So, what can we do?
Learn a little bit more about how urge urine incontinence occurs among those who face a stroke by clicking this link: https://www.strokecarer.com/peeing-problem-in-a-stroke/
Do you have similar experience and what actions you take to address this problem? Would you like to share for the benefit of others?
You can reach the Canadian report that I referred to in this post via this link: http://www.canadiancontinence.ca/pdfs/en-incontinence-a-canadian-perspective-2014.pdf