Posted in Advocacy For caregivers/stroke survivors

Detrimental effects of prolonged bed rest

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

Don’t let older adults lay in bed or only get up to a chair during their hospital stay.  Walking during the hospital stay is critical for maintaining functional ability in older adults.

American Academy of Nursing

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/

Source: 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.

A message from Cardiff and Vale University Health Board

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.

a hospital bed
Posted in Advocacy Best practices For caregivers/stroke survivors

Early mobility improves recovery after stroke

Evidence is convincing; early mobility improves recovery after stroke. Earlier the better, because moving body parts, if possible, stimulate the alive brain cells – neurons – to take over some of the jobs lost due to the death of their neighbors.

How early?

Evidence suggests 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.

The activity could be as simple as sitting on the bed. Obviously, not all who suffered can do that.

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 the Stroke journal published in 2014. The statement came as a result of research findings that early mobility improves the 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
  • repetition
  • 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

Pre-exercise evaluation

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.

Alternate tests

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