What is the recommended approach for global reconditioning in a hospital inpatient physiatry setting?

Recommended Approach for Global Reconditioning in Hospital Inpatient Physiatry

The optimal approach for global reconditioning in a hospital inpatient physiatry setting is an interdisciplinary rehabilitation program that includes aerobic and resistance exercise training, physiotherapy, nutritional support, and psychological interventions tailored to the patient's specific functional deficits. 1

Core Components of Inpatient Global Reconditioning

Assessment and Monitoring

• Initial comprehensive assessment should determine underlying problems amenable to physiotherapy and appropriate interventions 1
• Vital functions should be monitored during therapy to ensure interventions are both therapeutic and safe 1
• Functional assessment tools should be used to establish baseline and track progress, though many standard tools may not be applicable for acutely ill patients 1

Physical Reconditioning Program

• Exercise intensity should be moderated based on clinical condition and response to treatment 1

• For severely deconditioned patients, begin with:

  • Positioning changes to increase gravitational stress and associated fluid shifts 1
  • Early mobilization to reduce time to wean from mechanical ventilation 1
  • Walking and standing aids (modified walking frames, tilt tables) to facilitate mobilization 1

• Progress to more intensive reconditioning:

  • Moderate-intensity resistance training to improve muscle strength and lean body mass 1
  • Aerobic exercise (walking, stationary bike with light exercises) at moderate intensity (e.g., brisk walking at 5 km/h) 1
  • Functional exercises targeting activities of daily living 1

Recommended Exercise Parameters

• Aim for 150 minutes/week of aerobic exercise 1
• Include 2 days/week of strength training 1
• Add flexibility exercises on days when aerobic or resistance exercise is not performed 1
• Exercise intensity should be commensurate with anticipated benefit and tolerance 1

Multidisciplinary Team Approach

• Rehabilitation should be delivered by a specialized multidisciplinary team who communicate regularly and use their expertise to work toward common goals 1
• Team should include physiotherapists, occupational therapists, speech therapists, psychologists, and physiatrists 1
• Coordination and organization of the team is critical for improving patient outcomes 1

Specific Interventions by Domain

Respiratory Reconditioning

• Coughing and forced expiratory maneuvers to aid clearance of secretions 1
• Relaxation techniques and pursed-lip breathing to control breathing patterns 1
• Respiratory muscle training to improve respiratory muscle function 1

Muscular Reconditioning

• General exercise reconditioning is the best mode of rehabilitation, even in patients with severe limitations 1
• Walking is generally preferred, but stair-climbing, treadmill, or cycling exercises can also be used 1
• Patients with particularly severe muscle weakness benefit most from targeted strengthening 1

Nutritional Support

• Address both obesity and undernutrition as they affect rehabilitation outcomes 1
• Aim for ideal body weight through appropriate nutritional interventions 1
• Avoid high-carbohydrate diets and extremely high caloric intake to reduce risk of excess carbon dioxide production 1

Psychological Support

• Include psychotherapy and education to improve coping skills 1
• Address depression and anxiety that may accompany prolonged hospitalization 1
• Provide emotional support and enhance communication 1

Implementation Considerations

Timing and Intensity

• Early rehabilitation should be initiated as soon as the patient is medically stable 1
• However, high-dose, very early mobilization within 24 hours of stroke onset can reduce favorable outcomes and is not recommended 1
• Therapy intensity should be at least 3 hours daily for optimal functional gains 1

Prevention of Complications

• Regular assessment of skin and use of objective scales like the Braden scale to prevent skin breakdown 1
• Regular turning (at least every 2 hours), good hygiene, and proper positioning to prevent pressure ulcers 1
• Daily stretching of affected limbs to avoid contractures 1

Transitioning Care

• For patients with prolonged fatigue after active infection resolves, referral to physical therapy for "generalized weakness" can have positive therapeutic effects 1
• Structured reconditioning programs with periodic assessment provide patients with tangible signs of improvement 1
• Reconditioning programs are typically useful if continued for several weeks or months 1

Special Considerations

Post-COVID Reconditioning

• Patients recovering from COVID-19 often require comprehensive rehabilitation addressing physical, mental, and cognitive impairments 2
• A multidisciplinary rehabilitation program can significantly improve COVID-19 residual symptoms, muscular strength, cardiopulmonary parameters, and psychological well-being 3

Chronic Fatigue

• For patients with chronic fatigue, reconditioning programs should focus on gradually improving strength, endurance, balance, and proprioception 4
• Such programs can improve strength, balance, and quality of life with minimal risk of relapse 4

Hospital-Associated Deconditioning

• Acute inpatient rehabilitation is effective for improving function in patients with hospital-associated deconditioning 5
• Older adults are most frequently affected and require special attention 5

Pitfalls and Caveats

• Avoid viewing critically ill patients as "too sick" for physical activity, as prolonged immobilization enhances deconditioning and complicates clinical course 1
• Balance the risk of moving critically ill patients against the risks of immobility and recumbency 1
• Protracted fatigue may initially be a direct symptom of infection but can become a deconditioned state that persists after active infection resolves 1
• Ensure appropriate monitoring of vital functions during therapy to maintain safety 1
• Recognize that patients with hemodynamic instability or those requiring high levels of ventilatory support are not candidates for aggressive mobilization 1