What is the recommended physical medicine and rehabilitation (PM&R) approach for a hospital inpatient with deconditioning?

Physical Medicine and Rehabilitation for Hospital Inpatients with Deconditioning

Early mobilization and progressive rehabilitation should be initiated as soon as a hospitalized patient is medically stable to prevent complications of prolonged inactivity and improve functional outcomes. 1

Assessment and Initial Approach

• Prior to treatment, conduct a targeted assessment to determine underlying problems amenable to physiotherapy and identify appropriate interventions 1
• Evaluate cardiorespiratory reserve, muscle strength, joint mobility, and functional status to guide progressive mobilization 1
• Monitor vital functions during interventions to ensure safety and therapeutic benefit 1
• For critically ill patients, assess level of cooperation, neurological status, and hemodynamic stability before determining appropriate activity level 1

Early Mobilization Protocol

• Begin rehabilitation as early as possible after medical stabilization to prevent deconditioning, which can lead to muscle weakness, joint stiffness, and reduced functional capacity 1
• Start with positioning changes to increase gravitational stress through head tilt and positions that approximate upright posture 1
• Progress through a stepwise approach based on patient tolerance and clinical condition 1:
  1. Passive range of motion exercises for unconscious or severely limited patients 1
  2. Active-assisted exercises in bed 1
  3. Sitting on edge of bed (dangling) 1
  4. Transfer to chair 1
  5. Standing with assistance 1
  6. Walking with appropriate aids 1

Exercise Prescription for Deconditioned Patients

• Aerobic Training:

  • Implement using appropriate modalities (treadmill, cycle ergometer, or functional exercises) based on patient capabilities 2
  • Intensity: 40-70% of heart rate reserve; Rating of Perceived Exertion 11-14 on 6-20 scale 2
  • Frequency: 3-7 days per week 2
  • Duration: 20-60 minutes per session or multiple 10-minute sessions for severely deconditioned patients 2

• Strength Training:

  • Begin with resistance training for clinically stable patients using circuit training, weight machines, free weights, or isometric exercises 2
  • Prescription: 1-3 sets of 10-15 repetitions of 8-10 exercises involving major muscle groups 2
  • Frequency: 2-3 days per week 2
  • For severely deconditioned patients, start with simple active range of motion exercises before progressing to resistance training 1

• Flexibility Exercises:

  • Include stretching exercises to increase range of motion and prevent contractures 2
  • Frequency: 2-3 days per week (before or after aerobic or strength training) 2
  • Hold each stretch for 10-30 seconds 2

Special Considerations

For Critically Ill Patients

• For unconscious patients, implement passive cycling, joint mobilization, muscle stretching, and neuromuscular electrical stimulation 1
• Continuous passive motion can prevent contractures in immobile critically ill patients 1
• For mechanically ventilated patients, protocolized rehabilitation directed toward early mobilization reduces ventilation duration and increases likelihood of walking at discharge 1

For Respiratory Conditions

• For patients with respiratory insufficiency, consider inspiratory muscle training to improve respiratory muscle function 1
• Pulmonary rehabilitation initiated early (within 3 weeks) after acute exacerbation is safe and effective, improving exercise tolerance and quality of life 1
• Supplemental oxygen should be provided during exercise for hypoxemic patients to ensure safety and allow for increased exercise intensity 1

For Cardiac Conditions

• For patients with heart failure, implement a combined program of aerobic and resistance training 1
• Continue exercise programs indefinitely, as benefits are not sustained when programs are terminated 1
• For patients awaiting cardiac transplantation, initiate exercise programs that include both aerobic and resistive exercise 1

Progression and Maintenance

• Gradually increase exercise intensity and duration based on patient tolerance and progress 2
• Assess functional status regularly using standardized tools to track progress and adjust rehabilitation program accordingly 2
• For long-term maintenance of benefits, consider supervised exercise programs, home exercise programs with regular follow-up, or repeat rehabilitation sessions 1

Common Pitfalls and Caveats

• Avoid viewing critically ill patients as "too sick" for physical activity, as this leads to prolonged immobilization and further deconditioning 1
• Recognize that patients with hemodynamic instability, high FiO2 requirements, or high levels of ventilatory support may not be candidates for aggressive mobilization 1
• Be aware that transportation issues, psychological factors, and general frailty can be barriers to rehabilitation adherence, particularly after hospital discharge 1
• Understand that without maintenance strategies, benefits of rehabilitation diminish over 6-12 months 1

By implementing early, progressive rehabilitation for hospitalized patients with deconditioning, clinicians can reduce complications, improve functional outcomes, and potentially decrease hospital length of stay and readmission rates.