How should deconditioning be managed and treated?

Management and Treatment of Deconditioning

Begin structured exercise training immediately after medical stabilization, starting with recumbent or semi-recumbent activities at low intensity (5-10 minutes daily) and progressing gradually by 2 minutes per day each week, combined with adequate protein intake of ≥1.6 g/kg body weight distributed throughout the day. 1

Initial Assessment and Safety Monitoring

• Conduct a targeted physiological assessment focusing on cardiorespiratory reserve, muscle strength, joint mobility, and functional status rather than medical diagnosis alone 1, 2
• Monitor vital functions continuously during all interventions to ensure both therapeutic benefit and safety, particularly heart rate, blood pressure, and oxygen saturation 1
• Assess hemodynamic stability and level of consciousness before determining appropriate activity level—patients with hemodynamic instability or requiring high FiO2 are not candidates for aggressive mobilization 1

Exercise Prescription: The Core Intervention

Starting Point and Progression

• Begin with recumbent or semi-recumbent exercise (rowing, swimming, or cycling) rather than upright exercise, as upright activities can worsen fatigue and cause postexertional malaise 1
• Start with only 5-10 minutes daily at submaximal intensity where patients can speak in full sentences 1
• Progress gradually by adding 2 minutes per day each week to avoid setbacks and worsening fatigue 1
• Transition to upright exercise only after orthostatic intolerance resolves 1

Exercise Parameters for Stable Patients

• Aerobic training: 40-70% of heart rate reserve, 3-7 days per week, 20-60 minutes per session 2
• Resistance training: 1-3 sets of 10-15 repetitions of 8-10 exercises using circuit training, weight machines, or free weights 2
• Stretching exercises: 2-3 days per week, holding each stretch for 10-30 seconds to prevent contractures 2

Critical caveat: This structured approach applies to all patients with deconditioning regardless of age or whether postural orthostatic tachycardia syndrome (POTS) is present 1. The key is avoiding upright exercise initially, which distinguishes this from traditional graded exercise therapy that has been cautioned against by UK NICE guidelines for post-viral conditions 1.

Nutritional Management: Essential for Muscle Preservation

• Provide ≥1.6 g/kg body weight of protein daily distributed throughout the day in 20-30 g portions, including pre-sleep 1
• Monitor energy balance carefully as both positive and negative energy balance will modulate deconditioning 1
• Ensure adequate micronutrients: calcium, vitamins D and C, zinc, copper, and manganese to support tissue repair 1

Important note: Muscle develops "anabolic resistance" to protein intake rapidly during disuse, making these specific protein recommendations critical rather than optional 1. Declining protein intake will accelerate muscle loss regardless of energy balance 1.

Non-Pharmacological Adjuncts for Orthostatic Symptoms

• Implement salt and fluid loading: 5-10 g sodium daily (1-2 teaspoons table salt, NOT tablets to avoid nausea) plus 3 liters of water or electrolyte-balanced fluid daily 1
• Elevate head of bed with 4-6 inch (10-15 cm) blocks during sleep 1
• Use waist-high support stockings to support central blood volume 1
• Avoid dehydration triggers: alcohol, caffeine, large heavy meals, and excessive heat exposure 1

Pharmacological Options (When Non-Pharmacological Measures Insufficient)

• Low-dose beta-blockers (bisoprolol, metoprolol, nebivolol, propranolol) or non-dihydropyridine calcium-channel blockers (diltiazem, verapamil) can be titrated to slow heart rate if palpitations predominate 1
• Ivabradine may be used for severe fatigue exacerbated by beta-blockers 1
• Fludrocortisone (up to 0.2 mg at night) combined with salt loading can increase blood volume, but requires monitoring for hypokalemia 1

Wean patients from these medications as fitness and activity improve 1.

Early Mobilization Protocol for Hospitalized Patients

• Initiate mobilization as soon as medically stable to prevent complications of prolonged inactivity 1, 2
• Progress stepwise: positioning changes → passive range of motion → active-assisted exercises → sitting on edge of bed → transfer to chair → standing with assistance → walking with aids 2
• Use positioning to increase gravitational stress through head tilt and positions approximating upright posture, which increases lung volumes and stimulates autonomic activity 1

Special Populations

Critically Ill Patients

• Implement passive cycling, joint mobilization, muscle stretching, and neuromuscular electrical stimulation when active exercise is not feasible 2
• Consider continuous passive motion to prevent contractures 2

Mechanically Ventilated Patients

• Protocolized rehabilitation toward early mobilization reduces ventilation duration and increases likelihood of walking at discharge 2
• Inspiratory muscle training at moderate intensity (50% of maximal inspiratory pressure) may benefit patients with weaning failure, with 76% successfully weaned versus 35% in sham groups 1

Common Pitfalls to Avoid

Do NOT use anti-inflammatory nutritional strategies (phenolic compounds, curcuminoids, omega-3 fatty acids) to combat post-injury inflammation—these have not been shown to attenuate tissue deconditioning and could be counterproductive to healing 1.

Do NOT start with upright exercise in deconditioned patients, as this consistently worsens fatigue and causes postexertional malaise 1.

Do NOT use salt tablets for salt loading—use table salt in food to minimize gastrointestinal side effects 1.

Supervised vs. Home-Based Programs

• Formalized exercise programs should be initiated either in supervised settings with physical therapists or with specific instructions for home/gym implementation 1
• For long-term maintenance, supervised exercise programs, home programs with regular follow-up, or repeat rehabilitation sessions may be considered, though evidence for optimal maintenance strategies remains equivocal 1