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Don’t sit still: the negative effects of immobility

Kyle Freedman, P.T.

In the fall of 2014, I was asked to visit a woman (let’s call her Mary) at CareLife Fleetwood in Surrey. A diabetic, Mary had recently undergone double mid-thigh amputations. 

She desperately wanted to increase her strength, lose weight, and regain some independence. However, her physical limitations restricted much of her mobility.

"Give her something she can do while you're not here," Mary's daughter suggested. "Something she can do in bed." 

There isn't anything like that, I remember thinking. 

But what would it look like if there was?  So began our quest to get seniors moving.

 

The negative effects of immobility

The consequences of sedentarism are especially important to consider with our aging population. There will be more and more patients who have difficulty with mobility – it’s only a matter of time. Seniors admitted to the hospital are at severe risk of functional loss. Due to the immobilization of bed rest, seniors can experience 5% muscle strength loss per day of their stay. 

This type of function decline is described by Kosse et al. as “significantly associated with negative outcomes such as institutionalization, re-hospitalization and subsequent mortality.” In this 2013 systematic review, discharged patients who had participated in a multidisciplinary exercise program were less likely to be discharged to a nursing home compared to those who received only usual care. In addition, the presence of these programs significantly reduced the length of hospital stay

So my thinking was, what if there was a product that could serve as an adjunct to traditional walking and strengthening programs? 

What if there was a way for seniors to exercise while in bed?

 

Helpless to help themselves

In complex care facilities, I am often called to work with a new patient who has been admitted after a fall at home, with a subsequent hip fracture and hospital stay. Many care facilities do not have a physiotherapist on staff, and so the resident, until recently living at home independently, is stuck for their entire day sitting in a wheelchair or lying in bed, because they are a high falls risk if standing. 

They desperately want to walk again and return home, but nurses and care aides have neither the training nor the time to assist with this.

There is a critical rehab window in which the downward spiral of a senior’s health can be reversed; I have found this gap in healthcare to be problematic. 

 

I remember wishing I could give my clients exercises to do on their own, but they all need supervision and many can’t remember a traditional exercise program. 

I have seen many seniors in this care home situation, who, despite living at home independently just week's prior, experience temporary delirium after their hospital stay, surgery, subsequent chest or bladder infection and course of antibiotics.

In most care facilities, many cognitively capable but physically injured residents experience extreme frustration and depression with being cooped up in a facility with no mental stimulation, as well as relying on others to help them walk again. 

They are helpless to help themselves. Instead, they suffer a complete loss of independence, requiring help with activities of daily living. 

 

Exercise is medicine

One of the accepted treatment techniques for delirium is exercise (Balas et al. 2014).  This led me to brainstorm exercises that are repetitive and that seniors with impaired cognitive abilities could do on their own.

Numerous studies show that exercise in seniors can help improve cognitive function (Colcombe and Kramer 2003). 

Michelle Kho’s article in Physiotherapy Practice, “In-Bed Cycling as a Tool for Early Rehabilitation in the Intensive Care Unit” (reference below) discussed the findings from her systematic review, confirming that early exercise and mobilization in the ICU is safe, effective, and most importantly, enjoyable for patients.  

She found that “of 90 patients in the ICU, those who received in-bed cycling walked farther on the 6 Minute Walk Test (6MWT) at hospital discharge, reported better physical function, and had stronger quadriceps force, than those who received respiratory physiotherapy and standard care.” 

Her CYCLE Research Program is currently looking at the effects of starting in- bed cycling within the first few days of ICU admission. 

So we know that inactivity is bad and that moving, even during early rehabilitation, can be good. As confirmed by Maire et al. 2006 (reference below) we also found evidence which supports exercise for seniors who elect to have hip or knee replacement surgery. 

Maire et al. 2006 examined the influence of a six-week arm ergometry exercise program in seniors following a total hip replacement surgery. Despite the study’s small sample size, they found that arm ergometry combined with traditional rehab exercises was a much more effective form of cardiorespiratory exercise compared with a traditional physiotherapy program alone. 

The arm ergometry program resulted in a statistically significant improvement in upper-body aerobic capacity, walking ability, and subjective health status (WOMAC), both at two months and one-year post-surgery. As stated in the study, “Although patients [can] walk a few days after surgery, they [are not able to] perform training that would be strenuous enough to promote an improvement in cardiorespiratory fitness. Such training with the lower limbs might be more appropriate a few weeks or months after arthroplasty” (Maire et. Al, 2006).

The study also says, “one could speculate that the improvements induced by our [arm ergometry training] could have stemmed from systemic cardiovascular and cardiorespiratory effects (central adaptations) rather than local metabolic or haemodynamic changes. Upper-limb exercise has been reported to induce stronger cardiovascular stimuli for a given level of sub maximal work than does lower-limb exercise. This may explain, in part, our observed improvements in the incremental exercise tests and in the walking test” (Maire et. Al, 2006).

Perhaps arm ergometry could be done in bed, unsupervised, to improve cognitive function, and help prevent pneumonia.  This practise could give seniors back some power in having control over their own health outcomes. 

 

The idea takes shape

These findings couldn’t have been more encouraging. We noticed a problem impacting many of our senior patients—in summary:

  • There are significant negative effects to immobility
  • Senior populations with declining mobility continue to grow
  • Moving during immobility can help physical function and strength
  • Currently, there are few affordable solutions that are lightweight, easy to set up, and allows the user to exercise unsupervised

The work of these researchers confirmed for us that there was a proven need and a research-confirmed solution—but no one in the industry had offered a medical device or piece of exercise equipment to adequately fill the gap. 

I wanted to create a solution for seniors to be able to exercise safely in bed, without requiring supervision; something that they could do as often as they liked, giving seniors the power to aid in their own rehabilitation and lower their feeling of helplessness in their health decline. 

So, we decided to try.

In our next post, we explain our proposed solution to the negative effects of immobility and how it’s already helping some patients.

This is part one of a two-part post about the negative effects of immobility and a proposed solution. Read part two here.

 

References:

1. Kosse, Nienke M et al. “Effectiveness and Feasibility of Early Physical Rehabilitation Programs for Geriatric Hospitalized Patients: A Systematic Review.” BMC Geriatrics. 2013

2. Balas, M.C., et al. (2014). Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE) Bundle. Crit Care Med. 2014 May; 42(5): 1024–1036. 

3. Colcombe, SJ, and Kramer, AF. “Fitness Effects on the Cognitive Function of Older Adults: A Meta-Analytic Study”.

Psychological Science. 2003

4. Kho, ME, et al. “Quantifying active in-bed cycling in medical-surgical critically ill patients”. Am J Respir Crit Care Med. 6(4), 2016.

5. Maire, J, et al. “Influence of a 6-week arm exercise program on walking ability and health status after hip arthroplasty: a 1-year follow-up pilot study”. J Rehabil Res Dev. 43(4), Jul-Aug 2006, p445-50.

 

 

About Kyle Freedman

Kyle is the founder and CEO of PhysioHealth Technologies Ltd. He continues to practice at a multi-disciplinary clinic with a focus on orthopaedics and also treats geriatrics patients at their residential care facilities. One of his passions, besides his family and racquet sports, is to help provide access to affordable and portable equipment that allows for self-rehabilitation.