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Complications of

Immobilization and

Part 1: Musculoskeletal and cardiovascular


complications
DOUGL\S K. DITTMIER, MID, FRCPC
ROBERT TEASELL, ID, FRCPC
SUMMARY
Prolonged bed rest and
immobilization inevitably lead
to complications. Such
complications are much easier
to prevent than to treat.
Musculoskeletal complications ED RES I AND) IMMNOBILIZ.ATION * mental disorders (catatonia, hysterical
include loss of muscle strength D are time-honoured treat- paralysis); and
and endurance, contractures and D ments for managing trau- * loss of sensation: discomfort does not
soft tissue changes, disuse ma and acute and chronic dictate change of position.
osteoporosis, and degenerative illnesses. Although bed rest
joint disease. Cardiovascular and immobilization often benefit the Chronically ill, disabled, and geriatric
complications include an acutely affected part of the body, when
increased heart rate, decreased people are particularly at risk.2 These peo-
cardiac reserve, orthostatic prolonged, they often harm the rest of the ple already have little or no reserve physi-
hypotension, and venous body. Only within the last four decades ologic function, and any additional
thromboembolism. have clinicians become aware of the difficulties created by immobilization
harmful effects of bed rest and inactivity result in functional losses. Table 1 lists mus-
RESUME and the beneficial effects of activity.' culoskeletal and cardiovascular complica-
L'immobilisation et le repos Problems arising from immobilization can tions of bed rest and immobilization.
au lit prolong6 engendrent complicate a primary disease or trauma
inevitablement des complications and might actually become greater prob- Musculoskeletal complications
qui sont beaucoup plus faciles a lems than the primary disorder. Muscle weakness and atrophy. The
prevenir qu'a guerir. Parmi Complications of immobilization are most obvious effect of prolonged immobi-
les complications musculo- much easier to prevent than to treat. lization is loss of muscle strength and
squelettiques, notons la perte NMany types of immobilizations can lead to endurance. A muscle at complete rest
de force et d'endurance
musculaire, les contractures et complications: loses 1O0% to 15% of its strength each
les changements tissulaires, * enforced bed rest (illness or convales- week. Nearly half of normal strength is
I'osteoporose due a l'inactivite cence); lost within 3 to 5 weeks of immobilization.
et l'arthropathie degenerative. * paralysis; Patients immobilized in bed and astro-
Quant aux complications * immobilizations of body parts with nauts3; in zero gravity (Figure 1) find the
cardiovasculaires, on y retrouve braces, casts, or corsets; first muscles to become weak and atroph-
une acceleration du rythme * joint stiffness and pain with protective ic are those of the lower extremities and
cardiaque, une diminution limitations of motion; trunk that normally resist gravity.' The
de la reserve cardiaque, antigravity muscles are reported to expe-
I'hypertension orthostatique et Dr Dittmer and Dr Teasell are on staff in the rience greater loss of strength than other
la thromboembolie veineuse. Department of Physical ledicine and Rehabilitation skeletal muscles with inactivity and a
Can m San 1993;39:1428-1437. at the University of Jlestern Ontario in London, Ont. greater proportional loss of muscular

1428 (anadian Family Physician VOL 39 J1ne 1993


torque.6 Postural and locomotive muscles spastic (eg, stroke) paralysis or in patients
lose their tension-generating capacity. whose limbs are immobilized by splinting,
Generalized muscle weakness hampers the degree ofmuscle atrophy is less, gener-
people in the activities of daily living, work, ally around 30% to 40%. Combined mus-
climbing stairs, and even walking. Local cle atrophy, decreased strength, and
muscle weakness results from local immobi- limited endurance leads to poor coordina-
lization when fractured bones or injured tion of the movements of the extremities
joints are set in casts (Figure 2).7,8 LeBlanc et and could affect the patient's ability to
al' demonstrated changes in muscle atro- perform the activities of daily living.
phy and strength after immobilization
among nine male volunteers given absolute Contractures and soft tissue
horizontal bed rest. They used magnetic changes. Contractures, defined as fixed
resonance imaging to calculate muscle area deformities of joints as a consequence of
and a Cybex II dynamometer to measure immobilization, occur because of the
strength. The muscle area of the plantar dynamic nature of connective tissue and
flexors (gastrocnemius and soleus) muscle in the body. Connective tissue is
decreased 12% and strength decreased constantly being removed, replaced, and
26%; dorsiflexion muscle area and strength reorganized and can be seen to go through
were not significantly decreased. These a series ofphases during healing. " In areas
results have implications for patients with of frequent movement, loose areolar con-
severe orthopedic and neurologic disorders nective tissue develops. In areas of little or
and for persons who are voluntarily inac- no motion, collagen eventually is laid
tive (many of the elderly). down as a dense mesh of sheets. Collagen
Unfortunately the rate of recovery fibres maintain their length if frequently
from disuse weakness is slower than the stretched but shorten if immobilized.
rate of loss. Disuse weakness is reversed at Ligament complexes are affected bio-
a rate of only 6% per week using submax- mechanically, biochemically, and mor-
imal exercise (65% to 750% of maximum).8 phologically by immobilization, and
Muscle strength can be maintained with- these changes occur in both bony liga-
out loss or gain with daily muscle contrac- ment insertions and the ligament sub-
tions of 20% or more of maximal tension stance itself i2,13 Hence, after trauma to
for several seconds each day.' Functional the soft tissue and bone, it is important to
electrical stimulation and biofeedback realize that immobilization in a cast with
training can increase or maintain muscu- non-weight-bearing status (eg, a lower
lar strength in those muscles with less than limb fracture) can lead to changes that
antigravity strength. are difficult to reverse later. Experiments
Complete rest will also result in with animals have shown that, after
decreased endurance through a reduc- 8 weeks of immobilization in whole body
tion in muscle strength, metabolic casts, knee ligament stiffness, maximum
activity,"° and circulation. Decreased load at failure, and energy absorption
endurance levels that cause a sense of before failure decreased to 69%, 610%,
fatigue and reduce patient motivation set and 68% of normal, respectively, and Table 1. Potential
up a vicious circle of greater inactivity that the ligaments had not returned to complications of
and (both as a contributing factor to and normal even 1 year later.' 14 immobilization
a result of) further fatigue. Immobilization can cause fibrofatty
Muscle atrophy is defined as loss of infiltration in joints that can mature into MUSCULOSKELETAL
muscle mass. It might account for a strong adhesions within the joints and * Decreased muscle strength
decrease in muscle strength and might destroy cartilage. In periarticular and atrophy
endurance. Normal muscles at rest can connective tissue, increased cross-link- * Decreased endurance
lose half their bulk after only 2 months.8 * Contracture
age between existing collagen and new * Osteoporosis
During flaccid paralysis (ie, peripheral type I collagen that has been abnormal-
nerve injury) a totally denervated muscle ly deposited within the matrix con- (ARDIOVASCULAR
can lose as much as 95% of its bulk. With tributes to contracture rather than to the * Increased heart rate
irreversible denervation, muscle fibres synthesis of a new type of collagen. 16 * Decreased cardiac reserve
undergo permanent degeneration and are Shortening collagen fibres can restrict * Orthostatic hypotension
replaced by fat and connective tissue. In movement significantly even within * Venous thromboembolism

Canadian Family Physician VOL 39: June 1993 1429


F~gure 2..Patient t .

1 week. If a joint has to be immobilized, changes during a variety of muscle degener-


Jarvinen et al'7 suggest that immobiliz- ative and inflammatory disorders; soft tissue
ing the gastrocnemius muscle-tendon disorders, such as scleroderma or burns;
unit in a lengthened position causes less and joint degenerative or inflammatory dis-
muscle atrophy and less decrease in ten- orders. Contractures are most commonly
sile properties than immobilizing in a seen in individuals with joint diseases or
shortened position. paralysis of a muscle group or in elderly
Many factors contribute to contractures. individuals who are frail, cognitively
Denervated muscle (with no opposition to impaired, or very passive. Muscles that cross
antagonistic muscle) or spasticity (where two joints, such as the hamstring or back
either flexor or extensor muscle are muscles, tensor muscles of fascia lata, rectus
favoured) can lead to dynamic muscle muscle of the thigh, gastrocnemius muscles,
imbalance. Improper bed positioning can and biceps muscles, are particularly at risk
result in deformities, particularly in joints of of shortening during immobilization.I
the lower extremities. Adaptive shortening Contractures limit positioning, making
of soft tissues when the limb is held in a bathing and transfers difficult; increase
shortened position (eg, in a cast) might the risk of pressure sores; are often painful;
occur. Sometimes contractures arise from and sometimes prevent ambulation and
the disease itself, such as intrinsic muscle lengthen hospital stays. For instance, a hip

1430 Canadian Family Physician VOL 39 June 1993


flexion contracture shortens stride, used.'8" 9 Functional braces or hinged casts
increases lumbar lordosis, causes the ham- have also helped to avoid "cast disease."
string muscle to shorten resulting in a flex- Work by Sarmiento and Latta2" has shown
ion contracture, and leads to increased that, after initial stabilization and forma-
energy consumption while moving.' tion of early callus, joints associated with
Treatment of contractures emphasizes the fracture can be mobilized if properly
prevention. Varying the positions ofimmo- braced to prevent rotation. Eriksson2' first
bile joints regularly, performing active or promoted cast bracing following knee liga-
passive range-of-motion exercises twice ment repair to decrease muscle atrophy
daily, and using resting splints for joints and obtain a quicker return of motion.
that tend to maintain an undesirable posi- Continuous passive motion has also
tion help prevent contractures. Abundant been used to diminish the effects of immo-
evidence appears to show that early active bilization after surgery by enhancing reab-
mobilization after initial stabilization is sorption of the hemarthrosis; decreasing
beneficial. Achilles tendon ruptures and adhesions, pain, thrombophlebitis, and
ankle sprains seem to recover with greater muscle atrophy; and improving cartilage
strength and sooner (allowing earlier nutrition, range of motion, and collagen
return to work) when early functional orientation and strength. Yet continuous
activities are permitted than when casts are passive motion alone showed no significant

Canadian Family Physician VOL 39 June 1993 1431


advantages over active therapy after knee Osteoporosis can lead to fractures of the
ligament reconstructions.22Joints should be spinal vertebrae, femur, and distal radius.
immobilized in the neutral position so Repeated anterior fractures of the spinal
opposing muscles are at equal length vertebrae result in a dorsal kyphosis and
and tension.23-26' chronic back pain. But osteopenia some-
Established contractures are treated times is undetected for years. Routine radi-
with passive range of motion and terminal ographs do not demonstrate osteoporosis
stretch for 20 to 30 seconds. Prolonged until 40% of bone density is lost.
stretch can be provided manually or
through traction devices applied at low Degenerative joint disease. Exper-
tension after heating the tissues involved imental immobilization of animals has
to 40° to 45°C. Progressive dynamic resulted in severe degenerative joint
splinting can be used in specific cases. changes.3'3 Researchers now believe that
Contraindications to aggressive manage- both the contracted capsule and joint
ment of immobilized or contracted joints immobilization in a fixed position cause
include osteoporosis, heterotopic ossifica- prolonged compression of the cartilage
tion, acute arthritis, ligamentous instabili- contact sites and their subsequent degen-
ty, new fractures, insensate areas, and an eration.1 These findings have not been
inability to communicate pain. If contrac- correlated with human subjects. The ear-
tures are significantly impeding function lier work of Salter et al36 on damaged rab-
and do not respond to conservative man- bit cartilage showed that continuous
agement, surgery might be required. After passive motion had a beneficial biologic
contractures are overcome, the factors that effect on the healing of full thickness
caused them will remain and a preventive defects in articular cartilage.
maintenance program is a necessity. Finally, one randomized, clinical trial
of bed rest treatment for mechanical low
Disuse osteoporosis. Like connective back pain without neuromotor deficits
tissue, bone is a dynamic tissue. A constant showed convincingly that the sooner
equilibrium is maintained between bone patients were up and moving around
formation and resorption. Bone morphol- (ie, after 2 days' rest rather than 7 days')
ogy and density depend on forces that act the fewer days ofwork they missed. No dif-
upon the bone,27'281 such as the direct ferences in other functional, physiologic,
pulling action of tendons and weight bear- or perceived outcomes were noted.3' Bed
ing. Astronauts in weightless environments rest to allow an underlying lesion to heal
suffer profound loss of bone mass despite by avoiding biomechanical strain clearly is
rigorous physical activity, Immobilization being challenged as a useful way to treat
leads to bone mass loss in association with musculoskeletal injury.
hypercalciuria and negative calcium bal-
ance.29 Loss is generally greater with lower Cardiovascular complications
motor neuron flaccid lesions than with Cardiovascular complications of immobiiza-
upper motor neuron spastic lesions. tion include an increased heart rate,
Experimental studies demonstrate decreased cardiac reserve, orthostatic
that increased bone resorption accounts hypotension, and venous thromboembolism.
for loss of bone mass28,30-33 even though
the parathyroid hormone is not sup- Increased heart rate and decreased
pressed. Both cortical and trabecular cardiac reserve. Heart rate increases
bone are lost, trabecular bone predomi- (generally to more than 80 beats/min) fol-
nantly. 3 Trabecular bone is found in the lowing immobilization, probably due to
spine, femur, and wrist, making these increased sympathetic nervous system
areas susceptible to fractures after trau- activity. During bed rest, the resting pulse
ma. Bone loss during long-term immobi- rate speeds up one beat each minute every
lization tends to occur in stages: first, 2 days.38 Because the increased heart rate
rapid bone loss; second, beginning at results in less diastolic filling time and a
12 weeks, slower but more prolonged shortened systolic ejection time, the heart
bone loss; until third, stabilization at is less capable of responding to metabolic
4000 to 70%/o of original mass. demands above the basal level. Shorter

1432 Canadian lamily Plvsiciall \'0l,(i9:.7tlie 1993


diastolic time reduces coronary blood flow Venous thromboembolism. Venous
and decreases the oxygen available to car- thromboembolism is due primarily to
diac muscle. Cardiac output, stroke vol- venous stasis and to a lesser degree to
ume, and left ventricular function decline increased blood coagulability (two of the
overall.)18 41 Physical exertion can then three factors in Virchow's triad). Stasis
lead to tachycardia and angina in predis- occurs in the legs following decreased
posed individuals and work capacity is contraction of the gastrocnemius and
reduced. In a classic study by Saltin et al,42
soleus muscles. Most deep venous
24 male college students were subjected to thrombi occur in the calf and mainly
20 days of bed rest. Results showed a originate in the soleus sinus. Researchers
27% decrease in maximal °2 uptake, believe that 80% of the clots lyse before
25% decrease in stroke volume, 15% to reaching the level of the knee. Patients
26% increase in cardiac output, and a with proven deep venous thrombi involv-
20% increase in heart rate. ing the popliteal or more proximal leg
To reverse the effects of bed rest and veins have a 50% chance of developing
build endurance, patients should exercise pulmonary emboli.44 Mortality from
to between 50% and 70% of maximal untreated pulmonary embolism is
oxygen consumption, or 65% to 75% of 20% to 35%.4 Organization and resolu-
maximal heart rate. Maximal heart rate tion of a deep venous thrombosis occurs
(beats/min) can be calculated as 210 - (age within 7 to 10 days. Length of bed rest is
in years 0.65). This formula is justified directly related to frequency of deep
when, apart from deconditioning, the venous thrombosis.46
patient has no evident heart disease. Most patients who develop deep
TFarget heart rates can be achieved using venous thrombosis fail to demonstrate any
treadmill or bicycle ergometer (Figure 3) clinical signs. Venous collaterals are gener-
training, or arm ergometry (Figure 4) for ally so well developed that the thrombi
patients with lower limb injury or disease. must be quite extensive to clog the veins or
cause vessel wall inflammation. Clinical
Orthostatic hypotension. Orthostatic signs of deep venous thrombosis tend to be
hypotension is believed to occur when the unreliable. These include pain and ten-
cardiovascular system does not adapt nor- derness, swelling, venous distention, pal-
mally to an upright posture. It occurs lor, cyanosis, redness, or a positive
after 3 weeks of bed rest (earlier for the Homans' sign. More than 50% of patients
elderly) because of excessive pooling of who have clinical signs of deep venous
blood in the lower extremities and a thrombosis have no evidence of it on
decrease in circulating blood volume. venography.47 Clinical diagnosis is both
This, along with a rapid heart rate, results nonsensitive and nonspecific, and it is
in diminished diastolic ventricular filling important to verify clinical suspicions with
and a decline in cerebral perfusion.39'43 diagnostic tests such as Doppler ultra-
The circulatory system is unable to sonography, impedance plethysmography,
restore a stable pulse and blood pressure and contrast venography. Each test has
level. Generally, orthostatic hypotension specific advantages and disadvantages;
is characterized by a pulse rate increase of contrast venography is the gold standard.
more than 20 beats/min and a 70% or The clinical picture of pulmonary
more decrease in pulse pressure with thromboembolism is both nonspecific and
venous pooling in the legs. poorly sensitive. Symptoms of pulmonary
Treatment of orthostatic hypotension emboli include dyspnea, tachypnea,
involves leg exercises, early mobilization tachycardia, pleuritic chest pain, cough,
and ambulation, and elastic stockings. hemoptysis, or a pleural rub or effusion.48
In cases of prolonged bed rest, a tilt Less specific signs include fever, confusion,
table with graduated increase in the wheezing, and arrhythmia. Severe cases
standing posture might be necessary. might lead to pulmonary consolidation or
Reconditioning the cardiovascular system atelectasis, right heart failure, and even
generally takes longer than decondition- cardiovascular collapse with hypotension.
ing. Reconditioning appears to take even The key diagnostic test is a lung scan for
longer for elderly patients. ventilation and perfusion. Generally, a

Canadian Family Phy.sician VOL '3) June 1993 1435


mismatch is present with parts of the lung 7. MacDougallJD, Elder GCB, Sale DG,
appearing adequately ventilated but not MorozJR, SuttonJR. Effects of strength training
adequately perfused. Arterial blood gases and immobilization of human muscle fibres.
could show a fall in the arterial oxygen EurJ7 Appl Physiol 1980;43:25-34.
level and no change in the arterial carbon 8. Muller EA. Influence of training and of inactivity
dioxide level. An electrocardiogram can on muscle strength. Arch Phys Mfed Rehabil 1970;
rule out myocardial infarction. 51:449-62.
Treating venous thromboembolism 9. LeBlanc A, Gogia P, Schneider V, KrebsJ,
involves decreasing venous stasis by such Schonfeld E, Evans H. Calf muscle area and
physiotherapy as leg exercises, leg eleva- strength changes after five weeks of horizontal
tion, elastic stockings, early ambulation, bed rest. Am ] Sports Aled 1988; 16:6,624-9.
and mechanical compression. Methods 10. MacDougallJD, Ward GR, Sale DG,
to decrease blood coagulability include SuttonJR. Biochemical adaptation of human
dextran, antiplatelet drugs such as skeletal muscle to heavy resistance trainiing and
acetylsalicylic acid, and anticoagulants immobilization. 7 Appl Physiol 1977;43:700-3.
such as warfarin and heparin. 11. Van der MeulenJCH. Present state of
Prophylactic methods that effectively knowledge on processes of healing in collagen
prevent venous thromboembolism structures. Intff Sports Aled 1982;3:4-8.
include low-dose heparin, intermittent 12. Akeson WH, Amiel D, Abel MF, Garfin SR,
pneumatic compression, oral anticoagu- Woo SLY. Effects of immobilization on joints.
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thrombosis in many trials and is required alters cell metabolism in an immature ligament.
only in low doses because it does not Clin Orthop 1992;277:277-88.
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