Physical Activity in Acute Care

Original Editor - Karen Wilson

Top Contributors - Karen Wilson, Wendy Walker, Simisola Ajeyalemi, Michelle Lee, Kim Jackson, Rucha Gadgil, Amrita Patro and Lucinda hampton  

Introduction[edit | edit source]

Admittance to the acute care setting does not preclude the need to engage patients in physical activity. In the past, bed rest has been used as part of the standard treatment for managing patients following trauma, surgery and illness.[1] While immobilization can be beneficial for acutely affected body parts, on a global level prolonged immobility has deleterious effects on function.The complications of bed rest include muscle weakness and atrophy, contractures, disuse osteoporosis, decreased cardiac reserve, orthostatic hypotension, venous thromboembolism, glucose intolerance, pneumonia, constipation and delirium.[2][3][4]

Despite evidence showing bed rest treatment to be largely ineffective,[5] low patient mobility continues to be rampant in the acute care setting.[6][7][8][9][10] Particularly in older adults and the critically ill, low mobility during hospitalization has been associated with functional decline,[8][11][12] new institutionalization[8] and death.[8][12] Such outcomes warrant interventions to make physical activity a standard pillar of acute care management.

Determinants of Physical Activity in Acute Care[edit | edit source]

During hospitalization, the determinants of physical activity act at varying levels of intra- and interpersonal interaction. Some barriers are related to surgery,[13] medical treatments[13] and the patient's illness itself.[13][14][15] Others stem from a culture of immobility among healthcare providers. This culture is characterized by a fear of falls,[15][16] unnecessary bed rest orders[8] and a lack of perceived time and staff.[16][17] Fear of self injury,[17] insufficient training,[16] deferral of responsibility[14][15] and the expectation of increased workload[16][18] are additional barriers more prominent among nursing personnel. Patient and family expectations of low mobility[7] further predispose the environment to and reinforce inactivity.

The Role of Healthcare Providers[edit | edit source]

Removing barriers to physical activity is a multidisciplinary effort. First, it requires a critical examination of activity orders and a commitment to minimizing bed rest orders for which there is no medical indication. The continuous presence of nursing floor staff puts them in an optimal position to challenge inappropriate bed rest treatment, advocate for the removal of unnecessary restrictives lines (ex. foley catheters) and to help patients be active at their highest, yet safe level of function.

In patients requiring rehabilitation, physical and occupational therapists are experts in using therapeutic exercise, self-care activities and mobilization techniques to maximize functional independence. Moreover, the two professions make ideal allies to advocate for the removal of barriers to physical activity and train floor staff with the potential to mobilize patients, but who may not do so due to low self-efficacy.

Patient Mobility Interventions[edit | edit source]

More and more hospitals are implementing programs to help patients be more active. General recommendations for facilitating mobility include the following:

PP PA zimmer frame.jpeg
  • Limiting the use of physical and chemical restraints
  • Environmental modifications
  • Patient education
  • Implementation of activity protocols and
  • Regular assessment of patient function[6][19]

The application of these recommendations has taken on various forms. Within physical therapy, therapists are involved in the rehabilitation of patients across an array of acute specialty services including neurology, plastics, burns, trauma, general medicine, surgery, oncology, critical care and cardiology. Early mobilization in the ICU is of particular interest as a growing number of studies show that even the sickest of patients can safely participate and benefit from mobilization.[11][12]

In addition, many hospitals have successfully implemented therapy and/or nursing driven mobility programs to enhance patient care on wards. [20][21][22][23][24][25][26] Positive outcomes include improved maintenance of functional status,[21][24][27] greater likelihood of being discharged home[21] and decreased length of stay.[24][27]

Outcome Measures for the Acute Care Setting[edit | edit source]

Outcome measures are vital for helping nursing and rehabilitation staff to assess and monitor changes in patient function. The following are common measures of physical activity in the acute care setting:

Contraindications to Physical Activity[edit | edit source]

Safety is the most important consideration in patient mobilization. According to the American Heart Association,[28] absolute contraindications to exercise testing and training include the following:

  • Acute myocardial infarction
  • Unstable angina no previously stabilized by medical therapy
  • Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic response
  • Symptomatic severe aortic stenosis
  • Uncontrolled symptomatic heart failure
  • Acute pulmonary embolism or pulmonary infarction
  • Acute myocarditis or pericarditis
  • Acute aortic dissection

Relative contraindications are also specified:

  • Left main coronary stenosis
  • Moderate stenotic valvular heart disease
  • Electrolyte abnormalities
  • Severe arterial hypertension (SBP >200, DBP >100)
  • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
  • Mental or physical impairment leading to inability to exercise adequately
  • High-degree atrioventricular block

Depending on the patient's illness/injury complex and co-morbidities, additional restrictions/contraindications to exercise therapy may apply.

The Academy of Acute Care Physical Therapy (AACPT) offers resources on laboratory value interpretation. While the resource is based on best available evidence, standards regarding critical values and contraindications to physical therapy vary widely across institutions and patient populations. As such, the decision to defer or proceed with exercise therapy should be made within the context of the patient's clinical picture and the policies of the treating institution.[29]

References[edit | edit source]

  1. ↑ Sprague AE. The evolution of bed Rest as a clinical intervention [abstract]. Journal of Obstetric, J Obstet Gynecol Neonatal Nurs 2004; 33(5): 542-549
  2. ↑ Dittmer DK, Teasell R. Complications of immobilization and bed rest, part 1: musculoskeletal and cardiovascular complications. Can Fam Physician. 1993; 39: 1428-32, 1435-37
  3. ↑ Dittmer DK, Teasell R. Complications of immobilization and bed rest, part 1: musculoskeletal and cardiovascular complications. Can Fam Physician 1993; 39: 1428-32, 1435-37
  4. ↑ Corcoran, P. Use it or lose it---the hazards of bed rest and inactivity. West J Med 1991; 154(5): 536-538
  5. ↑ Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354(9186): 1229-1233.
  6. ↑ 6.0 6.1 Kuys S, Dolecka U, and Guard A. Activity level of hospital medical patients: an observational study. Arch Gerontol Geriatr 2012; 55: 417-421
  7. ↑ 7.0 7.1 Cattanach N, Sheedy R, Gill S, Hughes A. Physical activity levels and patients' expectations of physical activity during acute general medical admission. Intern Med J 2014; 501-504
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older adults. J Am Geriatr Soc 2004; 52(8): 1263-70
  9. ↑ Callen BL, Mahoney JE, Grieves CB, Wells TJ, Enloe M. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatr Nurs 2004; 25(4): 212-217
  10. ↑ Brown CJ, Redden DT, Kellie KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc 2009; 57: 1660-1665
  11. ↑ 11.0 11.1 Hodgson CL, Berney S, Harrold M, Saxena M, Bellomo. Clinical review: early patient mobilization in the ICU. Crit Care 2013; 17(1): 207
  12. ↑ 12.0 12.1 12.2 Adler, J & Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012; 23(1): 5-13
  13. ↑ 13.0 13.1 13.2 King, BD. Functional decline in hospitalized elders. Medsurg nurs 2006 Oct; 15(5): 265-271
  14. ↑ 14.0 14.1 Fisher SR, Graham JE, Brown CJ, Galloway RV, Ottenbacher KJ, Allman RM, Ostir GV. Factors that differentiate level of ambulation in hospitalised older adults Age Ageing 2011; 41(1):107-111
  15. ↑ 15.0 15.1 15.2 Fisher SR, Goodwin JS, Protas EJ, Kuo YF, Graham JE, Ottenbacher KJ, Ostir, GV. Ambulatory activity of older adults hospitalized with acute medical illness. J Am Geriatr Soc 2011; 59(1): 91-95
  16. ↑ 16.0 16.1 16.2 16.3 Hoyer EH, Brotman DJ, Chan K, Needham, D. Barriers to early mobility of hospitalized general medicine patients. Am J Phys Med Rehabil 2014; 94(4): 304-312
  17. ↑ 17.0 17.1 Doherty-King B, Bowers B. Attributing the responsibility for ambulating patients: A qualitative study. Int J Nurs Stud 2013; 50(9): 1240-1246
  18. ↑ Brown CJ, Williams B, Woodbury LL, Davis LL, Allman RM. Barriers to mobility during hospitalization from perspectives of older patients and their nurses and physicians. J Hosp Med 2007; 2(5): 305-313
  19. ↑ Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118: 219–23
  20. ↑ Resnick, B, Galik, E, Ender, H, et al. Pilot testing of function-focused care for acute care intervention. J Nurs Care Qual 2011; 26(2):169-77
  21. ↑ 21.0 21.1 21.2 Boltz M, Resnick B, Capezuti E, Shuluk J. Functional decline in hospitalized older adults: can nursing make a difference? Geriatr Nurs 2012; 33(4): 272-9
  22. ↑ Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995; 332: 1338–44
  23. ↑ Markey DW. Brown RJ. An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. J Nurs Care Qual 2002; 16(4):1-12
  24. ↑ 24.0 24.1 24.2 Padula CA, Hughes C, Baumhover L. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual 2009; 24(4):325-31
  25. ↑ Stolbrink M, McGowan L, Saman H, et al. The Early Mobility Bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay. J Hosp Infect 2014; 88(1):34-9
  26. ↑ Tucker D, Molsberger SC, Clark A. Walking for wellness: a collaborative program to maintain mobility in hospitalized older adults. Geriatr Nurs 2004; 25: 242–5
  27. ↑ 27.0 27.1 Pashikanti L & Von Ah D. Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature. Clin Nurse Spec 2012; 26(2): 87-94
  28. ↑ American Heart Association. Exercise Standards for Testing and Training. Circulation 2013: https://doi.org/10.1161/CIR.0b013e31829b5b44 (accessed 21 December 2017)
  29. ↑ The Academy of Acute Care Physical Therapy. Laboratory values interpretation resources- 2017 update. http://www.acutept.org/?page=ResourceGuides (accessed 21 December 2017)
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