Professional Documents
Culture Documents
030.08.202
Jakarta, 2011
CONTENT
ABSTRACT …………………………………………………………………………..…….. 3
INTRODUCTION ………………………………………………………………………..…. 4
DISCUSSION ……………………………………………………………………….……… 6
NUTRITION
CONCLUSION ………………………………………………………………………….
I. ABSTRACT
2
Bed rest and immobilization has been routinely and often casually prescribed,
body function, involving most of the physiological systems of the body, including the
nutrition which can make the patient more suffer each day.
disease or disorder. With this in mind, bed rest can be minimized as much as possible
and early ambulation and physical activity may be prescribed to limit the
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II. INTRODUCTION
Bed rest and immobilization is a long standing treatment for managing acute and
chronic injury and illness. It may have started with Hippocrates, the father of
medicine, who suggested that “In every movement of the body, whenever one begins
aware of the harmful effects of prolonged bed rest. Classic bed rest studies following
World War II documented the deconditioning that occurs following bed rest. Allen et
al. conducted an exhaustive search of the medical literature from 1966 to 1998, which
provided additional evidence for the harm of bed rest for any medical condition.(2) In
15 trials that investigated bed rest as a primary treatment for a variety of conditions,
infarction, and acute infectious hepatitis). In 24 trials that investigated bed rest after a
muscular, and skeletal systems, other organ systems that exhibit the most pronounced
deconditioning.
III. DISCUSSION
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Prolonged bed rest and immobilization inevitably lead to complications. Such
include loss of muscle strength and endurance, contractures and soft tissue changes,
Genitourinary problems include renal stones and more frequent urinary tract
develop. Central nervous system changes could affect balance and coordination and
upright position (1). A coordinated interaction between the cardiovascular and nervous
systems ensures adequate blood perfusion to the brain and other organs. When the
body assumes a horizontal position for an extended period of time during bed rest,
O2max, and
cardiovascular function in both health and disease. Bed rest decreases V
O2max decreasing
the extent of the loss depends on the length of the bed rest, with V
O2max
approximately 0.9% per day over 30 days of bed rest. The decrease in V
during bed rest appears to be independent of gender and age. However, more fit
5
O2max compared to less
individuals may experience a greater absolute decrease in V
6
7
Figure 1. O2max following bed rest.
Cardiovascular mechanisms affecting V
(Abbreviations: NE, norepinephrine; RBC, red blood cells). Figure modified from
Convertino (1).
O2max following 10 days of bed rest in 12 men resulted from a 23% reduction
in V
A change in heart rate is not responsible for the decreased cardiac output
following bed rest. In fact, both resting and maximum heart rate have been observed
to increase following bed rest. The increase in resting heart rate may be due to a
decrease in vagal tone, and the increase in maximum heart rate may be caused by an
O2max
adrenergic receptors. The primary cause of decreased cardiac output and V
following bed rest is a reduction in stroke volume. The reduction in stroke volume is
adrenergic receptors. Instead, the primary mechanism for the reduction in stroke
volume following bed rest is decreased preload due to a reduction in plasma volume.
Rapid diuresis occurs within the initial 24-48 h of bed rest, resulting in a 10-20%
with bed rest, which results in venous pooling in the lower extremities when an
8
Although decreased stroke volume and cardiac output are the primary causes of
(Figure 1). Prolonged bed rest resulted in a 9% decrease in red blood cell mass,
O2max (1).
flow following bed rest also may diminish V
9
Most patients are fail to demonstrate any clinical signs such as pain,
even though venography is the gold standard of modality, more than 50%
Patients immobilized in bed find the first muscles to become weak and
atrophy and experienced greater loss of strength than other skeletal muscles
with inactivity are those of the lower extremities (e.g. gastrocnemius – soleus)
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As would be expected, the decrease in muscle mass following bed rest
Dorsi flexors -8
Knee flexors -8
Elbow flexors -7
Maximal strength of the knee flexors (-6%) and knee extensors (-19%)
decreased following 30 days of bed rest (28). Thirty-five days of bed rest
ankle dorsi flexors (-8%), knee flexors (-8%), knee extensors (-19%), and
elbow flexors (-7%) (29). Similarly, maximal strength decreases of 26% were
observed in the ankle plantar flexors after 35 days of bed rest. (1).
living, work, climbing stairs, and even walking. Local muscle weakness
results from local immobilization when fractured bones or injured joints are
set in casts. The implication of immobilization can be worse for patients with
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severe orthopedic and neurologic disorders and for persons who are
the rate of loss. Disuse weakness is reversed at a rate of only 6 % per week
endurance levels that cause a sense of fatigue and reduced patient motivation
movements of the extremities and could affect the patient’s ability to perform
the activities of daily living.(2) In the first few days after returning from space,
the elderly.(1)
Importantly, the lost bone mass is not regained for some weeks or
months after muscle mass and strength have returned to normal, further
contributing to the risk of fracture. Those who enter a period of bed rest with
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subnormal muscle and bone mass, especially the elderly, are likely to incur
involvement of muscles that cross two joints in the hips, knees, and ankle
while in the upper limb, the shoulders, elbows, wrists, and fingers are more
susceptible. (5)
muscles), collagen eventually is laid down as a dense mesh of sheets. But the
worst part is collagen fibers maintain their length if their frequently stretched
mature into strong adhesions within the joints and might destroy the cartilage.
(3)
In periarticular connective tissue, new type I collagen has been abnormally
of the resorption and the formation on the bone mass caused by lack of
and negative calcium balance. Bone loss during long term immobilization
table or a standing frame may be used in patients who are unable to stand
unsupported.(5)
inspiration because the strength of their respiratory muscles are also affected.
muscle strength and failure to fully expand the chest wall results in a 25 – 50 %
In the supine patient, mucus secretions accumulate in the dependent segments (i.e.
posterior) while the non dependent respiratory segments might be dry and the
Secretions then accumulate in the lower part of bronchial tree, blocking airways
activity.(7)
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III.4.1. Cortisol secretion
skeletal muscle breakdown and the release of amino acids into the blood.(8)
drop in the metabolic rate. Research has shown that the basal metabolic rate
seem to change much during periods of immobility and bedrest. The metabolic
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rate continues to fall in patients who remain sedentary, probably reflecting the
with most patients confined to bed maintaining a fairly stable body weight. It has
been speculated that any potential weight gain that may be expected because of
reduced basal metabolism is offset by reduced lean muscle mass and consuming
Several studies have shown that, while lean body mass decreases; there is
development of type 2 diabetes. The loss of appetite and reduced calorific intake
associated with prolonged bed rest can potentially trigger a condition known as
Immobility and reduced food intake are associated with a reduction in the
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bed eat carbohydrate-rich meals, the sensitivity of the skeletal muscles to the
effects of insulin is much lower, resulting in lower glucose uptake and a higher
term control of blood pressure. When blood pressure drops, the kidneys release
the enzyme renin, which catalyses the conversion of the plasma protein
result of increased urine output. This loss of blood volume, together with sodium
can be seen in increased plasma renin activity and increased plasma aldosterone
The diuresis associated with long periods of bedrest has been shown to
promote the loss of nitrogen, sodium, potassium, zinc, phosphorus, sulphur and
magnesium. (8)
nitrogen loss through the urine could reach 2 gr/day. This nitrogen loss is due to
Sodium loss occurs rapidly in the early stages of bedrest, primarily due to
output and lead to a drop in total body sodium.(8) This sodium loss can be
stimuli because of severely limited opportunities for being mobile outside their
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This restriction is sometimes referred to as sensory deprivation and it can have a
knock-on effect on human behaviour. For example, information to the brain normally
comes from two main sources: outside the body and within the body. External
information constantly competes with internal information for the individual’s attention.
When the external environment is relatively ‘quiet’, it means increased attention is paid
Niven (2006) explained how people who perceive their occupation as boring and
dull report more physical symptoms and take more medication than people with
Sensory and social deprivations have both been linked to changes in brain
and confusion.
threshold.
and unpredictability, which may, in turn, lead to anxiety. The related mental state of
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Uncertainty and unpredictability may reflect a lack of information, knowledge or
education on patients’ part about the reasons for and consequences of bedrest. This is
why providing information and patient education about bedrest are important anxiety-
relying on medical staff to help with even trivial tasks. This dependency has previously
been referred to as learned helplessness syndrome and it is often reinforced by the well-
events initially react against the stressor (in this case enforced bedrest) by expressing
anger and frustration. On realising that their expressions of anger and frustration are
futile, they eventually lapse into a state of apathy marked by feelings of helplessness,
decline in cognitive function (such as memory lapses and difficulties with simple
It is also important for clinicians to keep in mind that perceptions are based on
personal experiences and are likely to vary between patients. This explains why patients
who experience similar conditions, such as a long period of bedrest, sometimes react in
It is also worth remembering that anxiety and depression are normal and
reversible responses to stressful situations but that they can lead to serious disabling
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The complications associated with psychosocial deprivation can be partly
Bedrest is often associated with a reduced sense of taste, smell and a loss of
appetite. The resulting drop in food intake leads to progressive disuse of the
gastrointestinal tract. This can have a major impact on gut structure and function,
including atrophy of the mucosal lining and shrinkage of glandular structures. (8)
Swallowing is more difficult for people confined to bed and it has been shown
that non-viscous substances pass through the oesophagus more slowly when the body is
supine. It also takes longer for food to pass through the stomach – 66% more slowly in
Increased transit times slow the movement of faeces through the colon and
and constrictive sphincters also takes a part in causing constipation in patien with
In an upright person, gravity causes stools within the rectum to exert pressure on
the anal sphincter, but this effect of gravity is negated in supine patients, reducing the
urge to defecate. If constipation becomes chronic, the build-up of faecal material can
exert significant pressure on the wall of the colon, increasing the chance of diverticuli. (8)
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The risk of constipation can be reduced by ensuring that patients get enough
dietary fibre, which should help to speed up gut transit times. Patients should also be
encouraged to take regular drinks of fresh water, which will be soaked up by fibre within
acidity within the stomach. When patients are in the supine position, these gastric
secretions can collect and press against the lower oesophageal (cardiac) sphincter,
causing irritation. Patients confined to bed can experience symptoms associated with
In both men and women, prolonged bedrest is associated with falling levels of
circulating sex hormones. Lack of physical activity in men reduces both the level of
and women.(8) In women it has been shown that an active sex life is associated with a
stable and regular menstrual cycle. Conversely, prolonged bedrest in women can lead
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III.7.2.1. Urine distribution
away from the kidneys through the ureters to the bladder. In the supine
position, urine is still transported from the kidneys into the bladder by
However, the renal calices rely entirely on gravity to drain fully and,
when the body is in a recumbent position, urine collects in the lower portions
of the renal calices, where it may form small static pools. (8)
bladder under the influence of gravity. As the bladder fills, pressure is exerted
on the bladder wall, neck and urinary sphincter, stimulating the urge to
urinate. In the supine position, the effects of gravity are negated and the urge
confined to bed, the abdominal organs undergo a shift towards the thorax and
the pressure exerted on the bladder is reduced. This can significantly decrease
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It is often difficult to completely empty the bladder into a bedpan or
urine bottle when in the supine position. Patients often feel uncomfortable and
the bladder wall and, over a period of time, the stretch receptors (which
monitor bladder filling) can lose sensitivity, reducing the urge to urinate. (8)
stones). (8)
demineralisation of bone tissue. The major minerals lost from bones are ionic
calcium and phosphate, which accumulate in the blood and are subsequently
excreted in the urine and faeces. Excess calcium in the glomerular filtrate
greatly increases the chances of renal calculi forming in the static urine pools
bacteria such as Proteus sp. These organisms can work their way up through
the urinary tract, and increase the pH of the urine to make it more alkaline,
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encouraging the precipitation of calcium and contributing further to the
They are usually found over bony prominences subjected to external pressure for
sores are those who are comatose, obese, or have burns or ill – fitting casts.
Patients older than age 70 have more than 70% of all pressure sores.
The longer the duration and the greater the magnitude of pressure, the
greater chance of necrosis. The complications of grade 3 and 4 pressure sores can
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Subcutaneous bursitis occurs when there is excessive pressure on the bursae
IV. CONCLUSION
From the available research, it is clear that prolonged bed rest has adverse
physiological effects on the most systems of human body. This deconditioning can
within days of confinement, but their consequences can last much longer. It is
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V. REFERENCES
JEPonline 2007;10(3):32-41.
2. Allen C, Glasziou P and Del Mar C. Bed rest: a potentially harmful treatment
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4. Teasel, R, Dittmer, DK. Complications of immobilization and bed rest. Part
2: Other complications. Can Fam Physician. 2007 Mar 31; 39: 1440-2, 1445-6.
7. DL, Belayy, et al. The effects of bed rest and counter measure exercise on the
reproductive and nervous systems. Nursing Times. 2009; 105; 22, early online
publication.
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