Physical Activity in Acute Care
Original Editor - Karen Wilson
Hospital-level care doesn't rule out the need to engage patients in physical activity. In the past, complete bed rest was thought to be the best treatment for managing patients after physical trauma, surgery, and/or illness. Although some conditions, such as fractures, require local immobilization to heal, often, physician orders to stay in bed are not based on medical necessity. In these cases, prolonged bed rest leads to unnecessary declines in function. The complications of prolonged bed rest include muscle weakness and atrophy, contractures, disuse osteoporosis, decreased cardiac reserve, orthostatic hypotension, venous thromboembolism, glucose intolerance, pneumonia, constipation, and delirium.
Despite evidence showing bed rest treatment to be largely ineffective, low patient mobility continues to persist in the acute care setting. Particularly in older adults and the critically ill, low mobility during hospitalization has been associated with functional decline, new institutionalization, and death. These risks support the need to make physical activity a pillar of acute care management.
Determinants of Physical Activity in Acute Care
During hospitalization, many factors influence physical activity. Common barriers include surgery, medical treatments, and the patient's illness. Among health care providers, a culture of immobility often exists. This culture is characterized by a fear of falls, unnecessary bed rest orders, and a lack of perceived time and staff. Nursing personnel cite fear of self-injury, insufficient training, deferral of responsibility, and the expectation of increased workload as added barriers. Moreover, inactivity is reinforced by patient and family beliefs that bed rest is vital to recovery.
The Role of Healthcare Providers
Removing barriers to physical activity is a multidisciplinary effort. On the part of physicians, it requires a critical examination of activity orders and a commitment to minimizing baseless bed rest prescriptions. Frequent nurse-physician communication and high patient interaction put beside nurses in an ideal position to challenge inappropriate bed rest orders, advocate for the removal of unnecessary lines (ex. foley catheters), and help patients move at their highest, yet safe level of function.
In patients requiring physical rehabilitation, physical and occupational therapists are experts in using therapeutic exercise, self-care activities, and mobilization techniques to maximize functional independence. Moreover, both disciplines possess the professional background to train and support nurses who lack the skills and/or confidence to help patients get out of bed.
Patient Mobility InterventionsMore and more hospitals are using mobility programs to keep patients active. General recommendations for promoting physical activity within hospitals include:
- Limiting the use of physical and chemical restraints
- Environmental modifications
- Patient education
- Implementation of activity protocols
- Regular assessment of patient function
The application of these recommendations has taken on various forms. Within physical therapy, therapists are involved in the rehabilitation of patients across a variety of acute specialty services, including neurology, plastics, burns, trauma, general medicine, surgery, oncology, critical care, and cardiology. Early mobilization in the intensive care unit is of particular interest as a growing number of studies show that even the sickest of patients can safely participate and benefit from physical activity.
In addition, many hospitals have successfully implemented therapy and/or nursing driven mobility programs to enhance patient care on wards.  Positive outcomes include improved maintenance of functional status, greater likelihood of being discharged home, and decreased length of stay.
Outcome Measures for the Acute Care Setting
Outcome measures are vital for helping nursing and rehabilitation staff assess and monitor changes in patient function. The following are common measures of physical activity in the acute care setting:
- AM-PAC "6 Clicks"
- Acute Care Index of Function (ACIF)
- Functional Independence Measure (FIM)
- Barthel index
- Katz Index of Independence in Activities of Daily Living
- Timed Up and Go (TUG)
- 2 & 6 minute walk test
Contraindications to Physical Activity
Safety is the most important consideration for physical activity participation. According to the American Heart Association, absolute contraindications to exercise testing and training include:
- Acute myocardial infarction
- Unstable angina not 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 or injury complex, and co-morbidities, additional restrictions and/or contraindications to exercise therapy may apply.
The Academy of Acute Care Physical Therapy offers this resource to help physical therapists identify critical laboratory values, a common contraindication to exercise. Although the document is based on best available evidence, standards regarding critical values and contraindications to physical therapy vary widely across institutions and patient populations. Consequently, 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.
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