Physical Activity in Acute Care
Original Editor - Karen Wilson
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. 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.
Despite evidence showing bed rest treatment to be largely ineffective, low patient mobility continues to be rampant 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. Such outcomes warrant interventions to make physical activity a standard pillar of acute care management.
Determinants of Physical Activity in Acute Care
During hospitalization, the determinants of physical activity act at varying levels of intra- and interpersonal interaction. Some barriers are related to surgery, medical treatments and the patient's illness itself. Others stem from a culture of immobility among healthcare providers. This culture is characterized by a fear of falls, unnecessary bed rest orders and a lack of perceived time and staff. Fear of self injury, insufficient training, deferral of responsibility and the expectation of increased workload are additional barriers more prominent among nursing personnel. Patient and family expectations of low mobility further predispose the environment to and reinforce inactivity.
The Role of Healthcare Providers
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 InterventionsMore and more hospitals are implementing programs to help patients be more active. General recommendations for facilitating mobility include the following:
- Limiting the use of physical and chemical restraints
- Environmental modifications
- Patient education
- Implementation of activity protocols and
- 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 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.
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 to 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 in patient mobilization. According to the American Heart Association, 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.
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