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DECONDITIONING

 

INTRODUCTION

The term deconditioning is almost never used in clinical practice and rarely in medico-legal practice.  It is however, a well-recognised situation whereby an organism such as a human, actually adapts to a less demanding environment or there is a physiological adaptation to what are current normal condition.

Within the setting of surgery, injury and illness deconditioning results from decreased physical activity.  Deconditioning may occur just as a consequence of reduced physical activity, which in turn will result in muscle loss including heart muscle.  In clinical practice, deconditioning commonly occurs in two situations.  The first being a sedentary lifestyle which is common in older people even without significant disease or disability, which then leads to a chronic decline in physical fitness.  The second arises if bed or chair rest is either advised or considered best during an acute illness.  This will lead rapidly to a significant and potentially disastrous physical decline.

Once muscle strength and muscle bulk diminishes, then this will become the most important and consistent feature of deconditioning.  Physiological changes occur with a reduced ability to take up oxygen during exercise, there will be an impairment of balance responses and decreased cardiac output.  Whether these are the cause or the effect of deconditioning is still uncertain.

It is also likely that physical, that is structural changes occur in the brain.  This is similar to what is being found in a range of disorders.

In an older population, it is necessary to consider whether there is just aging or deconditioning. It is much more likely to be deconditioning in older people with demotivation and possible cerebral vascular disease, dementia or even arthritis being responsible.  The use of drugs including the statins, medicines to reduce gastric acid and medications to reduce blood pressure will also be an important consideration as they may cause tiredness and/or muscle pain.

Within the legal process, it is apparent that many individuals with chronic pain, recovery from surgery and polytrauma will have a psychological and emotional state that contribute to deconditioning.   This is an avoidable state.  Early treatments so rarely available will reduce the likelihood of this happening.

When individuals within the legal process, are constantly being told that they have had injury and then being questioned incessantly about how “bad” they are, it isn’t surprising that with this perception there is enduring negativity this impacts on what would be a normal trajectory of recovery and a re-establishment of normal conditioning.

I have been involved in a number of cases where an illusion of for instance  brain injury has been fuelled by the legal process, possibly even diagnosed erroneously by individuals who ought to know better and this in turn has fundamental consequences on the individual.  This has got nothing to do with malingering or elaboration to deceive, this is an induced or iatrogenic state that is caused by specialists and lawyers who generate a concept of fear.

The thinking would go something like this:-
I have been injured and I now have pain.  Pain is a sign of my injury.  If I do exercise I get pain and thereby I must be generating more injury.  The only way that I will stop injury is by doing no exercise and not mobilising such that I will not get any pain.

The way the body and in particular the brain works means that this could not be further from the truth.

In these circumstances, chronic pain is useless pain.  Once it has been shown that there is no need for any kind of surgical management, the treatment has to be medical, as is well discussed in many articles throughout my website and that of the Body Factory website www.bodyfactory.org.uk.

Everyone after injury requires a specific multi-disciplinary programme of treatment and frequently this is not provided or even available in the UK.  Although outside the brief of this article deconditioning frequently occurs during pregnancy when the consequence of back pain is so common linked into the loosening of ligaments that is part of pregnancy.

 

MUSCLE MASS AND AGING

Muscle mass does decline steadily with increasing age.  Muscle strength will reduce by 1-2% per year, but this does not apply to young people.  The loss of muscle mass is known as sarcopenia.  This isn’t just inactivity, as highly trained elderly athletes will have the same problem.  The pattern of muscle loss however, is different between the two groups.  Aging will result in a reduced number of muscle fibres, whereas deconditioning causes a reduction in muscle fibre size.  Sustained muscular activity requires adequate oxygen to be given to the muscle and the mitochondria are the energy producing part of the muscle cell.

With age the ability to uptake oxygen diminishes.  Similarly, cardiac output will be important in the delivery of oxygen. That may not necessarily be a problem for most people, but if there is any heart disease.  This will be an added compromise.

The degree to which decreased physical activity with increasing age is a cause rather than an effect of reduced muscle bulk is uncertain.  There is no question however, that exercise training programmes focussing on muscle strength, general fitness and stamina, improve exercise capacity.  Working on the balance mechanism as well will diminish the physical decline of old age.  It is not a cure but it will slow the process of sarcopenia.

 

THE EFFECTS OF SURGERY, INJURY AND ILLNESS

Part of the body’s natural mechanism in response to major trauma, surgery or illness is to break down skeletal muscle. This provides nitrogen and amino acids which pour into the circulation to help the immune system and assist in tissue repair. This is known as catabolism.

This is a natural mechanism to generate benefit, but the resultant loss of muscle mass and strength will impede recovery of normal function after surgery, injury and illness. If there is prior deconditioning with pre-existing muscle weakness, then there is a smaller reserve of muscle for consumption and an individual is going to be much less capable of recovery. This is even more so when individuals are obese and where exercise may not be the norm. These people represent a particularly difficult group of people to rehabilitate, as are those who do no exercise at all in advance of the problems arising.

 

INJURY LEADING TO DECONDITIONING

Within medico-legal practice injury leading to deconditioning comes to the forefront.  On the day of dictating this, the writer has done a medico-legal assessment, where an injured individual who was more than capable of driving told me that their solicitor (who had now fortunately left the practice) had told them not to restart driving as this would reduce the claim.

This frankly unhelpful comment had done significant damage to the individual, who could not understand why this advice had been given, but as you would expect had taken it.  The fact that any expert worth their salt, would immediately have identified that the injured party should have gone back to driving years previous, had not been impressed on the client and if anything their claim was going to be compromised by a failure to even attempt at mitigating loss.  What had happened however, was a deconditioning with regard to driving and a need to relearn.  That would be fairly straightforward given the deeply ingrained skill of driving, which can rapidly be pulled down from even a damaged brain.  When such negative comments arise within the legal process with regard to any impairment this causes untold damage to people who are already injured.

These comments are not made from a Defendant perspective, they are made as a clinician who specialises in getting people better.  I can only emphasise that we are not talking about elaboration to deceive.  If someone says they cannot walk and need a wheelchair and a video film shows that they are jumping into a swimming pool or riding a motorbike, then that is the behaviour of someone not telling the truth.  Individuals who are deconditioned will have a whole range of reasons why that has happened, but dragging them out of that state by a multi-disciplinary programme of treatment will pay huge dividends for the rest of their life.

 

PREVENTION AND TREATMENT OF DECONDITIONING

There was an old saying “use it or lose it” and this applies to everyone.  It is best to try and prevent deconditioning.  Regrettably the NHS I under duress, there is inadequate rehabilitation as a resource through most of the country.  Minimal physical and psychological therapies are offered to those who need them after injury, and hence deconditioning will inevitably occur.

Often it will be the rehabilitation specialist, neurologist or pain expert who will draw this to the attention of a Court and the legal process.

If there is deconditioning then diabetes mellitus, osteoporosis and a range of other conditions will become more apparent.  Physical therapy, maintenance of nutrition, medical management that is appropriate, psychological support and a full rehabilitation programme will help prevent deconditioning from the very first phase of an acute illness or injury.  Activity and independence should be promoted from the time of admission.  This almost never happens.  Education of the healthcare team about deconditioning is vital and yet I have never known it to happen.  There is no evidence that bedrest helps anything to help.  I know of no condition that will not be benefitted by a multi-disciplinary exercise programme.

An American study looking at individuals who were institutionalised over the age of 80, demonstrated that a full rehabilitation programme saw 1/3 of them able to live independently, a further 1/3 had their care needs reduced dramatically, but it did leave 1/3 not unexpectedly who could not be improved, which is not surprising given the age of the trial subjects.

In the elderly, exercise improves lower limb strength, exercise endurance, balance, speed of walking and overall levels of physical activity.  Practising specific skills not only improves muscle strength, but it will also generate functional benefit, that is reduced impairment and diminished functional handicap.

As many writers have observed, restoring the physical capability and independence in deconditioned hospital patients is particularly difficult, but setting measurable and obtainable goals and monitoring progress will lead to improvement (Shaun O’Keefe).  An active multi-disciplinary rehabilitation programme is essential.  Such programmes are available at the therapies and training centre in Harrow called The Body Factory.