Author:

Patrick Kortebein, MD
Aging
Affiliations:
From the Departments of PM&R and
Geriatrics, Central Arkansas Veterans
Healthcare System and University of
Arkansas for Medical Sciences, LITERATURE REVIEW
Arkansas.

Correspondence:
All correspondence should be
addressed to Patrick Kortebein, MD,
Rehabilitation for
PM&R and Geriatrics, Geriatric
Research, Education and Clinical
Hospital-Associated Deconditioning
Center (3J/149), Central Arkansas
Veterans Healthcare System,
University of Arkansas for Medical
Sciences, 2200 Fort Roots Drive,
ABSTRACT
North Little Rock, AR 72214. Kortebein P. Rehabilitation for hospital-associated deconditioning. Am J Phys
Med Rehabil 2009;88:66 –77
0894-9115/09/8801-0066/0
American Journal of Physical Functional decline associated with acute hospitalization may be termed “hospital-
Medicine & Rehabilitation associated deconditioning.” This seems to be a relatively common problem, with
Copyright © 2008 by Lippincott older adults most frequently affected. As the older adult population in the United
Williams & Wilkins
States is projected to double by 2030, the incidence of this condition is likely to
DOI: 10.1097/PHM.0b013e3181838f70 increase in a similar manner. Despite the prevalence of hospital-associated
deconditioning, there is a paucity of research examining the functional recovery
and rehabilitation of these patients. The available evidence to date indicates that
acute inpatient rehabilitation seems to be effective for improving function in
patients with hospital-associated deconditioning. However, there are no studies
examining other rehabilitation programs or long-term outcomes after rehabilita-
tion in this patient population. The purpose of this article is to review the current
state of knowledge regarding the rehabilitation of patients with hospital-associated
deconditioning, including terminology, epidemiology, etiology, current rehabilita-
tion recommendations, and future areas of research.
Key Words: Debility, Rehabilitation, Hospitalization, Aged

H ospitalization is often a life-changing event, particularly for older adults

and the critically ill. For many patients, acute hospitalization can result in a
significant decline in functional ability (Fig. 1) that is unrelated to a specific
neurological or orthopedic insult. This generalized functional decline is fre-
quently, albeit inconsistently, termed deconditioning,1– 4 although hospital-
associated deconditioning is perhaps more accurate. Older adults (generally
defined as ⱖ65 yrs old) are most commonly affected, and previous studies
indicate that ambulatory function or the ability to perform basic activities of
daily living (ADL), or both, declines in at least one third of older (ⱖ70 yr)
hospitalized patients.5– 8 Functional decline in conjunction with hospitalization
is associated with an increased risk of institutionalization and death in older
patients.9 –12 Younger patients with prolonged stays in a critical care setting may
also develop clinically significant deconditioning that can have a prolonged
deleterious effect on their functional abilities.13
At the time of hospital discharge, patients with significant functional
deficits due to hospital-associated deconditioning may receive postacute reha-
bilitation services, including acute and subacute (skilled nursing facility) inpa-
tient rehabilitation. This is an important issue for rehabilitation clinicians, as a

66 Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1

FIGURE 1 Functional decline during hospitalization.

recent report indicates that up to 18% of all inpa- Terminology

tient rehabilitation patients may have decondition-
Although deconditioning seems to be a succinct
ing.14 In addition, it is generally assumed that
and intuitive diagnostic term, it is used rather incon-
these patients recover function more promptly and
sistently in clinical medicine. Specifically, this term
completely with rehabilitation (see patient A, Fig.
seems to have two different meanings, depending
1). The need for postacute rehabilitation services
upon the context in which it is being used. Com-
for patients with hospital associated decondition-
monly, deconditioning is used to describe the physi-
ing is likely to increase in the coming decades as
ologic phenomenon associated with inactivity and
older adults represent the majority of hospitalized
disuse. In fact, a medical dictionary defines decondi-
patients, and this population is anticipated to dou-
tioning as “A loss of physical fitness due to failure to
ble by 2030.15 Also, deconditioning is recognized as
maintain an optimal level of physical activity or train-
a distinct rehabilitation condition for the certifica-
tion examinations administered by the American ing.”19 Similarly, Siebens et al.20 defined decondition-
Board of Physical Medicine and Rehabilitation.16 ing as “the multiple changes in organ system physi-
Thus, physiatrists, in particular, are required to ology that are induced by inactivity and reversed by
have expertise in the etiology and management of activity.” In this regard, deconditioning is cited as a
this condition. At this time, there has been only a contributing factor for a variety of medical condi-
limited amount of research examining the rehabil- tions.1,3,21–24 In a similar vein, chronic decondition-
itation of patients with hospital associated decon- ing is mentioned as one contributing causative factor
ditioning. However, the studies that have been for the functional decline that occurs with a multi-
published indicate that functional recovery is good tude of chronic medical disorders, including frailty,
for older (ⱖ65 yr) deconditioned patients receiving sarcopenia, congestive heart failure, and chronic ob-
acute inpatient rehabilitation.17,18 Outcomes in al- structive pulmonary disease.25–29
ternative rehabilitation settings, or with other re- However, in the vernacular of the acute hos-
habilitation interventions, are not known at this pital setting, the diagnosis “deconditioning” im-
time. This article will review the current state of plies much more than just inactivity. In this situ-
knowledge regarding rehabilitation for hospital as- ation, deconditioning seems to be applied nearly
sociated deconditioning including terminology, ep- ubiquitously by clinicians of all specialties to suc-
idemiology, etiology, current rehabilitation man- cinctly infer that due to the cumulative effect of a
agement, and future areas of research. prolonged or complicated hospitalization, a patient
A literature search of MEDLINE and the Co- has experienced a significant functional decline.1,3
chrane Database of Systematic Reviews was per- Thus, in the acute hospital setting, deconditioning
formed with the terms deconditioning, debility, is a cumulative multifactorial phenomenon (see
weakness, asthenia, exercise, hospital, hospitaliza- Etiology below), rather than a discrete condition
tion, and rehabilitation up to December 2007. In solely due to bed rest inactivity. However, despite
addition, pertinent chapters of physical medicine its frequent use in the clinical lexicon, there are
and rehabilitation textbooks were reviewed,2,4 and several, perhaps insurmountable, obstacles regard-
a hand search of the references and citations from ing the use of deconditioning as a clinical diagno-
these articles and textbooks was also performed. sis. Specifically, there is neither an International

January 2009 Rehabilitation for Hospital Deconditioning 67

 Classification of Diseases (9th Revision, Clinical condition. One author also reported that more
Modification, [ICD-9-CM]) code nor a National than 20% of rehabilitation consults at a large ter-
Library of Medicine Medical Subject Heading tiary care hospital had a diagnosis of decondition-
(MESH) term for deconditioning (although, “car- ing, although the diagnostic criteria were not pro-
diovascular deconditioning” is a MESH term). Ad- vided.2 In studies of older hospitalized patients,
ditionally, as with the alternative diagnoses men- more than 30% receive home health services,30
tioned below, there are no objective diagnostic while discharge to a nursing home may range from
criteria for deconditioning at this time. Since no 8% to 14%; however, skilled nursing facility reha-
ICD-9 code exists for deconditioning, by necessity, bilitation may not have been the intent for all of
one of several other diagnostic codes must be used the latter group of patients.9,11
in the clinical setting. Alternative diagnoses for The active implementation of the United States
which there are ICD-9 codes include debility, mus- Centers for Medicare and Medicaid Services “75%
cle wasting/disuse atrophy, asthenia, malaise/fa- rule” in 2004 has most certainly had a detrimental
tigue, and generalized weakness. Generalized impact on the number of patients admitted to
weakness or disuse atrophy may be the most ap- inpatient rehabilitation facilities for hospital asso-
propriate alternative to deconditioning, although ciated deconditioning.31 Although several legisla-
only muscle weakness, muscle atrophy, and asthe- tive changes to this rule have occurred during the
nia are MESH terms. Given these inconsistencies, past few years, deconditioning has never been one
it may be reasonable to convene an expert panel or of the 13 medical conditions recognized by Centers
task force to make recommendations regarding a for Medicare and Medicaid Services under the “75%
consistent terminology for functional decline associ- rule.” Therefore, there is a distinct disincentive for
ated with acute hospitalization. As rehabilitation a physician to use this, or one of the alternative
professionals primarily manage patients with diagnoses mentioned above, when admitting a pa-
hospital associated deconditioning, a uniform tient for inpatient rehabilitation. As such, acute
terminology for the specialty will help advance inpatient rehabilitation admissions for decondi-
research and education regarding this condition. tioning have likely declined, and the use of alter-
For the sake of consistency, the terms hospital native postacute rehabilitation services has likely
associated deconditioning and deconditioning will be increased. However, there is no research data at
used essentially synonymously throughout this arti- this time to document this potential shift in reha-
cle to characterize the functional decline that occurs bilitative care or the consequences of such a shift.
during acute hospitalization due to illness or injury,
or both, and unrelated to a specific neurological or Etiology
orthopedic insult, or both.
There are essentially an infinite number of
Epidemiology permutations of medical and surgical illnesses that
may result in the development of hospital associ-
The specific incidence and prevalence of hospital
ated deconditioning. However, as previously recog-
associated deconditioning are not known. This is
nized, there are several common etiologic factors
most certainly due to the absence of a consistent
contributing to hospital associated deconditioning,
diagnostic terminology, as well as the lack of specific
including the specific medical or surgical illness
objective diagnostic criteria. However, as patients
necessitating hospitalization, the adverse effects of
with significant hospital associated deconditioning
treatment (including surgical interventions, if per-
often receive postacute rehabilitation services of
tinent), bed rest inactivity, and the detrimental
some type (e.g., acute rehabilitation, skilled nurs-
effects of aging.1,3 Most of these will be discussed in
ing facility rehabilitation, home health services), a
greater detail later, as well as several other con-
general estimate of the prevalence of decondition-
tributing factors not previously considered.
ing may be inferred from this literature.
A recent United States Government Account-
ability Office report examining inpatient rehabili- Prehospitalization Functional
tation admission criteria for Medicare patients Capacity/Reserve
found that for fiscal year 2003, slightly more than Recently, Killewich3 noted that the baseline
5% of acute rehabilitation patients were admitted physiologic capacity and functional reserve of a
for debility.14 However, an additional 13% of these particular patient is a key factor in an individual
patients received rehabilitation for conditions patient’s susceptibility to deconditioning. Intu-
listed as “cardiac,” “pulmonary,” and “medically itively, this makes sense, as patients with a more
complex.” For a significant majority of this latter limited functional reserve before hospitalization
group of patients, hospital associated decondition- are that much closer to losing their functional
ing may have been their primary problem rather independence (patient A as compared with patient
than ongoing issues related to their acute medical B in Fig. 1). Thus, it is not surprising that older

68 Kortebein Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1

adults are at greater risk for hospital associated subjects, we have recently reported on the results
deconditioning, because physiologic and functional ca- of 10 days of bed rest in healthy older adult sub-
pacity decline with age, regardless of how these are jects.46 Our results indicate that older individuals
measured (e.g., maximal aerobic capacity, muscle are more sensitive to bed rest inactivity; on aver-
strength).32,33 Indeed, increased age, deficits in basic or age, these subjects lost almost 1 kg of lower ex-
instrumental ADL at hospital admission/discharge, or tremity lean tissue, whereas younger subjects in a
both, cognitive deficits, and use of a gait aid have all previous 14-day bed rest study lost only 650 g.47
been identified as risk factors for functional decline or Interestingly, despite substantial declines in lower
nursing home admission, or both, in older hospital- extremity strength (14%) and aerobic capacity
ized patients.6,9,34 –36 Sarcopenia (i.e., the age-related (12%), our older adult subjects had no significant
loss of muscle mass) is also recognized as a risk factor functional compromise, as assessed with validated
for functional disability in community-dwelling older functional instruments. These results provide sup-
adults.37 Sarcopenic individuals are quite likely at portive evidence that in healthy older adults, bed
increased risk for hospital associated deconditioning rest inactivity, in and of itself, is not sufficient to
because skeletal muscle is an important reservoir of induce the marked functional deficits that can oc-
amino acids during periods of stress and reduced cur with hospital associated deconditioning. How-
nutritional intake (e.g., acute hospitalization).38 In ever, in a patient who is functionally compromised
addition, a number of causative factors linked to sar- before hospitalization, bed rest alone may lead to
copenia are further compromised during acute hospi- significant functional impairment if similar deficits
talization (e.g., inadequate nutrition, inactivity).27,39 in strength and aerobic function occur. This situation
has not been studied. Anecdotally, the other adverse
Bed Rest/Immobility effects listed in Table 1 also occur in patients with
As noted previously, bed rest inactivity results hospital associated deconditioning, although these
in physiologic deconditioning. Multiple studies ex- have not been formally evaluated either.
amining the effects of bed rest have been reported
since at least the 1940s,40 – 42 although it is beyond Medical/Surgical Conditions and Comorbid
the scope of this article to discuss all of this liter- Illness
ature in detail. Several excellent reviews of this No studies have examined the specific medical
subject are available, and the adverse effects of bed or surgical problems that result in significant hos-
rest are summarized in Table 1.4,43– 45 pital associated deconditioning. In addition, asso-
Although virtually all of the research on the ciations with specific illnesses were not reported in
effects of bed rest has been completed in young studies examining functional decline in older hos-

TABLE 1 Adverse effects of bed rest/immobility

System Effect (s)

Musculoskeletal Skeletal muscle atrophy, decreased muscle protein synthesis, decreased muscle
strength and endurance (LExt ⬎ UExt, Extensors ⬎ Flexors)
Joint contractures (Hip/knee flexion)
Osteoporosis
Impaired balance/fall risk
Cardiovascular Decreased aerobic/cardiopulmonary function (e.g., VO2max) due to decreased
cardiac output from reduced venous return and stroke volume
Orthostatic hypotension (secondary to reduced blood volume and increased
venous compliance of lower extremities)
Venous thromboembolism
Pulmonary Atelectasis
Hypostatic pneumonia
Gastrointestinal Decreased appetite
Constipation
Genitourinary Urinary stasis, stones, and infection
Metabolic/endocrine Glucose intolerance
Dermatological Pressure ulcers
Psychological/behavioral Sensory deprivation
Disorientation/confusion
Depression/anxiety
Adapted from Halar and Bell4 and Harper and Lyles.43
LExt, lower extremities; UExt, upper extremities; VO2max, maximal aerobic capacity.

January 2009 Rehabilitation for Hospital Deconditioning 69

 pitalized patients, although, cardiopulmonary con- Consequences of Deconditioning
ditions were common.7,9 However, patients with The main effect of hospital associated decon-
certain comorbid illnesses may be at increased risk of ditioning is an impairment of overall functional
functional decline with relatively prolonged hospital- ability. These functional deficits seem to be primar-
ization. This would include patients with cancer, car- ily due to a generalized decline in skeletal muscle
diovascular disease (e.g., severe heart failure, cardiac strength/endurance and aerobic capacity, although
transplantation), chronic renal insufficiency, and changes in these parameters have not been for-
solid organ transplantation, as well as individuals mally studied. However, similar to the bed rest
with severe, long-standing chronic obstructive pul- interventions, the lower extremity extensor muscle
monary disease and those surviving critical ill- groups seem to be most affected. The resultant
ness.13,28,29,48 –51 In general, these patients have less functional deficits may vary considerably depend-
muscle mass at baseline, thus they are likely to lose ing on the severity of the deconditioning, although
more muscle and experience additional functional virtually all of these patients seem to have limited
decline with acute hospitalization. ambulatory endurance and difficulty climbing
Patients surviving treatment in a critical care stairs. More severely affected patients may have
setting may also have significant functional defi- deficits of bed mobility, transfers, and basic ADL.
cits. Although hospital associated deconditioning Falls are often a concern, as many of these patients
alone may explain this decline, some patients, par- may also have orthostatic hypotension, and im-
ticularly those treated with systemic corticoste- paired balance. This combination of functional def-
roids, may, alternatively or concomitantly, have icits often results in a loss of independence and the
critical illness polyneuropathy/myopathy.13,52 Al- need for postacute rehabilitation services (see pa-
though, studies in young subjects have docu- tient A, Fig. 1).
mented that the addition of corticosteroids exacer-
bates the catabolic effects of bed rest alone,53 an Rehabilitation Considerations
electrodiagnostic study should be performed to de- Determination of Postacute Rehabilitative
finitively diagnose critical illness polyneuropathy/
Care Setting
myopathy.
Determining the most appropriate postacute
rehabilitation setting for patients with hospital as-
Inflammation
sociated deconditioning can be challenging for a
Recent studies have documented a significant number of reasons, including the extreme diversity
correlation between elevated inflammatory markers of this patient population (e.g., functional deficits,
and muscle weakness in older community-dwelling medical problems). Ideally, each patient should
adults,54 as well as older hospitalized patients.55 transition from an acute hospital setting to the
rehabilitation setting that can provide the most effi-
Nutrition cacious, and cost-effective, rehabilitation program for
It is well known that caloric intake during that particular patient, taking into consideration
acute hospitalization is suboptimal, especially in unique medical problems and functional deficits.
older adult and critically ill patients.56,57 Compro- However, multiple additional factors must be consid-
mised nutrition and reduced protein intake, in ered, including several that are difficult to objectively
particular, are associated with increased mortality evaluate. Variables to be considered in this decision-
in hospitalized patients.38,56 making process include the following: prehospitaliza-
tion functional status and living setting (e.g., single
vs. multilevel dwelling), social support available (e.g.,
Other family/friends), current active medical problems, cur-
A number of less well-studied factors may also rent physical or occupational therapy (PT/OT) toler-
contribute to functional decline and hospital asso- ance, cognition/ability to learn, patient motivation,
ciated deconditioning, including anemia, pain, patient/family preference, financial resources/insur-
sleep deprivation, fatigue, and depression. ance coverage, and potential for functional recovery.
Although the contribution of each of the above Determining the best rehabilitation fit for a particular
etiologic factors will certainly vary from patient to patient can be problematic as several of these vari-
patient, the cumulative effect is very similar (i.e., ables are largely subjective (e.g., potential for recov-
deconditioning). Further studies may examine the ery). Assessing a patient’s ability to participate in an
specific impact of each of these factors, as well as acute inpatient rehabilitation setting can be particu-
other as yet unidentified etiologic components of larly challenging as approximately 3 hrs of daily ther-
hospital associated deconditioning. This informa- apy is required, whereas acutely hospitalized patients
tion may then be utilized for preventive and treat- may, at most, receive approximately 1 hr of therapy
ment interventions. per day. However, data from two recent studies of

70 Kortebein Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1

deconditioned patients indicate that a significant ma- outcomes of rehabilitation for patients with hospi-
jority of these patients are successful with this tran- tal associated deconditioning in these various set-
sition.17,18 tings. However, two published studies have evalu-
Recently, a guideline developed by an expert task ated older adult patients participating in acute
force of the American Academy of Physical Medicine inpatient rehabilitation. Raj et al.17 reported on a
and Rehabilitation has been promulgated to assist select population of deconditioned patients older
clinicians and other interested parties in deciding the than the age of 55 yrs (mean, 72 yrs) from a single
appropriateness of patients for acute inpatient reha- facility. Before hospitalization, 100% of these pa-
bilitation.58 Although, this algorithm may be applied tients had resided in the community, whereas 94%
to virtually any patient in an acute medical inpatient were admitted from an acute hospital. These pa-
setting, it is primarily intended as guidance in deter- tients made substantial functional gains, and 71%
mining the appropriateness of a particular patient for were discharged home. However, 20% of these
acute inpatient rehabilitation as opposed to a skilled patients were discharged back to an acute hospital.
nursing facility. Although inpatient rehabilitation en- More recently, we reported on the outcomes of a
tails substantially more therapy on a daily basis, these similar patient population from a large national
patients are also more medically complex, thus close rehabilitation database. Specifically, we examined
medical supervision by an appropriately trained phy- data on patients older than 65 yrs of age (mean, 80
sician (typically a physiatrist) and 24-hr nursing cov- yrs) that were admitted for inpatient rehabilitation
erage are required. As per the recommendations of a during 2002–2003 with a diagnosis of debility.18
recent government report, this algorithm places a This cohort included nearly 15,000 adults with a
primary emphasis on function as an evaluation crite- primary debility diagnosis; 97% had previously
rion rather than specific medical diagnoses.14 been living in the community, and almost 90% had
As alluded to previously, the goal of any post- been admitted from an acute hospital setting. We
acute rehabilitation program for a patient with found that nearly 70% of these patients had been
hospital associated deconditioning should be to discharged back to the community, whereas only
maximize functional recovery and independence in 12% had been discharged to an acute medical fa-
a safe, cost-effective manner. The specific rehabil- cility. In both of these studies, a majority of the
itation program prescribed should be appropriately patients were discharged home, and the measured
challenging and progressive to reach this goal. In a functional improvement of these patients was at
practical sense, the ultimate goal of rehabilitation least as good as that previously reported for tradi-
for most, if not all, of these patients is to achieve tional rehabilitation populations, including stroke,
sufficient functional recovery to return to (or re- and brain dysfunction.59 Additional studies of this
main in) an independent living situation (i.e., patient population are needed, including evalua-
home alone or with family or assisted living). Thus, tions with more extended follow-up to determine if
deconditioned patients that had been residing in a postacute rehabilitation (acute inpatient or other) of
nursing home before acute hospitalization will, in these patients results in persistence of these func-
general, be expected to return to that setting di- tional improvements or improved long-term survival,
rectly, although there are exceptions. or both.
There are no studies specifically examining
Rehabilitation Settings patients with a diagnosis of deconditioning (or
At this time, there are essentially four rela- debility) for the other rehabilitation settings noted
tively distinct postacute rehabilitation settings for previously (e.g., skilled nursing facilities). However,
patients with clinically significant hospital associ- Johnson et al.60 evaluated functional recovery and
ated deconditioning: acute inpatient rehabilitation survival in three groups of Medicare patients (“med-
hospitals/units, skilled nursing facilities (often ical/surgical patients,” stroke and hip fracture) par-
referred to as “subacute rehabilitation”), home ticipating in rehabilitation in a skilled nursing facility
health care, and outpatient therapy. For older de- (87% of “medical/surgical patients”) or an inpatient
conditioned patients in the Veterans Administra- rehabilitation hospital. As the medical/surgical pa-
tion (VA) system, Geriatric Evaluation and Manage- tients had experienced a functional decline with hos-
ment (GEM) units are an additional option. Acute pitalization, this patient group may be similar to the
inpatient rehabilitation is the most rigorous, as patient populations discussed above.17,18 The medi-
patients must participate in at least 3 hrs of therapy cal/surgical patients patients were more likely to re-
per day, although they may transition up to this gain premorbid function, although their 1-yr mortal-
level over 10 –14 days. Therapy in the other set- ity rate was 30%. In other studies of older adults
tings listed typically ranges from 45 to 90 mins per receiving postacute rehabilitation (acute inpatient or
session, one to five times per week. VA GEM unit), the percentage of patients with a
Unfortunately, there is a very little data com- distinct diagnosis of deconditioning is either very
paring, let alone examining, the effectiveness and limited61 or is unknown as specific diagnoses were

January 2009 Rehabilitation for Hospital Deconditioning 71

 not listed.62,63 Interventions to prevent functional
TABLE 2 Rehabilitation therapy for hospital-
decline during acute hospitalization in older adults associated deconditioning
have included formal exercise training programs;
however, these have either been ineffective or not Physical therapy
feasible when attempted.20,64,65 However, physical ● Bed mobility/transfers
therapy (PT) in conjunction with a specialized com- ● Gait and balance training
prehensive geriatric program during acute hospital- ● Ambulatory endurance with/without gait aid/stair
climbing
ization has been documented to improve function ● Muscle strength and endurance training—hip
and long-term survival.66 and knee extensors primarily
● Range of motion and muscle flexibility/stretching
Rehabilitative Therapy Program of major joints and muscle groups of the lower
As previously noted, the primary goal of all extremities
postacute rehabilitative therapy programs for pa- Occupational therapy
tients with hospital associated deconditioning ● Activities of daily living (ADL) training, including
should be to maximize functional recovery and fine motor skills and adaptive equipment needs
● Instrumental ADL/homemaking/community
independence and to return each patient to an survival skills
independent living situation. Although the rehabil- ● Cognitive and safety awareness assessment and
itation programs for these patients may seem rel- remediation, if needed
atively intuitive, all current programs are almost ● Range of motion and muscle flexibility/stretching
exclusively based on historical tradition rather than of major muscle groups of the upper extremities
to facilitate ADL training
rigorous scientific evaluation or evidence-based med- ● Energy conservation and joint protection
icine. Thus, it is not surprising that there are no data principles, if needed
to indicate that one particular type of rehabilitative ● Muscle strength and endurance training—shoulder
therapy program or regimen is more effective than abductors/adductors, elbow flexors/extensors, and
any other for patients with hospital associated decon- finger flexors/grip strength
ditioning. However, the limited evidence presented
above indicates that at least for acute inpatient reha-
bilitation, these patients fare well. In the following
discussion, acute inpatient rehabilitation will be used training with functional body weight exercises (e.g.,
as a model of rehabilitative care for patients with partial squats), elastic resistance bands, or specific
hospital associated deconditioning, although the resistance exercise equipment (e.g., isotonic or isoki-
same rehabilitation principles can be applied to the netic) may be utilized in conjunction with a func-
other rehabilitation settings mentioned. The primary tional therapy program. There are no data to indicate
therapeutic interventions for deconditioned patients if, or how frequently, these types of exercises are
are outlined in Table 2. However, the overall rehabil- currently included as part of the therapy program for
itative therapy program must be tailored to the spe- deconditioned patients. However, there is some evi-
cific needs of each individual patient. dence that in the VA GEM setting, supplemental
resistance training may be of benefit,67 and task-
Physical Therapy specific resistance training for transfers has been ben-
As the most significant deficits for patients eficial for older ADL impaired adults.68
with hospital associated deconditioning include Ambulatory endurance training is virtually al-
lower extremity muscle strength and endurance, as ways a major component of the PT program for
well as basic mobility and ambulatory endurance, deconditioned patients. Typically, this will include
PT is arguably the most important aspect of their walking progressively longer distances with each
rehabilitation program. Functional therapeutic in- therapy session, or at least daily ambulation. Gait aids
terventions for deconditioned individuals may (e.g., cane, walker) are used as needed for patients
range from basic bed mobility and transfer training with lower extremity weakness or impaired balance,
to longer distance ambulation, stair climbing, and and a platform walker may be helpful for severely
instrumental ADL. These functional activities may deconditioned patients. As deconditioned patients are
be supplemented with a strength and endurance often at risk for falls, static and dynamic balance
training program focused on the hip and knee training may be incorporated into the therapy pro-
extensors in particular. Formal upper extremity gram, as well. Formal testing for orthostatic hypoten-
strength training may be incorporated as well, or sion or other pertinent medical conditions (e.g., ar-
this may be deferred to OT. However, strengthen- rhythmia, peripheral polyneuropathy) should be
ing the “crutch group” muscles (i.e., shoulder ad- performed if indicated. Deconditioned patients may
ductors, scapular stabilizers, and elbow extensors) also develop restricted joint motion from muscle con-
may be included in the therapy program of patients tractures or capsular adhesions related to prolonged
reliant on a gait aid, such as a walker. Strength supine bed rest. The hip and knee flexors are most

72 Kortebein Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1

commonly at risk, and formal range of motion ther- excellent reviews and position statements are avail-
apy (e.g., active or active assisted) and stretching may able regarding prescribing exercise in adults, in-
be required if these problems do not improve with a cluding older adults with chronic stable medical
standard functional therapy program. conditions.70 –72 It would seem reasonable to adapt
some or all of these exercise recommendations to
Occupational Therapy deconditioned patients participating in postacute
The OT program for deconditioned patients is rehabilitation. Parameters of interest might in-
primarily focused on achieving independence in clude intensity, frequency, or duration of rehabili-
basic ADL, as well as instrumental ADL (sometimes tation therapy/exercise in each postacute setting.
referred to as “community survival skills”). In ad- For instance, applying a specific intensity of ther-
dition to personal care skills, this may include apy as measured by rating of perceived exertion73
basic homemaking skills, such as meal preparation might be evaluated.
and safety awareness, if a patient is to return home Therapeutic exercise (i.e., PT/OT) is the pri-
alone. This program often includes fine motor train- mary treatment intervention during postacute re-
ing to improve functional activities (e.g., buttoning habilitation for patients with hospital associated
clothes), although adaptive equipment aids may be deconditioning, although certain anabolic medica-
required to compensate for specific deficits. Activities tions may augment the functional recovery of ther-
to improve upper extremity endurance (e.g., peg apy alone. To date, the only published studies have
boards) may be incorporated, as well as formal upper used testosterone in male VA GEM unit patients. In
extremity strengthening and endurance exercises, in- a pilot study, Bakhshi et al.74 reported significantly
cluding training with an upper extremity ergometer. greater functional gains, while Sullivan et al.75 in
Energy conservation techniques are provided to pa- a larger study of hypogonadal men reported no
tients with significant exertional fatigue, and instruc- change in function with testosterone or a high-
tion in joint protection principles may be warranted intensity resistance exercise program.
for patients with impaired hand function due to os- Although rehabilitation, in general, and cer-
teoarthritis, for instance. tain rehabilitation interventions/settings, in par-
The specific variables associated with maxi- ticular, are believed to provide more rapid and
mizing functional recovery during postacute reha- complete functional recovery for patients with
bilitation in deconditioned patients are not known. hospital associated deconditioning (see patient
However, a variety of factors needs to be consid- A, Fig. 1) there are no supportive data for this
ered, including the training and experience of the assertion. In addition, there are no data available
therapist(s) (PT and/or OT), patients past experi- to indicate what is the most efficacious postacute
ence with therapy or exercise, the rehabilitation rehabilitation program for a particular patient,
environment/facility (including available space/ or group of patients, with hospital associated
equipment), as well as the specific type of therapy deconditioning. Future evaluations of this pa-
provided (e.g., functional activities only or specific tient population should consider recently pub-
aerobic and resistance exercises). For instance, one lished recommendations for evaluating rehabili-
advantage of home health therapy may be that pa- tation treatments and effectiveness.76,77
tients are able to “train” in their home environment,
whereas therapists in the other settings must simu- Safety Concerns
late, often from patient or family descriptions, a pa- Contraindications to postacute rehabilitation
tient’s home environment. The total daily “dose” of may include all those listed in Table 3.78 In addi-
rehabilitative therapy is another key factor; while tion, clinicians managing these patients in a skilled
therapy sessions typically last 45 mins regardless of nursing facility or acute rehabilitation setting
setting, PT and OT are each required twice per day (3 should be cognizant of other medical conditions,
hrs total) at least 5 days per week during acute inpa- such as significant anemia or thrombocytopenia, as
tient rehabilitation and generally only once per day these are likely more common in these settings.79
for the other rehabilitation settings (45–90 mins total For patients with known or suspected cardiac
per day). Other variables that may affect outcomes in disease, specific heart rate limits or restrictions
these patients include intrinsic patient motivation,69 may be enforced during rehabilitative therapies,
pain, impaired sleep, fatigue, depression, and cogni- although no evidence-based parameters regarding
tive deficits. such limits are available for any of the postacute
Patients with hospital associated decondition- rehabilitation settings. However, there are exercise
ing may, in many respects, be considered untrained guidelines for general cardiac rehabilitation and
“functional” athletes. Using this paradigm, it may heart failure patients, as well as information re-
be worthwhile investigating the application of rec- garding the risk of acute cardiovascular events re-
ognized and effective exercise conditioning princi- lated to exercise.28,80 – 82 This literature may be
ples to the rehabilitation of these patients. Several helpful in identifying appropriate exercise parame-

January 2009 Rehabilitation for Hospital Deconditioning 73

 ing would be ideal, although this is impractical for
TABLE 3 Contraindications to participation in
therapeutic exercise/rehabilitation a number of reasons. Thus, recommendations re-
garding safety monitoring during exercise for com-
Unstable angina or severe left main coronary munity-dwelling older adults may be adapted to
disease deconditioned patients participating in postacute
End-stage congestive heart failure rehabilitation.83
Severe valvular heart disease
Malignant or unstable arrhythmias
Elevated resting blood pressure (systolic, ⬎200 General Medical Issues
mm Hg, diastolic, ⬎110 mm Hg)
Large or expanding aortic aneurysm Although functional recovery is the focus of
Known cerebral aneurysm or recent intracranial postacute rehabilitation for patients with hospital
bleed associated deconditioning, all of the adverse effects
Uncontrolled or end-stage systemic disease of bed rest/immobility listed in Table 1 should be
Acute retinal hemorrhage or recent ophthalmologic
surgery considered and addressed as needed.4 Although it is
Acute or unstable musculoskeletal injury beyond the scope of this article to address all of
Acute illness with systemic features (e.g., these issues, several problems warrant mention.
pneumonia) For instance, a primary concern in virtually all
Severe dementia or behavioral disturbance
patients that have been exposed to prolonged bed
Reprinted with permission from Elsevier: Bean JF, Vora rest should be surveillance or prophylaxis, or
A, Frontera WF: Benefits of exercise for community-dwell-
ing older adults. Arch Phys Med Rehabil 2004; 85: S33. both, for venous thromboembolism (VTE). VTE
is relatively common in hospitalized patients
(⬃15% incidence), and deconditioned patients
are likely also at increased risk immediately after
ters for deconditioned patients with cardiac disease acute hospital discharge.84 Guidelines for VTE
participating in postacute rehabilitative therapy. Of prophylaxis are available, although the duration
note, individuals that are habitually the least phys- of prophylaxis is unclear.84,85 Some clinicians
ically active have the greatest incidence of cardiac may use ambulatory function (e.g., ambulation
events related to exercise.81 Thus, a formal assess- ⬎100 –150 feet) as an indication that it is safe to
ment of cardiac risk factors, past cardiac history, discontinue these measures, although there is no
and perhaps prehospitalization physical activity to research to support this recommendation. Other
assess a particular patients risk may be worthwhile. conditions to be considered in this patient pop-
As these deconditioned patients are, in fact, exer- ulation include orthostatic hypotension, skin
cising during therapy, formal exercise stress test- breakdown/pressure ulcers, constipation, and

Table 4 Suggested research topics related to rehabilitation for hospital-associated deconditioning

1. Develop a consensus regarding terminology for functional decline associated with acute hospitalization to
further research and educate on this condition
2. Develop distinct, relatively objective diagnostic criteria
3. Evaluate the efficacy and outcomes of current rehabilitation programs, including randomized trials, if
possible
● Suggested outcome parameters: functional gain/efficiency, discharge location, recurrent hospitalization
rates during and after rehabilitation, short- and long-term survival, and persistence of functional
improvement
● Identify the specific components of current rehabilitation programs that maximize functional recovery
● Identify specific predictive criteria to determine patients most likely to benefit from each type of
rehabilitation program/setting currently available (i.e., acute inpatient, subacute/skilled nursing,
outpatient, home health care)
● Determine if distinct and/or relatively specific admission criteria can be developed for each of the
currently available rehabilitation settings
4. Evaluate the efficacy of novel rehabilitation/functional therapeutic exercise programs utilizing an exercise
conditioning paradigm (i.e., mode/specificity, intensity, frequency, and duration of therapeutic exercise)
● Suggested therapeutic exercise interventions: aerobic/cardiopulmonary exercise, resistance/power exercise
training, balance, and flexibility
● Evaluate the safety of these novel exercise programs
5. Evaluate alternative interventions (before or during postacute rehabilitation)
● Pharmacological agents (e.g., testosterone, other anabolic agents)
● Nutritional supplementation (e.g., essential amino acids, creatine monohydrate)

74 Kortebein Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1

compromised nutritional intake (e.g., total calo- 8. Covinsky KE, Justice AC, Rosenthal GE, et al: Mea-
ries and protein). suring prognosis and case mix in hospitalized elders.
J Gen Intern Med 1997;12:203– 8
CONCLUSION 9. Rudberg MA, Sager MA, Zhang J: Risk factors for
nursing home use after hospitalization for medical
Deconditioning is a fundamental rehabilita-
illness. J Gerontol A Biol Sci Med Sci 1996;51A:
tion problem that may affect a broad spectrum of M189 –94
patients. For patients experiencing a functional
decline in an acute hospital setting, the term hos- 10. Covinsky KE, Palmer RM, Fortinsky RH, et al: Loss of
independence in activities of daily living in older adults
pital associated deconditioning may be applied.
hospitalized with medical illnesses: increased vulnerabil-
This multifactorial condition seems to be relatively ity with age. J Am Geriatr Soc 2003;51:451–8
prevalent, particularly in older adults. However,
hospital associated deconditioning is currently not 11. Fortinsky RH, Covinsky KE, Palmer RM, et al: Ef-
fects of functional status changes before and during
well defined or adequately characterized. In addi-
hospitalization on nursing home admission of older
tion, the optimal postacute rehabilitation program
adults. J Gerontol A Biol Sci Med Sci 1999;54A:
for patients with hospital associated decondition- M521–M526
ing is not known, although rehabilitation may oc-
12. Walter LC, Brand RJ, Counsell SR, et al: Develop-
cur in one of several settings. Recent evidence
ment and validation of a prognostic index for 1-year
indicates that the functional recovery of decondi-
mortality in older adults after hospitalization. JAMA
tioned patients participating in acute inpatient re- 2001;285:2987–94
habilitation is quite favorable. However, a substan-
13. Herridge MS, Cheung AM, Tansey CM, et al: One-
tial amount of research related to this condition is
year outcomes in survivors of the acute respira-
needed, and suggested research topics related to
tory distress syndrome. N Engl J Med 2003;348:
hospital associated deconditioning and the rehabil- 683–93
itation of this condition are outlined in Table 4.
The rehabilitation community is uniquely qualified 14. Medicare: more specific criteria needed to classify in-
patient rehabilitation. Report to the Senate Committee
to address these questions, and should be at the
on Finance and the House Committee on Ways and
forefront in developing a research program for Means. Washington (DC), Government Accountability
deconditioning, in general, and for hospital associ- Office, April 2005. Publ GAO-05-366; 2005
ated deconditioning, in particular.
15. He W, Sengupta M, Velkoff VA, et al. U.S. Census
Bureau, Current Population Reports, P23-209, 65⫹
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