Author:
Patrick Kortebein, MD
Affiliations:
From the Departments of PM&R and
Geriatrics, Central Arkansas Veterans
Healthcare System and University of
Arkansas for Medical Sciences,
Arkansas.
Correspondence:
All correspondence should be
addressed to Patrick Kortebein, MD,
PM&R and Geriatrics, Geriatric
Research, Education and Clinical
Center (3J/149), Central Arkansas
Veterans Healthcare System,
University of Arkansas for Medical
Sciences, 2200 Fort Roots Drive,
North Little Rock, AR 72214.
0894-9115/09/8801-0066/0
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2008 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0b013e3181838f70
66
Aging
LITERATURE REVIEW
Rehabilitation for
Hospital-Associated Deconditioning
ABSTRACT
Kortebein P. Rehabilitation for hospital-associated deconditioning. Am J Phys
Med Rehabil 2009;88:66 –77
Functional decline associated with acute hospitalization may be termed “hospital-
associated deconditioning.” This seems to be a relatively common problem, with
older adults most frequently affected. As the older adult population in the United
States is projected to double by 2030, the incidence of this condition is likely to
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
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-
tient rehabilitation patients may have decondition-
ing.14 In addition, it is generally assumed that
these patients recover function more promptly and
completely with rehabilitation (see patient A, Fig.
1). The need for postacute rehabilitation services
for patients with hospital associated decondition-
ing is likely to increase in the coming decades as
older adults represent the majority of hospitalized
patients, and this population is anticipated to dou-
ble by 2030.15 Also, deconditioning is recognized as
a distinct rehabilitation condition for the certifica-
tion examinations administered by the American
Board of Physical Medicine and Rehabilitation.16
Thus, physiatrists, in particular, are required to
have expertise in the etiology and management of
this condition. At this time, there has been only a
limited amount of research examining the rehabil-
itation of patients with hospital associated decon-
ditioning. However, the studies that have been
published indicate that functional recovery is good
for older (ⱖ65 yr) deconditioned patients receiving
acute inpatient rehabilitation.17,18 Outcomes in al-
ternative rehabilitation settings, or with other re-
habilitation interventions, are not known at this
time. This article will review the current state of
knowledge regarding rehabilitation for hospital as-
sociated deconditioning including terminology, ep-
idemiology, etiology, current rehabilitation man-
agement, and future areas of research.
A literature search of MEDLINE and the Co-
chrane Database of Systematic Reviews was per-
formed with the terms deconditioning, debility,
weakness, asthenia, exercise, hospital, hospitaliza-
tion, and rehabilitation up to December 2007. In
addition, pertinent chapters of physical medicine
and rehabilitation textbooks were reviewed,2,4 and
a hand search of the references and citations from
these articles and textbooks was also performed.
January 2009
Terminology
Although deconditioning seems to be a succinct
and intuitive diagnostic term, it is used rather incon-
sistently in clinical medicine. Specifically, this term
seems to have two different meanings, depending
upon the context in which it is being used. Com-
monly, deconditioning is used to describe the physi-
ologic phenomenon associated with inactivity and
disuse. In fact, a medical dictionary defines decondi-
tioning as “A loss of physical fitness due to failure to
maintain an optimal level of physical activity or train-
ing.”19 Similarly, Siebens et al.20 defined decondition-
ing as “the multiple changes in organ system physi-
ology that are induced by inactivity and reversed by
activity.” In this regard, deconditioning is cited as a
contributing factor for a variety of medical condi-
tions.1,3,21–24 In a similar vein, chronic decondition-
ing is mentioned as one contributing causative factor
for the functional decline that occurs with a multi-
tude of chronic medical disorders, including frailty,
sarcopenia, congestive heart failure, and chronic ob-
structive pulmonary disease.25–29
However, in the vernacular of the acute hos-
pital setting, the diagnosis “deconditioning” im-
plies much more than just inactivity. In this situ-
ation, deconditioning seems to be applied nearly
ubiquitously by clinicians of all specialties to suc-
cinctly infer that due to the cumulative effect of a
prolonged or complicated hospitalization, a patient
has experienced a significant functional decline.1,3
Thus, in the acute hospital setting, deconditioning
is a cumulative multifactorial phenomenon (see
Etiology below), rather than a discrete condition
solely due to bed rest inactivity. However, despite
its frequent use in the clinical lexicon, there are
several, perhaps insurmountable, obstacles regard-
ing the use of deconditioning as a clinical diagno-
sis. Specifically, there is neither an International
Rehabilitation for Hospital Deconditioning 67
 Classification of Diseases (9th Revision, Clinical
Modification, [ICD-9-CM]) code nor a National
Library of Medicine Medical Subject Heading
(MESH) term for deconditioning (although, “car-
diovascular deconditioning” is a MESH term). Ad-
ditionally, as with the alternative diagnoses men-
tioned below, there are no objective diagnostic
criteria for deconditioning at this time. Since no
ICD-9 code exists for deconditioning, by necessity,
one of several other diagnostic codes must be used
in the clinical setting. Alternative diagnoses for
which there are ICD-9 codes include debility, mus-
cle wasting/disuse atrophy, asthenia, malaise/fa-
tigue, and generalized weakness. Generalized
weakness or disuse atrophy may be the most ap-
propriate alternative to deconditioning, although
only muscle weakness, muscle atrophy, and asthe-
nia are MESH terms. Given these inconsistencies,
it may be reasonable to convene an expert panel or
task force to make recommendations regarding a
consistent terminology for functional decline associ-
ated with acute hospitalization. As rehabilitation
professionals primarily manage patients with
hospital associated deconditioning, a uniform
terminology for the specialty will help advance
research and education regarding this condition.
For the sake of consistency, the terms hospital
associated deconditioning and deconditioning will be
used essentially synonymously throughout this arti-
cle to characterize the functional decline that occurs
during acute hospitalization due to illness or injury,
or both, and unrelated to a specific neurological or
orthopedic insult, or both.
Epidemiology
The specific incidence and prevalence of hospital
associated deconditioning are not known. This is
most certainly due to the absence of a consistent
diagnostic terminology, as well as the lack of specific
objective diagnostic criteria. However, as patients
with significant hospital associated deconditioning
often receive postacute rehabilitation services of
some type (e.g., acute rehabilitation, skilled nurs-
ing facility rehabilitation, home health services), a
general estimate of the prevalence of decondition-
ing may be inferred from this literature.
A recent United States Government Account-
ability Office report examining inpatient rehabili-
tation admission criteria for Medicare patients
found that for fiscal year 2003, slightly more than
5% of acute rehabilitation patients were admitted
for debility.14 However, an additional 13% of these
patients received rehabilitation for conditions
listed as “cardiac,” “pulmonary,” and “medically
complex.” For a significant majority of this latter
group of patients, hospital associated decondition-
ing may have been their primary problem rather
than ongoing issues related to their acute medical
68 Kortebein
condition. One author also reported that more
than 20% of rehabilitation consults at a large ter-
tiary care hospital had a diagnosis of decondition-
ing, although the diagnostic criteria were not pro-
vided.2 In studies of older hospitalized patients,
more than 30% receive home health services,30
while discharge to a nursing home may range from
8% to 14%; however, skilled nursing facility reha-
bilitation may not have been the intent for all of
the latter group of patients.9,11
The active implementation of the United States
Centers for Medicare and Medicaid Services “75%
rule” in 2004 has most certainly had a detrimental
impact on the number of patients admitted to
inpatient rehabilitation facilities for hospital asso-
ciated deconditioning.31 Although several legisla-
tive changes to this rule have occurred during the
past few years, deconditioning has never been one
of the 13 medical conditions recognized by Centers
for Medicare and Medicaid Services under the “75%
rule.” Therefore, there is a distinct disincentive for
a physician to use this, or one of the alternative
diagnoses mentioned above, when admitting a pa-
tient for inpatient rehabilitation. As such, acute
inpatient rehabilitation admissions for decondi-
tioning have likely declined, and the use of alter-
native postacute rehabilitation services has likely
increased. However, there is no research data at
this time to document this potential shift in reha-
bilitative care or the consequences of such a shift.
Etiology
There are essentially an infinite number of
permutations of medical and surgical illnesses that
may result in the development of hospital associ-
ated deconditioning. However, as previously recog-
nized, there are several common etiologic factors
contributing to hospital associated deconditioning,
including the specific medical or surgical illness
necessitating hospitalization, the adverse effects of
treatment (including surgical interventions, if per-
tinent), bed rest inactivity, and the detrimental
effects of aging.1,3 Most of these will be discussed in
greater detail later, as well as several other con-
tributing factors not previously considered.
Prehospitalization Functional
Capacity/Reserve
Recently, Killewich3 noted that the baseline
physiologic capacity and functional reserve of a
particular patient is a key factor in an individual
patient’s susceptibility to deconditioning. Intu-
itively, this makes sense, as patients with a more
limited functional reserve before hospitalization
are that much closer to losing their functional
independence (patient A as compared with patient
B in Fig. 1). Thus, it is not surprising that older
Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1
adults are at greater risk for hospital associated
deconditioning, because physiologic and functional ca-
pacity decline with age, regardless of how these are
measured (e.g., maximal aerobic capacity, muscle
strength).32,33 Indeed, increased age, deficits in basic or
instrumental ADL at hospital admission/discharge, or
both, cognitive deficits, and use of a gait aid have all
been identified as risk factors for functional decline or
nursing home admission, or both, in older hospital-
ized patients.6,9,34 –36 Sarcopenia (i.e., the age-related
loss of muscle mass) is also recognized as a risk factor
for functional disability in community-dwelling older
adults.37 Sarcopenic individuals are quite likely at
increased risk for hospital associated deconditioning
because skeletal muscle is an important reservoir of
amino acids during periods of stress and reduced
nutritional intake (e.g., acute hospitalization).38 In
addition, a number of causative factors linked to sar-
copenia are further compromised during acute hospi-
talization (e.g., inadequate nutrition, inactivity).27,39
Bed Rest/Immobility
As noted previously, bed rest inactivity results
in physiologic deconditioning. Multiple studies ex-
amining the effects of bed rest have been reported
since at least the 1940s,40 – 42 although it is beyond
the scope of this article to discuss all of this liter-
ature in detail. Several excellent reviews of this
subject are available, and the adverse effects of bed
rest are summarized in Table 1.4,43– 45
Although virtually all of the research on the
effects of bed rest has been completed in young
subjects, we have recently reported on the results
of 10 days of bed rest in healthy older adult sub-
jects.46 Our results indicate that older individuals
are more sensitive to bed rest inactivity; on aver-
age, these subjects lost almost 1 kg of lower ex-
tremity lean tissue, whereas younger subjects in a
previous 14-day bed rest study lost only 650 g.47
Interestingly, despite substantial declines in lower
extremity strength (14%) and aerobic capacity
(12%), our older adult subjects had no significant
functional compromise, as assessed with validated
functional instruments. These results provide sup-
portive evidence that in healthy older adults, bed
rest inactivity, in and of itself, is not sufficient to
induce the marked functional deficits that can oc-
cur with hospital associated deconditioning. How-
ever, in a patient who is functionally compromised
before hospitalization, bed rest alone may lead to
significant functional impairment if similar deficits
in strength and aerobic function occur. This situation
has not been studied. Anecdotally, the other adverse
effects listed in Table 1 also occur in patients with
hospital associated deconditioning, although these
have not been formally evaluated either.
Medical/Surgical Conditions and Comorbid
Illness
No studies have examined the specific medical
or surgical problems that result in significant hos-
pital associated deconditioning. In addition, asso-
ciations with specific illnesses were not reported in
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-
ditions were common.7,9 However, patients with
certain comorbid illnesses may be at increased risk of
functional decline with relatively prolonged hospital-
ization. This would include patients with cancer, car-
diovascular disease (e.g., severe heart failure, cardiac
transplantation), chronic renal insufficiency, and
solid organ transplantation, as well as individuals
with severe, long-standing chronic obstructive pul-
monary disease and those surviving critical ill-
ness.13,28,29,48 –51 In general, these patients have less
muscle mass at baseline, thus they are likely to lose
more muscle and experience additional functional
decline with acute hospitalization.
Patients surviving treatment in a critical care
setting may also have significant functional defi-
cits. Although hospital associated deconditioning
alone may explain this decline, some patients, par-
ticularly those treated with systemic corticoste-
roids, may, alternatively or concomitantly, have
critical illness polyneuropathy/myopathy.13,52 Al-
though, studies in young subjects have docu-
mented that the addition of corticosteroids exacer-
bates the catabolic effects of bed rest alone,53 an
electrodiagnostic study should be performed to de-
finitively diagnose critical illness polyneuropathy/
myopathy.
Inflammation
Recent studies have documented a significant
correlation between elevated inflammatory markers
and muscle weakness in older community-dwelling
adults,54 as well as older hospitalized patients.55
Nutrition
It is well known that caloric intake during
acute hospitalization is suboptimal, especially in
older adult and critically ill patients.56,57 Compro-
mised nutrition and reduced protein intake, in
particular, are associated with increased mortality
in hospitalized patients.38,56
Other
A number of less well-studied factors may also
contribute to functional decline and hospital asso-
ciated deconditioning, including anemia, pain,
sleep deprivation, fatigue, and depression.
Although the contribution of each of the above
etiologic factors will certainly vary from patient to
patient, the cumulative effect is very similar (i.e.,
deconditioning). Further studies may examine the
specific impact of each of these factors, as well as
other as yet unidentified etiologic components of
hospital associated deconditioning. This informa-
tion may then be utilized for preventive and treat-
ment interventions.
70 Kortebein
Consequences of Deconditioning
The main effect of hospital associated decon-
ditioning is an impairment of overall functional
ability. These functional deficits seem to be primar-
ily due to a generalized decline in skeletal muscle
strength/endurance and aerobic capacity, although
changes in these parameters have not been for-
mally studied. However, similar to the bed rest
interventions, the lower extremity extensor muscle
groups seem to be most affected. The resultant
functional deficits may vary considerably depend-
ing on the severity of the deconditioning, although
virtually all of these patients seem to have limited
ambulatory endurance and difficulty climbing
stairs. More severely affected patients may have
deficits of bed mobility, transfers, and basic ADL.
Falls are often a concern, as many of these patients
may also have orthostatic hypotension, and im-
paired balance. This combination of functional def-
icits often results in a loss of independence and the
need for postacute rehabilitation services (see pa-
tient A, Fig. 1).
Rehabilitation Considerations
Determination of Postacute Rehabilitative
Care Setting
Determining the most appropriate postacute
rehabilitation setting for patients with hospital as-
sociated deconditioning can be challenging for a
number of reasons, including the extreme diversity
of this patient population (e.g., functional deficits,
medical problems). Ideally, each patient should
transition from an acute hospital setting to the
rehabilitation setting that can provide the most effi-
cacious, and cost-effective, rehabilitation program for
that particular patient, taking into consideration
unique medical problems and functional deficits.
However, multiple additional factors must be consid-
ered, including several that are difficult to objectively
evaluate. Variables to be considered in this decision-
making process include the following: prehospitaliza-
tion functional status and living setting (e.g., single
vs. multilevel dwelling), social support available (e.g.,
family/friends), current active medical problems, cur-
rent physical or occupational therapy (PT/OT) toler-
ance, cognition/ability to learn, patient motivation,
patient/family preference, financial resources/insur-
ance coverage, and potential for functional recovery.
Determining the best rehabilitation fit for a particular
patient can be problematic as several of these vari-
ables are largely subjective (e.g., potential for recov-
ery). Assessing a patient’s ability to participate in an
acute inpatient rehabilitation setting can be particu-
larly challenging as approximately 3 hrs of daily ther-
apy is required, whereas acutely hospitalized patients
may, at most, receive approximately 1 hr of therapy
per day. However, data from two recent studies of
Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1
deconditioned patients indicate that a significant ma-
jority of these patients are successful with this tran-
sition.17,18
Recently, a guideline developed by an expert task
force of the American Academy of Physical Medicine
and Rehabilitation has been promulgated to assist
clinicians and other interested parties in deciding the
appropriateness of patients for acute inpatient reha-
bilitation.58 Although, this algorithm may be applied
to virtually any patient in an acute medical inpatient
setting, it is primarily intended as guidance in deter-
mining the appropriateness of a particular patient for
acute inpatient rehabilitation as opposed to a skilled
nursing facility. Although inpatient rehabilitation en-
tails substantially more therapy on a daily basis, these
patients are also more medically complex, thus close
medical supervision by an appropriately trained phy-
sician (typically a physiatrist) and 24-hr nursing cov-
erage are required. As per the recommendations of a
recent government report, this algorithm places a
primary emphasis on function as an evaluation crite-
rion rather than specific medical diagnoses.14
As alluded to previously, the goal of any post-
acute rehabilitation program for a patient with
hospital associated deconditioning should be to
maximize functional recovery and independence in
a safe, cost-effective manner. The specific rehabil-
itation program prescribed should be appropriately
challenging and progressive to reach this goal. In a
practical sense, the ultimate goal of rehabilitation
for most, if not all, of these patients is to achieve
sufficient functional recovery to return to (or re-
main in) an independent living situation (i.e.,
home alone or with family or assisted living). Thus,
deconditioned patients that had been residing in a
nursing home before acute hospitalization will, in
general, be expected to return to that setting di-
rectly, although there are exceptions.
Rehabilitation Settings
At this time, there are essentially four rela-
tively distinct postacute rehabilitation settings for
patients with clinically significant hospital associ-
ated deconditioning: acute inpatient rehabilitation
hospitals/units, skilled nursing facilities (often
referred to as “subacute rehabilitation”), home
health care, and outpatient therapy. For older de-
conditioned patients in the Veterans Administra-
tion (VA) system, Geriatric Evaluation and Manage-
ment (GEM) units are an additional option. Acute
inpatient rehabilitation is the most rigorous, as
patients must participate in at least 3 hrs of therapy
per day, although they may transition up to this
level over 10 –14 days. Therapy in the other set-
tings listed typically ranges from 45 to 90 mins per
session, one to five times per week.
Unfortunately, there is a very little data com-
paring, let alone examining, the effectiveness and
January 2009
outcomes of rehabilitation for patients with hospi-
tal associated deconditioning in these various set-
tings. However, two published studies have evalu-
ated older adult patients participating in acute
inpatient rehabilitation. Raj et al.17 reported on a
select population of deconditioned patients older
than the age of 55 yrs (mean, 72 yrs) from a single
facility. Before hospitalization, 100% of these pa-
tients had resided in the community, whereas 94%
were admitted from an acute hospital. These pa-
tients made substantial functional gains, and 71%
were discharged home. However, 20% of these
patients were discharged back to an acute hospital.
More recently, we reported on the outcomes of a
similar patient population from a large national
rehabilitation database. Specifically, we examined
data on patients older than 65 yrs of age (mean, 80
yrs) that were admitted for inpatient rehabilitation
during 2002–2003 with a diagnosis of debility.18
This cohort included nearly 15,000 adults with a
primary debility diagnosis; 97% had previously
been living in the community, and almost 90% had
been admitted from an acute hospital setting. We
found that nearly 70% of these patients had been
discharged back to the community, whereas only
12% had been discharged to an acute medical fa-
cility. In both of these studies, a majority of the
patients were discharged home, and the measured
functional improvement of these patients was at
least as good as that previously reported for tradi-
tional rehabilitation populations, including stroke,
and brain dysfunction.59 Additional studies of this
patient population are needed, including evalua-
tions with more extended follow-up to determine if
postacute rehabilitation (acute inpatient or other) of
these patients results in persistence of these func-
tional improvements or improved long-term survival,
or both.
There are no studies specifically examining
patients with a diagnosis of deconditioning (or
debility) for the other rehabilitation settings noted
previously (e.g., skilled nursing facilities). However,
Johnson et al.60 evaluated functional recovery and
survival in three groups of Medicare patients (“med-
ical/surgical patients,” stroke and hip fracture) par-
ticipating in rehabilitation in a skilled nursing facility
(87% of “medical/surgical patients”) or an inpatient
rehabilitation hospital. As the medical/surgical pa-
tients had experienced a functional decline with hos-
pitalization, this patient group may be similar to the
patient populations discussed above.17,18 The medi-
cal/surgical patients patients were more likely to re-
gain premorbid function, although their 1-yr mortal-
ity rate was 30%. In other studies of older adults
receiving postacute rehabilitation (acute inpatient or
VA GEM unit), the percentage of patients with a
distinct diagnosis of deconditioning is either very
limited61 or is unknown as specific diagnoses were
Rehabilitation for Hospital Deconditioning 71
 not listed.62,63 Interventions to prevent functional
decline during acute hospitalization in older adults
have included formal exercise training programs;
however, these have either been ineffective or not
feasible when attempted.20,64,65 However, physical
therapy (PT) in conjunction with a specialized com-
prehensive geriatric program during acute hospital-
ization has been documented to improve function
and long-term survival.66
Rehabilitative Therapy Program
As previously noted, the primary goal of all
postacute rehabilitative therapy programs for pa-
tients with hospital associated deconditioning
should be to maximize functional recovery and
independence and to return each patient to an
independent living situation. Although the rehabil-
itation programs for these patients may seem rel-
atively intuitive, all current programs are almost
exclusively based on historical tradition rather than
rigorous scientific evaluation or evidence-based med-
icine. Thus, it is not surprising that there are no data
to indicate that one particular type of rehabilitative
therapy program or regimen is more effective than
any other for patients with hospital associated decon-
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
as a model of rehabilitative care for patients with
hospital associated deconditioning, although the
same rehabilitation principles can be applied to the
other rehabilitation settings mentioned. The primary
therapeutic interventions for deconditioned patients
are outlined in Table 2. However, the overall rehabil-
itative therapy program must be tailored to the spe-
cific needs of each individual patient.
Physical Therapy
As the most significant deficits for patients
with hospital associated deconditioning include
lower extremity muscle strength and endurance, as
well as basic mobility and ambulatory endurance,
PT is arguably the most important aspect of their
rehabilitation program. Functional therapeutic in-
terventions for deconditioned individuals may
range from basic bed mobility and transfer training
to longer distance ambulation, stair climbing, and
instrumental ADL. These functional activities may
be supplemented with a strength and endurance
training program focused on the hip and knee
extensors in particular. Formal upper extremity
strength training may be incorporated as well, or
this may be deferred to OT. However, strengthen-
ing the “crutch group” muscles (i.e., shoulder ad-
ductors, scapular stabilizers, and elbow extensors)
may be included in the therapy program of patients
reliant on a gait aid, such as a walker. Strength
72 Kortebein
TABLE 2 Rehabilitation therapy for hospital-
associated deconditioning
Physical therapy
● Bed mobility/transfers
● Gait and balance training
● Ambulatory endurance with/without gait aid/stair
climbing
● Muscle strength and endurance training—hip
and knee extensors primarily
● Range of motion and muscle flexibility/stretching
of major joints and muscle groups of the lower
extremities
Occupational therapy
● Activities of daily living (ADL) training, including
fine motor skills and adaptive equipment needs
● Instrumental ADL/homemaking/community
survival skills
● Cognitive and safety awareness assessment and
remediation, if needed
● Range of motion and muscle flexibility/stretching
of major muscle groups of the upper extremities
to facilitate ADL training
● Energy conservation and joint protection
principles, if needed
● Muscle strength and endurance training—shoulder
abductors/adductors, elbow flexors/extensors, and
finger flexors/grip strength
training with functional body weight exercises (e.g.,
partial squats), elastic resistance bands, or specific
resistance exercise equipment (e.g., isotonic or isoki-
netic) may be utilized in conjunction with a func-
tional therapy program. There are no data to indicate
if, or how frequently, these types of exercises are
currently included as part of the therapy program for
deconditioned patients. However, there is some evi-
dence that in the VA GEM setting, supplemental
resistance training may be of benefit,67 and task-
specific resistance training for transfers has been ben-
eficial for older ADL impaired adults.68
Ambulatory endurance training is virtually al-
ways a major component of the PT program for
deconditioned patients. Typically, this will include
walking progressively longer distances with each
therapy session, or at least daily ambulation. Gait aids
(e.g., cane, walker) are used as needed for patients
with lower extremity weakness or impaired balance,
and a platform walker may be helpful for severely
deconditioned patients. As deconditioned patients are
often at risk for falls, static and dynamic balance
training may be incorporated into the therapy pro-
gram, as well. Formal testing for orthostatic hypoten-
sion or other pertinent medical conditions (e.g., ar-
rhythmia, peripheral polyneuropathy) should be
performed if indicated. Deconditioned patients may
also develop restricted joint motion from muscle con-
tractures or capsular adhesions related to prolonged
supine bed rest. The hip and knee flexors are most
Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 1
commonly at risk, and formal range of motion ther-
apy (e.g., active or active assisted) and stretching may
be required if these problems do not improve with a
standard functional therapy program.
Occupational Therapy
The OT program for deconditioned patients is
primarily focused on achieving independence in
basic ADL, as well as instrumental ADL (sometimes
referred to as “community survival skills”). In ad-
dition to personal care skills, this may include
basic homemaking skills, such as meal preparation
and safety awareness, if a patient is to return home
alone. This program often includes fine motor train-
ing to improve functional activities (e.g., buttoning
clothes), although adaptive equipment aids may be
required to compensate for specific deficits. Activities
to improve upper extremity endurance (e.g., peg
boards) may be incorporated, as well as formal upper
extremity strengthening and endurance exercises, in-
cluding training with an upper extremity ergometer.
Energy conservation techniques are provided to pa-
tients with significant exertional fatigue, and instruc-
tion in joint protection principles may be warranted
for patients with impaired hand function due to os-
teoarthritis, for instance.
The specific variables associated with maxi-
mizing functional recovery during postacute reha-
bilitation in deconditioned patients are not known.
However, a variety of factors needs to be consid-
ered, including the training and experience of the
therapist(s) (PT and/or OT), patients past experi-
ence with therapy or exercise, the rehabilitation
environment/facility (including available space/
equipment), as well as the specific type of therapy
provided (e.g., functional activities only or specific
aerobic and resistance exercises). For instance, one
advantage of home health therapy may be that pa-
tients are able to “train” in their home environment,
whereas therapists in the other settings must simu-
late, often from patient or family descriptions, a pa-
tient’s home environment. The total daily “dose” of
rehabilitative therapy is another key factor; while
therapy sessions typically last 45 mins regardless of
setting, PT and OT are each required twice per day (3
hrs total) at least 5 days per week during acute inpa-
tient rehabilitation and generally only once per day
for the other rehabilitation settings (45–90 mins total
per day). Other variables that may affect outcomes in
these patients include intrinsic patient motivation,69
pain, impaired sleep, fatigue, depression, and cogni-
tive deficits.
Patients with hospital associated decondition-
ing may, in many respects, be considered untrained
“functional” athletes. Using this paradigm, it may
be worthwhile investigating the application of rec-
ognized and effective exercise conditioning princi-
ples to the rehabilitation of these patients. Several
January 2009
excellent reviews and position statements are avail-
able regarding prescribing exercise in adults, in-
cluding older adults with chronic stable medical
conditions.70 –72 It would seem reasonable to adapt
some or all of these exercise recommendations to
deconditioned patients participating in postacute
rehabilitation. Parameters of interest might in-
clude intensity, frequency, or duration of rehabili-
tation therapy/exercise in each postacute setting.
For instance, applying a specific intensity of ther-
apy as measured by rating of perceived exertion73
might be evaluated.
Therapeutic exercise (i.e., PT/OT) is the pri-
mary treatment intervention during postacute re-
habilitation for patients with hospital associated
deconditioning, although certain anabolic medica-
tions may augment the functional recovery of ther-
apy alone. To date, the only published studies have
used testosterone in male VA GEM unit patients. In
a pilot study, Bakhshi et al.74 reported significantly
greater functional gains, while Sullivan et al.75 in
a larger study of hypogonadal men reported no
change in function with testosterone or a high-
intensity resistance exercise program.
Although rehabilitation, in general, and cer-
tain rehabilitation interventions/settings, in par-
ticular, are believed to provide more rapid and
complete functional recovery for patients with
hospital associated deconditioning (see patient
A, Fig. 1) there are no supportive data for this
assertion. In addition, there are no data available
to indicate what is the most efficacious postacute
rehabilitation program for a particular patient,
or group of patients, with hospital associated
deconditioning. Future evaluations of this pa-
tient population should consider recently pub-
lished recommendations for evaluating rehabili-
tation treatments and effectiveness.76,77
Safety Concerns
Contraindications to postacute rehabilitation
may include all those listed in Table 3.78 In addi-
tion, clinicians managing these patients in a skilled
nursing facility or acute rehabilitation setting
should be cognizant of other medical conditions,
such as significant anemia or thrombocytopenia, as
these are likely more common in these settings.79
For patients with known or suspected cardiac
disease, specific heart rate limits or restrictions
may be enforced during rehabilitative therapies,
although no evidence-based parameters regarding
such limits are available for any of the postacute
rehabilitation settings. However, there are exercise
guidelines for general cardiac rehabilitation and
heart failure patients, as well as information re-
garding the risk of acute cardiovascular events re-
lated to exercise.28,80 – 82 This literature may be
helpful in identifying appropriate exercise parame-
Rehabilitation for Hospital Deconditioning 73

TABLE 3 Contraindications to participation in
therapeutic exercise/rehabilitation
Unstable angina or severe left main coronary
disease
End-stage congestive heart failure
Severe valvular heart disease
Malignant or unstable arrhythmias
Elevated resting blood pressure (systolic, ⬎200
mm Hg, diastolic, ⬎110 mm Hg)
Large or expanding aortic aneurysm
Known cerebral aneurysm or recent intracranial
bleed
Uncontrolled or end-stage systemic disease
Acute retinal hemorrhage or recent ophthalmologic
surgery
Acute or unstable musculoskeletal injury
Acute illness with systemic features (e.g.,
pneumonia)
Severe dementia or behavioral disturbance
Reprinted with permission from Elsevier: Bean JF, Vora
A, Frontera WF: Benefits of exercise for community-dwell-
ing older adults. Arch Phys Med Rehabil 2004; 85: S33.
ters for deconditioned patients with cardiac disease
participating in postacute rehabilitative therapy. Of
note, individuals that are habitually the least phys-
ically active have the greatest incidence of cardiac
events related to exercise.81 Thus, a formal assess-
ment of cardiac risk factors, past cardiac history,
and perhaps prehospitalization physical activity to
assess a particular patients risk may be worthwhile.
As these deconditioned patients are, in fact, exer-
cising during therapy, formal exercise stress test-
ing would be ideal, although this is impractical for
a number of reasons. Thus, recommendations re-
garding safety monitoring during exercise for com-
munity-dwelling older adults may be adapted to
deconditioned patients participating in postacute
rehabilitation.83
General Medical Issues
Although functional recovery is the focus of
postacute rehabilitation for patients with hospital
associated deconditioning, all of the adverse effects
of bed rest/immobility listed in Table 1 should be
considered and addressed as needed.4 Although it is
beyond the scope of this article to address all of
these issues, several problems warrant mention.
For instance, a primary concern in virtually all
patients that have been exposed to prolonged bed
rest should be surveillance or prophylaxis, or
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
acute hospital discharge.84 Guidelines for VTE
prophylaxis are available, although the duration
of prophylaxis is unclear.84,85 Some clinicians
may use ambulatory function (e.g., ambulation
⬎100 –150 feet) as an indication that it is safe to
discontinue these measures, although there is no
research to support this recommendation. Other
conditions to be considered in this patient pop-
ulation include orthostatic hypotension, skin
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-
ries and protein).
CONCLUSION
Deconditioning is a fundamental rehabilita-
tion problem that may affect a broad spectrum of
patients. For patients experiencing a functional
decline in an acute hospital setting, the term hos-
pital associated deconditioning may be applied.
This multifactorial condition seems to be relatively
prevalent, particularly in older adults. However,
hospital associated deconditioning is currently not
well defined or adequately characterized. In addi-
tion, the optimal postacute rehabilitation program
for patients with hospital associated decondition-
ing is not known, although rehabilitation may oc-
cur in one of several settings. Recent evidence
indicates that the functional recovery of decondi-
tioned patients participating in acute inpatient re-
habilitation is quite favorable. However, a substan-
tial amount of research related to this condition is
needed, and suggested research topics related to
hospital associated deconditioning and the rehabil-
itation of this condition are outlined in Table 4.
The rehabilitation community is uniquely qualified
to address these questions, and should be at the
forefront in developing a research program for
deconditioning, in general, and for hospital associ-
ated deconditioning, in particular.
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