IMPORTANCE OF ENERGY CONSERVATION TECHNIQUES IN DAILY LIVING

Keep Learning and Exploring more➡️ https://otpthealthcarerehab.blogspot.com

Energy conservation refers to the way activities are performed in a way which will minimize fatigue, joint stress and pain. Implementing energy conservation techniques (ECT) in daily living tasks, by patients and common man, proves beneficial in completing any work with easy and less efforts. ECT aids in improving quality and quantity of work by completing the activity with minimal or no injury, mistakes and by improved ability to focus and concentrate while performing task.

Fig : Conserve your energy

There are many factors which should be taken into consideration while performing any activity : 

• the method in which task is performed
• the posture and position of the body while performing task
• the type of activity (light, moderate, heavy or very heavy level) and task demands
• time bound and limitations of activity
• physical condition of patient or person (neuro-musculoskeletal functioning)
• cognition and psychological requirements of task. 
• cognition and psychological mind-frame of patient during work
• quantity of work at a given time
• psychosocial pressure for completion of task        

If all the above factors adequately meet,  for any activity, then person will be able to complete the task efficiently by utilizing minimal body efforts and energy i.e. patient's energy is conserved. Patient experience less fatigue and tiredness, less or no muscle and joint pain during or post activity as compared to earlier methods of work which patient used to perform. Above factors should be taken into consideration while thinking about energy conservation techniques and how will you modify the activity accordingly for your patient. ECT will allow patients to remain independent and be less frustrated, by their illness, when the energy they have lasts for the day. 

Various disorders in which ECT is of major concern in activities of daily living:  

1) Anterior horn cell or motor neuron disease (MND) like Amyotrophic lateral sclerosis (ALS), primary muscular atrophy, Post polio residual paralysis, Spinal muscular atrophy :

• MND involves destruction or damage of motor neurons and ventral horns of spinal cord leading to atrophy of ventral roots. Neurons of frontal and temporal lobes also degenerates. Both upper motor neuron (UMN)  and lower motor neuron (LMN) signs are present depending on which motor areas are more affected i.e. brain, spinal cord or brainstem area.
• Motor neurons supplying respiratory muscles are also involved in MND type with progressive bulbar palsy. UMN involvement in patients are observed in Amyotrophic lateral sclerosis.
• If UMN is more affected, then LMN can't receive signals from UMN areas followed by muscles showing signs of spasticity and develops contracture and stiffness. Whereas if LMN areas are more affected (in Spinal cord and brainstem), then muscles can't receive output signals adequately followed by muscles showing signs of  hypotonia, atrophy, fasciculations, slowness in movements and muscle weakness. 
• All the above pathological changes makes it difficult for patients to perform ADL, walk and control movements, tiredness, depression etc.

2) In Cortical and Cortico-spinal tracts disorders like Stroke, Multiple sclerosis, Hemorrhage, etc :

• Voluntary movement is controlled by primary motor cortex and premotor cortex. The motor neural output form cortex is transmitted to motor neurons of spinal cord via corticospinal tracts.
• In these cases, volitional movements or voluntary control is affected which determines body’s muscle strength, its motor neurons recruitment capacity, muscle mass. Patient is not able to generate sufficient force (muscle force and motor neurons recruitment) which produces movements effective in controlling the body position in space.
• For example, in stroke or hemorrhage there are signs of paralysis or weakness and impaired voluntary control of the unilateral side of the body initially, which is followed by development of spasticity, muscle tightness. In Multiple sclerosis there is demyelination and destruction of the underlying nerve cells and their axons or nerve endings and also painfully heightened sensitivity to heat. Thus all these pathological changes cause debilitating fatigue and muscle weakness, often greatly limiting activity performance.

3) In Movement disorders like Parkinson's disease (PD), Progressive Supranuclear palsy (PSP), Wilson's disease (WD), Huntington's disease (HD), Sydenham's chorea, neurodegeneration with brain iron accumulation (NBIA), Choreoathetoid Cerebral palsy, cerebellar ataxia, spinocerebellar ataxia (SCA) etc :

• In hypokinetic movement disorders (PD, WD, PSP) the patients experience rigidity, akinesia or bradykinesia, stiff posture, slowness in activities, gait difficulties, postural instability. Patients develop poor equilibrium and protective reflex responses to injury. Patients experience slowness in upper-limb and lower-limb functional movements while doing any activities. Patients are at a risk of fall.
• In hyperkinetic movement disorders (HD, NBIA, choreoathetoid CP, SCA) patients experience involuntary movements like jerky (chorea, athetosis) and non-jerky (tremors, dystonia) which causes incoordination between bilateral sides of body, excessive effort and energy is needed to control or stop unnecessary movements while performing any activity. Patients has to put continuous conscious attention to complete task thus causing cognitive overload. In dystonia, patients experience slowness in upper-limb and lower-limb functional movements while doing any activities. SCA patients experience ataxia, postural instability, eye-hand incoordination and incoordination of upper-limbs and lower-limbs which,  negatively impacts their daily occupational functioning due to slowness and excess energy expenditure for controlling movements and balance. 

4) In Muscular disorders and myopathies like Duchenne muscle dystrophy, limb-girdle muscular dystrophy, Becker muscular dystrophy, polymyositis etc: 

• There is degeneration of the muscles rather than the nerve. It is a group of genetic diseases proceeding with progressive muscle weakness that causes subsequent limitations of joint movements, shortness of muscles, a decrease in respiratory capacity and posture disorders. 
• In most of the muscular dystrophy, proximal muscles are mainly involved which leads to gait impairment, difficulty in performing ADLs, decreased social participation and as the condition progresses patient becomes dependent of caregivers for almost all activities. Patients shows Gower's sign which indicates the weakness of the proximal muscles , namely those of the lower limbs. 
• Early progression from independent to dependent living is slowed down with proper early rehabilitation of these patients. Educating patient and relatives about ECT and work simplification so that patient will be able to conserve energy throughout the day, prevent patient from adopting wrong postures and avoid overburdening of the affected and non-affected muscles while performing activity.  

5) In Neuromuscular junction disorders (NMJ) like Myasthenia gravis, Lambert-Eaton syndrome etc:

• Most NMJ diseases are acquired and occur associated with presynaptic, synaptic and postsynaptic disorders. These disorders results from the destruction, impairment, or absence of one or more proteins during neuromuscular transmission.
• In generalized Myasthenia gravis patients, there is weakness in bulbar, extremity and respiratory muscles in varying degree due to cranial involvement. Myasthenic weakness typically fluctuates during the day, usually the least in the morning, and worsens as the day progresses with prolonged use of muscles, especially those that are stiff.  

6) In peripheral neuropathies like Charcot-Marie- tooth disease, Guillain Barre' syndrome, Leprosy, carpel tunnel syndrome, multifocal motor neuropathy etc : 

• In these cases, patients shows both motor and sensory symptoms. It causes demyelination in the nerve and axonal degeneration in the nerve by affecting the nerve myelin sheath or axon. It can lead to  muscle wasting or disuse atrophy and muscle weakness.
• Patient performs any activity using extra efforts or learns to compensate or begin to use different strategies to complete the activity. This makes the patient to use wrong muscles, overstrain muscles and attain wrong postures which can lead to overuse fatigue, muscle or ligament injury, muscle soreness.

7) In Cardiac and Respiratory disorders like Myocardial infarction, Rheumatic heart disease, Cardiac arrhythmia, Chronic obstructive pulmonary disease, Pneumonia, Covid-19, Interstitial lung disease etc :

• Proper functioning of heart and lungs is essential for adequate blood and oxygen supply respectively in the body. Continuous circulation of blood throughout the body is necessary for sufficient oxygen supply, removal of carbon dioxide, gases exchange in lungs and capillaries, adequate ATP production for energy, regulating body temperature and support the immune system.
• Cardiac impairments might lead to decrease in functioning of cardiac musculature or decrease in cardiac output and ejection fraction or insufficient cardiac contractility. This leads to insufficient amount of blood availability for oxygenation and carbon dioxide removal within lungs. To compensate for the impaired function, the unaffected cardiac musculature has to put more efforts in order to fullfill the patient's work demands to complete a task i.e. work of heart is increased compared to premorbid state of person's heart.
• Respiratory impairments might lead to decreased lung capacity or decreased tidal volume, impaired gases exchange.
• All the above pathological changes affects occupational performance as patients feel early fatigability, breathlessness, syncope, cough, decrease in quality and quantity of work.   

NOTE : Implementation of ECT is not limited to above conditions. It can be applied in almost all diseased conditions and even common man should apply it in activities of daily living. In diseased conditions patients experience weakness, easy fatigability, muscle pain or cramp, incoordination, attain abnormal or wrong postures while working and there might be chances of overwork stress or injury to muscles. Patients become frustrated and stressed for not being able to perform like earlier days and increase in dependency on others for activities. All these factors will hamper the healing process so it is always better and profitable to apply these techniques along with regular exercise schedule.

Fig : Overloaded with multiple activities leading to more amount of energy expenditure and early tiredness

Energy Conservation Principles and Techniques :

1) Organization of activity :

• Plan ahead a list of activities to do in a day.
• Prioritize your work.
• Analyze the work to be done prior to initiating it.
• Eliminate of the unnecessary steps of the activity.
• Combine task or activities. If there are many tasks to complete then usually combine light activity with heavy activity.
• Consider making changes or modification in activity if necessary. Modify the activity by applying ergonomic principles in mind. There should be a person-environment-occupation match for efficient working.

2)  Balance Rest and Activity :

• Frequent short rests are of more benefit than few longer ones. 
• The amount of rest you need and the amount of activity you do will vary day to day.
• Avoid activities which can be stopped immediately if they become too stressful.
• Plan your work so difficult tasks are done during your best time of the day and are distributed throughout the week.
• Stop or pause the activity before reaching maximal fatigue level or before you get exhausted. 
• Plan a balance of work, recreation, exercise and rest. If possible, lie down to take a rest.
• Do breathing exercises at regular interval while working.

3) Work Simplification :

• Cancel tasks that are not really necessary.
• Distribute or divide responsibilities to other members.
• Simplify your methods of work.
• Changing of working positions at regular interval. Whenever possible sit to complete your work. Avoid maintaining awkward postures for longer minutes.
• Adjust height of work surfaces to allow for good posture.
• Use equipment or machine when necessary to conserve energy because machines do the work by allowing us to apply less amount of force in same time interval. Machines reduce the workload on humans. 
• Avoid prolong exposure to moist heat. 

Examples of ECT in daily living :

1. During activities like lifting weight from floor bend from hip and knee more instead of waist.

2. While doing kitchen activities like making food, cutting vegetables etc the worktop height should be sufficient enough to avoid extra cervical flexion and bending from spine that would lead to stretch weakness and pain of back muscles.

3. While doing fine, precision work activities like jewellery making, stitching clothes, making embroidery on clothes, diamond cutting, small wood carving etc the platform height should be about 5 cm above elbow height (elbow support is needed)

4. When cleaning or sweeping floor make use of long handle rotatable brooms. This will prevent us from excess bending from spine, prevent excess kneeling and hip flexion while cleaning floor under table or sofa.

5. Soak dishes to eliminate the need to scrub with force. Allow dishes to air dry.

6. Store frequently used supplies or equipment close to the work area and with easy reach. Store frequently used items between shoulder and hip level to minimize excessive bending and reaching.

7. Work by putting less demands of gravity on body i.e. use wheels or slide objects rather than lifting or carrying them. Use a wheeled trolleys to assist pushing and carrying heavy objects.

8. Sit in front of water basin for cleaning face, brushing teeth, shaving and combing hair. Elbows should be supported on the rim of the water basin while grooming.

9. Avoid wearing tight clothing and use clothing with zips or press button for the ease of wearing and removal. Whenever possible sit during dressing and undressing.

10. Ensure good ventilation in bathroom by switching on exhaust fan or keeping windows open to avoid too much water vapor or steam. Use a long handle sponge and a long towel for washing back. Use a stool for sitting while bathing.

11. Minimize multi-tasking during cooking, e.g. frying vegetables and cutting other vegetables on table. It will make you tense.

12. Use HandSteady Mug (Adaptive device) for patients with movement disorder, decreased muscle power to avoid liquid spillage. 

13. Prescribing various assistive or adaptive devices like reacher for grabbing objects, ADL universal cuff, built-up handle for  firm grip, writing assist device, swivel spoon or liftware spoon for eating activity, button aid and zipper pull etc. These devices can make patient independent in their ADL. Use of wheelchairs or walker for gaining independence in mobility and improve social participation.

14. Ask for help from others whenever required for any task. Avoid doing complex and big task on the same day instead of that divide the task into sub-tasks and complete it within few days.   

15. Avoid travelling during peak or rush hours. Change your travel time accordingly so that you can go in a train or bus with less people and you get place to sit. Avoid travelling or going out in afternoon because the temperature is high at this time of the day.   

Thankyou for reading!!!

Dr. Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe