ORIGINAL PAPER
Nagoya J. Med. Sci. 85. 93–102, 2023
doi:10.18999/nagjms.85.1.93

Negative impact of behavior restriction amidst a clustered
COVID-19 infection on immobility syndromein older patients negative for COVID-19:
report from a chronic care hospital in Japan
Yoshinori Maki1, Akio Goda2, Masatoshi Koumo1, Tetsuya Yamamoto1,
Kouta Yokoyama1, Masashi Ueno1, Asuka Kishimoto1, Masami Kusumoto1,
Mayumi Takagawa1, Tamako Takahashi1, Chiharu Takahashi1,
Keisuke Nakajima1, Mika Hashimoto1, Tsumugi Hosokawa1,
Misuzu Kobayashi1, Junichi Katsura1
and Ken Yanagibashi121Department of rehabilitation, Ryozenkai Hikari Hospital, Otsu, Japan
Department of Physical Therapy, Faculty of Health Sciences, Kyoto Tachibana University, Kyoto, Japan

ABSTRACTPrevious studies have reported on associations between immobility syndrome and the COVID-19
pandemic. However, little is known about the aggravation of this syndrome in older patients negative for
COVID-19 infection amidst behavior restriction due to a clustered COVID-19 infection. Patients hospitalized
one month before a clustered COVID-19 infection occurred in our hospital were recruited. Rehabilitation
therapy was suspended for 25 days during behavior restriction. The ability of daily living of the patientswas evaluated with the functional independence measure and Barthel index. Chronological changes in thefunctional independence measure and Barthel index scores were evaluated monthly, beginning one month
before the clustered COVID-19 infection to one month after re-initiation of rehabilitation therapy. Patientswith minimum scores in the functional independence measure (18) and Barthel index (0) prior to theclustered COVID-19 infection were excluded. Functional independence measure scores of 73 older patientsand the Barthel index scores of 48 patients were analyzed. The mean total functional independence measurescore amidst the behavior restriction significantly changed from 36.3 to 35.1 (p = 0.019), while statisticalsignificance was not detected in the mean motor subtotal (from 21.6 to 20.9 with p = 0.247) or cognitive
subtotal functional independence measure scores (from 14.6 to 14.2 with p = 0.478). During the behavior
restriction, the mean Barthel index scores declined from 25.8 to 23.2 without statistical significance (p =0.059). Behavior restriction due to a clustered COVID-19 infection may aggravate immobility syndromein older patients who are negative for COVID-19.
Keywords: immobility syndrome, older adults, COVID-19, functional independence measure, Barthelindex
Abbreviations:
COVID-19: coronavirus disease 2019
FIM: functional independence measure

Received: February 17, 2022; accepted: March 31, 2022
Corresponding Author: Yoshinori Maki, MD
Department of Rehabilitation, Ryozenkai Hikari Hospital, 3-35-1 Saikawa, Otsu 520-0002, Japan
Tel: +81-749-68-2300, Fax: +81-749-65-1259, E-mail: passatempo19840816@gmail.com
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BI: Barthel index
ADL: activities of daily living
This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION
The coronavirus disease 2019 (COVID-19) has been a global health concern since the firstcase of COVID-19 was reported in Wuhan.1 Severe acute respiratory syndrome coronavirus 2 isthe representative symptom related to the COVID-19 infection, and the associated mortality rates
are higher in older patients and those with cardiovascular disease, chronic respiratory disease,and diabetes mellitus.2 COVID-19 infection can result in various symptoms, including decline ofphysical and cognitive function.3 Rehabilitation therapy is required from the acute phase to therecovery phase to ameliorate the declining status of patients positive for COVID-19.3-11
A nationwide lockdown was implemented to help cope with COVID-19 infection. Daily
activities of the population possibly negative for COVID-19 were restricted to prevent the spreadof COVID-19. Medical services that were not urgent were temporarily suspended. As a result,both the healthy population and those with underlying diseases were introduced to the immobility
syndrome.12-17 As a secondary medical issue, the COVID-19 pandemic can impair the quality ofdaily living among those negative for COVID-19.
However, to the best of our knowledge, little is known about the impact of suspension ofrehabilitation therapy on immobility syndrome in older patients who are negative for COVID-19
infection. The aim of this study was to explore the aggravation of immobility syndrome in older
patients negative for COVID-19, which can result from suspended rehabilitation therapy in casesof clustered COVID-19 infection.

PATIENTS AND METHODS
Study design
This study is a retrospective cohort study. This study was approved by the ethical committeeof Hikari Hospital. This study complied with the Declaration of Helsinki. All the clinical data
was anonymized in this study.
Behavior restriction related to a clustered COVID-19 infection
A clustered COVID-19 infection occurred at our chronic care hospital, which was administrated
by public health authorities to help prevent the spread of the infection. All patients positive for
COVID-19 were transferred to a hospital specializing in the treatment of COVID-19. Rehabilitation therapy was ceased as per instructions from the public health authorities until two weeks had
passed since the last patient positive for COVID-19 was confirmed. Thus, rehabilitation therapy
was suspended for 25 days, during which areas in the wards were categorized into red and green
zones. The patients’ activities were restricted to their rooms and a dining hall (categorized asa red zone) (Figure 1).

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Declined ADL in the older behind COVID-19

Fig. 1 A map of the ward zones during the clustered COVID-19 infection in our hospital
The area around a nurses’ station was categorized as a green zone while the patients’ rooms and the dining
hall were categorized as red zones (A: room for a single patient, B: room for two patients and C: room for
four patients).

Patients
Patients hospitalized one month before the clustered COVID-19 infection occurred in our
hospital were enrolled in this study. Patients who were transferred to other institutes due to
COVID-19 infection were excluded from the study, along with those who did not undergo
rehabilitation therapy. Patients who died due to underlying diseases were not enrolled.
Clinical information of the patients
Baseline characteristics that were compared are listed in Table 1. The patients could undergo
rehabilitation therapy comprising a maximum of six units (one unit is equal to at least 20 minutesof rehabilitation therapy) per day within the computation period (this period is defined according to the disease for which rehabilitation therapy is prescribed. For example, the computation
period is defined as six months from the onset date for patients with stroke in Japan); after thecomputation period, the patients could undergo only 13 units of therapy per month.
Table 1

Characteristics of the patients in this study

Patients (n = 73)
Sex (male:female)33 (45.2%):40 (54.8%)

Age (years old)
Minimum – maximum (mean)

62–97 (83.3)

Heights (m)Minimum – maximum (mean)

1.31–1.80 (1.54)

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Weights (kg)Minimum – maximum (mean)

27.3–69.4 (43.9)

Body mass index (kg/m2)
Minimum – maximum (mean)

11.3–28.9 (18.4)

Days from the admission date to the onset ofthe clustered COVID-19 (days)

24–1256 (302.5)

Rehabilitation prescription
Within computation period
Extended from computation period
Post computation period

21 (28.8%)
3 (4.1%)49 (67.1%)

Rehabilitation therapy
For cerebrovascular disease
For immobility syndrome
For motor disorder

31 (42.5%)
23 (31.5%)
19 (26.0%)

Underlying disease
Cardiovascular
CancerDehydration
Decubitus
Infection
Neuromotor
Orthopedics
Pulmonary
StrokeOthers3 (4.1%)4 (5.4%)2 (2.7%)3 (4.1%)21 (28.7%)
8 (10.9%)
11 (15.0%)
1 (1.3%)17 (23.2%)
10 (13.6%)

Feeding
Central venous
Oral
Tubal

4 (5.4%)53 (72.6%)
19 (26.0%)

Medication
Number of medications regularly prescribed
Antiarrhythmic
Anticonvulsant
Anticoagulant/antiplatelet
Anti-dementia
Antidiabetic
Hypnotic
Proton pomp inhibitor/H2 blocker

0–12 (5.5)
37 (50.6%)
8 (10.9%)31 (42.5%)
2 (2.7%)9 (12.3%)
19 (26.0%)
35 (47.9%)

Rehabilitation evaluation
The patients were evaluated monthly by rehabilitation therapists using the functional independence measure (FIM) and Barthel index (BI).
The FIM is used to evaluate patients’ activities of daily living (ADL) and consists of two
sections: the motor subtotal score (eating, grooming, bathing, upper body dressing, lower body
dressing, toileting, bladder management, bowel management, bed/chair/wheelchair transfer, toilet
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Declined ADL in the older behind COVID-19

Fig. 2 The definition of periods A, B, and C

transfer, tub/shower transfer, locomotion of walk/wheelchair/walk and wheelchair, and locomotionof stairs) and the cognitive subtotal score (comprehension, expression, social interaction, problem
solving, and memory). The minimum and maximum scores for FIM are 18 and 126, respectively.
The BI is used to evaluate the ability of patients to perform daily activities and has ten
subdivision items: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet
use, transfer, mobility, and stair use. The minimum and maximum BI scores are 0 and 100,
respectively.
The FIM and BI approximately one month before the onset of clustered COVID-19 infection
were defined as the baseline scores. The FIM and BI scores of patients were also assessed
before and after the behavior restriction related to the clustered COVID-19 infection. The FIM
and BI scores after the behavior restriction related to the clustered COVID-19 were evaluatedwithin one week after reinitiating rehabilitation therapy. The FIM and BI scores were also
followed one month after reinitiating rehabilitation therapy. Period A was defined as that frombaseline evaluation to the evaluation before the behavior restriction, and period B was defined asthat between the evaluation just before the behavior restriction to evaluation after the behavior
restriction. Period C was defined as that between the evaluation after the behavior restriction toevaluation one month after reinitiating rehabilitation therapy (Figure 2). The change in the FIM
and BI scores in period A, B, and C were calculated and statistically analyzed. Patients with abaseline FIM score of 18 and/or those with a baseline BI score of 0 were respectively excluded
from the study (ie, patients with a baseline FIM score of 18 and baseline BI score of 0 were
excluded in both evaluation of FIM and BI scores, meanwhile, patients with a baseline FIM
score of 20 and baseline BI score of 0 were included only for the evaluation of the FIM score).
We used SPSS Statistics software version 26 (IBM, Armonk, NY, USA); statistical significancewas set at P <0.05.

RESULTS
Baseline characteristics
Seventy-three patients (33 men and 40 women) were enrolled in this study. The characteristicsof the patients are summarized in Table 1. The mean age of the patients was 83.3 years. The
mean height and weight of the patients were 1.54 m and 43.9 kg, respectively. The mean bodymass index was 18.4 kg/m2. The mean duration from the date of admission to the onset ofclustered COVID-19 infection was 302.5 days. At the time of the study, 31 patients were undergoing rehabilitation therapy for cerebrovascular disease, while 19 and 23 patients were undergoingrehabilitation therapy for motor disorder and immobility syndrome, respectively (Table 1).
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Outcomes: FIM and BI
The baseline motor subtotal, cognitive subtotal, and total scores (minimum–maximum withmean score) of the patients were 13–53 (21.2), 6–33 (14.4), and 19–83 (35.6), respectively. The
pre- and post-clustered COVID-19 infection motor subtotal, cognitive subtotal, and total scores
were 13–53 (21.6), 6–33 (14.6), and 19–83 (36.3); and 13–53 (20.9), 6–33 (14.2), and 19–83(35.1), respectively. The one month after post-clustered COVID-19 infection motor subtotal,
cognitive subtotal, and total scores were 13–53 (20.9), 5–33 (13.7), and 18–84 (34.7) (Table 2).
The baseline, pre-, post-clustered, and one month after post-clustered COVID-19 infection BIscores (minimum–maximum with mean score) of the patients were 5–65 (25.6), 0–60 (25.8),
0–60 (23.2) and 0–75 (23.6) (Table 2).
Table 2

Baseline functional independent measure (n = 73) and Barthel index scores (n = 43)

Functional independent measure
Minimum – maximum (mean)<Baseline>
Motor
Cognitive
Sum<Pre-cluster of COVID-19>
Motor
Cognitive
Sum<Post-cluster of COVID-19>
Motor
Cognitive
Sum<One month after post-cluster of COVID-19>
Motor
Cognitive
Sum
Barthel index
Minimum – maximum (mean)<Baseline><Pre-cluster of COVID-19><Post-cluster of COVID-19><One month after post-cluster of COVID-19>

13–53 (21.2)
6–33 (14.4)
19–83 (35.6)
13–53 (21.6)
6–33 (14.6)
19–83 (36.3)
13–53 (20.9)
6–33 (14.2)
19–83 (35.1)
13–53 (20.9)
5–33 (13.7)
18–84 (34.7)

5–65 (25.6)
0–60 (25.8)
0–60 (23.2)
0–75 (23.6)

Comparison of the score change of the mean FIM and mean BI in periods A, B and C
Figure 3 compares the mean FIM and mean BI scores in periods A, B, and C. There were
statistically significant changes only in the total score of the mean FIM in period B (p = 0.019),
but not that in period A or C (p = 0.962, and p = 0.247, respectively). There were no statistically significant changes in the mean motor subtotal score in periods A, B and C (p = 0.409,
p = 0.247, and p = 1.000, respectively) or in the mean cognitive subtotal scores of the FIM in
periods A, B, and C (p = 1.000, p = 0.478, and p = 0.556, respectively). Changes in the mean
BI score in periods A, B, and C were not statistically significant (p = 0.059).
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Fig. 3 Comparison of score changes of the mean FIM and mean BI scores in periods A, B, and C
Changes in the motor subtotal, cognitive subtotal, and total scores in the functional independence measure (FIM)(a, b, c) and Barthel index (BI) (d). The average value is shown with a x-mark. The median value is shown witha horizontal line. Statistical significance was detected in the total score of FIM in period B (*).

DISCUSSION
Herein, we reported the aggravation of immobility syndrome in older patients who were
negative for COVID-19 during behavior restriction due to a clustered COVID-19 infection. The
decline in the mean FIM and mean BI scores of the older patients in this study demonstrates
the impact of suspension of rehabilitation therapy and restricted daily life as part of the protocol
to prevent the spread of the COVID-19 infection. There was a statistically significant decline in
the mean total score in the FIM of the patients during behavior restriction. To the best of ourknowledge, this is the first report from a chronic care hospital that demonstrates the aggravationof immobility syndrome in older adults negative for COVID-19 as secondary medical issue related
to the COVID-19 pandemic.
Previous studies have reported on hospitalization as a risk factor for a decline in ADL in
older patients.18-23 Kortebein et al reported decreased lower extremity strength after 10 days of bed
rest. In their study, the participants were healthy sexagenarians.24 The patients in our study wereolder than the participants in the study by Kirtebein et al; thus, we believe that environmental
factors may have further affected our patients compared to those in the study by Kirtebein et al.
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In our study, the FIM mean motor score improved during period A due to rehabilitation therapy;
however, the FIM mean motor score declined during period B though statistical significance was
not detected. Cessation of rehabilitation therapy and restricted life space may have resulted inaggravation of motor function decline in the patients. A decline in cognitive function, which
was also observed in our study, has also been described as a negative impact of restricted life
environment related to lockdown measure.16 Cessation of rehabilitation therapy also negatively
affected the maintenance or amelioration of cognitive function in our patients. The reason forwhich statistical significance was not detected in the decline of the mean motor and cognitive
subtotal score of FIM might have been related to the limited number of the patients in this study.
The change in the BI score in period B was not statistically significant. The discrepancy
in the statistical results between the FIM and BI scores is notable. Generally, the FIM reflects
patients’ ADL, while the BI reflects the ability to perform daily activities. Our patients lived ina restricted space for 25 days due to zoning management for the wards, resulting in restrictionsin ADL, which may have resulted in significantly declined FIM scores. While statistical significance was not detected in the change in the BI scores in period B, the tendency for statisticalsignificance was demonstrated with a p-value of 0.059. This may mean that the ability to perform
ADL indicated by the BI score may decline when ADL are restricted or not performed. As the
responsiveness of FIM is considered superior to that of BI,25 the aggravated immobility syndromein our patients following suspension of rehabilitation therapy may be indicated by the statisticalsignificance of the changes in FIM. The FIM scores continued to decline even one month after
reinitiating rehabilitation therapy, while the recovery in the BI score was observed. This finding
also might result from the superiority of FIM to that of BI. As the decline of the FIM scoresin period C was smaller than that in period B, the reinitiated rehabilitation therapy must havecontributed toward improving the ability of daily living of the patients. However, the declined
ability of the patients one month after reinitiating rehabilitation therapy remained worse than theability evaluated one month before the behavior restriction.
Telerehabilitation therapy has become an alternative treatment to conventional rehabilitation
during COVID-19 pandemic. The usefulness of telerehabilitation therapy in hospitals and in thedomestic environment has been described.5,17,26-28 However, the efficacy of telerehabilitation therapy
in older patients with a mean FIM cognitive score of 15.0 remains questionable. Thus, further
research is warranted to establish simple and effective telerehabilitation therapy for older patients.
Rehabilitation therapy should be planned and implemented based on the cognitive function ofolder individuals. Continuous rehabilitation therapy with standard infection control precautions
during the clustered COVID-19 infection in our hospital may have prevented the aggravation of
immobility syndrome in our patients; however, rehabilitation therapy was suspended, and patient
space was restricted as per instructions by the public health authorities to prevent the spread ofclustered COVID-19 infection. We believe that rehabilitation therapy was ceased partially because,at the time of the study, there was still a lack of evidence or reports concerning the risk for
aggravation of immobility syndrome in older patients negative for COVID-19 as a secondary
negative impact of the COVID-19 pandemic.
The threat of COVID-19 infection persists with the spread of various viral subtypes.29 Basedon this article, medical staff should be aware not only of the threat of COVID-19 infection, butalso of indirect and secondary negative impact related to the COVID-19 pandemic.
Limitations
This study had some limitations. First, this study was performed at a single chronic care
hospital. The number of recruited patients was limited, which may have affected the discrepancy
in the statistical results of the changes in FIM and BI scores. In addition, although patient
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ADL were evaluated using FIM and BI, multiple rehabilitation therapists evaluated the patients’performance. Thus, subjective bias cannot be completely excluded, and inter-rater variation may
exist. No concrete method to prevent the aggravation of immobility syndrome in older patientswith clustered COVID-19 infection was proposed in this study. Therefore, further research
regarding this issue is warranted.

CONCLUSION
Behavior restriction due to a clustered COVID-19 infection may result in the aggravation of
immobility syndrome in older patients negative for COVID-19. Medical staff should be awareof this secondary risk amidst the COVID-19 pandemic. Rehabilitation therapy oriented to older
people negative for COVID-19 should be established to prevent the aggravation of immobility
syndrome.

ACKNOWLEDGMENTS
We appreciate all the stuff in Hikari Hospital for their collaboration. We would like to thank
Editage (www.editage.com) for English language editing.

CONFLICT OF INTERESTNone.

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