Patient Energy Conservation to Facilitate Increased Independence

Decreased functional activity tolerance, also known as functional activity intolerance, results from various factors. These factors may include but are not limited to, acute, chronic, or progressive medical conditions. Not having the functional capacity to perform or endure meaningful daily life tasks defines functional activity intolerance. Acute causes for functional activity intolerance, like the flu,  may be remediated via a biomechanical approach to therapy, such as therapeutic exercises and activities that challenge a person’s endurance in a graded manner. A rehabilitation approach can also be beneficial early in treatment. Due to the incurable nature of some chronic conditions, such as chronic obstructive pulmonary disease (COPD), management requires self-management strategies. Therapists can employ a rehabilitation approach and educate patients on using energy conservation techniques as compensatory approaches to treatment (Benthall et al., 2022). Energy conservation is the preservation of effort required during daily life tasks to compensate for functional activity intolerance. Utilizing energy conservation techniques for persons with acute or chronic conditions can help them be active participants in their daily lives, contributing to their overall quality of life.

There are a variety of factors that can lead to functional activity intolerance. Musculoskeletal conditions, autoimmune diseases, respiratory conditions, cardiac conditions, and cancer are some diagnostic categories that, when paired with factors such as age, pain, and fatigue, can cause impairment in functional activity tolerance(Emfietzoglou, n.d.). Mental health conditions, such as depression and disruption of the sleep cycle, can impact the amount of rest afforded to individuals, causing functional activity tolerance impairments (Emfietzoglou, n.d.). Associated fatigue and pain can affect every aspect of daily life, from getting dressed to leaving the home to attend a function. Factors contributing to functional activity intolerance can contribute to decreased independence in the occupational areas of activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, education, work, play, leisure, and social participation for individuals across the lifespan (American Occupational Therapy Association [AOTA], 2020). To carefully assess the multifactorial causes of functional activity intolerance and their impact on areas of occupation, it is recommended that the evaluating clinician engage in collaboration with other professionals in a care team to create a treatment plan that reflects sound and safe clinical reasoning (Peralta et al., 2024).

Collaborating with the multidisciplinary team, conducting a thorough review of the patient’s electronic medical record, interviewing the patient, and observing for signs and symptoms of activity intolerance during the performance of ADLS can indicate and confirm functional activity tolerance impairments. Some signs and symptoms of functional activity intolerance that clinicians should be aware of include shortness of breath or abnormal breathing, fatigue, weakness, change of color in the face, and dizziness(Emfietzoglou, n.d.).

Monitoring vital signs in patients with decreased functional activity tolerance enables clinicians to track changes in response to daily life activities ranging from simple to complex (Emfietzoglou, n.d.). This information can be helpful to the clinician in anticipating the types of energy conservation techniques to employ and preventing an adverse event such as a fall (Brekke et al., 2019). It is recommended that clinicians treating individuals with functional activity intolerance monitor their blood pressure, heart rate, respiration rate, and oxygen saturation levels (Bartholomew & Vera, 2024). For example, a higher-than-usual heart rate and abnormal pulse oximetry reading coupled with observation of shortness of breath during a low-effort task would necessitate that the clinician stop and reevaluate the situation. The therapist might suggest energy conservation techniques like a rest break and pursed lip breathing and continue to monitor the patient’s vital signs.

The Borg Rating of Perceived Exertion (RPE) revised category-ratio scale is an assessment tool that enables patients to subjectively rate how hard they feel their body is working during activity/exercise using a scale of 0-10 with 0 being no exertion and 10 being maximal exertion (Cleveland Clinic, 2023). A task like donning a t-shirt from a seated position may seem like it requires minimal exertion. Still, a patient with a chronic health condition may rate it at a four on the RPE, indicating that it was moderately difficult for them to complete (Cleveland Clinic, 2023). This helpful information may provide insight into additional energy conservation techniques for the therapist to recommend. In addition to rest breaks and pursed lip breathing techniques, the clinician can recommend that the patient prop their elbows on a surface to don a shirt overhead, which is less taxing on the upper extremities and requires less energy. When using the RPE, it is important to observe signs and symptoms of activity intolerance, like shortness of breath, increased heart rate, muscle fatigue, and sweating, which indicate the need to monitor vital signs and alter activity levels. The RPE scale may help clinicians maintain their patients’ activity levels in a symptom-free zone and determine when and how to decrease patient activity exertion levels by implementing energy conservation techniques (Cleveland Clinic, 2023).

Clinicians can use the 6-Minute Walk Test (6MWT) to assess functional aerobic capacity and endurance (Academy of Neurologic Physical Therapy, 2019). It captures the distance walked in 6 minutes and is appropriate for patients aged two or older with various diagnoses, allowing clinicians to gather baseline information regarding functional activity tolerance. For some older adult age ranges, the Academy of Neurologic Physical Therapy (2019) has provided normative values by gender. In a study by Meys et al. (2023), the 6MWT was proven reliable and valid in assessing the aerobic capacity of adults diagnosed with asthma. Clinicians can use the 6MWT with patients with acute medical conditions to track improvements in functional aerobic capacity by implementing graded remediation-based interventions. For patients with chronic health conditions, the 6MWT can provide clinicians with a baseline functional aerobic capacity that could help tailor specific energy conservation techniques for the patient. For example, suppose a patient covered a distance of 3 meters during the 6MWT, which is approximately 10 ft in 1 minute before needing to sit down (at which point the test is considered complete). In that case, the clinician can recommend placement of a lounge chair in the pathway from the owner-suite bedroom to the owner-suite bathroom, which is a distance of 15 ft, to accommodate a seated rest break while en route to the bathroom. This energy conservation recommendation would also help decrease the risk of falls.

Research on using the Metabolic Equivalent of Task (MET) levels as a tool for energy conservation prescription is limited. However, clinicians working in cardiac rehabilitation are encouraged to use MET levels to estimate required energy consumption for daily life tasks (Bartholomew & Vera, 2024). Consequently, it is important to recognize that energy consumption increases depending on the intensity level of the activity, the type of activity engaged in,  and the environmental and lifestyle context of the individual (Omura et al., 2022). The MET has been organized into four categories per range of energy expenditure: quiet, light-intensity, moderate-intensity, and vigorous-intensity (Omura et al., 2022). This categorization does not fully correlate with energy conservation because, for each category, there is an energy cost for activity that gets more intense as activities progress from one level to the next. At best, along with a client-centered treatment plan inclusive of energy conservation techniques, clinicians can use MET levels to assign patients to either the quiet or light-intensity activity category.

With medical diagnoses evolving, patient complexity increasing, and evidence-based research emerging on conditions that cause functional activity intolerance, clinicians must stay informed and use clinical reasoning skills in selecting appropriate assessment tools to create effective and holistic treatment plans for their patients. Clinicians should consider general energy conservation principles when creating a customized treatment plan for individuals with functional activity intolerance.

Energy conservation recommendations are derived from broader principles to reflect each individual's unique values, habits, routines, and contexts. When creating a client-centered treatment plan inclusive of energy conservation techniques, clinicians need to consider the five major energy conservation principles (Royal Papworth Hospital (2019). The energy conservation principles depicted in Table 1 are broad ideas that can be individualized for persons with chronic conditions to maximize their function in daily life activities (Benthall et al., 2022).

In addition to the five principles of energy conservation, clinicians can foster a positive attitude by collaborating with clients on creative solutions and reminding them of their abilities and strengths versus focusing on what they cannot do. Clinicians can make specific recommendations based on the five principles of energy conservation to address cardiovascular conditions, COPD, and cancer, the most common chronic health conditions in America (Raghupathi & Raghupathi, 2018).

A chronic condition is a long-lasting medical condition that causes functional activity limitations and requires ongoing medical management, treatment, and lifestyle changes (Raghupathi & Raghupathi, 2018). It has been reported that over 50% of Americans have at least one chronic condition, with increased age increasing its incidence and the number of chronic conditions experienced (Raghupathi & Raghupathi, 2018). Chronic conditions like heart disease, COPD, and cancer are the leading cause of death in the United States and account for more than 75% of annual public and private health sector costs (Raghupathi & Raghupathi, 2018). Factors like age, pain, and fatigue associated with prevalent chronic conditions such as heart disease and cardiovascular conditions, COPD, and cancer can put individuals at risk for functional changes that limit their participation in daily meaningful life activities. Energy conservation also referred to as work simplification strategies, are compensatory interventions based on the rehabilitation treatment approach that can be implemented to help individuals modify the way they engage in areas of occupation that are valuable to them when remediation of functional activity intolerance is not possible (Benthall et al., 2022).

Age-related changes in the cardiovascular system put older adults at risk for chronic heart conditions such as peripheral vascular disease, congestive heart failure (CHF), atrial fibrillation (AFib), hypertension, and angina pectoris (Bartholomew & Vera, 2024). Chronic conditions like COPD and diabetes often accompany cardiovascular conditions and must be considered when treating patients (Bartholomew & Vera, 2024). Some cardiac conditions may require surgical intervention, necessitating adherence to specific precautions set forth by the physician. In conjunction with consistently monitoring vital signs before, during, and after treatment, energy conservation and work simplification techniques are recommended components of each of the three phases of cardiac rehabilitation to help patients maintain their safety in daily life tasks as they experience functional activity intolerance (Bartholomew & Vera, 2024). Clinicians can simplify tasks by setting up supplies required for various activities of daily living, for example, retrieval and placement of oral hygiene items on a bedside table so the patient can complete grooming tasks from a seated edge of bed position. This work simplification strategy minimizes the number of steps required to perform oral hygiene, and with seated positions, energy expenditure is lower than with standing positions (Amaro-Gahete et al., 2019). Using arms propped on a stable surface to perform self-care grooming tasks like oral hygiene and an electric toothbrush can assist with energy conservation. Rest breaks are necessary for this population, especially if they have an increased heart rate and shortness of breath. Assistive devices like long-handled reachers, shoehorns, and sock aids eliminate the need for excessive bending and reaching, helping cardiac patients adhere to post-surgery precautions and fully employ the diaphragm to facilitate breathing (Bartholomew & Vera, 2024). Excessive bending and reaching can cause shortness of breath and fatigue, especially in patients with cardiopulmonary conditions(American Lung Association, 2023a).

Person Sitting Using Long-handled Reacher

Chronic bronchitis and pulmonary emphysema are common conditions that contribute to COPD, causing airway obstruction and making breathing difficult (Peralta et al., 2024). Symptoms associated with COPD, like coughing, wheezing, shortness of breath, and production of sputum, are exacerbated by air pollution, respiratory tract infections, and lifestyle choices like cigarette smoking (American Lung Association, 2023b). COPD causes limitations in daily life activities due to the experience of increased fatigue, leading to functional activity intolerance and the need for clinicians to monitor patients’ vital signs and utilize MET levels for activity prescription (Peralta et al., 2024). Energy conservation and work simplification techniques should be practiced with patients to develop habits and routines that help them stay safe while actively participating in daily life activities. Scheduling rest breaks, engaging in activities from a seated position, reducing or eliminating unnecessary steps, pulling items versus pushing them, having everyday use items within easy reach, and planning activities for various times spread throughout the day are some energy conservation techniques that can be helpful for patients experiencing COPD. Good ventilation and using warm water versus hot water to prevent the symptoms of shortness of breath is recommended as an energy conservation strategy for bathing and showering(American Lung Association, 2023a). Adaptive equipment like a rolling laundry cart and assistive devices like a rollator can help compensate for functional activity intolerance and increase independence in home establishment, management, and functional mobility (AOTA, 2020). Clinicians working with individuals with COPD need to incorporate and reinforce breathing techniques like pursed lip breathing, which has been shown to help regulate the pace of breathing and mitigate shortness of breath(American Lung Association, 2023c; Peralta et al., 2024).

Currently, cancer ranks as the second leading cause of death in the United States, with age being the highest risk factor (Byers-Connon, 2024). Approximately one-half of all cancer cases in the United States are attributed to breast, lung, prostate, and colorectal cancers (National Cancer Institute, 2023). Increased fatigue is a universal symptom of all types of cancer and the most commonly experienced side effect for those undergoing chemotherapy, a popular and aggressive treatment option for cancer (American Cancer Society, 2023; Byers-Connon, 2024). Anemia, characterized by a decrease in the body’s red blood cell count, is a complication associated with cancer that causes shortness of breath and fatigue, making it difficult for patients to complete daily life activities (Byers-Connon, 2024). Limited functional activity tolerance issues arising from blood count issues and signs and symptoms of cancer itself and treatment, also known as cancer-related fatigue, can be addressed by clinicians monitoring patients’ vital signs and incorporating energy conservation and work simplification strategies into their treatment plans (Byers-Connon, 2024). Some types of cancer are susceptible to spreading or metastasizing to the bone, making the individual more prone to pathological fractures. To prevent pathological fractures and to help conserve energy, patients can be advised on sliding, pushing, or pulling items versus lifting or carrying them. Performing daily activities that require 10 minutes or more of standing from a seated position, asking family or friends for help or delegating tasks to them like meal preparation, using adaptive equipment like a shower chair and long-handled bath sponge for bathing, performing pursed lip breathing techniques, and scheduling periodic rest breaks throughout the day are some excellent energy conservation and work simplification techniques that help patients safely and actively participate in daily life activities (Byers-Connon, 2024).

Patients with functional activity tolerance deficits should be afforded options for energy conservation and work simplification techniques based on their unique socioeconomic status. For example, some patients may not have the financial means to pay for a bimonthly cleaning service, which would be a good energy conservation strategy for maintaining the home's cleanliness. The energy conservation recommendations in Table 2 are specific to different areas of daily living and include low-cost and costly options. Disclaimer: Mention of specific services/retailers is not part of a paid partnership, and consumers should inquire about the various fees associated with suggested services/retailers before making purchases.

Ms. Smith is a 75-year-old female discharged home from a skilled nursing facility after hospitalization after a fall leading to a left hip fracture. Her physician has ordered a home health occupational therapy (OT) evaluation. Upon receiving the OT evaluation order, the occupational therapist developed an occupational profile of the patient before proceeding to analyze the patient’s occupational performance. Aspects of the evaluation process and energy conservation recommendations will be provided through an occupational therapy lens.

Ms. Smith is status post open reduction internal fixation of the left hip, and her initial weight-bearing restriction on the left lower extremity, per her physician, was toe-touch weight bearing. During her stay at the skilled nursing facility, she had a follow-up with her orthopedic surgeon, who changed her weight-bearing restriction to weight-bearing as tolerated. Ms. Smith’s current medical diagnoses include atrial flutter, anemia, hypertension, Type 2 Diabetes Mellitus, and major depressive disorder. Most of these medical diagnoses are chronic in nature and can contribute to functional activity intolerance.

Ms. Smith lives alone in a six-hundred-square-foot apartment on the fourth floor of the complex. Before the fall leading to her hospitalization, she was Independent with the use of various equipment in her daily life activities. Ms. Smith's equipment includes a rollator (a wheeled walker with a seat), a long-handled reacher, and a sock aid. The rollator enables Ms. Smith to functionally mobilize in her environment while providing opportunities for seated rest breaks as needed since she has several chronic conditions that cause her increased fatigue.

Rollator

The long-handled reacher assists Ms. Smith in reaching for items during daily life activities, eliminating the need to bend or reach and helping her conserve energy. Her bathroom is accessible with a flip-up grab bar on the right side of the commode, a walk-in shower with a grab bar on the faucet wall and adjacent wall, a horizontal grab bar on the wall outside the shower, a built-in shower seat, and a handheld shower head. Grab bars can help Ms. Smith safely transfer on and off the toilet and in and out of the shower while conserving her energy. She can further conserve energy by using the shower seat to sit and shower versus standing. The handheld showerhead enables Ms. Smith to adequately clean all areas of her body without standing. As the patient demonstrated using some of the mentioned equipment during the evaluation, the occupational therapist verbally reinforced the importance of using all these items as energy conservation techniques to manage her existing and new diagnoses.

During the dressing portion of the evaluation, the occupational therapist reminded Ms. Smith to dress the lower body first since it is more taxing than dressing the upper body. The occupational therapist observed Ms. Smith for signs and symptoms of activity intolerance, monitored her vital signs, and gave periodic rest breaks throughout the evaluation. Ms. Smith performed the requested daily living tasks slowly and reported that the pain in her left hip contributed to her fatigue.

During the evaluation, the occupational therapist noticed that Ms. Smith’s toilet was low, requiring more effort to stand up. With Ms. Smith being a tall lady, the occupational therapist requested that the home health agency provide Mrs. Smith with a bedside commode or a toilet seat riser. Adjusting the height of the bedside commode and placing it over the toilet to raise the seat or installing a toilet seat riser will reduce the effort required for her to transfer on and off the commode safely. Even with Ms. Smith’s living quarters being small, it was nice to see that Ms. Smith had a few chairs placed throughout her apartment, one between her bed and the kitchen and another between her bed and her TV. Seated options dispersed throughout the home allow individuals with decreased activity tolerance to sit and take rest breaks as they become fatigued while en route to other areas of the home. The chair between the bed and TV was an appropriate height and had armrests, but the lounge chair between the bed and the kitchen was low and had soft cushions and a deep seat, making it difficult for her to transfer out safely and easily. Ms. Smith reported that on the day of her discharge from the skilled nursing facility to her apartment, she had fallen from that chair as she tried to stand to go to the kitchen to grab a snack. The occupational therapist recommended that Ms. Smith’s son, who was present during the evaluation, replace that chair with one similar but taller, which would be the most cost-effective option. A more costly suggestion was purchasing a chair lift system that could be placed on the existing chair to help assist with transfers.

During the evaluation, it became obvious that Ms. Smith could not conduct her daily life activities in meal preparation, laundry, cleaning, and shopping as she did before her hospitalization. Her current level of function did not match her prior level of function. Her son was also concerned about these areas and wanted to know what some low-cost options would be to help Ms. Smith compensate for her activity intolerance issues and remain as independent as she could be in her home. The occupational therapist suggested contacting their local community agency or senior center to set up Meals on Wheels to deliver warm meals to her home. A website was also provided to make it easier to locate the agency for Meals on Wheels (Meals On Wheels America, 2023). Delegating meal preparation, housework (laundry and cleaning), and grocery shopping to trusted family members, friends, and neighbors were also suggested as no-cost or low-cost options. Considering that Ms. Smith lives alone and her apartment is small, the occupational therapist recommended that they inquire about local laundry and in-home cleaning services available at a low cost and as a combined service (some in-home cleaning services offer laundry services). The occupational therapist advised Ms. Smith and her son to think about the options suggested, take some time to inquire and set up aspects of care recommended, and reach out if they wanted to explore more costly options. Ms. Smith has a good prognosis and rehabilitation potential, considering she incorporates the recommended energy conservation techniques into her daily activities.

With close to 60% of adult Americans currently diagnosed with one (or more) chronic health condition, and these conditions identified as the primary contributor to death and disability in the United States, it is imperative that allied health professionals employ energy conservation principles to target meaningful and relevant occupational areas of life impacted by functional activity intolerance, thereby promoting quality of life and active participation in daily life activities (Hoffman, 2022; National Center for Chronic, 2022).

When addressing functional activity intolerance, clinicians need to contemplate contributing factors like increased age, experience of pain and fatigue, and chronic health conditions and their impact on daily life activities. Allied health professionals should monitor patients’ vitals and recognize the signs and symptoms associated with functional activity intolerance. Clinicians are responsible for selecting evidence-based assessments that support the need for skilled services to address functional activity intolerance and creating a treatment plan reflective of sound clinical reasoning and inclusive of appropriate energy conservation recommendations.

Energy conservation principles are broad recommendations that can be applied to daily life activities to help people with chronic health conditions like heart conditions, COPD, and cancer do the things they want to do despite factors like age, pain, and fatigue. Prioritizing, pacing, planning, positioning, and pursed lip breathing are five energy conservation principles that, when applied to specific areas of occupation (like grooming, bathing, toileting, dressing, housework, laundry, cooking, and shopping), can facilitate independence in daily life activities. Use of adaptive equipment, free or cost-based services, and delegation of tasks to trusted family, friends, or neighbors are options for energy conservation. Rehabilitation clinicians, like occupational therapists, are specially equipped to assign and oversee the implementation of energy conservation recommendations because they are trained to utilize a holistic and client-centered rehabilitation approach for persons with chronic health conditions to compensate for functional activity intolerance, thereby promoting independence in daily life activities.

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