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Early Mobilization in the ICU

Original Editor - Ashmita Patrao Top Contributors - Ashmita Patrao, Vidya Acharya, Alicia Fernandes, Kim Jackson, Saud Alghamdi, Uchechukwu Chukwuemeka and Sehriban Ozmen

Introduction

Globally people recover from critical illnesses and get discharged from an ICU setup, however, it has been noticed that patients develop weakness, probably credited to their prolonged period of immobilization.[1] Post intensive care syndrome was the term used that describes the worsening of physical, mental, and cognitive problems.[2] Early mobilization of critically ill patients is a safe option with additional benefits of improving functional outcomes.[3] The term mobilization in the Intensive care unit is referred to as physical activity performed to the intensity that can bring about physiological changes.[4] Early mobilization is the application of physical activity as early as the 2nd to 5th day after the onset of critical illness or injury.[1]

Why Early Mobilization

Long term ICU care is always associated with complications in a high proportion of ICU survivors. Prolonged periods of immobility have often been associated with physical deconditioning, fatigue, loss of function and a decreased quality of life.[1]

A systematic review and meta-analysis suggest early rehabilitation in the ICU reduces the incidence of developing Intensive care unit-acquired weakness (ICUAW).[5] Another cross-sectional survey suggests patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%) are the most common barriers to early mobilization.[6] Also, the study infers a significant positive relationship between the type of ventilation and out-of-bed patient mobilization.

According to a retrospective cohort study in survivors of a prolonged ICU-stay, the ability to ambulate was related with a higher possibility of being discharged. Thus, emphasizing the importance of mobility training in long-term acute care hospitals.[7] Furthermore, a recent study involving more than 6000 patients have found that each additional 10 minutes of Physiotherapy and or Occupational therapy interventions resulted in a 1.2 day lower hospital length of stay. [8]

Below is a gist of the system-wise complications of prolonged immobility.

Barriers to early mobilisation in ICU

Despite the consistently reported benefits of early mobilisation in ICU, studies have shown that only 54% of all patient days involved mobility. In fact, in those patients who are receiving mechanical ventilation, 95% of them were not mobilised within the first 72 hours. [11]  Furthermore, A study completed between 2009-2010 that observed 38 ICUs in Australia and New Zealand on a specific day found that no mechanically ventilated patients were engaged in early mobility and its varying forms. i.e., sitting out on the edge of the bed or performing bed based exercises.[12]

Is it safe?

Patient safety and stability appear to be a very common concern when investigating barriers to early mobilisation in ICU. [13] Some studies have reported that physiotherapists often avoid early mobilisation due to believing that patients are physiologically unstable; often relating to the cardiopulmonary system. [14] [15]

Although ICU patients are often deemed unready and unsafe to mobilise, there is an overwhelming body of literature to suggest otherwise. Studies have consistently shown that early ICU mobility is associated with low adverse effects. [15] [16] Early mobilisation in ICU has also been reported to be safe with low adverse effects in mechanically ventilated ICU patients. [17]

Time constraints and limited staffing

Another common barrier to early mobilisation in ICU was time related. Physiotherapists and other healthcare professionals have repeatedly reported that time constraints, increased workload and limited staffing hindered their ability begin early mobilisation in ICU patients. [18] [19]

Low confidence and lack of training

Lack of specific ICU training can cause low confidence levels among physiotherapists and can contribute to previously mentioned barriers. In a survey that questioned physiotherapists about their attitudes towards early mobilisation in ICU, 71% reported low confidence in managing ICU cases while 42% reported inadequate training. [20] Low confidence and inadequate training are interlinked. In order to assist physiotherapists in overcoming the feeling of low confidence, providing adequate multidisciplinary team training is crucial. [21]

Physiological Effects

The acute physiological effects of early mobilization are summarized below

Systems Physiological effects
Pulmonary system Increased Regional ventilation

Increased regional diffusion

Increased Regional perfusion

Increase tidal volume

Increase efficiency of respiratory mechanics

Reduce air flow resistance

Increase flow rates

Increase zone 2 (Area of ventilation perfusion matching)

Increase or decrease Breathing frequency

Increase floe rates

Increase strength and quality of a cough

Increase mucociliary transport and airway clearance

Increase distribution and function of pulmonary immune factors

Cardiovascular system Incraease venous return

Increase stroke volume

Increase heart rate

Increase myocardial cntractilty

Increase stroke volume, heart rate and cardiac output

Increase coronary perfusion

Increase circulating blood volume

Increase chest tube drainage

Peripheral circulatory effects Reduced peripheral vascular resistance

Increase blood flow

Increase peripheral tissue oxygen extractiion

Lymphatic system Increase pulmonary lymphatic flow

Increase pulmonary lymphatic drainage

Hematologic system Increase circulatory transit times

Reduce circulatory stasis

Neurological system Increase arousal

Increase cerebral electrical activity

Increase stimulus to breathe

Increase sympathetic stimulation

Increase postural reflexes

Endoricne system Increase release, distribution and degradation of catechoamines
Genitourinary system Increase glomerular filtration

Increase urinary output

Gastrointestinal system Increase gut motility

Reduce constipation

Integumentary system Increase cutaneous circulation for thermoregulation
Multisystemic effects Reduce effects of anesthesia and sedation

Reduce deleterious cardiopulmonary effects of surgery

Reduce the risk of loss of gravitational stimulus and exercise stimulus

There is an improved ventilation/perfusion matching, better lung compliance, mucociliary clearance, reduced work of breathing in upright positions. Movement of the lower limbs mainly the ankle prevented stasis of blood and hence prevents Deep vein thrombosis as well as pulmonary embolus formation.

Prescription of Early Mobilization

To assist in the clinical decision-making process, you can follow the steps below:

Step 1: Identifying the contributing factors towards oxygen transport deficits

  • Understanding the pathophysiology of the condition or disease[22][23]
  • Extrinsic factors that affect patient care
  • Intrinsic factors related to the patient[24]
  • Relative immobility[25][26]

Step 2: Determining the specific need for mobilization and subsequently the form of mobilization or exercise that will address the oxygen transport deficiency[27][28].[29]

Step 3: Matching the selected mobilization technique or exercise type to the patient’s oxygen-carrying capacity.[30]

Step 4: Set the dosage, i.e. the intensity to match the safe limits of oxygen transport of the patient.[31][32]

Step 5: Combining body positions with these maneuvers[33][34]

  • Thoracic mobility exercises
  • ROM exercises (Active, passive and active-assisted)
  • Coordinating breathing control with body movements
  • Coughing, supported by self or others

Step 6: Use oxygen transport and its indices to monitor the dosage of mobilization, not a fixed duration of time.[35][36][37]

Step 7: Repeat this mobilization as frequently and safely as the beneficial effects are tolerated by the subject or patient.

Step 8: The intensity of the mobilization stimulus can be increased as long as the patient capacity permits the effects of the mobilization stressor, keeping the oxygen transport as the benchmark, constantly monitoring vitals.[38]

Tools and systems

in ICU settings, early mobility is crucial for improving patient outcomes, reducing ICU length of stay, and preventing complications such as muscle weakness and delirium. Several tools and systems help guide physiotherapists in safely implementing early mobility. The Traffic Light System is one such tool, widely used to help guide clinical decisions based on patient stability and response to mobilization.

1. Traffic Light System

The Traffic Light System classifies patients into three categories (green, yellow, and red), based on safety indicators, which helps physiotherapists make real-time decisions[39]:[40]

  • Green (Go): Patients are cleared for early mobilization. Indicators include stable vital signs, cooperative state, and minimal sedation.
  • Yellow (Caution): Mobilization may be performed but with caution. These patients may have fluctuating vitals or moderate sedation, requiring close monitoring and potential assistance.
  • Red (Stop): Mobilization is contraindicated. This may be due to severe instability, high ventilatory support requirements, or other critical concerns.

This system is usually customized according to hospital or unit-specific protocols and helps ensure that patients mobilize safely without compromising their stability.

2. ICU Mobility Scoring Tools

These scoring tools help guide and track patient progress:

  • Perme ICU Mobility Score: Assesses a patient’s mobility barriers, including their mental state, respiratory support, strength, and functional mobility. This score is useful in creating a baseline and tracking improvements.
  • PFIT (Physical Function ICU Test): A validated assessment of physical function that involves activities like sitting, marching, and shoulder flexion. It provides an objective measure of progress in ICU patients.[41]
  • AM-PAC (Activity Measure for Post-Acute Care): Covers basic and complex mobility tasks, aiding in setting realistic mobility goals based on patient ability and support needs[42].[43]

3. ABCDE Bundle

This holistic approach combines different aspects of ICU care to support safe mobilization:

  • A: Assess, prevent, and manage pain
  • B: Both spontaneous awakening and breathing trials
  • C: Choice of sedation and pain management protocols
  • D: Delirium prevention and management
  • E: Early mobilization and exercise

Using this approach helps ensure that multiple disciplines are involved in the patient's care, which can support safe early mobilization.

4. Richmond Agitation-Sedation Scale (RASS)

RASS evaluates sedation and agitation, essential for determining a patient's readiness for early mobilization. A RASS score of -1 to +1 generally indicates a stable and responsive patient, suitable for mobilization.

Early Mobilization Intervention

The frequency of early mobilization can be conducted every day of the week or five days a week.[1] Although active techniques are preferred more than passive and attribute more to the prevention of complications, these are some of the listed techniques that come under the scope of early mobilization:

References

  1. ↑ 1.0 1.1 1.2 1.3 Castro-Avila AC, Serón P, Fan E, Gaete M, Mickan S. Effect of early rehabilitation during intensive care unit stay on functional status: systematic review and meta-analysis. PloS one. 2015;10(7):e0130722. Doi: 10.1371/journal.pone.0130722.
  2. ↑ Harrold ME, Salisbury LG, Webb SA, Allison GT, Australia and Scotland ICU Physiotherapy Collaboration. Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers. Crit Care. 2015;19(1):336. Doi: 10.1186/s13054-015-1033-3
  3. ↑ Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med. 2012;40(2):502-9.
  4. ↑ Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest 2013;144(3):825–47.
  5. ↑ Anekwe DE, Biswas S, Bussières A, Spahija J. Early Rehabilitation Reduces the Likelihood of Developing Intensive Care Unit-Acquired Weakness: A Systematic Review and Meta-Analysis. Physiotherapy. 2020;107:1-10. Doi: 10.1016/j.physio.2019.12.004..
  6. ↑ Tadyanemhandu C, van Aswegen H, Ntsiea V. Organizational structures and early mobilization practices in South African public sector intensive care units—A cross‐sectional study. Journal of Evaluation in Clinical Practice. 2021; 27(1):42-52. Doi: 10.1111/jep.13378.
  7. ↑ Tran DH, Maheshwari P, Nagaria Z, Patel HY, Verceles AC. Ambulatory Status Is Associated With Successful Discharge Home in Survivors of Critical Illness. Respiratory Care. 2020; 65(8):1168-1173. Doi: 10.4187/respcare.07437.
  8. ↑ Jenkins AS, Isha S, Hanson AJ, Kunze KL, Johnson PW, Sura L, et al. Rehabilitation in the intensive care unit: How amount of physical and occupational therapy affects patients’ function and hospital length of stay. PM & R [Internet]. 2024 Feb 14;16(3):219–25.
  9. ↑ Morris PE, Herridge MS. Early intensive care unit mobility: future directions. Crit Care Clinics. 2007;23(1):97-110.
  10. ↑ 10.0 10.1 Amidei C. Mobilisation in critical care: a concept analysis. Intens Crit Care Nur. 2012;28(2):73-81.
  11. ↑ Barber E, Everard T, Holland AE, Tipping CJ, Bradley SJ, Hodgson C. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Australian Critical Care [Internet]. 2015 Nov 1;28(4):177–82. Available from: https://doi.org/10.1016/j.aucc.2014.11.001
  12. ↑ Berney S, Harrold M, Webb S a R, Seppelt I, Patman S, Thomas PJ, et al. Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Critical Care and Resuscitation [Internet]. 2013 Dec 1;15(4):260–5. Available from: https://doi.org/10.1016/s1441-2772(23)01424-2
  13. ↑ Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, et al. Early Physical Medicine and Rehabilitation for patients with acute Respiratory Failure: a quality improvement project. Archives of Physical Medicine and Rehabilitation [Internet]. 2010 Apr 1;91(4):536–42. Available from: https://doi.org/10.1016/j.apmr.2010.01.002
  14. ↑ Winkelman C, Peereboom K. Staff-Perceived barriers and facilitators. Critical Care Nurse [Internet]. 2010 Apr 1;30(2):S13–6. Available from: https://doi.org/10.4037/ccn2010393
  15. ↑ 15.0 15.1 Harrold M, Salisbury L, Webb S, Allison G. Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers. Critical Care [Internet]. 2015 Dec 1;19(1). Available from: https://doi.org/10.1186/s13054-015-1033-3
  16. ↑ Bailey P, Thomsen G, Spuhler VJ, Blair RV, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients*. Critical Care Medicine [Internet]. 2007 Jan 1;35(1):139–45. Available from: https://doi.org/10.1097/01.ccm.0000251130.69568.87
  17. ↑ Schweickert WD, Pohlman M, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. The Lancet [Internet]. 2009 May 1;373(9678):1874–82. Available from: https://doi.org/10.1016/s0140-6736(09)60658-9
  18. ↑ Capell EL, Tipping CJ, Hodgson C. Barriers to implementing expert safety recommendations for early mobilisation in intensive care unit during mechanical ventilation: A prospective observational study. Australian Critical Care [Internet]. 2019 May 1;32(3):185–90. Available from: https://doi.org/10.1016/j.aucc.2018.05.005
  19. ↑ Johnson K, Petti J, Olson AL, Custer T. Identifying barriers to early mobilisation among mechanically ventilated patients in a trauma intensive care unit. Intensive and Critical Care Nursing [Internet]. 2017 Oct 1;42:51–4. Available from: https://doi.org/10.1016/j.iccn.2017.06.005
  20. ↑ Alqahtani M, Kashoo FZ, Alzhrani M, Ahmad F, Seyam M, Ahmad M, et al. Current physical therapy practice in the intensive care unit in Saudi Arabia: a Multicentre Cross-Sectional survey. Critical Care Research and Practice [Internet]. 2020 Dec 29;2020:1–7. Available from: https://doi.org/10.1155/2020/6610027
  21. ↑ Anekwe D, Milner SC, Bussières A, De Marchie M, Spahija J. Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework. Journal of Physiotherapy [Internet]. 2020 Apr 1;66(2):120–7. Available from: https://doi.org/10.1016/j.jphys.2020.03.001
  22. ↑ Voiriot G, Oualha M, Pierre A, Salmon-Gandonnière C, Gaudet A, Jouan Y, Kallel H, Radermacher P, Vodovar D, Sarton B, Stiel L. Chronic critical illness and post-intensive care syndrome: from pathophysiology to clinical challenges. Annals of intensive care. 2022 Jul 2;12(1):58.
  23. ↑ Tirelbar MA, Shalaby HM. An Evaluation of The Pathophysiology, Prevention, and Rehabilitation Strategies for ICU-Acquired Weakness in Critically Ill Patients. Asian Journal of Medical Principles and Clinical Practice. 2024 May 15;7(1):248-54.
  24. ↑ Gruenberg DA, Shelton W, Rose SL, Rutter AE, Socaris S, McGee G. Factors influencing length of stay in the intensive care unit. American Journal of critical care. 2006 Sep 1;15(5):502-9.
  25. ↑ O’Neill DE, Heckman GA, Graham MM. The epidemic of immobility in hospitalized patients: How to get your patient up and moving. Canadian Journal of Cardiology. 2024 Mar 22.
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  27. ↑ Engel HJ, Brummel NE. What Exactly Is Recommended for Patient Physical Activity During an ICU Stay?. Critical Care Medicine. 2024 May 1;52(5):842-7.
  28. ↑ Jayachandran B, Venkatesan K, Tan SB, Yeo LS, Venkatacham J, Selvakumar MP, Tan BY. Feasibility of Combining Functional Mobilisation with Resistance and Endurance Training for Mechanically Ventilated Patients in Intensive Care Unit Setting—A Pilot Study. Journal of Clinical Medicine. 2024 Apr 20;13(8):2412.
  29. ↑ Zhang H, Sheng Y, Yu C, Cheng Q. Understanding the needs and perceptions of early mobilization for critically ill patients: A systematic review of qualitative studies. Intensive and Critical Care Nursing. 2024 Apr 1;81:103584.
  30. ↑ Thomas B, Morgan S, Smith JM. Impact of early mobilization within the intensive care unit after coronary artery bypass grafting: A systematic review. Cardiopulmonary Physical Therapy Journal. 2024 Apr 1;35(2):56-70.
  31. ↑ Wang YT, Lang JK, Haines KJ, Skinner EH, Haines TP. Physical rehabilitation in the ICU: a systematic review and meta-analysis. Critical Care Medicine. 2022 Mar 1;50(3):375-88.
  32. ↑ Chiarici A, Andrenelli E, Serpilli O, Andreolini M, Tedesco S, Pomponio G, Gallo MM, Martini C, Papa R, Coccia M, Ceravolo MG. An early tailored approach is the key to effective rehabilitation in the intensive care unit. Archives of physical medicine and rehabilitation. 2019 Aug 1;100(8):1506-14.
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  44. ↑ Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008;34(7):1188-1199. Doi: 10.1007/s00134-008-1026-7.
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