Early Mobility Assessment for Critically Ill Patients

Introduction[edit | edit source]

As technology and science evolve in intensive care medicine, more patients are surviving critical illness episodes.[1] However, prolonged stays in intensive care units (ICU) are linked with functional declines, increased morbidity and mortality and increased length of stay in hospital.[2] Patients who survive a stay in ICU often go on to experience various long term challenges on discharge, some psychological (i.e. cognitive impairment, post traumatic stress disorder, persistent anxiety),[3] as well as social, financial and physical impairments, including  ICU acquired weakness,[1] decreased physical function and a decrease in quality of life.[3] These long lasting sequelae are  referred to as post-intensive care syndrome.[1]

It has been found that early mobility (EM) programmes can have a positive impact on these factors.[2] Mobilisation is described as physical activity which results in certain physiological effects.[4][5] It is energy consuming and includes various activities that produce movement (such as actively moving limbs, actively rolling in bed, sitting on the edge of the bed etc).[6]

What is Early Mobility?[edit | edit source]

Early Mobility (EM) is defined as mobilization started within 24-48 hours of admission into ICU.[7] It is a safe and achievable practice that has the potential to mitigate the effects of critical illness on several body systems.[8]

EM consists of a series of planned movements that are progressed in a sequential manner.[2] It is commenced with minimal or no participation from the patient. It can also be safely implemented for mechanically ventilated patients and patients receiving continuous hemofiltration.[9] A comprehensive assessment enables the physiotherapist and other members of the mobility team to make an informed decision on the individual mobility requirement of the patient.[10]

Levels of mobility[edit | edit source]

Robust mobility protocols have been developed to guide critical care clinicians in EM.[2][11][12][13][14] It is important to liaise with every member of the team to ensure a flow of communication when planning interventions. Goals should be set with the patient and these should always follow the SMART (Specific, Measureable, Achievable, Realistic and Time bound) and FITT (Frequency, Intensity, Time and Type) principles.[10]  It is important to note that goal setting is not always straightforward.[15] The goal setting process should be undertaken in such a way that the clinician is able to gain an understanding of what is important to the patient.[16]

For more information on Early Mobility in ICU, please click here.

Evidence of Effectiveness for Early Mobility Programmes[edit | edit source]

Evidence exists for the clinical effectiveness of EM in combating the negative effects associated with prolonged immobility during critical illness. Early progressive mobility programmes can be safely implemented for patients in ICU.[2] These programmes can have a positive impact on many outcomes in critical illness survivors.[17][6][18][19]

In particular, they can improve ventilation, circulation, perfusion, muscle metabolism and alertness,[6] as well as decrease the incidence of delirium, reduce the number of days on a ventilator, decrease the length of hospital stay and improve function on discharge.[3]

Evidence has also shown short-term improvements in physical-related outcomes such as muscle strength and a reduction in the incidence of Intensive Care Unit Acquired Weakness (ICU-AW).[20][21] A review by Stiller provides specific evidence on the efficacy of EM on secondary outcomes such as ICU and hospital length of stay.[22] Although some studies provide contrasting reports,[23][24][25] this has been attributed to poor study quality and a delay in initiation of early mobilization interventions.[10]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Clarissa C, Salisbury L, Rodgers S, Kean S. Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities. J Intensive Care. 2019;7:3.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18(3):212-221.
  3. ↑ 3.0 3.1 3.2 Linke CA, Chapman LB, Berger LJ, Kelly TL, Korpela CA, Petty MG. Early Mobilization in the ICU: A Collaborative, Integrated Approach. Crit Care Explor. 2020;2(4):e0090. 
  4. ↑ Iwashyna TJ, Hodgson CL. Early mobilization in ICU is far more than just exercise. The Lancet. 2016; 388(10052): 1351‐1352.
  5. ↑ Lai CC, Chou W, Chan KS, Cheng KC, Yuan KS, Chao CM et al. Early Mobilization Reduces Duration of Mechanical Ventilation and Intensive Care Unit Stay in Patients With Acute Respiratory Failure. Arch Phys Med Rehabil. 2017;98(5):931-939.
  6. ↑ 6.0 6.1 6.2 Arias-Fernández P, Romero-Martin M, Gómez-Salgado J, Fernández-García D. Rehabilitation and early mobilization in the critical patient: systematic review. J Phys Ther Sci. 2018;30(9):1193-1201.
  7. ↑ Anekwe DE, Koo KK, de Marchie M, Goldberg P, Jayaraman D, Spahija J. Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada. J Intensive Care Med. 2019;34(3):218-226. 
  8. ↑ Nydahl P, Sricharoenchai T, Chandra S, et al. Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann Am Thorac Soc. 2017;14(5):766-777. 
  9. ↑ Damluji A, Zanni JM, Mantheiy E, Colantuoni E, Kho ME, Needham DM. Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit. J Crit Care. 2013;28(4):535.e9-535.e5.35E15. 
  10. ↑ 10.0 10.1 10.2 Okeke C. Early Mobility Assessment for Critically Ill Patients Course. Physioplus. 2020.
  11. ↑ Vollman KM. Understanding critically ill patients hemodynamic response to mobilization: using the evidence to make it safe and feasible. Crit Care Nurs Q. 2013;36(1):17-27. 
  12. ↑ Davis J, Crawford K, Wierman H, et al. Mobilization of ventilated older adults. J Geriatr Phys Ther. 2013;36(4):162-168. 
  13. ↑ Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014;18(6):658. 
  14. ↑ Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Cook DJ. TryCYCLE: A prospective study of the safety and feasibility of early in‐bed cycling in mechanically ventilated patients. PLOS One 2016; 11(12): 1-17.
  15. ↑ Schoeb V, Staffoni L, Parry R, Pilnick A. "What do you expect from physiotherapy?": a detailed analysis of goal setting in physiotherapy. Disabil Rehabil. 2014;36(20):1679-1686.
  16. ↑ Melin J, Nordin Å, Feldthusen C, Danielsson L. Goal-setting in physiotherapy: exploring a person-centered perspective [published online ahead of print, 2019 Aug 26]. Physiother Theory Pract. 2019;1-18.
  17. ↑ Martínez-Velilla N, Cadore EL, Casas-Herrero Á, Idoate-Saralegui F, Izquierdo M. Physical Activity and Early Rehabilitation in Hospitalized Elderly Medical Patients: Systematic Review of Randomized Clinical Trials. J Nutr Health Aging. 2016;20(7):738-751. 
  18. ↑ McWilliams D, Jones C, Atkins G, et al. Earlier and enhanced rehabilitation of mechanically ventilated patients in critical care: A feasibility randomised controlled trial. J Crit Care. 2018;44:407-412. 
  19. ↑ Anekwe DE, 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. J Physiother. 2020;66(2):120-127. 
  20. ↑ Fuke R, Hifumi T, Kondo Y, et al. Early rehabilitation to prevent postintensive care syndrome in patients with critical illness: a systematic review and meta-analysis. BMJ Open. 2018;8:e019998.
  21. ↑ 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. 
  22. ↑ Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest. 2013;144(3):825-847. 
  23. ↑ Denehy L, Skinner EH, Edbrooke L, et al. Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care. 2013;17(4):R156. 
  24. ↑ Moss M, Nordon-Craft A, Malone D, et al. A Randomized Trial of an Intensive Physical Therapy Program for Patients with Acute Respiratory Failure. Am J Respir Crit Care Med. 2016;193(10):1101-1110. 
  25. ↑ Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017;43(2):171-183. 
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