Early Mobility and Exercise

Early Mobility and Exercise

Within the ABCDEF bundle, the E element, Early Mobility and Exercise, focuses on understanding the physical deficits that ICU survivors face, and identifying strategies for successful implementation of early mobilization programs.


Implementation Tools
Implementing the E component of the ABCDEF bundle
Barriers to Early Mobility
Comparison of Three ICU Early Mobility Quality Improvement Projects
Daily Mobility Assessment and Treatment
Multidisciplinary Approach to Early Mobilization in the ICU
Treatment Lessons Learned

The key question to ask during rounds is: Did the patient achieve maximal mobility activity or exercise today? If mobility activity or exercise is falling short, it is important to determine the reasons. Some factors to consider are:

  • Was the patient walking before admission?
  • Is the patient hemodynamically stable?
  • Is the patient awake?

Also take into account the following aspects before mobilizing a patient in the ICU:

  • Neurologic (level of alertness)
  • Cardiac (hemodynamic stability and vasoactive medications)
  • Pulmonary (ventilation/oxygenation needs)
  • Risk versus benefit
  • Guidelines versus protocols (fewer absolute contraindications, importance of interdisciplinary collaboration)
 

 Assessment

 

Step 1: Patient Selection Process

Do any of the following exclusion criteria apply?

  • Patient has immediate plans to transfer to outside hospital
  • Patient requires significant doses of vasopressors for hemodynamic stability (maintain mean arterial pressure > 60 mm Hg)
  • Patient is mechanically ventilated and requires Fio2 > 0.8 and/or positive end-expiratory pressure > 12 mm Hg, or has acutely worsening respiratory failure
  • Patient is maintained on neuromuscular paralytic agents
  • Patient has an acute neurologic event (e.g., cerebrovascular accident, subarachnoid hemorrhage, or intracranial hemorrhage) with reassessment for mobility every 24 hours
  • Patient is unresponsive to verbal stimuli
  • Patient has an unstable spine or extremity fracture
  • Patient has a grave prognosis and is transferring to comfort care
  • Patient has an open abdomen with a risk for dehiscence

These are guidelines, not precautions. In the presence of any exclusion criterion, consult with patient’s providers to determine if participation in physical activity or exercise is safe.

Step 2: Assess Patient’s Activity History

What was the patient’s level of activity in the past two hours, two days, two weeks, two months, and two years?

Step 3: Grossly Assess Patient’s Strength

How easily can the patient lift legs off the bed? How well does the patient bear weight on the legs?

Step 4: Assess Patient’s Ability to Engage

How well does the patient follow commands and engage in activity?

 

 Treatment

 

While encouraging and physically supporting patients in their efforts to achieve their individual goals, staff must watch the patient, watch the monitors, and watch the lines while gradually increasing the activity level.

Mobility therapy steps

Step 1: Untangle and create slack on the lines. Secure the lines. Connect the portable monitor.
Step 2: Initiate bed exercise. Watch the patient, watch the monitor, and watch the lines.
Step 3: Sit the patient on the edge of the bed. Assess for pain and orthostatic blood pressure.
Step 4: Assist seated patient in standing.
Step 5: Initiate walking. Keep a chair close to the patient. Utilize aides, volunteers and students to push chair and intravenous poles.
Step 6: Seat and rest the patient as needed.

Consider the following factors with each physical rehabilitation or ICU mobility session:

  • Determine whether the level of activity is therapeutic.
  • Identify the available equipment.
  • Schedule a time to work on physical activity with the patient, family, nurse and respiratory therapist. Ascertain whether sedation should be suspended.
  • Assess and manage the patient’s pain before, during and after mobility activity.
  • Optimize the work of breathing and patient level of alertness to make treatment beneficial.
  • Create activities that are goal-oriented for the patient.
  • Do not delay or defer physical activity and rehabilitation even if the patient is to be extubated that day.
  • Do not delay or defer physical activity because of agitation if it can be safely managed by the nurse and therapist. For patients who are agitated or experiencing disorganized thinking and delirium, a focused task provides an opportunity for reorienting conversation.

Stop and rest the patient if the patient:

  • Is unresponsive
  • Is fatigued or appears pale
  • Has a respiratory rate consistently > 10 beats/min above baseline
  • Has decreased muscle recruitment
  • Loses balance
  • Has decreased weight-bearing ability
  • Has diaphoresis
 

 Additional Reading

 

Kayambu G, Boots R, Paratz J. Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomized controlled trial. Intensive Care Med. 2015 May;41(5):865-874.

Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD, Needham DM. Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care. 2014 Jun;29(3):395-400.

Fan E, Cheek F, Gosselink R, et al. An official American Thoracic Society Clinical Practice guideline: the diagnosis of intensive care unit-acquired weakness in adults. Am J Respir Crit Care Med. 2014 Dec;190(12):1437-1446.

Kress JP, Hall JB. ICU-acquired weakness recovery from critical illness. N Engl J Med. 2014 Apr;370(17):1626-1635.

Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review. Chest. 2013 Nov;144(5):1469-1480.

Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013 Oct;310(15):1591-1600.

Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013 Oct;369(14):1306-1316.

Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013 Jun;41(6):1543-1554.

Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM. ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med. 2013 Mar;41(3):717-724.

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 Aug;28(4):535 e9-15.

Hopkins RO, Miller RR III, Rodriguez L, Spuhler V, Thomsen GE. Physical Therapy on the wards after early physical activity and mobility in the intensive care unit. Phys Ther. 2012 Dec;92(12):1518-1523.

Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM. Diaphragm muscle thinning in patients who are mechanically ventilated. Chest. 2012 Dec;142(6):1455-1460.

Winkelman C. Ambulating with pulmonary artery or femoral catheters in place. Crit Care Nurse. 2011 Oct;31(5):70-73.

Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011 May;341(5):373-377.

Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011 Apr;364(14):1293-1304.

Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010 Nov;38(11):2089-2094.

Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010 Apr;91(4):536-542.

Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009 May;373(9678):1874-1882.

Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008 Apr;36(4):1119-1124.

Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008 Mar;358(13):1327-1335.

De Jonghe B, Lacherade JC, Durand MC, Sharshar T. Critical illness neuromuscular syndromes. Crit Care Clin. 2007 Jan:23(1);55-69.

Bailey P, Thomesn GE, Spuhler JV, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007 Jan;35(1):139-145.

Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003 Feb;348(8):683-693.

Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012 Apr;28(2):88-97.

Blair SN, Morris JN. Healthy hearts--and the universal benefits of being physically active: physical activity and health. Ann Epidemiol. 2009 Apr;19(4):253-256.

Clemmer T, Spuhler VJ. Keys to successful mobility in the ICU. November 27, 2007. http://www.hanys.org/ihi_campaign/upload/4_NYNY_Mobility.pdf. Accessed June 28, 2013.

Haskell WL. J.B. Wolffe Memorial Lecture. Health consequences of physical activity: understanding and challenges regarding dose-response. Med Sci Sports Exerc. 1994 Jun;26(6):649-660.

Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr.. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar; 340(9):669-676.

Kress JP. Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009 Oct;37(10 Suppl):S422-S427.

Lipshutz AKM, Engel H, Thornton K, Gropper M. Early Mobilization in the Intensive Care Unit: Evidence and Implementation. ICU Dir. 2012 Jan;3(1):10-16.

Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma. 2009 Aug;67(2):341-348; discussion 348-349.

Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008 Aug;36(8):2238-2243.

Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil. 2010 Jul-Aug;17(4): 271-281.

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 May;18(3):212-221.

Perme C, Nalty T, Winkelman C, Kenji Nawa R, Masud F. Safety and Efficacy of Mobility Interventions in Patients with Femoral Catheters in the ICU: a Prospective Observational Study. Cardiopulm Phys Ther J. 2013 Jun;24(2):12-17.

Perme CS, Southard RE, Joyce DL, Noon GP, Loebe M. Early mobilization of LVAD recipients who require prolonged mechanical ventilation. Tex Heart Inst J. 2006;33(2):130-133.

Timmers TK, Verhofstad MH, Moons KG, van Beeck EF, Leenen LP. Long-term quality of life after surgical intensive care admission. Arch Surg. 2011 Apr;146(4):412-418.

Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006 Mar;174(6):801-809.

 

 Suggested Videos

 

Both Johns Hopkins University and Vanderbilt University Medical Center provide additional resources on early mobility. These selected videos have been identified by the ICU Liberation Initiative to be most relevant and helpful to ICU clinicians.


PT/OT team ambulating with intubated middle aged woman

 


PT/OT team ambulating with intubated young male – session 1

 

PT/OT team ambulating with intubated young male – session 2

 

84 y/o woman with H1N1 walking on day 1 after intubation on no sedation

 

Early Parkinsonian man with pneumonia walking intubated

 

Middle aged man walking PAD-1 following pancreatic pseudocyst drainage

 

Middle aged man walking PAD-4 following pancreatic pseudocyst drainage

 

Johns Hokpkins:Research Update "ICU Early Exercise" Johns Hopkins Medicine


ICU & Acute Care Physical Therapy: Phyllis' Recovery, Darin Trees PT DPT

 

Newton Wellesley Hospital ICU: Ambulating the Ventilated Patient - A Tutorial