ICU early mobility involves more than changing the patient’s position. It is a preventative form of physical and cognitive rehabilitation, engaging the critically ill person in activity that assists with recovery of the cardiopulmonary system, prevents muscle deterioration and joint contractures, and begins restoration of autonomy. This engagement can be a labor-intensive process, but the early initiation of daily activity – preferably at the beginning of a patient’s ICU stay – pays off for the patient with greater physical independence, greater chance of discharge to home rather than to a skilled nursing facility, and lower rates of delirium.
One- to three-year follow-up studies of former patients from medical, surgical, and trauma ICUs report that less than half of patients are able to return to their premorbid level of functioning or work. What is holding them back?
Critical illness is catabolic and depleting, often with rapidly developing weakness that can last for years. A prolonged ICU stay can also cause delirium and cognitive changes for most patients. When combined with minimal or no sedation from the start of an ICU stay, mobility is protective and preventative, an essential part of reducing pain, agitation, delirium, and weakness.
Neuromuscular weakness can occur in 25% to 50% of ICU patients and can last for years after hospital discharge. Early mobilization therapy is the evidence-based intervention recommended to prevent or ameliorate ICU-acquired weakness. Early and progres¬sive rehabilitation is safe for ICU patients, can reduce the incidence and duration of delirium, can shorten ICU and hospital lengths of stay, and can lower hospital costs. Developing an ICU system and culture to achieve these benefits can be challenging.
Clinician-imposed barriers to mobility – such as lack of awareness, fearful attitude, patient sedation, culture of immobility, and unfamiliar professions – need to be addressed. Patient lines and drains can be accommodated, including femoral lines, mechanical ventilation, continuous venovenous hemodialysis lines, drains, catheters, external ventricular drain, and even extracorporeal membrane oxygenation.
Think of the known beneficial effects of exercise:
- Improves blood sugar homeostasis
- Enhances cardiovascular function
- Enhances endothelial function
- Decreases chronic inflammation
- Regulates hormone levels
- Preserves musculoskeletal and neuromuscular integrity
- Decreases depression and improves cognition
These benefits of physical activity are improvements we strive to achieve in our patients medically with all of our treatment modalities. What makes physical activity unique is how little adverse side effects are encountered, and how linear the benefits are. The more activity a person can accomplish within their individual tolerance and capacity, the more benefits they will achieve.
As with any medicine, determining the correct dosage and frequency for mobility is a skill. This is why established ICU early mobility programs rely on the consultation or permanent addition of physical and occupational therapists to their ICUs for delivery of early mobility.
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