Early Mobility

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

 

 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; look at the patient, watch the monitor, watch the lines.
  • Step 3: Sit 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 with each physical rehabilitation or ICU mobility session:

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

Stop and rest the patient if:

  • Unresponsive
  • Fatigued, pale appearance
  • Respiratory rate consistently >10 beats/min above baseline
  • Muscle recruitment decreased
  • Losing balance
  • Weight-bearing ability decreased
  • Diaphoresis present
 

 Assessment

 
Step 1: Patient Selection Process

Do any of the following exclusion guidelines 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)
  • Mechanically ventilated patient who requires FiO2 >0.8 and/or positive end-expiratory pressure >12 mm Hg, or who has acutely worsening respiratory failure
  • Patient maintained on neuromuscular paralytics
  • Patient in an acute neurological event (cerebrovascular accident, subarachnoid hemorrhage, intracranial hemorrhage) with reassessment for mobility every 24 hours
  • Patient unresponsive to verbal stimuli
  • Patient with unstable spine or extremity fractures
  • Patient with a grave prognosis, transferring to comfort care
  • Patient with an open abdomen (risk for dehiscence)
  • These are guidelines, not precautions. In the presence of any exclusion criterion, consult with the nursing staff and patient physicians to determine if participation in physical activity is safe.

Step 2: Assess Patient Activity History
What was the patient’s level of activity in the past 2 hours, 2 days, 2 weeks, 2 months, and 2 years? 

Step 3: Grossly Assess the Patient’s Strength 
How easily can the patient lift the legs off the bed? How well does the patient bear weight on the legs?

Step 4: Assess Ability to Engage
How well does the patient follow commands and engage in activity? 
Suggested Reading

  • Gosselink R, Bott J, Johnson 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.
  • 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; 36(8): 238-2243.
  • Engel HJ, Tatebe S, Alonzo PB, Mustille RL, Rivera MJ. A physical therapist-established intensive care unit early mobilization program: a quality improvement project for critical care at the University of California San Francisco Medical Center. Phys Ther. 2013;93(7): 975-985.
  • Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300(14): 1685-1690.

Step 5: Assess the Patient for Pain, and Minimize Pain Before Initiating Mobility
 

 Suggested Reading

 

 

  • Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145.
  • 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;28(2):88-97. doi:10.1016/j.iccn.2011.12.001.
  • Blair SN, Morris JN. Healthy hearts--and the universal benefits of being physically active: physical activity and health. Ann Epidemiol. 2009;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.
  • 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.e15.
  • Haskell WL. J.B. Wolffe Memorial Lecture. Health consequences of physical activity: understanding and challenges regarding dose-response. Med Sci Sports Exerc. 1994;26(6):649-660.
  • Herridge MS, Cheung AM, Tansey CM, et a. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003;348(8):683-693.
  • Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999; 340(9):669-676.
  • Kress JP. Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009;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;3(10): 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;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;36(8):2238-2243.
  • 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;341(5):373-377.
  • 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; 91(4):536-542.
  • Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil. 2010;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. 2008;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;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.
  • 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; 373(9678):1874-1882.
  • Timmers TK, Verhofstad MH, Moons KG, van Beeck EF, Leenen LP. Long-term quality of life after surgical intensive care admission. Arch Surg. 2011;146(4):412-418.
  • Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174 (6): 801-809.
  •  

     

     Video Resources

     

    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