1. Early Mobilization in the Acute Care Setting
How can we better assist our patients?
TIRR Memorial Hermann Neurologic Physical Therapy Residency
Ann Valentine, PT, DPT
Professional background

2. Objectives
Discuss current practice and investigate why current interventions/limitations with activity exist.
Explore common impairments that occur with prolonged bedrest and prolonged Intensive Care Unit (ICU) stays.
Define Early Mobilization.
Discuss the benefits of Early Mobilization.
Review an Early Mobilization Protocol.
Discuss Further Considerations with Early Mobilization in the ICU.
So basically what we are going to look at:
How far we have come.
What do we currently do for our patients in the acute care setting?
Investigate why we have this current practice.
Discuss the potential pitfalls with this current practice.
Explain early mobilization and the potential benefits with this innovative intervention
Discuss how we can implement an early mobilization protocol.

3. Current practice in many hospitals
We’ve come a long way but more improvements can be made.1
Delayed initiation of physical therapy 1
Infrequent treatments in the ICU
Once PT is initiated bed therapeutic exercise is usually the first intervention6,7
“Early mobilization after uncomplicated acute myocardial infarction was proposed in Before this , patients were prescribed 6-8 weeks of bedrest to allow time for myocardial healing and scar formation.”
Currently “ Guidelines now propose 12 hours bedrest after uncomplicated acute myocardial infarction, with early mobilization and early discharge considered the norm.”
Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:
“High intensity bed ther ex doesn't necessarily counteract the negative affects of prolonged bedrest due to the patient’s position in supine allowing intravascular fluid to redistribute more into the chest because of lack of gravitational stress.
Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:

4. Barriers to Early Mobilization 2,3,7
Psychosocial barriers
Comorbidities
Advanced age
Physiologic instability
ICU environment
Limited Evidence
Why do we have this current practice? Because getting our patients up early can be challenging due to a number of barriers to patient participation and endurance.
Agitation, Confusion, impaired or no response to simple commands
Complex comorbidities,
Advanced age with an increasing issue as the baby boom generation continues to age
Shock = SBP < 90 mm Hg or need for ongoing vasopressors, Persistent respiratory failure = RR >35 bpm
Ongoing renal replacement therapy, Ongoing sedation, Out of the ICU for a procedure, Multiple lines and equipment
Limited Evidence to support this intervention
It is difficult to find good studies that are randomized control trials looking at the benefits of early mobilization. This may in part be due to ethical issues with comparing an intervention to a no-intervention group given all the impairments that can occur with immobilization. Also creating a study with a large enough sample size, homogenous sample group (no 2 patients are alike), specific outcome measures to monitor progress from a very low level of activity and consistent duration of intervention is difficult.
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:

5. Impairments seen with prolonged bedrest 2-6
Increased respiratory dysfunction
Impaired strength
Physiologic impairments
Increased risk for skin breakdown
Decreased quality of life
But we know there are serious consequences to inactivity especially in the acute setting.
Increased energy requirements for the lung and heart, Increased oxygen demand, Difficult to wean a patient from the vent
Decreased muscle strength/mass
Decreased orthostatic tolerance, Deep vein thrombosis, Vital organ dysfunction, Sepsis, Hypoxemia, Acidosis
Skin breakdown
Neuromuscular drug toxicity
Decreased quality of life
Prolonged bedrest is also with increased risk for deep vein thrombosis, increased energy requirements for the lung and heart, decreased orthostatic tolerance and increased risk for skin breakdown. A 20% decline in muscle strength can occur within the first week of prolonged bedrest and a further decline of 20% every week afterwards with continued bedrest.1 These weakened muscles increase a patient’s oxygen demand and make it more difficult to wean a patient from the vent.1
“Patients who experience more than 1 week of bedrest exhibit up to 40% loss of muscle strength in the antigravity muscles of the calf and back.”
Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby
Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.

6. Prolonged hospital stays with mechanical ventilation  DECREASED FUNCTION! 3, 6-7
Increased morbidity/mortality
Increased cost of care
Increased length of stay
Respiratory muscle weakness and increased duration of ventilation
Sleep deprivation
Lack of social interaction
Prolonged sedation
Delirium
I believe early mobilization can be especially valuable when applying to patients that are mechanically ventilated for a long period of time.
Loss of upper limb motor strength impairs weaning outcome.
Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:
Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.

7. Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1
This open observational behavioral mapping study occurred in Melbourne, Australia between
 Observed 58 patients, <14 days after first or recurrent stroke, between the hours of 8 a.m. to 5 p.m. over 2 days with observers taking note of the patients’ activity level, location and others present every 10 minutes.
The average length of treatment provided by therapists was 22.8 minutes for occupational therapy, 32.5 minutes for speech and language therapy, and 24.0 minutes for physical therapy.
“Those with high levels of physical activity were more likely to be younger have lower NIHSS and a high walking score.
Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:

8. Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

9. Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1
If there are limitations with OOB mobility given multiple lines and the patient being medically unstable it is important that we maximize activity opportunities while the patient is in the bed or bedside the bed and that a goal of ours be to transition the patient to OOB bed activities as soon as possible.

10. What is Early Mobilization? 6
The initiation of mobility when a patient is minimally able to participle, presents with hemodynamic stability and the patient receives acceptable levels of oxygen.
So how can we change these above pie charts for the better? I think early mobilization is a great answer.
Early mobilization is an innovative intervention in the Intensive Care Unit (ICU) for patients that are mechanically ventilated. This is an advanced treatment in physical therapy and currently limited research available for this intervention.
Why is this an innovative treatment?
“New technologies in critical care and mechanical ventilation have led to long-term survival of critically ill patients and a dramatic increase in the number of ventilator-dependent patients. Each year, more than 1 million patients who require mechanical ventilation are admitted to intensive care units (ICUs) in the United States.” The ICU culture promotes bedrest which further causes functional decline.
DEFINITION
Studies have supported early mobilization in as short as 4 days after mechanical ventilation was initiated.
Medical stability is defined as “having sufficient perfusion to maintain normal organ function. The acceptable parameters are :
a HR <110 bpm at rest
MAP mm Hg
SpO2>88% with activity
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:

11. Benefits of Early Mobilization 2, 4-8
Improved respiratory function
Maintains strength and joint range of motion
Fewer physiologic impairments
Repositioning allows for other interventions
Improved quality of life
The evidence that does exist highly supports early initiation of activity improving orthostatic tolerance, decreasing length of stay in the ICU, decreasing ICU delirium, decreasing days breathing with assist, and promotes less complications such as atelectasis and pressure wounds.
Maintains strength and joint range of motion
Prevents alterations in cardiovascular response to interventions, Early weaning from vent, Decreases days breathing with assist, Promotes less complications such as atelectasis
Improves orthostatic tolerance, fewer issues with skin breakdown.
Improved sense of well being
Repositioning allows for other interventions, Increases patient arousal and as the patient’s endurance improves it can allow for further opportunities for increase social interaction.
Decreases length of stay in the ICU and hospital
Decreasing ICU delirium
Decreased cost of stay
Higher Barthel Index Scores, decreased length of stay in the ICU and hospital, decreased ICU delirium, decreased cost of stay and patients that can ambulate are able to ambulate greater distances, unassisted at hospital discharge
Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:
West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14.
Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby
Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):

12. Initiating an Early Mobilization Protocol
What is needed to start an Early Mobilization Protocol?
Multidisciplinary involvement is crucial!
A thorough initial physical therapy evaluation
An individualized plan of care
Appropriate goals that meet patient’s values are needed
Determine what phase of the Early Mobilization Program the patient is starting in.
So, our clinical expertise and the evidence supports this idea that early mobilization could further assist our patients and improve their quality of life in the acute care setting. But how do we go about initiating this concept into our practice
It is crucial that multidisciplinary involvement occur to ensure patient safety.1,2,3 You always want to consult the RN to discuss the patient’s current medical status, medications, and therapeutic ranges for vital signs during treatment. Good communication between physician, PT, RN (to administer meds) and RT (to assist with ventilator management)
What is needed to start an Early Mobilization Protocol?
A thorough initial physical therapy evaluation
individualized plan of care
appropriate goals that meet patients values
Then determine what phase of the Early mobilization program the pt is in.

13. Initiating an early mobilization protocol for mechanically ventilated patients 6,7
Heart rate <130 beats per minute
Mean arterial pressure: mm Hg,
FiO2:<60%
PEEP ≤10 cm H2O
SpO2 > 88%
When we initiate mobilization with our patients that are mechanically ventilated there is a specific protocol that exists.
Perme et al clearly described a treatment protocol for initiating bed mobility in mechanically ventilated patients. Mobilization is indicated if the patient has a heart rate <130 bpm, mean arterial pressure (MAP): mm Hg, FiO2: <60%, PEEP < or equal to 10 cm H2O, and SpO2 >88%. 1,2
Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:

14. Phase 1
Patient presentation: considerable weakness, limited activity tolerance, occasional altered mental status, minimally participate in therapy and are unable to ambulate.
15-30 minute treatments
Goal: to start mobilization as soon as the patient is medically stable.
Progression: bed ther ex  rolling  sitting balance  standing with a walker and assistance
Includes critically ill patients with multiple medical problems in unstable medical conditions at times. These unstable conditions can include: unstable cardiovascular status, sedation, paralysis, comatose state, burns and severe orthopedic or neurologic deficits.
Treatments should last minutes with patients seen daily.
Bed mobility for patients that have marked weakness, limited activity tolerance, and the patient can still be medically unstable at times.

15. Further Treatment Options for Phase 1 2
Tilt table with arms supported for minutes
Standing Frame
Chair sitting
Rehabilitation protocol
Tilt table with arms supported was preferred when pt’s scored <3 on a MMT. The tilt up position is held for minutes. Tilting up significantly increased HR and RR suggesting substantial patient effort is required.
Standing frame when the patient’s trunk and leg muscles are strong enough to partly sustain the erect position but not strong enough to allow for walking. (averaged 15 minutes per session)
Chair sitting indicated when pt has the tone in the trunk, arms and legs to sustain an upright position. “patient is left sitting in the chair up to 1 hour at the first attempt. The duration of further chair sitting interventions is increased to 1-2 hours per intervention and the number of interventions to 1-2 per day.” “Chair sitting significantly reduced RR and HR which may be the result of improved lung volumes and ventilation-perfusion matching.”
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):

16. Phase 2
Includes patients that have the strength to perform standing activities with a walker and assistance.
Goal: to start walking re-education and functional training
Progression: weight shift  steps in place  side steps along the EOB  chair transfer using a walker and assistance
Includes patients that have the strength to perform standing activities with a walker and assistance. These patients can follow simple commands consistently.
Increase patient upright sitting time to improve orthostatic tolerance. These patients typically ambulate limited distances due to weakness and poor endurance.

17. Phase 3
Includes patients that can tolerate ambulation with a walker and assistance for a short distance.
Goal: Master transfer training and increase endurance.
Goal: to master transfer training and increase endurance through gait training. Appropriate ventilation and oxygenation is key in this phase as patients’ progress their endurance

18. Phase 4 6
Includes patients that are no longer on a ventilator and/or have been transferred out of the ICU.
Goal: functional training
Ultimate goal: Promote maximum independence by discharge.
Ultimate goal: is to promote the maximal level of independence before hospital discharge and an increased walking capacity for the patients who meet criteria for ambulation.
This program is used by Methodist Hospital since 1996.
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:

19. Further Considerations with Early Mobilization 2,3,7
ALWAYS USE YOUR CLINICAL JUDGEMENT
Other Interventions: e-stim, UE exercise, inspiratory muscle training
Transitions back and forth between phases
Perform during “sedation vacations”
Need assistance to manage multiple lines
Monitor vital signs
Involvement of a multidisciplinary team is crucial!
“In patients with COPD and heart failure, (e-stim) has been shown to delay muscle wasting during immobility and promote recovery of muscle strength.” In a study by Zanotti et al. Pts that performed e-stim with limb movement after 4 weeks showed a greater increase in muscle strength and required fewer days to transfer from bed to chair.
Arm cycling for 20 min while sitting up in bed showed greater patient improvement in endurance.
Weakness in the diaphragm and accessory inspiratory muscles such as the intercostals, scalenes and SCMs is considered to be the biggest contributor to vent weaning failure. However inspiratory muscle training using resistance training devices incentive spirometry and positive expiratory pressure can significantly increase mean inspiratory pressure and vital capacity.
Also, evidence supports performing physical therapy during “sedation vacations” to allow for maximum patient participation.2,3 When performing this treatment safety is a major concern and one needs to have assist to manage multiple lines.1
Daily interruption of sedation in combination with PT and OT might prevent sedative related immobility.
Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:

20. When should an Early Mobilization Intervention be deferred/stopped
HR <40 or >130 bpm
RR <5 or >35 bpm
SpO2 <88% for <1 minute
SBP <90 mm Hg or >180 mm Hg
Elevated ICPs
Changes in patient presentation occur
New medical findings occur
Some safety parameters for initiating an early mobilization intervention exist so that a therapist can best use patient vital signs and presentation to determine how the patient is tolerating this intervention. Patient agitation, anxiety requiring sedation medication in past 30 minutes.
HR <40 or >130 bpm
RR <5 or >35 bpm
SpO2 <88% for <1 minute
SBP <90 mm Hg or >180 mm Hg
Elevated ICPs
Patient agitation, anxiety requiring sedation medication, reduced consciousness, Diaphoresis noted
Pulmonary Emboli presence, chest infection, active bleeding
Intermittent hemodialysis
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:

21. Adverse Effects with Early Mobilization 2,7
Adverse events are rare.
Fall to knees
Hypoxemia <88% SpO2 for >1 minute
Unscheduled extubation
Orthostatic Hypotension < 80 mm Hg SBP
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:

22. Bottom line 1,2, 6-8
No medical status decline occurred with an early physical therapy intervention.
This is a safe and feasible intervention.
Early mobilization has the potential to prevent/treat neuromuscular complications of critical illness.
Early Mobilization Requires a Culture Change
The current evidence supports no medical status decline with an early physical therapy intervention.
Evidence supports this as safe and feasible intervention. “Never saw a patient’s medical condition deteriorate as a direct result of the interventions used in the early mobility and walking program.”
There is strong potential to prevent/treat neuromuscular complications of critical illness with early mobilization.
Early Mobilization Requires a Culture Change
“This underlines that even with a protocol an activity does not happen in the ICU unless there is a culture change. Successful implementation of respiratory care process model, including early mobility, requires the ICU culture to be transformed.”
Patients managed in a stroke unit promoting early mobilization had fewer deaths and better outcome than patients managed in general medicine floors without early mobilization.
Journal Club Discussions
Early mobilization with compression in the presence of a proximal DVT
Aggressive treatment warranted for patients with blunt head trauma and a GCS of 3.
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:
West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14.
Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:

23. Questions

24. References
Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:
Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):
Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.
Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby
Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company
Perme C, Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:
West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14.
*References for images available upon request.