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

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.
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
Barriers to Early Mobilization 2,3,7
 Psychosocial barriers
 Comorbidities
 Advanced age
 Physiologic instability
 ICU environment
 Limited Evidence
Impairments seen with prolonged bedrest 2-6
 Increased respiratory dysfunction
 Impaired strength
 Physiologic impairments
 Increased risk for skin breakdown
 Decreased quality of life
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
Inactive & Alone: Physical Activity Within the
First 14 days of Acute Stroke Unit Care 1
Inactive & Alone: Physical Activity Within the
First 14 days of Acute Stroke Unit Care 1
Inactive & Alone: Physical Activity Within the
First 14 days of Acute Stroke Unit Care 1
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.
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
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.
Initiating an early mobilization protocol
for mechanically ventilated patients 6,7
 Heart rate <130 beats per minute
 Mean arterial pressure: 60-100 mm Hg,
 FiO2:<60%
 PEEP ≤10 cm H2O
 SpO2 > 88%
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
Further Treatment Options for Phase 1 2
 Tilt table with arms supported for 10-30 minutes
 Standing Frame
 Chair sitting
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
Phase 3
 Includes patients that can tolerate
ambulation with a walker and
assistance for a short distance.
 Goal: Master transfer training and
increase endurance.
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.
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!
When should an Early Mobilization
Intervention be deferred/stopped? 1,2,7
 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
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
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
Questions
References
1.
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;35:1005-1009.
2.
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):400-407.
3.
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.
4.
Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby. 2006.
5.
Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company. 2007.
6.
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;18:212-221.
7.
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;373:1874-82.
8.
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.