Professional Documents
Culture Documents
A Systematic Review
Joseph Adler, PT, DPT, CCS1
Daniel Malone, PhD, MPT, CCS2
1
Good Shepherd Penn Partners at The Hospital of the University of Pennsylvania, Philadelphia, PA
2
Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, CO
RESULTS
Fifteen studies were included in
this review and submitted to analysis.
Many outcomes were reported in the
mobilization of critically ill patients
and included a wide range of data.
The studies were categorized into
two groups based on the outcome
addressed: safety and functional out-
comes. Functional outcomes were
further subdivided into one of 3 areas:
muscle strength; quality of life/patient
symptoms, and mobility. Some stud-
ies overlapped multiple categories. Of
the studies reviewed, 4 reported on
muscle strength, two on quality of life,
and 13 on functional mobility.
Studies included both prospective
and retrospective design while ran-
domization occurred in just 3 stud-
ies.20-22 The randomization in Chiang
et als study22 occurred in a postinten-
sive care environment. Ten studies ex-
amined cohort populations or samples
of convenience. Eleven of those were
Figure 1. Search algorithm. prospective.4,20-29 Four studies were
Stiller K. 200427 Prospective 4 Functional mobility 69 mobilization sessions with 31 patients Study highlights the physiologic responses
Supine-to-sit (MV = 7 patients (23%)): (HR, BP, SpO2) and patient safety
One-group pretest-posttest design Sitting edge of bed associated with mobilization
Standing 3 events (4%) during PT treatments (2 Paper reintroduces an algorithm for safe
N= 160 total patients with 31 Transfers patients on MV) patient handling pertaining to the acute
receiving mobilization Ambulation desaturation ( 88%) responsive to care/ ICU settings
increased FIO2 Only 31 of 160 of patients (19%) were
Overall, no serious adverse medical mobilized following the screening process
consequences
Zafiropoulos B. Prospective 4 Patients participated in Minute ventilation increased Study emphasized the hemodynamic and
200429 progressive mobilization due to increases in tidal volume respiratory responses in patients who were
One-group pretest-posttest design from supine> sitting> & respiratory rate with standing s/p abdominal surgery
standing> marching x 1 with no additional increase with Included measurements of chest
N=17 minute for each activity marching; the breathing pattern wall and abdominal movements to
demonstrated greater upper chest characterize the breathing pattern
versus abdominal excursion No hemodynamic or respiratory
ABG values were normal compromise
HR/ BP/ MAP increased with Altered breathing pattern favored upper
mobilization from supine> sitting chest breathing/ ventilation
Pain was not monitored
Overall, no adverse medical consequences No control group for comparison
Bailey P. 200723 Prospective 4 Twice daily PT/ activity 1449 PT/ activity sessions: Study provides systems review criteria
sessions (neurologic/ circulatory/ respiratory) used
One-group pretest-posttest design Functional Mobility 14 events (<1%) occurred during PT to screen patients prior to mobilization
Supine-to-sit sessions: Of the approximate 1500 activities
N=103 patients Sitting edge of bed falls to knees (x5) performed:
Standing desaturation < 80% (x3) Sit at edge of bed (16%)
Transfers SBP <90 mm (x4) OOB (31%)
Ambulation SBP> 200 mmHg (x1) Ambulate (53%)
Nasogastric tube removal (x1) Age & co morbidities did not influence
FIO2 was increase 0.2 prior Overall, no serious adverse medical ambulatory status
to sessions consequences
Morris PE. 200825 Prospective 2B Mobilization program 116 of 135 patients (80%) of Protocol for mobilization(activity
implemented 7 days/ protocol patients received PT during algorithm) and criteria for limiting therapy
Cohort study week by mobility team hospital stay for approx. 638 total PT sessions are well defined
consisting of: sessions Mobility sessions primarily ended due
(N=330; 165 intervention/ PT Therapy sessions not initiated if to patient c/o fatigue without significant
protocol; 165 usual care) Critical care RN BP/ HR outside of listed inclusion change in vital signs
Nursing assistant criteria ( 1.4% of total sessions)
Overall, no serious adverse medical
consequences
Burtin C. 200921 Prospective 2B 5 days/ week 425 total exercise sessions Achilles tendon rupture could be considered a
Both groups received: 16 sessions (<4%) terminated due to serious adverse event
RCT Upper extremity ther. ex. desaturation <90% or HTN; injury most likely due to the addition of
Lower extremity ther 3 subjects withdrawn: cycling as a treatment modality
(N = 90 enrolled; 67 completed) ex. Functional training. Achilles tendon rupture (x1) cardio-respiratory instability not well
(36 control; 31 treatment group) Treatment group: Additional cardiorespiratory instability defined in paper.
cycling session x 20 minutes (x2)
total, daily
Schweickert WD. Prospective 1B 7 days/ week 498 PT/ OT sessions: Protocol for mobilization and criteria for
200920 Treatment group: 1 desaturation <80% limiting therapy sessions are well defined
RCT Progressive UE/ LE ther 1 radial artery line removed Study supports that early PT/ OT is safe
ex.; Trunk control/ balance PT/ OT was discontinued during 19 and the primary event limiting patient
(N=104; all patients completed activities sessions (4%) for perceived patient- participation in PT/OT was patient-
study) Functional training including ventilator asynchrony ventilator asynchrony
ADLs Overall, no adverse medical consequences
Pohlman MC. Retrospective 4 As noted above In patients receiving MV, the primary Early PT/ OT is feasible & safe within 24-
201032 reasons for missed therapy session 48 hours of ICU admission/ MV
Descriptive study/ case series MV asynchrony (<4%) PT/OT occurred on 87% of eligible days
using data from prior study (see MAP <65 mm Hg (<1%) (n=498 of 570); # of missed session similar
Schweickert above) Vasoactive medication (<1%) between MV and extubated patients
Active GIB (<1%) Patients performed more aggressive
N= 49 patients mobilization as they progressed from MV
PT/ OT sessions were terminated due to to extubation
Desaturation >5% (6%) PT/ OT sessions proceeded even though
HR & MV asynchrony (4%) patients had central venous access/ HD
Agitation/ discomfort (2%) catheters; arterial lines; ETT/ tracheostomy
Device/ line removal (<1%) tubes
Overall, no adverse medical consequences Following extubation, PT/ OT held
primarily due to patient refusal (c/o fatigue)
Zanni JM. Prospective 4 Observational report to 50 reviewed PT/ OT session with 19 Study identified common barriers &
20104 Pilot Project define patient profiles and patients provides helpful recommendations to
therapy services in ICU: Overall, no serious adverse medical implement PT/OT in ICU setting
One-group pretest-posttest design consult & treatment consequences over half of patients required post-acute
frequency rehabilitation following ICU stay
(N= 32 eligible; 22 completed mobility/ ADLs
81% of patients had an episode of delirium
study to hospital discharge) ROM/ strength
patient safety
Bourdin G. 2010 28 Prospective 4 Functional mobility training 424 interventions with 13 events (3%) Study emphasizes the physiologic
(chair sitting; tilting up with responses associated with a variety of
loss of muscle tone without fall
One-group repeated & without arms supported, mobilization procedures
measurements ambulation) extubation; desaturation <88%, Study determined barriers to rehabilitation
hypotension
N=20 consecutive patients Study determined that early mobilization
Overall, no serious adverse medical was feasible and safe
consequences
Included use of equipment to
facilitate upright/ assisted standing
MV=mechanical ventilation, PT=physical therapy, OT=occupational therapy, FiO2=fraction of inspired oxygen , HR= heart rate, HTN=hypertension
BP=blood pressure, SBP=systolic blood pressure, MAP=mean arterial pressure, SPo2=saturation of peripheral oxygen, ICU=intensive care unit
ABG=arterial blood gas, OOB=out of bed, RN=nurse , s/p=status post, c/o=complains of, RCT=randomized controlled trial, Ther ex.=therapeutic exercise, ROM=range of motion, UE/LE=upper/lower
extremity, ADL=activity of daily living, GIB=gastrointestinal bleed, HD=hemodialysis , ETT=endotracheal tube
retrospective analyses.18,30-32 Two of those studied patients who required mechanical ventilation for >4 days. There were
in a postacute environment.30,31 14 activity-associated untoward events during 1,449 activity
sessions, none of which were deemed serious. In the study
Safety/Adverse Events by Pohlman and colleagues32 a descriptive analysis of the
Of all studies reviewed, 10 papers reported data concern- intervention arm of the study by Schweickert et al,20 activ-
ing untoward events (eg, line removal, extubation), physiolog- ity associated adverse events occurred in 16% (80 of 498)
ical responses [eg, heart rate (HR), blood pressure (BP), pulse of therapy sessions with patients on mechanical ventilation.
oximetry] and/or need for alteration in medical plan of care The authors describe many of the events as expected physi-
(eg, sedative or vasopressor administration). The authors (JA ological changes with exercise. Examples include a HR in-
and DM) defined these events as pertaining to patient safety. crease greater than 20% of baseline (21 of 498 or 4.2 %), and
As noted in Table 2 untoward events occurred in 4% of a respiratory rate (RR) greater than 40 breaths per minute (20
total patient interactions. The reviewed studies used specific of 498 interactions or 4.0%). Activity sessions were halted
physiologic responses and patient complaints (see Table 3) due to exceeding the predetermined criteria (see Table 3).
to initiate and terminate exercise or activity sessions. Bailey Overall, the most commonly cited adverse event was
et al23 consecutively enrolled patients with respiratory failure oxygen desaturation. These episodes were of short dura-
Table 3. Criteria for Terminating a PT/ OT Mobilization Session as Summarized from the Literature
Heart Rate: Pulse Oximetry/ SpO2:
> 70% APMHR > 4% decrease
> 20% decrease in resting HR < 88%- 90%
< 40 beats/ minute; > 130 beats/ minute
New onset dysrhythmia
New anti-arrhythmia medication
New MI by ECG or cardiac enzymes
Blood Pressure: Mechanical Ventilation:
SBP > 180 mmHg FIO2 0.60
> 20% decrease in SPB/ DBP; orthostatic hypotension PEEP 10
MAP < 65 mmHg; >110 mmHg Patient-ventilator asynchrony
Presences of vasopressor medication; new vasopressor or escalating MV mode change to assist-control
dose of vasopressor medication Tenuous airway
Martin UJ. 200530 Retrospective 4 Treatment group Increased UE/ LE N/A All patients bedridden setting is a post intensive care unit (vent
underwent UE/ LE strength as measured initially; Following rehab unit; MV > 14 days)
One-group pretest- ther ex., trunk control on 5 point scale; rehab program, negative correlation between UE
posttest design tasks; cycle ergometry, increased inspiratory patients demonstrated strength at admission and weaning
inspiratory muscle muscle force higher scores on duration
N = 49 enrolled; training and functional (maximal NIF) FIM for supine <> sit no control group
49 completed training x 5 days/ week and sit<> stand but
study) no differences for
ambulation/ stairs
Chiang LL. 200622 Prospective 2B Treatment group Increased UE/ LE N/A Treatment group setting is a post-ICU
underwent UE/ LE ther strength (hand-held had higher scores median MV days 46
RCT ex., breathing retraining dynamometry) and on FIM and Barthel may not be applicable to acute
ex., and functional respiratory muscle Index following 3 care/ ICU
(N = 39 enrolled; training x 5 days/ week x force (PImax & PEmax) and 6 weeks of PT increased vent free time in treatment
32 completed 6 weeks intervention group
study) moderate correlation b/w limb strength
(15 control; 17 and ADL performance and mobility
treatment group) impaired cognitive status at a baseline
improved throughout intervention
period
small sample size
Bailey P. 2007 23 Prospective 4 Twice daily PT/ activity N/A N/A Median distance Study provides criteria (neurologic/
session ambulated by circulatory/ respiratory) for initiating
One-group pretest- survivors was 64.6 mobility
posttest design meters Study verifies that early mobilization of
ICU patients can be achieved
Increased number of co morbid
(N=103 patients) conditions did not influence
ambulatory status
Ambulation distance at ICU discharge
may predict post-acute d.c. destination
No control group for comparison
Morris PE. 200825 Prospective 2B Mobilization program N/A N/A Intervention group Protocol for mobilization is well
implemented 7 days/ reached mobilization defined
Cohort study week by mobility team milestones sooner (eg: Intervention group had shorter hospital
consisting of PT, critical day to first OOB) & ICU lengths of stay potentially
(N=330; 165 care RN and nursing leading to cost savings
intervention; 165 assistant Intervention group had increased PT
usual care) frequency throughout hospital length of
stay
On average, protocol patients initiated
OOB 7 days earlier compared to usual
care
No differences in MV duration or d.c.
destinations
Nonrandomized
Thomsen GE. Prospective 4 Functional mobility N/A N/A More advanced Mean distance of ambulation at d.c.
200824 training (ROM; sitting at mobilization activities was 200 feet
One-group pretest- edge of bed and OOB; (OOB transfers & Sedatives, even intermittent sedation
posttest design ambulation) sitting; ambulation) administration decreased likelihood of
increased within 24 ambulation
[N = 104 patients hours of transfer female gender and reduced illness
(91 Survivors)] to the unit where severity (ie, APACHE score) associated
mobilization is with greater ambulation
emphasized
Schweickert WD. Prospective 1B Treatment group No difference in N/A Increased % of Early mobilization associated with
200920 underwent progressive UE/LE strength as intervention group reduced incidence of delirium and
RCT UE/ LE ther ex., trunk measured by MRC or returned to functional ventilator free days
control/ balance activities hand grip baseline as defined MV did not preclude acquisition of
(N=104; all and functional training by FIM and Barthel mobility milestones
patients completed including ADLs x 7 Index and had greater Study included performance of ADLs
study) days/ week unassisted walking 87% of therapy sessions completed
distance at hospital No differences in ICU or hospital
d.c. length of stay
No differencein ICU-acquired
weakness
Burtin C. 200921 Prospective 2B Both groups received UE/ Hand held Improved No differences at time moderate correlation between
LE ther ex and functional dynamometry: QOL (SF-36 of discharge from ICU. quadriceps strength and 6 MWT and
RCT training x 5 days/ week no difference in PF) at time of SF-36
quadriceps muscle hospital d.c. Treatment group had trends noted for proportion of patients
treatment group had force at ICU d.c. but increased 6 MWT who were ambulatory and/ or
(N = 90 enrolled; additional cycling session increased quadriceps distance and at time of discharged home (study not adequately
67 completed) x 20 minutes total muscle force noted hospital discharge powered)
(36 control; 31 duration x 5 days/ week at hospital d.c.; no differences in ability to transfer from
treatment group) sit<> stand or ambulate independently
No difference in between groups
hand grip strength at no differences in weaning time, length
either time point of ICU or hospital stay
Morris PE 201118 Retrospective 2B Mobilization program N/A N/A Patient participation in Study determined additional variables
implemented 7 days/ an ICU mobilization associated with hospital readmission
cohort analysis week by mobility team program was including female gender, co-morbidties,
of survivors from consisting of PT, critical associated with and tracheostomy
prior study*** (see care RN and nursing reduced hospital >50% of survivors will have a
Morris 2008) assistant readmission or death readmission or die in the year following
in the year following hospitalization
N = 258 of 280 hospitalization
survivors of acute
respiratory failure
Montagnani G Retrospective 4 WP patients performed N/A Dyspnea Both groups Setting was post-acute/ long-term
201131 UE/ LE ther. ex including scores demonstrated weaning center
Non-equivalent UE/ LE cycling and declined in improvement in FIM Included objective measurement of
Pretest-Posttest mobilization 6 days/week both groups scores dyspnea
Control Group FIM may be useful outcome tool in this
Design PR subjects exercise novel setting for patients who require
on treadmill/ UE/ LE prolonged MV
(N= 56 weaning ergometer and low Patients who are deemed
program (WP); intensity PREs daily x difficult to wean
N= 63 pulmonary 15- 21 days Not randomized with small sample size
rehab (PR))
PT=physical therapy, OT=occupational therapy, MV=mechanical ventilation, NIF=negative inspiratory force, QOL=quality of life, N/A=not applicable
FIM=functional independence measure, PImax=peak inspiratory pressure, PEmax=peak expiratory pressure, HR= heart rate, ICU=intensive care unit
D.C.=discharge, c/o=complains of, s/p=status post, OOB=out of bed, RN=nurse, RCT=randomized controlled trial, LOS=length of stay
APACHE=acute physiology and health evaluation score, 6MWT=six minute walk test, MRC=Medical research council SF-36=short form health survey
Table 5. Medical Research Council (MRC) Scoring System for Muscle Strength*
Score Description
0 No visible contraction Movements Assessed
1 Visible muscle contraction, but no limb movement Upper Extremity: Lower Extremity:
2 Active movement, but not against gravity Shoulder abduction Hip flexion
3 Active movement against gravity Elbow flexion Knee Extension
4 Active movement against gravity and resistance Wrist extension Dorsiflexion
5 Active movement against full resistance
Maximum score: 60 (4 limbs; 3 movements per extremity with maximum score of 15 points per limb)
Minimum score: 0 (quadriplegia)
tion lasting less than 3 minutes. In studies that reported charge. In postacute settings where patients were mechani-
on adverse events, accidental removal of patient support cally ventilated for a minimum of 14 days prior to transfer,
equipment happened rarely (<1%) further highlighting the strength gains were observed. In one study,30 subjects were
safety of patient mobilization. Burtin et al21 reported one mechanically ventilated for a median duration of 46 to 52
Achilles tendon rupture in their intervention group that days (22.8 80.8 days) and demonstrated upper extremity/
used in-bed cycle ergometry. There were no serious adverse lower extremity (UE/ LE) strength gains measured by dyna-
events that required life saving measures or alterations in mometry. In another study30 patients were mechanically
the patients medical care. ventilated for 18.1 7 days and also demonstrated UE/LE
strength gains by manual muscle testing (MMT). Both stud-
Functional Outcomes ies found increases in respiratory muscle strength.
Muscle Strength
Extremity muscle strength was measured by hand-held Functional Mobility: The most frequently described func-
dynamometry or manual muscle testing [eg, Medical Re- tional outcomes assessed were: time to mobility milestones
search Council (MRC) scoring] in 4 studies as noted in [eg, time to first out of bed (OOB), standing]; ambulation
Table 4 and defined in Table 5. Medical Research Council distance,24 the Barthel Index,33 the Functional Indepen-
scores, handgrip, and extremity strength did not differ at dence Measure (FIM)34 or select parts of the FIM [Function-
time of discharge from the ICU20,21 but Burtin et al21 showed al Status Score in the ICU (FSS-ICU)].4 The FSS-ICU, similar
increased quadriceps muscle force at time of hospital dis- to the FIM, rates functional activities between 1 (total assist)