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Early Mobilization in the Intensive Care Unit:

A Systematic Review
Joseph Adler, PT, DPT, CCS1
Daniel Malone, PhD, MPT, CCS2

Good Shepherd Penn Partners at The Hospital of the University of Pennsylvania, Philadelphia, PA
Physical Therapy Program, Department of Physical Medicine and Rehabilitation; University of Colorado; Denver, CO

ABSTRACT muscle strength, functional outcomes such as activities of

Purpose: The purpose of this review is to evaluate the litera- daily living, duration of mechanical ventilation, ICU length
ture related to mobilization of the critically ill patient with of stay, hospital length of stay, and mortality.
an emphasis on functional outcomes and patient safety. There are inherent complications to mobilizing critical-
Methods: We searched the electronic databases of PubMed, ly ill patients that appear straightforward but are not well
CINAHL, Medline (Ovid), and The Cochrane Library for a established. These apparent complications include, but are
period spanning 2000-2011. Articles used in this review in- not limited to: tenuous hemodynamic status, severe weak-
cluded randomized and nonrandomized clinical trials, pro- ness, multiple central catheters and life supporting moni-
spective and retrospective analyses, and case series in peer- tors, artificial airways and operational factors such as vari-
reviewed journals. Sackett’s Levels of Evidence were used able rehabilitation work practices.4-7
to classify the current literature to evaluate the strength of Studies have demonstrated that survivors of critical ill-
the outcomes reported. Results: Fifteen studies met inclu- ness have impaired exercise capacity and persistent weak-
sion criteria and were reviewed. According to Sackett’s ness, suboptimal quality of life, enduring neuropsychologi-
Levels of Evidence, 9 studies were level 4 evidence, one cal impairments and high costs of health care utilization.8-12
study was level 3, 4 studies were level 2, and one study was It has been hypothesized that ICU-based interventions may
level one evidence. Ten studies pertained to patient safety/ play a role in reducing these ongoing physical and neu-
feasibility and 10 studies pertained to functional outcomes ropsychological impairments in ICU survivors in both the
with 5 fitting into both categories. Conclusion: A search of short- and long-term, highlighting the importance of study-
the scientific literature revealed a limited number of studies ing this population.12
that examined the mobilization of critically ill patients in When patients require admission or readmission to the
the intensive care unit. However, literature that does exist ICU, a period of enforced bed rest generally ensues. Despite
supports early mobilization and physical therapy as a safe knowledge of the deleterious effects of bed rest on multiple
and effective intervention that can have a significant impact body systems,13-16 the ICU is a complicated and difficult
on functional outcomes. environment in which to mobilize the critically ill.1,17 Mul-
tiple life-sustaining catheters and monitors, sedative medica-
Key Words: mobilization, exercise, intensive care unit, crit- tion used to calm agitation or reduce energy expenditure,
ical illness, physical therapy impaired levels of alertness from medications, sleep distur-
bances, electrolyte imbalances, and tenuous hemodynamic
INTRODUCTION status all are contributing factors that limit mobilization.
The early mobilization of patients in the intensive care As critical care medicine improves and overall mor-
unit (ICU) has received considerable attention in clini- tality decreases, survivors of ICU admissions are realizing
cal and scientific literature over the past several years.1-3 greater morbidity. Severe weakness, deficits in self-care
A wide range of published reports has attempted to study and ambulation, poor quality of life, hospital readmission,
the effects of mobilization and physical therapy on mul- and death have all been reported in patients up to 5 years
tiple factors including patient safety, ambulation capacity, after discharge from the ICU.12,18
Mobilizing patients in the intensive care environment
is not without risk. Catheters and supportive equipment at-
tached to patients can become dislodged and cause injury.
Address correspondences to: Joe Adler, PT, DPT, CCS, Insertion and reinsertion of catheters can increase infection
Good Shepherd Penn Partner’s at the Hospital of the risk and cause unwanted stress and pain for patients and
University of Pennsylvania, Department of Occupa- families already stressed by the medical acuity of the ICU.
tional and Physical Therapy, 1st Floor White Build- Critically ill patients with physiological derangements can
ing, 3400 Spruce Street, Philadelphia, PA 19104 (joe. have adverse hemodynamic responses to activity. Patients with limited aerobic capacity may respond to exertional

Vol 23 YNo 1 YMarch 2012 Cardiopulmonary Physical Therapy Journal 5

stress with exaggerated heart rate and blood pressure re- the title, and the list of potential articles was further sorted
sponses or conversely may not have enough physiologic by reviewing abstracts by the primary author (JA). Studies
reserve to meet even the seemingly simple task of sitting on were excluded if they were review articles, only studied
the edge of the bed. nonmobility interventions, and/or described programs or
Although the frequency of published reports related to protocols designed to promote early mobilization. If rel-
mobilizing critically ill patients is increasing, the number evancy was questioned, both authors then collaborated on
of controlled, randomized trials is few. The purpose of this the final decision for inclusion.
review was to examine the literature and characterize the
clinical benefits of mobilizing critically ill patients found Levels of Evidence
predominantly in the ICU, specifically related to safety and Sackett’s Levels of Evidence were used to rate the
functional outcomes. strength of the research19 process where research was
ranked from strongest to weakest using a 5 point grading
METHODS system as outlined in Table 1. The authors (DM and JA) col-
Literature Search laborated equally on scoring.
The electronic databases of PubMed, CINAHL/Nursing,
Medline (Ovid) and the Cochrane Library were searched Table 1. Sackett’s Levels of Evidence
as noted in Figure 1. The key search terms, “mobilization,” 1A Systematic Review of Randomized Controlled Trials (RCTs)
“exercise,” and “physical therapy” were combined with 1B RCTs with Narrow Confidence Interval
“intensive care unit” and “critical illness.” Reference lists of
1C All or None Case Series
review articles and original publications were manually re-
viewed supplementing the electronic search to ensure that 2A Systematic Review Cohort Studies
the database searches were comprehensive. 2B Cohort Study/Low Quality RCT
2C Outcomes Research
Study Selection Criteria
Articles included in this review were: prospective ran- 3A Systematic Review of Case-Controlled Studies
domized trials, prospective cohort studies, retrospective 3B Case-controlled Study
analyses, and case series. We further limited our inclusion 4 Case Series, Poor Cohort Case Controlled
to articles that focused on adults that were published in
English between January 1, 2000 and June 1, 2011 to cap- 5 Expert Opinion
ture the most recently published work. Studies were evalu- Adapted from Levels of Evidence. Oxford Centre for Evivdence-based Medicine - Levels of
Evidence (March 2009) Website. Available at Accessed September 26, 2011.
ated to determine fit to the inclusion criteria by review of

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 al’s 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

6 Cardiopulmonary Physical Therapy Journal Vol 23 Y No 1 YMarch 2012

Table 2. Safety and ICU Mobilization
Study Study Design Sackett’s Physical Therapy Safety profile Other notable findings
(N= subjects) Levels of Interventions

Stiller K. 200427 Prospective 4 Functional mobility 69 mobilization sessions with 31 patients t 4UVEZIJHIMJHIUTUIFQIZTJPMPHJDSFTQPOTFT
t 4VQJOFUPTJU (MV = 7 patients (23%)): (HR, BP, SpO2) and patient safety
One-group pretest-posttest design t 4JUUJOHFEHFPGCFE associated with mobilization
t 4UBOEJOH 3 events (4%) during PT treatments (2 t 1BQFSiSFJOUSPEVDFTwBOBMHPSJUINGPSTBGF
N= 160 total patients with 31 t 5SBOTGFST patients on MV) patient handling pertaining to the acute
receiving mobilization t "NCVMBUJPO t EFTBUVSBUJPO õ
SFTQPOTJWFUP care/ ICU settings
Overall, no serious adverse medical mobilized following the screening process

Zafiropoulos B. Prospective 4 Patients participated in t .JOVUFWFOUJMBUJPOJODSFBTFE t 4UVEZFNQIBTJ[FEUIFIFNPEZOBNJDBOE

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 t /PIFNPEZOBNJDPSSFTQJSBUPSZ
t "#(WBMVFTXFSFOPSNBM compromise
mobilization from supine> sitting chest breathing/ ventilation
Overall, no adverse medical consequences t /PDPOUSPMHSPVQGPSDPNQBSJTPO

Bailey P. 200723 Prospective 4 Twice daily PT/ activity 1449 PT/ activity sessions: t 4UVEZQSPWJEFTTZTUFNTSFWJFXDSJUFSJB
sessions (neurologic/ circulatory/ respiratory) used
One-group pretest-posttest design Functional Mobility 14 events (<1%) occurred during PT to screen patients prior to mobilization
◊ Sit at edge of bed (16%)
◊ OOB (31%)
◊ Ambulate (53%)
FIO2 was increase 0.2 prior Overall, no serious adverse medical ambulatory status
to sessions consequences

Morris PE. 200825 Prospective 2B Mobilization program t PGQBUJFOUT 

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
(N=330; 165 intervention/ PT t 5IFSBQZTFTTJPOTOPUJOJUJBUFEJG 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

Burtin C. 200921 Prospective 2B 5 days/ week 425 total exercise sessions Achilles tendon rupture could be considered a
Both groups received: t TFTTJPOT 
UFSNJOBUFEEVFUP serious adverse event
RCT Upper extremity ther. ex. desaturation <90% or HTN; t JOKVSZNPTUMJLFMZEVFUPUIFBEEJUJPOPG
Lower extremity ther t TVCKFDUTXJUIESBXO cycling as a treatment modality
(N = 90 enrolled; 67 completed) ex. Functional training. ◊ Achilles tendon rupture (x1) t DBSEJPSFTQJSBUPSZJOTUBCJMJUZOPUXFMM
(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: t 1SPUPDPMGPSNPCJMJ[BUJPOBOEDSJUFSJBGPS

200920 Treatment group: t EFTBUVSBUJPO limiting therapy sessions are well defined
ex.; Trunk control/ balance t 1505XBTEJTDPOUJOVFEEVSJOH 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
ADL’s Overall, no adverse medical consequences

Pohlman MC. Retrospective 4 As noted above In patients receiving MV, the primary t &BSMZ1505JTGFBTJCMFTBGFXJUIJO
201032 reasons for missed therapy session 48 hours of ICU admission/ MV
Descriptive study/ case series t .7BTZODISPOZ 
using data from prior study (see t ."1NN)H 
(n=498 of 570); # of missed session similar
Schweickert above) t 7BTPBDUJWFNFEJDBUJPO 
between MV and extubated patients
t "DUJWF(*# 
N= 49 patients mobilization as they progressed from MV
PT/ OT sessions were terminated due to to extubation
patients had central venous access/ HD
catheters; arterial lines; ETT/ tracheostomy
Overall, no adverse medical consequences t 'PMMPXJOHFYUVCBUJPO 1505IFME
primarily due to patient refusal (c/o fatigue)

Zanni JM. Prospective 4 Observational report to t SFWJFXFE1505TFTTJPOXJUI t 4UVEZJEFOUJmFEDPNNPOCBSSJFST

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
frequency rehabilitation following ICU stay
(N= 32 eligible; 22 completed t NPCJMJUZ"%-T
study to hospital discharge) t 30.TUSFOHUI

Vol 23 YNo 1 YMarch 2012 Cardiopulmonary Physical Therapy Journal 7

Needham DM. Prospective 3B Functional mobility Pre-QI: 210 PT/ OT treatment session t *ODSFBTFEOVNCFSPG1505DPOTVMUT
201026 Quality Improvement (QI) project treatment sessions incorporating more
t 4VQJOFUPTJU t /PFWFOUT advanced mobilization activities without
Case controlled t 4JUUJOHFEHFPGCFE increased incidence of adverse events
QI Period: 810 PT/ OT treatment sessions
t 5SBOTGFST displacement)
(N = 57 total (27 pre QI; 30
Overall, no serious adverse medical

Bourdin G. 2010 28 Prospective 4 Functional mobility training 424 interventions with 13 events (3%) t 4UVEZFNQIBTJ[FTUIFQIZTJPMPHJD
(chair sitting; tilting up with responses associated with a variety of
One-group repeated & without arms supported, mobilization procedures
Overall, no serious adverse medical was feasible and safe
◊ 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
"T OPUFE JO5BCMF  VOUPXBSE FWFOUT PDDVSSFE JO õ  PG 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:
t "1.)3 t EFDSFBTF
Blood Pressure: Mechanical Ventilation:
t 4#1NN)H t 'IO2 ≥ 0.60
dose of vasopressor medication t 5FOVPVTBJSXBZ

Respiratory Rate: Alertness/ Agitation and Patient symptoms:

medication; RASS >2
PT=physical therapy, OT=occupational therapy, HR= heart rate, RR=respiratory rate
SPo2=saturation of peripheral oxygen, MI=myocardial infarction, ECG=electrocardiogram
BP=blood pressure, SBP/DBP=systolic/diastolic blood pressure, MAP=mean arterial blood pressure
FiO2=fraction of inspired oxygen, Peep=positive end expiratory pressure, MV=mechanical ventilation
APMHR=age predicted maximum heart rate, RASS=Richmond Agitation Sedation Scale, DOE=dyspnea on exertion

8 Cardiopulmonary Physical Therapy Journal Vol 23 Y No 1 YMarch 2012

Table 4. Outcomes of ICU Mobilization
Study Study Design Levels of Physical Therapy Functional Outcomes Other notable findings
(N= subjects) Evidence Interventions

Strength/ ROM QOL Mobility

Martin UJ. 200530 Retrospective 4 Treatment group Increased UE/ LE N/A All patients bedridden t TFUUJOHJTBQPTUJOUFOTJWFDBSFVOJU WFOU
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, t OFHBUJWFDPSSFMBUJPOCFUXFFO6&
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 t OPDPOUSPMHSPVQ
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 t TFUUJOHJTBQPTU*$6
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 t JODSFBTFEWFOUGSFFUJNFJOUSFBUNFOU
32 completed 6 weeks intervention group
(15 control; 17 and ADL performance and mobility
improved throughout intervention

Bailey P. 2007 23 Prospective 4 Twice daily PT/ activity N/A N/A Median distance t 4UVEZQSPWJEFTDSJUFSJB OFVSPMPHJD
session ambulated by circulatory/ respiratory) for initiating
One-group pretest- survivors was 64.6 mobility
ICU patients can be achieved
(N=103 patients) conditions did not influence
ambulatory status
may predict post-acute d.c. destination

Morris PE. 200825 Prospective 2B Mobilization program N/A N/A Intervention group t 1SPUPDPMGPSNPCJMJ[BUJPOJTXFMM
implemented 7 days/ reached mobilization defined
Cohort study week by “mobility team” milestones sooner (eg: t *OUFSWFOUJPOHSPVQIBETIPSUFSIPTQJUBM
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 t *OUFSWFOUJPOHSPVQIBEJODSFBTFE15
“usual” care”) frequency throughout hospital length of
OOB 7 days earlier compared to usual

Thomsen GE. Prospective 4 Functional mobility N/A N/A More advanced t .FBOEJTUBODFPGBNCVMBUJPOBUED
200824 training (ROM; sitting at mobilization activities was ≥ 200 feet
One-group pretest- edge of bed and OOB; (OOB transfers & t 4FEBUJWFT FWFOJOUFSNJUUFOUTFEBUJPO
posttest design ambulation) sitting; ambulation) administration decreased likelihood of
increased within 24 ambulation
[N = 104 patients hours of transfer t GFNBMFHFOEFSBOESFEVDFEJMMOFTT
(91 Survivors)] to the unit where severity (ie, APACHE score) associated
mobilization is with greater ambulation

Schweickert WD. Prospective 1B Treatment group No difference in N/A Increased % of t &BSMZNPCJMJ[BUJPOBTTPDJBUFEXJUI

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 t .7EJEOPUQSFDMVEFBDRVJTJUJPOPG
(N=104; all and functional training by FIM and Barthel mobility milestones
patients completed including ADL’s x 7 Index and had greater t 4UVEZJODMVEFEQFSGPSNBODFPG"%-T
study) days/ week unassisted walking t PGUIFSBQZTFTTJPOTDPNQMFUFE
distance at hospital t /PEJGGFSFODFTJO*$6PSIPTQJUBM
d.c. length of stay

Burtin C. 200921 Prospective 2B Both groups received UE/ Hand held Improved No differences at time t NPEFSBUFDPSSFMBUJPOCFUXFFO
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 t USFOETOPUFEGPSQSPQPSUJPOPGQBUJFOUT
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.; t OPEJGGFSFODFTJOBCJMJUZUPUSBOTGFSGSPN
treatment group) sit<> stand or ambulate independently
No difference in between groups
either time point of ICU or hospital stay

Vol 23 YNo 1 YMarch 2012 Cardiopulmonary Physical Therapy Journal 9

Needham DM Prospective QI 3B Functional mobility N/A N/A Greater percentage Additional QOL goals accomplished:
201026 project training (supine to of patients engaged t JODSFBTFOVNCFSPG1505DPOTVMUT
sit; sitting at edge of in more advanced interventions; reduction in missed PT/
Case controlled bed; OOB transfers; mobilization (i.e.: OT sessions
pre QI; N=30 delirium

Morris PE 201118 Retrospective 2B Mobilization program N/A N/A Patient participation in t 4UVEZEFUFSNJOFEBEEJUJPOBMWBSJBCMFT
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 t PGTVSWJWPSTXJMMIBWFB
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 t 4FUUJOHXBTQPTUBDVUFMPOHUFSN

201131 UE/ LE ther. ex including scores demonstrated weaning center
Non-equivalent UE/ LE cycling and declined in improvement in FIM t *ODMVEFEPCKFDUJWFNFBTVSFNFOUPG
Pretest-Posttest mobilization 6 days/week both groups scores dyspnea
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 PRE’s daily x “difficult to wean”
N= 63 pulmonary 15- 21 days t /PUSBOEPNJ[FEXJUITNBMMTBNQMFTJ[F
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)

*Adapted from Schweickert and Hall. ICU-Acquired Weakness. Chest. 2007;31:1541-1549.

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 patient’s 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)

10 Cardiopulmonary Physical Therapy Journal Vol 23 Y No 1 YMarch 2012

and 7 (complete independence). A score of 0 is assigned was transient oxygen desaturation that was attenuated by
if a patient is unable to perform a task. Only 5 of the items rest and increasing the FiO2 delivered to the patient. Line
from the FIM are included: (1) rolling, (2) transfer from su- dislodgment and/or accidental extubation, frequently men-
pine to sit, (3) sitting at the edge of bed, (4) transfer from sit tioned dangers of mobilization, happened rarely, further
to stand, and (5) ambulation are combined in the cumula- highlighting the safety profile of patient mobilization.
tive FSS-ICU score.4 In all studies, hemodynamic, respiratory, and cognitive
Mobility milestones were accomplished earlier in the criteria were established a priori to ensure patient safety
intervention groups than the comparison groups in 4 stud- (Table 3). These criteria guided the clinicians to determine
ies.20,24-26 Compared to controls, ambulation frequency was patient eligibility for mobilization and, it is presumed, lim-
greater in the study by Thomsen et al24 and ambulation dis- ited untoward events by providing the treating physical
tance was greater at time of hospital discharge in the stud- therapist and/or occupational therapist parameters to guide
ies by Schweickert et al20 and Burtin et al.21 the intensity of the mobilization sessions. Mobilization was
Objective measures such as the FIM & Barthel Index loosely described in most studies citing therapist discretion
improved in the intervention groups at time of hospital for advancing activities based on patient tolerance and sta-
discharge but without significant differences at time of bility. However, Stiller et al27 provided an algorithm for
ICU discharge in the study by Schweickert et al.20 In the initiating and terminating therapy sessions based on physi-
postacute care setting, bed mobility and transfers were im- ologic and laboratory data while Morris et al25 provided an
proved in 3 studies22,30,31 but ambulation/locomotion were algorithm for mobility progression based on patient’s physi-
only improved in the studies by Chiang et al22 and Montag- cal capabilities.
nani et al.31 Overall activity-induced increases in HR, BP, respiratory
rate (RR), tidal volume, and minute ventilation were within
Quality of Life & Patient Symptoms: Burtin et al21 noted acceptable ranges, challenging the perception that patients
improvements in the physical functioning (PF) subscore in the ICU are “too sick” to participate in mobilization activi-
of the SF-36 at time of hospital discharge but quality of ties.4,27,28 As noted multiple studies have reported on safety
life (QOL) was not reported for the transition from ICU to and feasibility but the lack of reported negative events could
ward. Dyspnea was measured in the postacute care set- reflect a bias of nonreporting of adverse incidents.
ting in the study by Montagnani et al.31 These patients were
hospitalized for approximately 40 days prior to postacute Muscle Strength: Although it is generally accepted that pa-
admission, had tracheostomies, and required prolonged tients in critical care settings for prolonged periods of time
mechanical ventilation. The symptom of dyspnea was re- are often “bed ridden,” deconditioned, and weak, muscle
duced following the rehabilitation period. strength was infrequently reported as an outcome measure
in the reviewed studies. In studies that did address muscle
DISCUSSION force production, strength was not significantly improved
The focus of critical care medicine in the ICU is res- in the ICU20,21 but did improve by the time of discharge
toration of physiological or hemodynamic stability and from the hospital.21 Interestingly, strength was consistently
prevention of death. The historical approach to achieve improved in the postacute care setting.22,30
these goals has included long periods of immobility and
bedrest. The impact of life-sustaining ICU technology on Functional Mobility: The literature reviewed supports
patients that have required sedation, long-term mechani- improvements in functional mobility following early and
cal ventilation, and bedrest has been profound with re- progressive physical therapy/occupational therapy (PT/ OT)
spect to severe muscle weakness, functional impairments, in the ICU but the measurement of this outcome was not
and loss of quality of life.15 By understanding the nega- uniform across the literature. For example, as mentioned
tive sequella of ICU-induced bed rest, investigators are in the results section, variability of outcome measurements
attempting to correct these derangements by reducing the included acquisition of mobility milestones,18,20,21,23,24,26
dosage and frequency of sedative medication and mobi- FIM,20,22,30,31 FSS-ICU,4 and the Barthel Index.33 Time to
lizing critically ill patients once hemodynamic stability mobility milestones was reduced and patient participation
has been achieved. We have reviewed published reports in advanced mobilization activities occurred more fre-
that have studied this clinical approach. quently in ICUs where mobilization and PT/ OT were em-
phasized.20,24-26 Within the ICU setting, objective measures
Safety: Studies included in this review persuasively con- such as the FIM & Barthel Index were used infrequently
clude that the mobilization of critically ill but stable pa- although two of the cited studies used these tools.4,20
tients in the ICU and immediate postacute environment, The FIM and Barthel Index scores improved in the inter-
who have required a period of mechanical ventilation, can vention group in the study by Schweickert et al20 with over
be done safely with minimal risk to the patient. Although 59% of patients achieving functional independence (FIM
most studies included patients receiving 4 or more days of * 5) compared to 35% of the control group at time of hos-
mechanical ventilation, Pohlman et al20 demonstrated the pital discharge. The FIM scores also improved following
safety of physical therapy intervention occurring within rehabilitation in the postacute setting.22,30,31 Use of the FIM,
two days of intubation. The most common untoward event or the related FSS-ICU4 to measure patient disability and to

Vol 23 YNo 1 YMarch 2012 Cardiopulmonary Physical Therapy Journal 11

compare functional outcomes is attractive since the tool is of physical activity will lead to optimal patient outcomes?
well known to rehabilitation professionals. However, the (4) What generalization to other patient populations can
validity and reliability of this tool has not been established be made since the majority of patients studied are found
in the ICU setting. in medical ICUs? (5) Should all patients who require me-
chanical ventilation or ICU admission be referred to physi-
Quality of Life & Patient Symptoms: Quality of life and cal therapy? And (6) Are there optimal patient populations
patient symptoms were seldom measured within the ICU. who would benefit most from early mobilization, as well
One study21 measured QOL and one study measured pa- as populations for whom physical therapy is clearly contra-
tient’s symptoms.31 Burtin et al21 demonstrated improve- indicated? The answer to these questions will provide an
ments in the physical functioning domain of the SF-36 at evidence-based approach to optimize patient outcomes for
hospital discharge while Montagnani et al31 reported re- the critically ill patient.
duced patient dyspnea. As noted in the introduction, qual-
ity of life and neuropsychological impairments such as REFERENCES
depression, anxiety, and posttraumatic stress disorder are 1. Morris P. Moving our critically ill patients: mobility
negatively impacted by prolonged mechanical ventilation barriers and benefits. Crit Care Clin. 2007;23:1-20.
and ICU duration. Rehabilitation in the ICU and its influ- 2. Truong AD, Fan E, Brower RG, Needham DM.
ence on these factors should be an area of future research. Mobilizing patients in the intensive care unit-
from pathophysiology to clinical trials. Crit Care.
The physiology and complications of bed rest are 2009;13:216.
well understood. Intensive care unit-acquired weakness 3. Kress JP, Clinical trials of early mobilization of critically
and functional dependency are recognized as unfortu- ill patients. Crit Care Med. 2009;37[Suppl.]:s442-s447.
nate consequences of prolonged duration in ICUs and 4. Zanni JM, Korupolu R, Fan E, et al: Rehabilitation
mechanical ventilation. Although sedative medications therapy and outcomes in acute respiratory failure: an
are used to reduce metabolic energy demand for patients observational pilot project. J Crit Care. 2010;25(2):254-
in respiratory failure they inhibit participation in exercise 262.
and functional activity and often cause disturbances in 5. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML,
levels of arousal. Despite the inherently complex envi- Moss M. Physical therapy utilization in intensive care
ronment and challenges that face critical care teams, in- units: Results from a national survey. Crit Care Med.
cluding the human resources required to safely mobilize 2009;37(2):561-566; quiz 566-568.
patients, feasibility and safety has been demonstrated as 6. Norrenberg M, Vincent JL. A profile of European in-
noted in Table 2. Critically ill patients can exercise, sit tensive care unit physiotherapists. Intensive Care Med.
up, transfer to bedside chairs, and ambulate in the hall- 2000;26:988-994.
ways; however, few published papers have randomized 7. Nava S, Ambrosino N. Rehabilitation in the ICU: the Eu-
and controlled this intervention. The work of Schweickert ropean phoenix. Intensive Care Med. 2000;26:841-844.
et al,20 Burtin et al,21 and Chiang et al22 have found that 8. Dejonghe B, Sharshar T, Lefaucheur JP, et al. Paresis ac-
participation in monitored programs of physical activity quired in the intensive care unit: A prospective multi-
can lead to statistically significant improvements in am- center study. JAMA. 2002;288:2859-2867.
bulation independence, reduced duration of mechanical 9. Stevens RD, Dowdy DW, Michaels RK, et al. Neuromus-
ventilation, better ability to perform self care activities, cular dysfunction acquired in critical illness: a systemat-
and improved respiratory function. ic review. Intensive Care Med. 2007;33(11):1876-1891.
10. Herridge MS, Cheung AM, Tansey CM, et al. One year
CONCLUSION/IMPLICATIONS FOR FUTURE RESEARCH outcomes in survivors of the acute respiratory distress
In summary, the body of evidence that has studied the syndrome. N Engl J Med. 2003;348:683-693.
mobilization of critically ill patients is small. The few ran- 11. Cheung AM, Tansey CM, Tomlinson G, et al. Two-year
domized controlled trials include a total of only 171 pa- outcomes, health care use and costs in survivors of
tients limiting the strength of evidence. Based on the stud- ARDS. Am J Resp J Crit Care Med. 2006;174:538-544.
ies reviewed, early physical therapy and ICU mobilization 12. Herridge MS, Tansey CM, Matte A, et al. Functional
is feasible and safe. Acquisition of mobility milestones is disability 5 years after acute respiratory distress syn-
enhanced in ICUs that promote early rehabilitation. Im- drome. N Engl J Med. 2011;364:1293-1304.
provements in quality of life and muscle strength cannot be 13. Harper CM, Lyles YM. The physiology and complications
determined at this time. of bedrest. J Am Geriatr Soc. 1988;36(11):1047-1054.
In reviewing the literature, there are several questions 14. Bergouignan A, Rudwill F, Simon C, Blanc S. Physical
that must be addressed. These questions include, but are inactivity as the culprit of metabolic inflexibility:
not limited to: (1) How do published papers reflect current evidences from bedrest studies. J Appl Physiol. 2011
practice as mobilization has been reported in a small per- Aug 11 (Epub ahead of print).
centage of ICUs? (2) What is the appropriate level of clinical 15. Bloomfield SA. Changes in musculoskeletal structure
expertise or experience required to safely work in a critical and function with prolonged bedrest. Med Sci Sports
care environment? (3) What intensity, frequency, and dose Exerc. 1997;29(2):197-206.

12 Cardiopulmonary Physical Therapy Journal Vol 23 Y No 1 YMarch 2012

16. Brower RG, Consequences of bed rest. Crit Care Med. ventilation is difficult. Phys Ther. 2011;91(7):1109-
2009;37(10):422-428. 1115.
17. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming 32. Pohlman, MC, Schweickert WD, Pohlman AS et al.
ICU culture to facilitate early mobility. Crit Care Clin. Feasibility of physical and occupational therapy
2007;23:81-96. beginning from initiation of mechanical ventilation.
18. Morris PE, Griffen L, Berry M, et al. Receiving early Crit Care Med. 2010;38:2089-2094.
mobility during and intensive care unit admission is a 33. MahoneyFI, Barthel DW. Functional evaluation: the
predictor of improved outcomes in acute respiratory Barthel Index. Md State Med J. 1965;14:61-65.
failure Am J Med Sci. 2011;341(5):373-377. 34. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The
19. Centre for Evidence-based Medicine. Levels of functional independence measure: a new tool for reha-
Evidence (March 2009) Website. Available at www. bilitation. Adv Clin Rehabil. 1987;1:6-18. Accessed September 26, 2011.
20. Schweickert WD, Pohlman MC, Pohlman AS. Early
physical and occupational therapy in mechanically
ventilated, critically ill patients: a randomized
controlled. Lancet. 2009;373:1874-1882.
21. Burtin C, Clerckx B, Robbeets C, et al. Early exercise
in critically patients enhances short-term functional
recovery. Crit Care Med. 2009;37(9):2499-2505.
22. Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT. Effects
of physical training on functional status in patients
with prolonged mechanical ventilation. Phys Ther.
23. 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.
24. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO.
Patients with respiratory failure increase ambulation
after transfer to an intensive care unit where early
activity is a priority. Crit Care Med. 2008;36(4):1119-
25. 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-
26. 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;91:536-542.
27. Stiller K, Phillips, AC, Lambert P. The safety of mobilisa-
tion and its effects on haemodynamic and respiratory
status of intensive care patients. Physio Theory Pract.
28. 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. Resp Care.
29. Zafiropoulus B, Allison JA, McCarren B. Physiological
responses to the early mobilization of the intubated,
ventilated abdominal surgical patient. Austr J Physio-
ther. 2004;50(2):95-100.
30. Martin UJ, Hincapie L, Nimchuk M, Gaughan J. Criner
GJ. Impact of whole-body rehabilitation in patients re-
ceiving chronic mechanical ventilation. Crit Care Med.
31. Montagnani G, Vagheggini G, Panait Vlad E, Berrighi
D, Pantani L, Ambrosino N. Use of the functional
independence measure in people for whom mechanical

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