[Downloaded free from http://www.ijhas.in on Monday, April 15, 2019, IP: 223.185.8.

244]

Original Article

Effect of graded early mobilization versus routine

physiotherapy on the length of intensive care
unit stay in mechanically ventilated patients:
A randomized controlled study
Priyakshi Bezbaruah, Narasimman Swaminathan, Cherishma D’silva, Shabari Kidyoor
Department of Physiotherapy, Father Muller Medical College, Mangalore, Karnataka, India

ABSTRACT was observed between early mobilization and routine

Background: Early mobilization is an important component
of physiotherapy used to prevent and decrease pulmonary
and immobilization complications, which are the major goals
of physiotherapy in the intensive care unit (ICU). Prolonged
bed rest and hospitalization leads to deconditioning and
weakness which can further increase the length of the
ICU stay. This study was conducted to find an answer
to whether early mobilization is as effective as or better
than routine physiotherapy in reducing the length of ICU
stay in mechanically ventilated patients. Study Design:
Randomized controlled study. Study Setting: Medical
ICU, Father Muller Medical College Hospital. Mangalore,
Karnataka, India. Aim: To detect the effectiveness of
graded early mobilization and routine physiotherapy and to
compare these techniques with respect to the length of ICU
stay in mechanically ventilated patients. Materials and
Methods: Fifteen subjects of both gender who were on
mechanical ventilators fulfilling the inclusion criteria were
randomly assigned to two groups, group 1 (graded early
mobilization, n = 8) and Group 2 (routine physiotherapy,
n = 7) by using the randomization plan from the website
www.randomization.com. All the vitals of the subjects
were noted as they were made to perform particular
maneuvers depending on the group they belonged to.
Participants recruited into the early mobilization group
were mobilized as soon as their vitals were stable and
were able to participate in the therapy. The patients who
underwent routine physiotherapy were mobilized once
they were extubated. At the time of discharge from the
ICU, days of weaning, days first out of bed, and length
of ICU stay were noted. Results: A significant difference
physiotherapy groups with respect to the length of ICU
stay. Conclusion: Early mobilization showed better
outcome compared to routine physiotherapy in reducing
the length of ICU stay in mechanically ventilated patients.
The results of this study cannot be generalized due to the
small number of subjects.
Key words: Complications, early mobilization, ICU,
physiotherapy
INTRODUCTION
In most of the intensive care units (ICUs), bed rest is
considered as the routine standard of care which leads to
immobility, deconditioning, and weakness.[1-4] Patients who
are admitted in ICUs are surrounded by various equipments
and life support systems, and therefore mobilization is
considered to be a complex task.[5] Muscle strength decreases
to 20% within one week of immobilization with an additional
decrease of 20% in each subsequent week.[6,7] The presence
of muscle weakness is associated with the duration of
mechanical ventilation and length of ICU stay.[8,9] Prolonged
bed rest also increases the production of reactive oxygen
species (ROS) with a decrease in antioxidative defence.[10,11]
The term ROS describes a variety of molecules and free
radicals derived from molecular oxygen. ROS plays a very
important role in tumor necrosis factor (TNF)-alpha-induced
oxidation of myofilaments resulting in contractile dysfunction
Access this article online
Quick Response Code:
Website:
www.ijhas.in

Address for correspondence: Mr. Narasimman Swaminathan,

DOI:
Department of Physiotherapy, Father Muller Medical College,
10.4103/2278-344X.105081
Mangalore, Karnataka, India.
E-mail: naraswamin2001@gmail.com

172 International Journal of Health & Allied Sciences • Vol. 1 • Issue 3 • Jul-Sep 2012
[Downloaded free from http://www.ijhas.in on Monday, April 15, 2019, IP: 223.185.8.244]
Bezbaruah, et al.: Graded mobilization in mechanically ventilated patients
and atrophy.[12,13] Critically ill patients in the ICU commonly
receive less than 60% of their nutritional intake during
their ICU stay leading further to malnutrition.[14] Early
mobilization in ICUs may help to improve the respiratory
function by optimizing the ventilation/perfusion matching,
increase the lung volume and improve the airway clearance,
reduce the adverse affects of immobility, increase the level
of consciousness, improve cardiovascular fitness, increase
functional independence, and increase psychological
well- being.[15-17] Mechanically ventilated patients usually
receive very high doses of sedatives and analgesics which leads
to prolonged periods of unconsciousness and immobility.[15]
Kollef and colleagues identified excessive ICU sedation to
be an important cause of prolonged mechanical ventilation
and length of ICU stay.[18] Physical mobilization during
mechanical ventilation of the ICU patients helps them to
be active.[19]
Although physical therapy has a theoretical appeal, it has
not been determined whether it benefits when initiated early
during the ICU treatment.
Bailey and colleagues first reported the trial of early
[20]
mobilization in mechanically ventilated patients. They
reported that early mobilization after physiologic
stabilization in the ICU might lead to patients accomplishing
ambulation by the time of discharge from the ICU. Patients
with respiratory failure admitted to respiratory ICU (RICU)
at LDS Hospital in Salt Lake City over a seven-month
period were included in the study. Patients with mechanical
ventilation >4 days were eligible. Mobilization began when
patients had neurological stability, respiratory stability, and
circulatory stability.
Schweickert and colleagues[21] reported a randomized trial
of early physical and occupational therapy in patients with
respiratory failure requiring mechanical ventilation. The
patients were randomized into the intervention group and
the control group. The intervention group received early
mobilization which included range of motion (ROM), side
sitting, Activities of daily living ADL, transfer training,
and ambulation. Patients in the control group underwent
physical/occupational therapy, as ordered by the primary
care team physician, occurring after extubation. The
primary end point was to return to functional independence
at discharge from hospital. There was a shorter duration
of delirium (median 2 vs. 4 days), more ventilator-free
days (median 23.5 vs. 21.1 days), and improved return to
independent functional status (59% vs. 35%).
Perme and Chandreshekhar developed a four-phase
protocol which provides guidelines for early mobilization in
International Journal of Health & Allied Sciences • Vol. 1 • Issue 3 • Jul-Sep 2012
the ICU as well as criteria for progressing to the next phase.
The purpose of this study was to find out the effect of early
mobilization on the length of ICU stay in mechanically
ventilated patients.[22]
Materials And Methods
Patients
A sample of 15 subjects who were on mechanical ventilator
between May 25, 2011 and October 30, 2011 at the medical
ICU, Father Muller Medical College Hospital were included
in the study. The study was approved by the ethical
committee of the institution.
The inclusion criteria were mechanically ventilated patients
with respiratory pathology, in the age group 30-60 years,
out of sedation with Glasgow Coma Scale (GCS) of 14/15
(VET), and stable vitals. Patients with any neurological
impairment, unstable fractures, spinal fractures, and
fractures of the lower limb were excluded from the study.
Procedure
Those subjects fulfilling the inclusion criteria were randomly
assigned early mobilization and control group by using a
predetermined computer generated randomization plan.
Group 1 experimental group: Graded early
mobilization protocol
According to this protocol, graded early mobility can be
defined as beginning the mobility program when the patient
is minimally able to participate in the therapy, has stable
hemodynamic status, and is receiving acceptable levels of
oxygen.
The criteria for mobilization were heart rate less than
110/ min at rest, mean arterial blood pressure between 60
and 110 mmHg, fraction of inspired oxygen less than 0.6,
and oxygen saturation greater than 88% on activity.
The vitals of the patient were to be assessed before, during,
and after any mobility intervention.
The protocol was modified due to practical concerns and
was divided into four phases.
Phase 1
This included patients who were critically ill with multiple
medical problems, had limited activity tolerance, and were
unable to walk.
The goal of phase 1 was to make the patient sit at the
edge of the bed unsupported or with minimal assistance
173
[Downloaded free from http://www.ijhas.in on Monday, April 15, 2019, IP: 223.185.8.244]

Bezbaruah, et al.: Graded mobilization in mechanically ventilated patients

and initiate standing with manual assistance and walker
support.
General criteria for progressing to the next phase were that
the patient followed commands, had stable hemodynamics
and acceptable oxygenation, and was able to stand with a
walker.
Phase 2
This phase included patients in acute/subacute phase with
multiple medical problems, in a stable condition, and able
to participate better in the activities.
The goal of phase 2 was to initiate re-education of gait
with the walker.
mechanical ventilation, were able to participate actively. The
goal of phase 4 was to promote progressive transfers and
walking independence. Assessment of physical therapy was
carried out, the phase of the program in which the patient
should be included was determined, and the mobility plan
of care was established.
Group 2 control group (patients who received
routine physiotherapy)
This included positioning, postural drainage, percussion,
vibration, suctioning, and passive ROM exercises. They
were mobilized after they were extubated from the
ventilator. The duration of the physiotherapy session was
30–45 minutes for both the groups as tolerated, twice a day
till the day of discharge from the ICU.

General criteria for progressing to the next phase involved the
patient following commands, having stable hemodynamics
and acceptable oxygen, being capable of transfer to chair with
the assistance of a walker, and walker re-education.
Phase 3
This included patients in acute/subacute phase with
multiple medical problems or resolving medical problems
and able to participate actively in the therapy.
Outcome measures were days first out of bed, days of
weaning, and length of ICU stay which were taken on the
day of discharge from the ICU [Figure 1].
Statistical analysis
Chi-square test was used to analyze differences within
the group. Mann-Whitney test was used to compare the
outcomes between the groups following the intervention.
The software used for statistical analysis was SPSS 13.

The goal of phase 3 was to initiate independent transfer RESULTS

training with walker and provide progressive walking
re-education. General criteria for progressing to the next
phase included the patient following commands, being
hemodynamically stable, with acceptable oxygen levels,
and with improved tolerance to a progressive walking
program.
Phase 4
Patients in subacute phase, who had been weaned from
Group 1 (early mobilization) comprised eight subjects with
a mean age of 50.38 [standard deviation (SD): 8.400] and
group 2 (routine physiotherapy), seven subjects with a mean
age of 50.43 (SD: 4.158). In Group 1, there were two males
and six females. In Group 2, there was one male and six
females. Table 1 shows the demographic data.
The mean days first out of bed in early mobilization and

Table 1: Baseline characteristics

Characteristic Category Early mobilization Routine physiotherapy P value
Gender Male 2 1
Female 6 6
Age [yrs; M (SD)] 50.38 (8.4) 50.43 (4.158) 0.908
Diagnosis Acute asthma 2 1
Acute exacerbation of COPD 4 5
Brochiectasis 2 0
Pulmonary TB 1
Mode of ventilator SIMV 8 6
CPAP 0 1
PCO2 52.888 (8.99) 56.943 (7.6339) 0.242
PO2 145.925 (52.944) 139.943 (70.124) 0.563
pH 7.3450 (.11123) 7.3643 (.09964) 0.908
HCO3 29.213 (7.0015) 44.7 (9.7101) 0.728
SD=Standard deviation, COPD=Chronic obstructive pulmonary disease, TB=Tuberculosis, SIMV=Synchronized intermittent mandatory ventilation,
CPAP=Continuous positive airway pressure, PCO2=Carbon dioxide partial pressure, PO2=Oxygen partial pressure, HCO3=Bicarbonate

174 International Journal of Health & Allied Sciences • Vol. 1 • Issue 3 • Jul-Sep 2012
[Downloaded free from http://www.ijhas.in on Monday, April 15, 2019, IP: 223.185.8.244]

Bezbaruah, et al.: Graded mobilization in mechanically ventilated patients

15 patients on mechanical ventilator Table 2: Comparison of days first out of bed between
the two groups
Group N Min Max Mean SD Median Mann- P value
GROUP 1 (n=8) GROUP 1 (n=7) Whitney
(Early Mobilization) (Routine Physiotherapy) test
Inter 8 2 4 2.88 0.641 3.00 3.33 0.001
Control 7 7 9 7.71 0.756 8.00
Min=Minimum, Max=Maximum, SD=Standard deviation
Routine Physiotherapy + Early Mobilization Routine PT

Table 3: Comparison of days of weaning between the

Positioning (with stable hemodynamic parameters Till pt. is intubated two groups
Percussion and intubated pts) Group N Min Max Mean SD Median Mann- P value
Vibration Whitney
Postural drainage Bed mobility-bridging test
Suctioning Side sitting Once extubated Inter 8 5 6 5.38 0.518 5.00 3.38 0.001
Unsupported sitting Control 7 7 9 7.43 0.787 7.00
Transfer training-transfer from bed to chair Min=Minimum, Max=Maximum, SD=Standard deviation
Sit to stand, spot marching
Walking re education Mobilization initiated
Table 4: Comparison of the length of ICU stay between
the two groups
Group N Min Max Mean SD Median Mann- P value
Till the day of ICU discharge Till the day of ICU discharge
Whitney
(n=8) (n=7)
test
Figure 1: PT: Physiotherapy, pt.: Patient Inter 8 5 6 5.63 0.518 6.00 3.38 0.001
Control 7 7 9 8.00 0.577 8.00
routine physiotherapy were 2.88 (SD: 0.641) and 7.71 Min=Minimum, Max=Maximum, SD=Standard deviation

(SD: 0.756), respectively [Table 2].

Difference in days first out of bed between the two groups

on the day of discharge from the ICU was statistically
significant (P = 0.001) [Table 3].

The mean days of weaning in early mobilization and routine

physiotherapy were 5.38 (SD: 0.518) and 7.43 (SD: 0.787),
respectively [Table 4].

Difference in days of weaning between the two groups was

statistically significant (P = 0.001).

The mean length of ICU stay in early mobilization and
routine physiotherapy was 5.63 (SD 0.518) and 8.00
(SD 0.577), respectively Figure 2.
Difference in the length of ICU stay between the two groups
was statistically significant (P = 0.001).
DISCUSSION
In most of the ICUs, bed rest is considered as the routine
standard of care. Prolonged bed rest leads to neuromuscular
weakness and deconditioning.[7] There is a significant reduction
in the strength of both skeletal and respiratory muscles.[23,24]
All of these lead to delayed weaning from the ventilator and
prolong the length of ICU stay. Routine physiotherapy is the
standard of care in all ICUs[1] Early mobilization is not a
new concept but it is not routinely practiced in mechanically
Figure 2: Between the group comparison on out of bed, days
of weaning, days of ICU stay
ventilated patients. Its role and safety measures are yet to be
established. Many articles in the literature have documented
the effect of early mobilization in critically ill patients but
there were no fixed protocols pertaining to this. To the best
of our knowledge, there are no randomized trials to check the
feasibility of early mobilization in mechanically ventilated
patients based on a protocol.
It was found in the literature that the presence of muscle
weakness was associated with the duration of mechanical
ventilation and length of ICU stay.[19-21,25] Therefore the
main outcome measures used were days first out of bed,
duration of mechanical ventilation, and length of stay
in the ICU.

International Journal of Health & Allied Sciences • Vol. 1 • Issue 3 • Jul-Sep 2012 175
[Downloaded free from http://www.ijhas.in on Monday, April 15, 2019, IP: 223.185.8.244]
Bezbaruah, et al.: Graded mobilization in mechanically ventilated patients
To identify the length of stay in the ICU, subjects on
mechanical ventilators with a history of respiratory
pathology were included in the study. All the subjects
were conscious and oriented with GCS = 14/15 so that
they could actively participate in the therapy. Subjects
were hemodynamically stable with a heart rate less than
110/ minute at rest, mean arterial blood pressure between
60 and 110 mmHg, fraction of inspired oxygen less than
0.6, and oxygen saturation greater than 88% on activity.
The protocol used in this study was a four-phase protocol
which was modified from Perme and Chandrashekhar
from the American Journal of Critical Care, 2009. Each phase
provided guidelines on types of exercises, positioning, bed
mobility, transfers, and gait. General criteria for progressing
to the next phase were also mentioned.
There was a significant difference in all the outcome
measures between the groups. The early mobilization
group was out of bed earlier, had more ventilator-free days,
and had a much more reduced length of stay in the ICU
compared to the routine physiotherapy group. As a result,
it was found that patients in the early mobilization group
remained more active most of the time compared to those
in routine physiotherapy. Furthermore, the patients in the
early mobilization group had fewer complications than
those in routine physiotherapy and were able to cope with
the condition more efficiently than the control group.
The advantages of early mobilization are that it enhances
the cardiovascular function including increase in cardiac
output, increases myocardial contractility, decreases
peripheral resistance, decreases chronic inflammation, and
preserves neuromuscular and musculoskeletal integrity. It
is also hypothesized that mobilization improves pulmonary
mechanics, improves ventilation/perfusion matching,
improves gaseous exchange, and helps in better airway
clearance.
As a result of all these positive factors, the patients were out
of bed earlier compared to the routine physiotherapy group.
The psychological benefit of early mobility is another
positive outcome observed in the study. Once the patients
progress to functional mobility, they develop a much more
positive outlook towards their recovery. The medical
condition of the patients did not deteriorate as a direct
result of intervention associated with the early mobility and
walking program.
Once a patient is being able to sit, stand, and ambulate
with the ventilator, it can have an encouraging effect on the
176 International Journal of Health & Allied Sciences • Vol. 1 • Issue 3 • Jul-Sep 2012
activity level of the patient and this in turn could assist in the
patient being weaned early from the mechanical ventilator.
Moreover, critically ill patients in the ICUs receive heavy
sedation which is associated with increased duration
of mechanical ventilation, whereas early mobilization
could further result in decreased duration of mechanical
ventilation and decreased length of ICU stay.
There was a sudden drop in the saturation level of one patient
in the intervention group during early mobilization who,
however, recovered within a few seconds. No other adverse
effects were identified in both the groups. Patients in the early
mobility group could be ambulated with the ventilator around
the bedside and there were no adverse effects noted. All the
patients could tolerate early mobility well with the ventilator
and there were no unstable hemodynamics noted after the
ambulation. There was also no dislodgement of any tubes or
lines while ambulating the patients which suggested that early
mobilization was feasible. Thus it can also be concluded that
early mobilization is safe and can be administered effectively.
This study was mainly done to demonstrate the efficacy
of early mobilization and routine physiotherapy and to
compare the effect of the two techniques on the length of
ICU stay in critically ill patients on mechanical ventilators.
There was a statistically significant difference in all the
outcome measures used in the study. This shows that
early mobilization has a positive effect, thereby reducing
the length of ICU stay and can be administered safely in
mechanically ventilated patients.
This study included subjects with different respiratory
pathologies, that is, the groups were not homogenous which
might have affected the outcomes. Moreover, functional
improvement of the subjects could not be assessed because
the patients were shifted to the wards as soon as they were
extubated. The study could not be generalized because
of the small size of the sample. Another limitation of the
study was that the mobility protocol was limited in its
delivery only to the ICUs. Further follow-up of the patients
could be done to see its effect on the length of stay in the
hospital. The study was not blinded as the same therapist
who allocated the patients into groups also administered the
intervention and measured the outcomes. A similar study
with a large sample size and a more homogenous group
with blinding of the assessor can be used which will improve
the understanding in this regard. Future studies measuring
functional improvements may provide clarification as to
the effect of early mobilization on long-term functional
outcomes.
[Downloaded free from http://www.ijhas.in on Monday, April 15, 2019, IP: 223.185.8.244]
Bezbaruah, et al.: Graded mobilization in mechanically ventilated patients
REFERENCES
1. Stiller K. Physiotherapy in intensive care. Towards an evidence-based
practice. Chest 2000;118:1801-13.
2. Bailey PP, Miller RR 3rd, Clemmer TP. Culture of early mobility in
mechanically ventilated patients. Crit Care Med 2009;37:S429-35.
3. Herridge MS, Cheung AM, Tansey CM. One year outcomes in survivors
of acute respiratory distress syndrome. N Engl J Med 2003;348:683- 93.
4. De Jonghe B, Sharshar T, Lefaucher JP, Authier FJ, Durand-Zaleski  I,
Boussarsar M, et al. Paresis acquired in Intensive Care Unit: A
prospective multicenter study. JAMA 2002;288:2859-67.
5. Morris PE. Moving our critically ill patients: Mobility barriers and
benefits. Crit Care Clin 2007;23:1-20.
6. Gosselink R, Bott J, Johnson M. Physiotherapy for adult patients
with critical illness. Recommendation of European Respiratory
Society and European Society of Intensive Care Medicine Task
force on Physiotherapy for Critically ill patients. Intensive Care Med
2008;34:1188-99.
7. Sciaky AJ. Mobilising the intensive care unit patient. Pathophysiology
and treatment. Physiother Theory Pract 1994;3:69-80.
8. De Letter MA, Schmitz PI, Visser LH, Verheul FA, Schellens RL, Op
de Coul DA, et al. Risk factors for the development of polyneuropathy
and myopathy in critically ill patients. Crit Care Med 2001;29:2281-6.
9. Garnacho-Montero J, Madrazo-Osuna J, García-Garmendia JL, Ortiz-
Leyba C, Jiménez-Jiménez FJ, Barrero-Almodóvar A, et al. Critical
illness polyneuropathy: Risk factors and clinical consequences. A
cohort study in septic patients. Intensive Care Med 2001;27:1288-96.
10. Pawlak W, Kedziora J, Zolynski K, Kedziora-Kornatowska K,
Blaszczyk  J, Witkowski P. Free radicals generation by granulocytes
from men during bed rest. J Gravit Physiol 1998;5:131-2.
11. Pawlak W, Kedziora J, Zolynski K, Kedziora-Kornatowska K,
Blaszczyk  J, Witkowski P, et al. Effect of long term bed rest in men on
enzymatic antioxidative defence and lipid peroxidation in erythrocytes.
J Gravit Physiol 1998;5:163-4.
12. Buck M, Chojkier M. Muscle wasting and dedifferentiation induced by
oxidative stress in a murine model of cachexia is prevented by inhibitors
of nitrous oxide synthesis and antioxidants. EMBO J 1996;15:1753-65.
13. Reid MB, Li YP. Tumor necrosis factorsu–alpha and muscle wasting:
A cellular perspective. Respir Res 2001;2:269-72.
International Journal of Health & Allied Sciences • Vol. 1 • Issue 3 • Jul-Sep 2012
14. Truong AD, Fan E, Brower RG, Needham DM. Bench to bedside
review: Mobilizing patients in the intensive care- from pathophysiology
to clinical trials. Crit Care 2009;13:216.
15. Stiller K. Safety issues that should be considered when mobilizing
critically ill patients. Crit Care Clin 2007;23:35-53.
16. Narasimman S, Mohammad H. Early mobilization in ICU. Current
perspective and future directions. Physio Times 2010;2:18-23.
17. Kress JP. Clinical trials of early mobilization of critically ill patients.
Crit Care Med 2009;37:S442-7.
18. Kollef MH, Levy NT, Shrens TS. Use of continuous i.v. Sedation is
associated with prolonged mechanical ventilation. Chest 1998;114:541-8.
19. Kress JP, Pohlman AS, O’Connor MF. Daily interruption of sedative
infusion in critically ill patients undergoing mechanical ventilation. N
Engl J Med 2000;342:1471-7.
20. Bailey P, Thomsen GE, Spuhler VJ. Early activity is feasible and safe
in respiratory failure patients. Crit Care Med 2007;35:139-45.
21. Schweickert WD, Pohlman MC, Pohlman AS. Early physical and
ocuupational therapy in mechanically ventilated, critically ill patients.
A randomized controlled trial. Lancet 2009;373:1874-82.
22. Perme C, Chandrashekhar R. Early mobility and walking program
for patients in ICU, creating a standard for care. Am J Crit Care
2009;18:212-21.
23. Honkonen SE, Kannus P, Natri A, Latvala K, Jarvinen MJ. Isokinetic
performance of the thigh muscles after tibial pleatue fracture. Int Orthop
1997;21:323-6.
24. Miller EA. Influence of training and of inactivity on muscle strength.
Arch Phys Med Rehabil 1970;51:449-62.
25. Thomsen GE, Snow GL, Rodriguez L. Patients with respiratory failure
increase ambulation after transfer to ICU where early mobility is a
priority. Crit Care Med 2008;36:1119-24.
How to cite this article: Bezbaruah P, Swaminathan N, D«SQ»silva C,
Kidyoor S. Effect of graded early mobilization versus routine
physiotherapy on the length of intensive care unit stay in mechanically
ventilated patients: A randomized controlled study. Int J Health Allied
Sci 2012;1:172-7.
Source of Support: Father Muller Medical College Hospital, Conflict
of Interest: None declared
177