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ACO 310214

REVIEW

CURRENT
OPINION Recent evidence on early mobilization in
critical-Ill patients
Kristina Fuest and Stefan J. Schaller

Purpose of review
To examine the benefits of early mobilization and summarize the results of most recent clinical studies
examining early mobilization in critically ill patients followed by a presentation of recent developments in
the field.
Recent findings
Early mobilization of ICU patients, defined as mobilization within 72 h of ICU admission, is still uncommon.
In medical and surgical critically ill patients, mobilization is well tolerated even in intubated patients. In
neurocritical care, evidence to support early mobilization is either lacking (aneurysmal subarachnoid
hemorrhage), or the results are inconsistent (e.g. stroke). Successful implementation of early mobilization
requires a cultural change; preferably based on an interprofessional approach with clearly defined
responsibilities and including a mobilization scoring system. Although the evidence for the majority of the
technical tools is still limited, the use of a bed cycle ergometer and a treadmill with strap system has been
promising in smaller trials.
Summary
Early mobilization is well tolerated and feasible, resulting in improved outcomes in surgical and medical
ICU patients. Implementation of early mobilization can be challenging and may need a cultural change
anchored in an interprofessional approach and integrated in a patient-centered bundle. Scoring systems
should be integrated to define daily goals and used to verify patients’ achievements or identify barriers
immediately.
Keywords
critically ill, early mobilization, ICU, physical therapy, rehabilitation

INTRODUCTION Unfortunately, there is not a uniform definition

Long-term complications such as postintensive care
syndrome, ICU acquired weakness, physical debil-
ity, and neuropsychiatric dysfunction have become
a clinical and scientific focus as their impact on
long-term quality of life is becoming increasingly
&
obvious [1 ,2]. Immobilization has been also found
to negatively affect 1-year mortality and long-term
functional outcomes [3,4]. After the landmark pub-
lication from Schweickert et al. [5], early mobiliza-
tion was thought to be a successful approach to
prevent functional disability. However, more recent
high-quality publications show conflicting results
&& &
[6,7,8 ,9 ,10].
The review will present the evidence of the effect
of early mobilization on short and long-term func-
tional outcome, summarize the results of most
recent clinical studies examining early mobilization
in critically ill patients, and present recent develop-
ments in the field.
of the term ‘early mobilization.’ For the purpose of
this review, we will use the definition used by the
German guidelines on ‘Positioning and early mobi-
lization in prophylaxis or therapy of pulmonary
disorders’ defining early mobilization as mobiliza-
tion within 72 h [11].
RANDOMIZED CONTROLLED TRIALS IN
MEDICAL ICU PATIENTS
In the years 2005–2007, Schweickert et al. [5] stud-
ied 104 sedated adults in three medical ICUs who
Klinik f€
ur Anaesthesiologie, Klinikum rechts der Isar, Technische Univer-
sität M€
unchen, Munich, Germany
Correspondence to Dr Stefan J. Schaller, MD, MHBA, Klinik f€ ur Anaes-
thesiologie, Klinikum rechts der Isar der TUM, Ismaningerstr, 22, 81675
Munich, Germany. Tel: +49 89 4140 9635; e-mail: s.schaller@tum.de
Curr Opin Anesthesiol 2018, 31:000–000
DOI:10.1097/ACO.0000000000000568

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Intensive care and resuscitation
KEY POINTS
 Positive effects on functional outcomes are supported by
high-level evidence for early mobilization in medical
and surgically critically ill patients.
 Early mobilization is well tolerated, needs a cultural
change in the ICU, and should be implemented
interprofessionally as part of a bundle with other
patient centered concepts for delirium or sedation.
 Important aspects, for example, adequate dosing of
mobilization, technical devices including bed cycle
ergometer are lacking adequate evidence.
had been mechanically ventilated for less than 72 h,
and were expected to continue for at least 24 h.
Patients were randomly assigned to receive either
standard care including daily interruption of seda-
tion or an intervention including early exercise and
mobilization (physical and occupational therapy)
during periods of daily interruption of sedation.
Patients who were mobilized early showed a
better functional outcome at hospital discharge
(59 vs. 35%, P ¼ 0.02), a shorter duration of delirium
(2 vs. 4 days, P ¼ 0.03), and more ventilator-free days
compared to standard care patients (3.4 vs. 6.1 days,
P ¼ 0.02). Patients in the mobilization group started
physical therapy on average on day 2 as opposed to
day 7 (1.5 vs. 7.4 days, P < 0.001).
From 2009–2014, Morris et al. [7] randomized
300 patients with acute respiratory failure in a single
centre study. Usual care was compared with stan-
dardized rehabilitation physiotherapy during the
hospital stay, that is, not early mobilization. Length
of hospital stay as primary outcome did not
show any difference between the groups. Although
most secondary outcomes did not show any effect
as well, patient with standardized rehabilitation
physiotherapy had a better functional status at
6 months.
During the same period (2009–2014) Moss et al.
[6] enrolled 120 patients in five medical ICUs in the
Denver area who were ventilated for at least 4 days.
The intervention by physical therapists was contin-
ued for 28 days, even after the patients were dis-
charged from the hospital. It did not result in
improved functional independence. However, it is
important to note, that the intervention started on
day 8 of ICU therapy (median) and is, therefore,
not an early mobilization intervention as defined
above. This also applies to a similar study of
exercise rehabilitation with a 12-month follow-up,
where patients were only included after 5 days of
intensive care therapy and no difference in physical
outcomes could be found [12].
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RANDOMIZED CONTROLLED TRIALS IN
SURGICAL ICU PATIENTS
In the only international randomized, controlled
&&
study, Schaller et al. [8 ] used an algorithm based
on the validated and simple surgical optimal mobil-
ity score (SOMS) in 200 patients from 2011 till 2015
&&
[8 ,13,14]. The score ranges from 0 (no mobiliza-
tion) to 4 (ambulation). In addition, a facilitator
assured that the daily mobilization goal was met
and barriers preventing mobilization were dis-
cussed, addressed, and overcome if possible. This
combination of an algorithm with a facilitator led to
an increased mobilization level in the ICU (SOMS
2.2 vs. 1.5, P < 0.0001), a shorter ICU length of stay
(7 vs. 10 days, P ¼ 0.0054), and a better functional
outcome at hospital discharge (independence 51 vs.
28%, P ¼ 0.0030). Secondary outcomes, such as
delirium-free days (25 vs. 22 days, P ¼ 0.016), hospi-
tal length of stay (15 vs. 21.5 days, P ¼ 0.011), and
discharge disposition (to home 51 vs. 27%,
P ¼ 0.0007), were also significantly better in the
early, goal-directed mobilization group.
RANDOMIZED CONTROLLED TRIALS IN
MIXED/GENERAL ICU PATIENTS
In contrast to the studies above, the intervention in
all three randomized controlled trials (RCTs) con-
ducted in a mixed ICU population was exclusively
based on physical therapists and lacked an interpro-
fessional approach. In a small single center study,
50 septic patients received early physical rehabilita-
tion, consisting of physical therapy 1–2 times a day
for 30 min [10]. Electrical muscle stimulation, active
and passive range of motion, sitting out of bed as
well as transfers, and ambulation were components
of physical rehabilitation intervention. Standard
care provided in the control group included physical
therapy strategies provided by the ICU physiothera-
pist. Although there was no difference in outcomes
at ICU discharge, there was an improvement in the
self-reported physical function and role of the 36-
item short form health survey (SF-36).
In the small binational multicenter trial in
50 critically ill mechanically ventilated patients,
Hodgson et al. [2] demonstrated that applying early
goal-directed mobilization using the ICU mobility
scale was feasible and increased the level of activity
of patients in the ICU without any adverse events.
In contrast, the Extra Physiotherapy in Critical
Care (EPICC) trial reported a lack of benefit of early
&
mobilization [9 ]. This prospective randomized
study intended to investigate the impact of
90 min physical rehabilitation therapy compared
to a standard of 30 min. The authors concluded that
more ICU-based physical rehabilitation did not
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appear to improve physical outcomes at 6 months. It
is important to note, that the intervention group
received an average of 23 min instead of planned
90 min of physical therapy, if the intervention was
provided at all, as the intervention was provided
only 57% of days. The standard group patients
received 13 min of physical therapy on 40% of days.
Consequently, one may argue, this study provides
evidence that 10 min of additional physical rehabil-
itation/day did not improve patient outcomes.
RANDOMIZED CONTROLLED TRIALS IN
NEUROCRITICAL CARE ICU PATIENTS
There are no RCTs available in neurocritical inten-
sive care patients. However, the A Very Early Reha-
bilitation Trial (AVERT) investigated more than
2000 patients admitted to stroke units. Patients were
randomized to receive either very early mobilization
(commencing within 24 h) or usual care [15]. Sur-
prisingly, the increased amount of mobilization
reduced the odds of a favorable outcome (modified
Rankin scale score of 0–2: operating room 0.94,
95% confidence interval 0.91–0.97, P < 0.001) at
3 months. The predefined post hoc analysis of the
data, however, indicates that the dose (frequency
and duration) of mobilization is crucial for a positive
&&
outcome [16 ]: The data suggest that a shorter more
frequent mobilization after acute stroke is associated
with greater odds of a good neurological outcome at
3 months. Consequently, we would recommend to
mobilize stroke patients 24 h after the on-set in
frequent, short sessions split over the day.
The smaller and current Active Mobility Very
Early after Stroke (AMOBES) trial, also in stroke
units, compared soft physiotherapy (20 min) vs.
intensive physiotherapy (45 min) in 104 patients
[17]. No difference was seen in their primary out-
come (change in motor control between day 90 and
0) or their secondary outcomes including autonomy
and quality of life. The study was terminated early
with a planned sample size of 400 and is, therefore,
underpowered. However, the authors argue that
based on their results the new calculated sample
size would be more than 4000, which is not feasible
and, therefore, the expectation to achieve a positive
result with physical therapy is low.
SUMMARY OF THE RECENT RANDOMIZED
CONTROLLED TRIALS
Of the seven RTCs that examined the effects of
mobilization in medical, surgical, or mixed ICU
populations, only four had an early mobilization
intervention. Two reported clear benefits of early
mobilization on primary outcomes. Another one
reported improvements limited to secondary
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Recent evidence on early mobilization Fuest and Schaller
functional status outcomes only. Finally, the EPICC
trial with the above discussed limitations, reported a
lack of benefit of early mobilization.
Taken together, it appears that
(1) To be effective the mobilization has to start
(very) early, otherwise even a prolonged phys-
iotherapeutic intervention will not be able to
achieve the desired results.
(2) Early, protocol-based mobilization improved
functional abilities at hospital discharge and
reduced ICU and hospital length of stay.
(3) A multiprofessional approach including nurses
and physical therapists might be superior to
interventions using physical therapists alone.
(4) The dose of mobilization might be important
&&
[16 ], but no recommendation can be provided
at this time point, as this outcome has been
neglected so far in RCTs.
(5) There is lack of evidence of benefit of early
mobilization in neurocritical care.
(6) There is lack of data on long-term outcomes
such as mortality, health-related activities of
&
daily life or rate of return to work [9 ,12,18,19].
CURRENT DEVELOPMENTS IN SAFETY
AND IMPLEMENTATION
Early mobilization is a well tolerated intervention
&&
for ICU patients [20 ,21]. An endotracheal tube
should not be a contraindication for an out of bed
&&
mobilization [20 ,22]. Yet, the mobilization rate in
mechanically ventilated patients still depends on
the airway utilized. Patients with endotracheal tubes
were significantly less frequently actively mobilized
(e.g. sitting at the edge of the bed) to noninvasive
&
ventilation or tracheostomy [23,24 ]. In the most
recent worldwide survey, 91% of respondents
declared they would prescribe early mobilization
in critically ill patients, 69% without using a mobil-
ity team and 79% without using a mobility scale
[25]. Despite these encouraging results, data from
American hospitals suggest, that early mobilization
and rehabilitation is still uncommon [22]. The main
reason, aside from the medical condition of the
patient, was the perception that the patient was
too sick to attend physical activity. In an interview
series with nurses regarding ambulation of mechan-
ically ventilated patients, concern of a deteriorating
patient condition was mentioned, even though ben-
efits and positive effects on clinical outcome are well
known [26]. Another reason for the discrepancy of
reported frequency of early mobilization might be
the lack of a uniform definition of early mobiliza-
tion as mentioned before.
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A change in ICU culture coupled with team
training and education may be an essential step
to promote the routine use of early mobilization
&
[27,28 ,29,30]. Clarifying responsibilities and roles
within the team is a key component in this process.
Boehm et al. [31] showed in a survey examining
implementation of early mobilization in the ICU that
team culture and task autonomy have the strongest
associations with providers’ attitudes toward imple-
mentation. As soon as several professions are
in charge of early mobilization without a distinct
leadership structure, a higher workload burden was
sensed and adherence with mobility decreased imme-
diately. An interprofessional approach is necessary to
change the existing culture and environment [31].
SCORING SYSTEMS
There are three scores intended to be used as part
of a mobilization algorithm: the above mentioned
&&
SOMS [8 ,13,14,32], the ICU mobility scale
[2,33,34], and the Manchester mobility score [35]
(Table 1). The ICU mobility scale ranges from 0 to
10 but provides a more detailed, stepwise approach
and is simple to use [2,33,34,36]. It will be utilized
in the large scale upcoming randomized Trial
of Early Activity and Mobilization (TEAM) trial
(NCT03133377). The purpose of other available
scoring systems is to measure function of patients.
Four instruments have been created to be used in the
ICU: The Perme ICU mobility score [36–38], the
scored physical function ICU test [39], functional
status score for the ICU [40], and Chelsea critical
care physical assessment tool [41].
Table 1. Comparison of the SOMS, ICU mobility scale, and Manchester mobility score levels
Surgical ICU optimal
mobility score ICU mobility scale
0–No activity 0–Nothing (lying in bed)
1–Passive range of motion, 1–Sitting in bed, exercises in bed
upright in bed
2–Sitting up 2–Passively moved to chair (no standing)
2–Sitting up 3–Sitting over edge of bed
3–Standing 4–Standing
5–Transferring bed to chair
6–Marching on spot (at bedside)
4–Ambulating 7–Walking with assistance of two or more people
8–Walking with assistance of 1 person
9–Walking independently with a gait aid
10–Walking independently without a gait aid
The surgical ICU optimal mobility score consists of 5 levels (0–4). The ICU mobility scale with 11 levels (0–10) and the Manchester mobility score (eight levels)
each subdivide the surgical optimal mobility score mobilization levels further but differently.
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SPECIAL PATIENT GROUPS
Patients undergoing mechanical ventilation or
extracorporeal circulation systems such as extracor-
poral membrane oxygenation (ECMO) or hemofil-
tration need particular attention. Eden et al. [42]
presented a best-practice agreement in which using
checklists and defining responsibilities within the
ICU team lead to well tolerated and efficient phys-
iotherapy in patients undergoing ECMO. Also, with
renal replacement therapy, a group from South
Korea showed a feasible physiotherapy intervention
with few safety events during treatment [43].
CURRENT DEVELOPMENTS IN EARLY
MOBILIZATION IN NEUROCRITICAL CARE
In neurocritical care it seems to be necessary to dis-
tinguish between the different disease entities, for
example, acute hemorrhagic stroke vs. acute ische-
mic stroke. For a detailed overview of this specific
field of early mobilization in the neurocritical ICU,
&&
we recommend the review by Olkowski et al. [44 ].
The question if early mobilization is beneficial
for patients with acute aneurysmal subarachnoid
hemorrhage remains unanswered. Although small
pilot studies suggest safety [45–47], a reduction in
clinical vasospasm rate could not be radiologically
verified [46]. Consequently, no clear recommenda-
tion in patients with acute aneurysmal subarach-
&&
noid hemorrhage can be made [44 ,48–50].
CURRENT TECHNICAL ADVANCES
Bed-side cycle ergometers might be especially useful
in the ICU setting given the evidence that ICU
Manchester mobility score
1–In bed interventions (passive movements,
active exercise, chair position in bed)
3–Hoisted to chair (including standing hoist)
2–Sit on edge of bed
4–Standing practice
5–Step transfers with assistance
6–Mobilizing with or without assistance
7–Mobilizing >30 m
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acquired muscle weakness primarily affects lower
limb muscles [51]. Furthermore, ergometers are able
to decrease protein catabolism and reduce oxidative
&
stress compared to standard of care [52 ,53]. Larger
outcome studies (e.g. activities of daily live) with
ergometers are on their way with expected results in
2018 [54,55].
&
The pilot study by Sommers et al. [56 ] used a
treadmill with a strap system in critical-ill patients.
Apart from safety being provided even in mechani-
cally ventilated patients, the authors concluded that
74% of their mobilized patients would not have
been mobilized without their device. A planned
multicentre study will provide more evidence on
this topic.
The ventilation mode for mechanically venti-
lated patients undergoing exercise and rehabilita-
tion was also recently examined. Akoumianaki et al.
[57] pointed out the risk of increased work of breath-
ing during pressure support ventilation (PSV) limit-
ing the effect of exercise because of a mismatch
between demand and assist. In this pilot study from
Greece oxygen consumption was measured through
indirect calorimetry during physiotherapy (cycle
ergometer). Ten patients were randomized to PSV
and proportional assisted ventilation mode (PAV) or
neutrally adjusted ventilation assist mode (NAVA).
Oxygen consumption was significantly increased
in patients undergoing PSV compared with PAV/
NAVA. Results indicate that in mechanically venti-
lated patients PAV/NAVA could improve the train-
ing effect and rehabilitation.
There is lack of new data on neuromuscular
electrical stimulation [58] or whole-body vibration.
Although both seem to be well tolerated, an
improvement in outcome or muscle strength has
so far not been proven [59].
THINK BUNDLE
Daily awakening and breathing trials, delirium
monitoring and management, and early mobiliza-
tion are interventions proved to improve patient
outcomes. If put together in a bundle like the awak-
ening and breathing coordination, delirium moni-
toring and management, early mobilization and
inclusion of family members bundle, there seem
to be an additional synergistic bundle effect beyond
the sum of the components [60–62].
Family members can have a very positive effect
on mobilization of patients in acute care hospitals
&
[18]. Lai et al. [63 ] recently provided an interesting
approach on how to involve the family in early
mobilization in the challenging ICU setting. In that
study, parts of physiotherapy interventions were
performed during family visits of 30 min. Patients
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Recent evidence on early mobilization Fuest and Schaller
with this family-embedded protocol had a shorter
time of mechanical ventilation (4.7 vs. 7.5 days;
P < 0.001) and ICU stay (6.9 vs. 9.9 days;
P ¼ 0.001) compared to the historical control group.
This kind of physical therapy directly associated
with emotional support of critical ill patients repre-
sents an interesting aspect in early mobilization
and rehabilitation.
FUTURE TRENDS AND DEVELOPMENTS
The biggest mobilization trial, planned to be inter-
national, is on its way (TEAM, NCT03133377). Sev-
eral studies are investigating bed cycle ergometers
but none of them in the context of early mobiliza-
tion [54,55]. As ergometers can be applied to uncon-
scious patients or patients without core control, this
approach would be worth investigating especially
in the neurocritical care setting. In addition, the
&
treadmill-strap system by Sommers et al. [56 ] is an
interesting new concept to mobilize patients outside
the bed and ambulate them early. At the moment
motion sensors do not provide any benefit so far
[30].
CONCLUSION
Early mobilization, defined as mobilization within
72 h of ICU admission is well tolerated and feasible
and should be standard of care. However, implicat-
ing early mobilization is arduous and may need a
cultural change in intensive care with an interpro-
fessional approach. Scoring systems should be inte-
grated to define daily goals and verify achievements
of patients or identify barriers during the same day
to immediately address them. Finally, early mobili-
zation should be implemented in combination with
other outcome-improving measures such as the
awakening and breathing coordination, delirium
monitoring and management, early mobilization
and inclusion of family members bundle to improve
quality of patient care.
Acknowledgements
The authors would like to thank University Professor. Dr
Gerhard Schneider, head of department Klinik fu€r Anaes-
thesiologie at Klinikum rechts der Isar, Munich,
Germany for his support.
Financial support and sponsorship
The work was supported by the Department of Anesthe-
siology, Klinikum rechts der Isar der TUM, Munich,
Germany.
Conflicts of interest
There are no conflicts of interest.
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0952-7907 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Recent evidence on early mobilization Fuest and Schaller
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Trial with interesting concept how to involve family members for mobilization.
www.co-anesthesiology.com 7