Benefits of Early Mobility/ADL Retraining

Since the late 19th century, data has shown that early mobility and rehabilitation for hospitalized patients shortens post-operative bed rest, resulting in decreased muscle weakness.1 Intensive, early rehabilitation for patients in the ICU is safe, feasible, and effective.2-11 The benefits of early rehabilitation include improved respiratory function, muscle strength, physical functioning, and quality of life, as well as decreased ICU and hospital length of stay, readmission, and mortality.12,13 These efforts result in a 29-37% reduction in potential development of ICU-AW.2

Early rehabilitation programs are beneficial and the timing as well as duration of treatment is important.

The literature supports that early mobility and rehabilitation can be initiated as early as 24 hours after ICU admission and should occur for at least 45 minutes per discipline for a minimum of five days per week.3,8,10,14-16 This is a vague statistic that can make it challenging to figure out when to initiate therapy, how much therapy to provide, and for how long. In short:

“How do you figure out the right amount of treatment to provide?”

Use the literature as a guideline to support therapy in the ICU and provide a roadmap for you to follow. You may see patients the day they are admitted to the ICU if they are stable. Your patient may only tolerate 15 minutes of therapy once a day. Treatment frequency and dosage needs to be individualized and based on the patient’s tolerance, medical appropriateness, and their own specific needs. In short, use the literature to guide your but use your own clinical judgment to dictate dosage!

  • Treatment sessions can focus on:
    • Mobility tasks: sitting on edge of bed, standing, transferring, and ambulation
    • Pre-ADL tasks: grooming, simulated self-feeding tasks, and upper extremity exercise, both passive and active-assisted
    • Cognitive therapy: orientation, memory, attention, and problem-solving activities3,9,10,14,16
    • Staff/Caregiver Training: including positioning, ROM, role of therapy, treatment activities to carryover outside of the session, and general ways to best set the patient up for success.

References

  1. Hashem, M. D., Nelliot, A., & Needham, D. M. (2016). Early mobilization and rehabilitation in the ICU: Moving back to the future. Respiratory Care, 61(7), 971–979. https://doi.org/10.4187/respcare.04741

  2. Anekwe, D. E., Biswas, S., Bussières, A., & Spahija, J. (2020). Early rehabilitation reduces the likelihood of developing intensive care unit-acquired weakness: A systematic review and meta-analysis. Physiotherapy, 107, 1–10. https://doi.org/10.1016/j.physio.2019.12.004

  3. Bailey, P. P., Thomsen, G. E., Spuhler, V. J., Blair, R., Jewkes, J., Bezdjian, L., Veale, K., Rodriquez, L., & Hopkins, R. O. (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine, 35(1), 139–145. https://doi.org/10.1097/01.CCM.0000251130.69568.87

  4. Corcoran, J. R., Herbsman, J. M., Bushnik, T., Van Lew, S., Stolfi, A., Parkin, K., McKenzie, A., Hall, G. W., Joseph, W., Whiteson, J., & Flanagan, S. R. (2017). Early rehabilitation in the medical and surgical intensive care units for patients with and without mechanical ventilation: An interprofessional performance improvement project. PM&R, 9(2), 113–119. https://doi.org/10.1016/j.pmrj.2016.06.015

  5. Falkenstein, B. A., Skalkowski, C. K., Lodise, K. D., Moore, M., Olkowski, B. F., & Rojavin, Y. (2020). The economic and clinical impact of an early mobility program in the trauma intensive care unit: A quality improvement project. Journal of Trauma Nursing, 27(1), 29–36. https://doi.org/DOI: 10.1097/JTN.0000000000000479

  6. Leditschke, I. A., Green, M., Irvine, J., Bissett, B., & Mitchell, I. A. (2012). What are the barriers to mobilizing intensive care patients? Cardiopulmonary Physical Therapy Journal, 23(1), 26–29.

  7. Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., Anderson, L., Baker, S., Sanchez, M., Penley, L., Howard, A., Dixon, L., Leach, S., Small, R., Hite, R. D., & Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238–2243. https://doi.org/10.1097/CCM.0b013e318180b90e

  8. Needham, D. M., Korupolu, R., Zanni, J. M., Pradhan, P., Colantuoni, E., Palmer, J. B., Brower, R. G., & Fan, E. (2010). Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Archives of Physical Medicine and Rehabilitation, 91(4), 536–542. https://doi.org/10.1016/j.apmr.2010.01.002

  9. Pohlman, M. C., Schweickert, W. D., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K., Hall, J. B., & Kress, J. P. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical Care Medicine, 38(11), 2089–2094. https://doi.org/10.1097/CCM.0b013e3181f270c3

  10. Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. The Lancet, 373, 1874–1882. https://doi.org/DOI:10.1016/S0140- 6736(09)60658-9

  11. Sigler, M., Nugent, K., Alalawi, R., Selvan, K., Tseng, J., Edriss, H., Turner, A., Valdez, K., & Krause, D. (2016). Making of a successful early mobilization program for a medical intensive care unit. Southern Medical Journal, 109(6), 342–345. https://doi.org/10.14423/SMJ.0000000000000472

  12. Adler, J., & Malone, D. (2012). Early mobilization in the intensive care unit: A systematic review. Cardiopulmonary Physical Therapy Journal, 23(1), 5–13. https://doi.org/10.1097/01823246-201223010-00002

  13. Parker, A., Sricharoenchai, T., & Needham, D. M. (2013). Early rehabilitation in the intensive care unit: Preventing physical and mental health impairments. Current Physical Medicine and Rehabilitation Reports, 1(4), 307–314.

  14. Brummel, N. E., Girard, T. D., Ely, E. W., Pandharipande, P. P., Morandi, A., Hughes, C. G., Graves, A. J., Shintani, A., Murphy, E., Work, B., Pun, B. T., Boehm, L., Gill, T. M., Dittus, R. S., & Jackson, J. C. (2014). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: The activity and cognitive therapy in ICU (ACT-ICU) trial. Intensive Care Medicine, 40(3), 370–379. https://doi.org/10.1007/s00134-013-3136-0

  15. Algeo, N., & Aitken, L. M. (2019). The evolving role of occupational therapists in adult critical care in England: A mixed methods design using role theory. Irish Journal of Occupational Therapy, 47(2), 74–94. https://doi.org/10.1108/IJOT-04-2019-0005

  16. Bakhru, R. N., Wiebe, D. J., McWilliams, D. J., Spuhler, V. J., & Schweickert, W. D. (2015). An environmental scan for early mobilization practices in U.S. ICUs. Critical Care Medicine, 43(11), 2360–2369. https://doi.org/10.1097/CCM.0000000000001262