|Year : 2012 | Volume
| Issue : 3 | Page : 172-177
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
|Date of Web Publication||26-Dec-2012|
Department of Physiotherapy, Father Muller Medical College, Mangalore, Karnataka
Source of Support: Father Muller Medical College Hospital, Conflict of Interest: None
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 was observed between early mobilization and routine 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.
Keywords: Complications, early mobilization, ICU, physiotherapy
|How to cite this article:|
Bezbaruah P, Swaminathan N, D'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
|How to cite this URL:|
Bezbaruah P, Swaminathan N, D'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 [serial online] 2012 [cited 2020 Apr 3];1:172-7. Available from: http://www.ijhas.in/text.asp?2012/1/3/172/105081
| 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. ,,, 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.  Muscle strength decreases to 20% within one week of immobilization with an additional decrease of 20% in each subsequent week. , The presence of muscle weakness is associated with the duration of mechanical ventilation and length of ICU stay. , Prolonged bed rest also increases the production of reactive oxygen species (ROS) with a decrease in antioxidative defence. , 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 and atrophy. , Critically ill patients in the ICU commonly receive less than 60% of their nutritional intake during their ICU stay leading further to malnutrition.  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. ,, Mechanically ventilated patients usually receive very high doses of sedatives and analgesics which leads to prolonged periods of unconsciousness and immobility.  Kollef and colleagues identified excessive ICU sedation to be an important cause of prolonged mechanical ventilation and length of ICU stay.  Physical mobilization during mechanical ventilation of the ICU patients helps them to be active. 
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 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  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 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. 
| Materials and Methods|| |
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.
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.
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 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.
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.
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.
This included patients in acute/subacute phase with multiple medical problems or resolving medical problems and able to participate actively in the therapy.
The goal of phase 3 was to initiate independent transfer 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.
Patients in subacute phase, who had been weaned from 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.
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].
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.
| Results|| |
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 routine physiotherapy were 2.88 (SD: 0.641) and 7.71 (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).
|Figure 2: Between the group comparison on out of bed, days of weaning, days of ICU stay|
Click here to view
| 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.  There is a significant reduction in the strength of both skeletal and respiratory muscles. , 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  Early mobilization is not a new concept but it is not routinely practiced in mechanically 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. ,,, Therefore the main outcome measures used were days first out of bed, duration of mechanical ventilation, and length of stay in the ICU.
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 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.
| 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. |
|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. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
|This article has been cited by|
||Physician-leaders and hospital performance revisited
| ||Florian Kaiser,Andreas Schmid,Jörg Schlüchtermann |
| ||Social Science & Medicine. 2020; : 112831 |
|[Pubmed] | [DOI]|
||S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders
| ||Th. Bein,M. Bischoff,U. Brückner,K. Gebhardt,D. Henzler,C. Hermes,K. Lewandowski,M. Max,M. Nothacker,Th. Staudinger,M. Tryba,S. Weber-Carstens,H. Wrigge |
| ||Der Anaesthesist. 2015; 64(S1): 1 |
|[Pubmed] | [DOI]|
||Kurzversion S2e-Leitlinie – „Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“
| ||T. Bein,M. Bischoff,U. Brückner,K. Gebhardt,D. Henzler,C. Hermes,K. Lewandowski,M. Max,M. Nothacker,T. Staudinger,M. Tryba,S. Weber-Carstens,H. Wrigge |
| ||Der Anaesthesist. 2015; 64(8): 596 |
|[Pubmed] | [DOI]|