SNPG905 Minor Project: Early Mobilization in ICU - Rapid Review Report

This report presents a rapid review examining the effectiveness of early mobilization for critically ill patients in the Intensive Care Unit (ICU). The study aims to answer the research question: "What is the effectiveness of early mobilization for patients in intensive care units?" The review includes systematic reviews and meta-analyses, focusing on adult patients aged 18 and above undergoing early mobilization, defined as progressive movement activities initiated upon hemodynamic and respiratory stabilization. The report outlines inclusion criteria, interventions, control/comparison groups, and outcome measures such as muscle strength, functional ability, and duration of mechanical ventilation. The search strategy involves online database searches using keywords like "mobilization" and "intensive care unit." The methodological quality of the selected articles will be assessed using tools like AMSTAR, and data will be extracted using the Joanna Briggs Institute (JBI) data extraction tool. The findings will be presented thematically, with figures and graphs used to visually represent the outcomes. The report highlights the need for a re-examination of early mobilization's effects, considering recent studies and guidelines, and it addresses conflicting outcomes from previous reviews. The project follows the guidelines provided by SNPG905 for a minor project proposal, including objectives, background, criteria, search strategy, and methods of review.

Running head: MINOR PROJECT 1
The Effectiveness of Early Mobilization of Critically Ill Patient in the Intensive Care Unit: A
rapid Review
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Date of Submission

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Objectives
The purpose of this rapid review is to examine the effectiveness of early mobilization for
patients in intensive care units using evidence from systematic reviews.
The research question will be:
What is the effectiveness of early mobilization for patients in intensive care units?
Keywords: “mobilization”, “early mobilization”, “physical therapy”, “rehabilitation”, and
“intensive care unit”.
Background
The survival of critically ill patients can be attributed to the care received in the Intensive
care Unit (ICU), however, they are usually affected both physically and emotionally by the
sequelae that may be deteriorated by immobility. Part of the clinical prescription for such
patients is usually immobilization or bed rest because of the medication or mechanical
ventilation (Drolet, et al., 2012). About 20-50% of acute cases undergo intensive care unit-
acquired weakness (ICU-AW) (Puthucheary et al., 2013; Denehy, Lanphere, & Needham, 2017).
ICU-AW consists of multiple complications caused by pharmacological sedation after ICU
admission and is linked to the general health and high death rates after hospital discharge (Jolley,
Bunnell, & Hough, 2016; Fan et al., 2014).
ICU-AW is significantly worsened by along time of total rest due to medication and
motionlessness (Friedrich et al., 2015). It is a routine practice of the use of movement approaches
in the ICU as a treatment to avert or reduce immobility and ICU-AW (Li et al., 2013). Studies
have proposed the use of early mobilization as an effective intervention for ICU-AW since it
reduces life-threatening sickness related to muscle wasting (Verceles et al., 2018). Berry and
Morris (2013) conducted a study in 2013 and found out that early exercise was effective in

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reducing the period of staying in the hospital and enhance performance among adults with severe
respiratory complications.
Santos et al. (2017) recommended the use of early movement as a potential intervention
in the aversion of postoperative problems, enhanced functionality and minimizing the period of
stay at the hospital length by heart surgey patients. In 2017, Nydahl et al. (2017) observed that
early mobilization and physical functionality for severely sick patients were much safer and had
minimal risk of significant severe effects. Another systematic review was conducted in 2018 16
on the efficiency of early movement on acute patients under mechanical ventilation. The authors
reported that early mobilization among ICU patients produced positive results on hospital results
for patients in need of mechanical ventilation since it has the potential advantage of reducing the
length of mechanical ventilation and the duration in ICU.
However, several reviews of early movement internetion in seriously sick patients have
produced conflicting outcomes. Some of the reviews show varying effects on functional
recovery, duration of ICU, quality of life, or complete stay at the hospital, and long or short-term
death, whereas others completely oppose the existence such benefits (Castro-Avila et al., 2015).
According to Sosnowski et al. (2015), such conflicting outcomes may be attributed to multiple
factors like variation in the intervention, differences in reporting, quality of assessed resources
among others. Most of the qualitative reviews of the existing literature have so far found out that
the existing evidence on the effect of early movements on the physical enhancement of critically
ill patients is inadequate (Doiron, Hoffmann, & Beller, 2018).
Additionally, it is important to observe that some qualitative reviews have completely
considered the existing evidence as inadequate for comparison citing the inconsistency or
reliability of the intervention. For instance, Reid et al. (2018) reviewed 117 studies and found out

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that none of them reported the same intervention precisely the same way. 37% of the studies did
not indicate the time the intervention began and 26% did not indicate the duration the
intervention took, thus limiting the comprehension and generalizability of the interventions. A
meta-analysis carried out in 2015 by Castro-Avila et al. (2015) contended that early mobilization
in the duration of ICU is not linked to enhanced functionality, quality of life, muscle strength, or
the optimization of healthcare outcomes.
Another qualitative review conducted in 2016 by Laurent et al. (2016) proposed that early
physical activity in the ICU is reasonable and safe, however the significant advantages of
initiating an early program has not been evidently proven by research. Mixed outcomes on the
impact of early mobilization on physical function were reported in 2018 in the study by Doiron,
Hoffmann, and Beller (2018). The authors explained the challenges in ascertaining whether early
mobilization or physical activity carried out by seriously sick patients in the ICU enhanced their
capacity to undertake routine activities, better quality of life and muscle strength.
Furthermore, the latest Pain, Agitation/Sedation, Delirium, Immobility, and Sleep
Disruption (PADIS) guideline (2018) proposes that early movement can safely be introduced in
seriously sick adults on condition that their cardiovascular, neurological, and respiratory
conditions are stable) Devlin et al., 2018). Additionally, there has been the publication of latest
studies examining the effect of early movement in the ICU settings. Therefore, there should be a
re-examination of the effect of early mobilization on critically ill patients in the ICU. It is on this
basis that the current rapid review is aimed at expansively assessing the existing evidence on the
effect of early mobilization on critically ill patients in the ICU.
Inclusion Criteria
Types of studies

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Any systematic review and meta-analysis will be used to examine the effectiveness of
early mobilization for patients in intensive care units. Early mobilization constitutes progressive
movement activities that commence upon hemodynamic and respiratory stabilization, usually
within 24-28 hours of admission into the ICU.
Types of participants
The review of the studies meeting the inclusion criteria will consist of participants with the
following demographic characteristics:
 Adults aged 18 years and above
 Critically ill patient in the intensive care unit
Those patients not meeting the above inclusion criteria will be excluded from the review.
Types of interventions
The assessment of the studies will consist of early mobilization intervention. Early
mobilization will consist of a range of movements, movements consisting of axial loading
exercises, motions against gravity, active movements, and movements characteristic of energy
use among patients. “Active” is hereby defined as adult patients with muscle strength and the
capacity to manage the movements, a cognizant muscle initiation and some types of motions
such as movements with functional advantages, strengthening and motion activities and aided
movements.
Types of Control/Comparison
The study will compare the outcomes in the treatment\ group with the placebo group after
early mobilization treatment. Patients in the placebo group will receive the usual or standard
treatment
Types of outcome measures

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The expected outcomes will include muscle strength such as ICU-AW, the MRC sum
score and the force of handgrip. Functional ability will be measured by the patient’s ability to
stand, unaided walking distance, distance covered among others. Other outcome measures will
include the period of mechanical ventilation, death rate, rate of discharge, days without the
ventilator, and critical events.
Search Strategy
The articles to be included in the review will independently be searched online using the
Web of Science, CINAHL, and PubMed databases by one researcher. The keywords to be used
for the search include “mobilization”, “early mobilization”, “physical therapy”, “rehabilitation”,
and “intensive care unit”, in addition to their specific synonyms and derivatives. The search will
be restricted to the English language, and only those studies conducted within the last ten years.
The period was chosen to comprehensively explore the existing current evidence on the topic of
research. The relevant studies will also be ascertained by examining the reference lists of the
obtained articles. The search strategy for one of the databases will be attached in the appendix.
Review Methods
Evaluation of Methodological Quality
The chosen articles will first be assessed for the methodological quality using
standardized tools such as the Assessment of Multiple Systematic Reviews (AMSTAR). The
assessment tool is made up of eleven brief measures that ascertain the methodological quality of
any systematic review (Pollock, Fernandes, & Hartling, 2017). The unit score for AMSTAR is
determined by assigning a score of one if the article meets the criteria and score zero when the
study doesn’t meet the criteria. The overall score varies from 0-11 and the quality of the article is

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categorized into three levels of scores. The AMSTAR appraisal tool has been attached in the
appendix.
Data Extraction
A standard data extractor form will be used to extract relevant data from the articles the
meet the inclusion criteria. More specifically, The Joanna Briggs Institute (JBI) data extraction
tool will be used. The tool consists of two forms, the first form examines the study description
including the methodology, method, area of interest, the context of the study among others. The
second part is made up of three major columns namely the findings, illustration for publication
and evidence ratings. A sample JBI data extraction tool is attached in the appendix.
Data Synthesis
The outcomes of the rapid review will be presented under different themes based on the
results. Figures and graphs will also be used to provide a visual representation of the outcomes
where necessary.

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References
Berry, M. J., & Morris, P. E. (2013). Early exercise rehabilitation of muscle weakness in acute
respiratory failure patients. Exercise and sport sciences reviews, 41(4), 208.
Castro-Avila, A. C., Serón, P., Fan, E., Gaete, M., & Mickan, S. (2015). Effect of early
rehabilitation during intensive care unit stay on functional status: systematic review and
meta-analysis. PloS one, 10(7).
Denehy, L., Lanphere, J., & Needham, D. M. (2017). Ten reasons why ICU patients should be
mobilized early. Intensive care medicine, 43(1), 86-90.
Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J., Pandharipande, P. P., ...
& Balas, M. C. (2018). Clinical practice guidelines for the prevention and management of
pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the
ICU. Critical care medicine, 46(9), e825-e873.
Doiron, K. A., Hoffmann, T. C., & Beller, E. M. (2018). Early intervention (mobilization or
active exercise) for critically ill adults in the intensive care unit. Cochrane Database of
Systematic Reviews, (3).
Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., ... & Williams, S.
(2013). Move to improve: the feasibility of using an early mobility protocol to increase
ambulation in the intensive and intermediate care settings. Physical Therapy, 93(2), 197-
207.
Fan, E., Dowdy, D. W., Colantuoni, E., Mendez-Tellez, P. A., Sevransky, J. E., Shanholtz, C., ...

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& Pronovost, P. J. (2014). Physical complications in acute lung injury survivors: a 2-year
longitudinal prospective study. Critical care medicine, 42(4), 849.
Friedrich, O., Reid, M. B., Van den Berghe, G., Vanhorebeek, I., Hermans, G., Rich, M. M., &
Larsson, L. (2015). The sick and the weak: neuropathies/myopathies in the critically
ill. Physiological reviews, 95(3), 1025-1109.
Jolley, S. E., Bunnell, A. E., & Hough, C. L. (2016). ICU-acquired weakness. Chest, 150(5),
1129-1140.
Laurent, H., Aubreton, S., Richard, R., Gorce, Y., Caron, E., Vallat, A., ... & Coudeyre, E.
(2016). Systematic review of early exercise in intensive care: A qualitative
approach. Anaesthesia Critical Care & Pain Medicine, 35(2), 133-149.
Li, Z., Peng, X., Zhu, B., Zhang, Y., & Xi, X. (2013). Active mobilization for mechanically
ventilated patients: a systematic review. Archives of physical medicine and
rehabilitation, 94(3), 551-561.
Nydahl, P., Sricharoenchai, T., Chandra, S., Kundt, F. S., Huang, M., Fischill, M., & Needham,
D. M. (2017). Safety of patient mobilization and rehabilitation in the intensive care unit.
Systematic review with meta-analysis. Annals of the American Thoracic Society, 14(5),
766-777.
Pollock, M., Fernandes, R. M., & Hartling, L. (2017). Evaluation of AMSTAR to assess the
methodological quality of systematic reviews in overviews of reviews of healthcare
interventions. BMC medical research methodology, 17(1), 48.

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Puthucheary, Z. A., Rawal, J., McPhail, M., Connolly, B., Ratnayake, G., Chan, P., ... & Velloso,
C. (2013). Acute skeletal muscle wasting in critical illness. Jama, 310(15), 1591-1600.
Reid, J. C., Unger, J., McCaskell, D., Childerhose, L., Zorko, D. J., & Kho, M. E. (2018).
Physical rehabilitation interventions in the intensive care unit: a scoping review of 117
studies. Journal of intensive care, 6(1), 80.
Santos, P. M. R., Ricci, N. A., Suster, É. A., Paisani, D. M., & Chiavegato, L. D. (2017). Effects
of early mobilisation in patients after cardiac surgery: a systematic
review. Physiotherapy, 103(1), 1-12.
Sosnowski, K., Lin, F., Mitchell, M. L., & White, H. (2015). Early rehabilitation in the intensive
care unit: an integrative literature review. Australian Critical Care, 28(4), 216-225.
Verceles, A. C., Wells, C. L., Sorkin, J. D., Terrin, M. L., Beans, J., Jenkins, T., & Goldberg, A.
P. (2018). A multimodal rehabilitation program for patients with ICU acquired weakness
improves ventilator weaning and discharge home. Journal of critical care, 47, 204-210.

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Appendix 1: JBI QARI DATA EXTRACTION TOOL

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