Clinical review: Early patient mobilization in the ICU
© BioMed Central Ltd 2013
Published: 28 February 2013
Early mobilization (EM) of ICU patients is a physiologically logical intervention to attenuate critical illness-associated muscle weakness. However, its long-term value remains controversial. We performed a detailed analytical review of the literature using multiple relevant key terms in order to provide a comprehensive assessment of current knowledge on EM in critically ill patients. We found that the term EM remains undefined and encompasses a range of heterogeneous interventions that have been used alone or in combination. Nonetheless, several studies suggest that different forms of EM may be both safe and feasible in ICU patients, including those receiving mechanical ventilation. Unfortunately, these studies of EM are mostly single center in design, have limited external validity and have highly variable control treatments. In addition, new technology to facilitate EM such as cycle ergometry, transcutaneous electrical muscle stimulation and video therapy are increasingly being used to achieve such EM despite limited evidence of efficacy. We conclude that although preliminary low-level evidence suggests that EM in the ICU is safe, feasible and may yield clinical benefits, EM is also labor-intensive and requires appropriate staffing models and equipment. More research is thus required to identify current standard practice, optimal EM techniques and appropriate outcome measures before EM can be introduced into the routine care of critically ill patients.
Diagnostic criteria for ICU-acquired weakness
Weakness associated with critical illness
Weakness is bilateral, flaccid and involves both proximal and distal muscles but generally spares the cranial nerves
Medical Research Council sum score <48
Prolonged mechanical ventilation
Other causes of weakness have been excluded
In general terms, EM of ICU patients includes the application of traditional modes of physical therapy at an earlier stage than and delivered more regularly than conventional practice, and/or the early use of novel mobilization techniques (for example, cycle ergometry, transcutaneous electrical muscle stimulation). EM appears physiologically logical in patients who would otherwise remain almost immobile, and may also be a safe and feasible process. More importantly, EM may also improve functional recovery, reduce the ICU length of stay, decrease readmissions to the ICU and even improve survival [12–16]. Yet limited systematic attention and analysis has so far been applied to the understanding and assessment of EM . In this article we aim to define the concept of EM in comparison with traditional physical therapy, to review the evidence for its feasibility, safety and possible efficacy, and to define the research agenda for its more comprehensive assessment.
Traditional physical therapy
There are international guidelines on the traditional approach to physical therapy for patients in the ICU. They include the application of a passive range of movements and the encouragement of an active range of movements early in the ICU stay . Attempts at full active mobilization are often reserved until after the acute phase of the illness has resolved. In particular, it is recognized that rehabilitation may not commence until after ICU discharge, as the patients are viewed as too sick to participate whilst receiving mechanical ventilation. These traditional practices are not based on high-quality evidence and are simply derived from expert opinion. Despite such opinions, however, practice and attitudes surrounding physical therapy and mobilization in the ICU show wide variability worldwide , and even within the same country .
The evidence to support the use of passive movements as part of a program of early mobilization is weak . Such evidence suggests that passive movements may prevent protein degradation, maintain muscle mass and alter the inflammatory profile in humans [21, 22]. For example, in 20 subjects with severe sepsis or septic shock randomized to 30 minutes of predominantly passive exercise or no intervention, the passive exercise group preserved fat-free mass, decreased IL-6 and increased IL-10 levels compared with control patients who lost 7.2% of fat free mass in the first 7 days following admission to the ICU . Clearly this level of evidence is minimal and requires further investigation. Clinical observation, however, suggests that more than simple passive movement should be done in order to help preserve muscle strength. EM might represent a better approach than traditional delayed passive movements. Before such an intervention can be advocated, however, it needs to be defined.
What is early mobilization?
Observational studies of early mobilization in the ICU
Number of patients
Primary outcome and key findings
Bailey and colleagues 
Acute respiratory failure with MV >4 days
Sit on bed, sit on chair and ambulate
Early activity events: 1,449 (53% ambulate). Adverse events: <1% (fall to the knees with no injury, SBP >200 or <90 mmHg and desaturation <80%)
Thomsen and colleagues 
Acute respiratory failure with MV >4 days
Early activity protocol; PROM, SOEOB, transfer to chair, walk
Ambulation (increased probability P <0.0001)
Morris and colleagues 
Medical patients with acute respiratory failure requiring MV
Early activity protocol with four levels of activity: PROM, active resisted exercise and sitting, SOEOB, and transfer to chair
PT (more patients in the protocol group received PT versus usual care, 80% vs. 47%, P ≤0.001)
Zanni and colleagues 
Medical patients ventilated >4 days
Individualized stretching, strengthening, balance training and functional activities (rolling, sitting, standing, walking, grooming, bathing)
Total consultations to PT and OT per patient: median 2 (1 to 4). Duration of rehabilitation (minutes): median 45 (34 to 47)
Needham and colleagues 
Medical patients ventilated >4 days
Multidiscplinary team to focus on decreased sedation and increased PT and OT, particularly with functional mobility
Sedation (benzodiazepam reduced P <0.002). Rehabilitation treatments (increased P <0.001). Functional mobility (treatment involving sitting or greater increased P = 0.03)
Bourdin and colleagues 
Medical patients in ICU ≥7 days and MV ≥2 days
Chair sitting, tilt table and walking
Physiological response: HR and RR increased with sitting, tilting up with arms unsupported and walking, oxygen saturation decreased with tilting up arms unsupported and walking
Kho and colleagues 
Medical ICU adults receiving PT
Safety (zero adverse events). Feasibility (5% patients receiving PT used video games)
Genc and colleagues 
Critically ill obese patients
Mobilization; SOEOB, standing, transfer to chair by walking, sitting in the chair
Transient episodes of altered SBP or HR in six patients. No deterioration in clinical status. SpO2 significantly increased after mobilization
Leditschke and colleagues
Mixed medical-surgical ICU
Active mobilization: MOS >30 seconds. Active transfer: transfer bed-chair against gravity. Passive transfer: passively lifted to out of bed (lifter, sling)
Two adverse events in 176 mobilization episodes (1.1%), which were hypotension requiring return to bed and fluid loading or vasopressors. Avoidable barriers to mobilization include femoral lines, sedation and scheduling procedures
Two randomized, controlled, clinical trials [12, 24] and several observational studies [4, 25–31] provide data on the feasibility and safety of EM as well as preliminary data on its efficacy in patients dependent on ventilatory support (Table 2). For instance, in an observational study, Bailey and colleagues described 1,449 EM interventions in 103 patients . Overall, 53% of these interventions included ambulating patients that were dependent on positive pressure ventilation via an endotracheal tube or tracheostomy. Only 1% of these EM activities were associated with an adverse event. These events included five episodes of the patient falling to their knees without injury, three episodes of hypotension to a systolic blood pressure <90 mmHg, one case of increase in systolic blood pressure to >200 mmHg, three episodes of oxygen saturation decreases to <80% and the removal of one enteral feeding tube. This type of EM treatment was resourced from within the existing ICU staff structure, including ICU nurses, technicians, physical therapists and respiratory therapists.
In a further study, the same group described a before-and-after cohort study in 104 patients with respiratory failure who were transferred from another ICU to their respiratory ICU . Transfer to the EM-based respiratory ICU increased the probability of ambulation (P <0.0001) during the patient's ICU stay. By multivariate logistic regression analysis, independent predictors of increased ambulation were transfer to the respiratory ICU with a commitment to EM, female gender, absence of sedatives and lower Acute Physiology and Chronic Health Evaluation II scores. Eighty-eight percent of patients survived to hospital discharge with a mean ambulated distance in the ICU of 200 feet.
In addition to the above work, Schweickert and colleagues completed a prospective, outcome assessor-blinded, randomized trial of EM and occupational therapy in two centers in the USA . In this study, patients who were mechanically ventilated for <72 hours and expected to stay ventilated in the next 24 hours were randomized either to an EM protocol (rapid progression from passive range of movements to active range of movements, to bed mobility, to sitting balance, to standing, to standing transfers and gait re-education during sedation interruption) or to a control group, which underwent physical and occupational therapy as prescribed by standard care, typically only after extubation. This trial found that EM was safe and feasible and that it was associated with improved functional outcomes as measured using the Katz Index  and independent walking at hospital discharge. Importantly, patients in the EM intervention group started physical therapy earlier (1.5 days vs. 7.3 days, P = 0.0001) and were significantly more likely to return to functional independence (defined as being able to wash, dress, groom, eat, transfer from bed to chair and walk independently) at hospital discharge (59% vs. 35%, P = 0.02). This study differed from other trials because patients were mobilized very early (day 1.5on average) and the results documented functional outcomes in a blinded manner. Major adverse events were rare (one in 498 EM-related events, with no extubations, falls or change in systolic blood pressure and one episode of decreased oxygen saturation <80%). However, in order to maximize the degree of mobilization, new techniques are rapidly emerging that can be more easily and perhaps more safely applied to ventilated supine patients.
Early mobilization using novel techniques
Cycle ergometer-based mobilization in addition to standard care has now been used as a form of EM in a single-center randomized trial of 90 critically ill patients, and compared with standard care alone. In this study, cycle ergometer-based mobilization improved the median 6-minute walk distance at hospital discharge (196 m vs. 143 m, P <0.05) . In addition, the mobilization method was reported to be safe and feasible, with a median of four cycle sessions completed per week and the time taken from ergometer set-up to clean-up inclusive reported at 30 to 40 minutes. There were no major adverse events and only 4% of cycle sessions were stopped early due to adverse changes in oxygen saturation <90%.
Transcutaneous electrical muscle stimulation
TEMS has been used to preserve muscle mass and strength in patients with chronic heart failure [36, 37] and in patients with chronic obstructive pulmonary disease . In a recent systematic review, TEMS was found to improve muscle strength, exercise capacity and disease-specific health status . TEMS is of particular interest in the ICU setting because the loss of muscle mass is rapid and more severe than in other chronic conditions . In addition, the TEMS technique can be used easily in immobile sedated patients.
Despite the physiological attractiveness and promise of TEMS, the randomized controlled trials that have evaluated the effects of EM by means of TEMS initiated in the first 7 days of ICU stay have reported conflicting results [41–45]. Differences in patient selection, the inclusion or exclusion of patients with sepsis, the application of TEMS to heterogeneous populations, and variable study methodology have all probably contributed to discrepancies in reported outcomes.
The largest study of TEMS to date investigated 140 critically ill patients and randomly assigned them to TEMS or standard care . TEMS was conducted daily for 55 minutes to the lower limb (vastus lateralis, vastus medialis and peroneous longus muscles). The primary outcome was ICU-acquired (neuromuscular) weakness diagnosed using the Medical Research Council score (<48/60) by two unblinded independent investigators. The Medical Research Council score was significantly higher in patients in the TEMS group compared with those of the control group (58 (33 to 60) vs. 52 (2 to 60)). However, this study has been criticized for several reasons . First, measurement of the primary outcome could only be performed in awake, cooperative patients. This limitation excluded 39 patients who died and 44 patients who were cognitively impaired from the final analysis. Accordingly, the intention-to-treat principle was violated. In the intervention group, data from three patients were also excluded due to the use of neuromuscular blockers. Finally, TEMS was applied only to the lower limb but the Medical Research Council score reflects upper and lower limb strength. Although it is theoretically possible that TEMS has systemic effects, the change in upper limb strength seems unusual . There was no report of patient tolerance to TEMS. Future studies should include a report of patient discomfort with the use of this technique.
Other small randomized controlled trials (n <25 subjects) have evaluated the effects of TEMS in patients who were chronically critically ill and requiring mechanical ventilation for >14 days. Such trials have reported improvements in muscle mass as measured by ultrasound , muscle strength as assessed using manual muscle testing (2.2 ± 1.0 vs. 1.3 ± 0.8, P = 0.02) and function as measured by changes in the number of days required to transfer from bed to chair (11 ± 2 days vs. 14 ± 2 days, P = 0.001) . In this regard, the results of the small study (n = 24) by Zanotti and colleagues are of particular interest because improvements in muscle strength were accompanied by improved function . The intervention protocol, however, included the use of TEMS in conjunction with a program of active limb exercise in ventilator-dependent patients with chronic obstructive pulmonary disease. Their results therefore suggest that TEMS may act synergistically with active exercise and thus should not be used in isolation but should rather be a useful component of a wider-ranging EM protocol aimed at restoring muscle mass in chronically critically ill patients. There was no report of patient tolerance to TEMS.
Despite the above reports, the assessment of efficacy in small trials remains difficult and investigators are increasingly focusing on surrogate outcomes that would justify the conduct of larger phase II studies. Among such outcomes, muscle layer thickness and muscle cross-sectional area measured by ultrasound appear to have a relationship with muscle strength [49, 50]. Further research is required to establish whether these outcomes are associated with sustained improvement in function and health-related quality of life and can be reliably used as surrogates for such clinical outcomes.
Custom-made technological aids
Among other descriptive papers of novel techniques for EM in the ICU, the feasibility of Wii and other interactive video therapies has been described. In an observational, single-center study, Kho and colleagues investigated the use of video therapies as a form of EM in critical illness . Of 410 patients receiving physical therapy, 5% used video games for balance (52%) and endurance (45%). The most common games were boxing, bowling and balance board. No adverse events occurred (95% upper confidence limit for safety event rate: 8.4%). No trials, however, have compared such interventions with a control group receiving standard care.
Barriers to early mobilization
Although EM seems intuitively useful and physiologically logical it can in fact be a complex and effort-intensive therapy, which is made even more challenging by the presence of multiple barriers that impede its wider uptake . Such barriers include inadequate staff to deliver physical therapy, lack of equipment, concern regarding patient safety and physiological stability , sedation and ventilation practices, placement of vascular lines, and the paucity of data on efficacy and health-economic evaluation to convince clinicians to apply EM .
A key barrier to the delivery of EM is concern about the safety of the patient . Adverse events may include the dislodgement of vascular lines, nasogastric tubes and urinary catheters and, much more importantly, of an artificial airway, leading to life-threatening hypoxia. To counter these concerns, however, there is an emerging body of data suggesting that EM does not impose an increased risk to patients if it is performed with appropriately trained staff [4, 12, 24, 25, 27, 28, 30]. In several studies conducted in US centers, EM involved a mobilization team of three ICU clinicians, including a physical therapist, a nurse and an occupational therapist or an assistant [25, 27, 28]. In addition, patients were carefully evaluated holistically prior to undertaking EM with a comprehensive assessment of age, level of fitness prior to ICU admission, presenting condition, tolerance of other interventions and the amount of ventilatory and cardiac support required prior to EM.
EM is feasible only if the patient is awake and cooperative  and therefore the use of sedation needs to be minimized to facilitate EM . The importance of interactions between the degree of sedation and the ability to apply EM has been highlighted in several publications [30, 53]. Other key factors that appear to be associated with successful EM include adequate pain management and early recognition and management of delirium [13, 54–56].
Early mobilization research agenda
International differences in staff availability result in heterogeneous research questions in relation to EM in different countries. In American studies, for example, research has concentrated on providing information to justify appropriate resources for physical therapy input in ICUs . In contrast, in Europe and Australia physical therapy is generally considered part of standard management. Two national surveys, however, have reported a striking degree of variability between institutions within the same country in terms of referral to physical therapy during critical illness, staff ratios and frequency of such therapy [19, 20]. This variability in practice underscores the importance of carefully defining and understanding usual care prior to undertaking any interventional studies to evaluate the efficacy and safety of EM in different jurisdictions. The variability also highlights the limited external validity of single-center studies.
Key research questions
Standard mobilization practice in ICUs nationally and internationally remains poorly defined. Until standard mobilization is clearly defined and measured in multicenter studies it is impossible to conduct studies of any EM interventions that are relevant to modern ICU treatment, have external validity, and provide sufficient treatment separation. There may be limitations to establishing a true, ethical control group to establish the effect of EM, especially in those countries where physiotherapy practice already includes elements of EM. The typical functional outcomes of candidate patients who survive and are treated with standard care also need to be defined. Once baseline practice and functional outcomes are established in multicenter prospective cohort studies, then multicenter pilot studies of a candidate EM intervention can be tested for separation and contamination. In addition, several potential relevant outcomes (muscle thickness, muscle strength for different muscle groups, functional independence) must also be assessed as outcome measures for EM interventions and their relationships with each other understood in order to power future larger studies of these interventions.
ICU survivors recovering from a prolonged illness often have muscle weakness and major functional impairment. Early mobilization is a physiologically logical candidate intervention to attenuate such weakness. Observational studies and initial small randomized trials evaluating EM suggest safety and feasibility. These studies also suggest that EM has the potential to improve functional outcomes in survivors. Unfortunately, such studies are mostly single center in design and carry limited external validity. Further trials to investigate the potential benefits of EM and the best techniques to maximize its efficacy are warranted but require careful consideration of standard practice, optimal treatment strategies and outcome measures.
transcutaneous electrical muscle stimulation.
Written consent for publication was obtained by the patients.
- Saxena MK, Hodgson CL: Intensive care unit acquired weakness. Anaesth Intensive Care Med 2012, 13: 145-147. 10.1016/j.mpaic.2012.01.003View ArticleGoogle Scholar
- Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S, Haponik E: Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011, 341: 373-377. 10.1097/MAJ.0b013e31820ab4f6PubMed CentralView ArticlePubMedGoogle Scholar
- Needham DM: Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 2008, 300: 1685-1690. 10.1001/jama.300.14.1685View ArticlePubMedGoogle Scholar
- Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91: 536-542. 10.1016/j.apmr.2010.01.002View ArticlePubMedGoogle Scholar
- Griffiths RD, Hall JB: Intensive care unit-acquired weakness. Crit Care Med 2010, 38: 779-787. 10.1097/CCM.0b013e3181cc4b53View ArticlePubMedGoogle Scholar
- Maramattom BV, Wijdicks EF: Acute neuromuscular weakness in the intensive care unit. Crit Care Med 2006, 34: 2835-2841. 10.1097/01.CCM.0000239436.63452.81View ArticlePubMedGoogle Scholar
- de Jonghe B, Lacherade JC, Sharshar T, Outin H: Intensive care unit-acquired weakness: risk factors and prevention. Crit Care Med 2009,37(10 Suppl):S309-S315.View ArticlePubMedGoogle Scholar
- Nordon-Craft A, Moss M, Quan D, Schenkman M: Intensive care unit-acquired weakness: implications for physical therapist management. Phys Ther 2012, 92: 1494-506. 10.2522/ptj.20110117PubMed CentralView ArticlePubMedGoogle Scholar
- Herridge MS: Long-term outcomes after critical illness: past, present, future. Curr Opin Crit Care 2007, 13: 473-475. 10.1097/MCC.0b013e3282eff3afView ArticlePubMedGoogle Scholar
- Herridge MS: Legacy of intensive care unit-acquired weakness. Crit Care Med 2009,37(10 Suppl):S457-S461.View ArticlePubMedGoogle Scholar
- Rubenfeld GD, Herridge MS: Epidemiology and outcomes of acute lung injury. Chest 2007, 131: 554-562. 10.1378/chest.06-1976View ArticlePubMedGoogle Scholar
- Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373: 1874-1882. 10.1016/S0140-6736(09)60658-9View ArticlePubMedGoogle Scholar
- Morandi A, Brummel NE, Ely EW: Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care 2011, 17: 43-49. 10.1097/MCC.0b013e3283427243View ArticlePubMedGoogle Scholar
- Morris PE: Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin 2007, 23: 1-20. 10.1016/j.ccc.2006.11.003View ArticlePubMedGoogle Scholar
- Perme C, Chandrashekar R: Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care 2009, 18: 212-221. 10.4037/ajcc2009598View ArticlePubMedGoogle Scholar
- O'Connor ED, Walsham J: Should we mobilise critically ill patients? A review. Crit Care Resusc 2009, 11: 290-300.PubMedGoogle Scholar
- Adler J, Malone D: Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012, 23: 5-13.PubMed CentralPubMedGoogle Scholar
- Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schonhofer B, Stiller K, van de Leur H, Vincent JL: Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008, 34: 1188-1199. 10.1007/s00134-008-1026-7View ArticlePubMedGoogle Scholar
- Norrenberg M, Vincent JL: A profile of European intensive care unit physiotherapists. European Society of Intensive Care Medicine. Intensive Care Med 2000, 26: 988-994. 10.1007/s001340051292View ArticlePubMedGoogle Scholar
- Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M: Physical therapy utilization in intensive care units: results from a national survey. Crit Care Med 2009, 37: 561-568. 10.1097/CCM.0b013e3181957449PubMed CentralView ArticlePubMedGoogle Scholar
- Griffiths RD, Palmer TE, Helliwell T, MacLennan P, MacMillan RR: Effect of passive stretching on the wasting of muscle in the critically ill. Nutrition 1995, 11: 428-432.PubMedGoogle Scholar
- Paratz JD, Kayambu G: Early exercise and attenuation of myopathy in patient with sepsis in ICU. Phys Ther Rev 2011, 16: 58-65. 10.1179/1743288X11Y.0000000002View ArticleGoogle Scholar
- Kayambu G, Boots RJ, Paratz JD: Early rehabilitation in sepsis: a prospective randomised controlled trial investigating functional and physiological outcomes The i-PERFORM Trial (Protocol Article). BMC Anesthesiol 2011, 11: 21. 10.1186/1471-2253-11-21PubMed CentralView ArticlePubMedGoogle Scholar
- Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans G, Decramer M, Gosselink R: Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009, 37: 2499-2505. 10.1097/CCM.0b013e3181a38937View ArticlePubMedGoogle Scholar
- Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO: Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007, 35: 139-145. 10.1097/01.CCM.0000251130.69568.87View ArticlePubMedGoogle Scholar
- Bourdin G, Barbier J, Burle JF, Durante G, Passant S, Vincent B, Badet M, Bayle F, Richard JC, Guerin C: The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care 2010, 55: 400-407.PubMedGoogle Scholar
- Morris PE, 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 RD, Haponik E: Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008, 36: 2238-2243. 10.1097/CCM.0b013e318180b90eView ArticlePubMedGoogle Scholar
- Thomsen GE, Snow GL, Rodriguez L, Hopkins RO: Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008, 36: 1119-1124. 10.1097/CCM.0b013e318168f986View ArticlePubMedGoogle Scholar
- Zanni JM, Korupolu R, Fan E, Pradhan P, Janjua K, Palmer JB, Brower RG, Needham DM: Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. J Crit Care 2010, 25: 254-262. 10.1016/j.jcrc.2009.10.010View ArticlePubMedGoogle Scholar
- Leditschke A, Green M, Irvine J, Bissett B, Mitchell I: What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J 2012, 23: 26-29.PubMed CentralPubMedGoogle Scholar
- Genc A, Ozyurek S, Koca U, Gunerli A: Respiratory and hemodynamic responses to mobilzation of critically ill obese patients. Cardiopulm Phys Ther J 2012, 23: 14-18.PubMed CentralPubMedGoogle Scholar
- Brorsson B, Asberg KH: Katz index of independence in ADL. Reliability and validity in short-term care. Scand J Rehabil Med 1984, 16: 125-132.PubMedGoogle Scholar
- Ellis S, Kirby LC, Greenleaf JE: Lower extremity muscle thickness during 30-day 6 degrees head-down bed rest with isotonic and isokinetic exercise training. Aviat Space Environ Med 1993, 64: 1011-1015.PubMedGoogle Scholar
- Moug SJ, Grant S, Creed G, Boulton Jones M: Exercise during haemodialysis: West of Scotland pilot study. Scott Med J 2004, 49: 14-17.PubMedGoogle Scholar
- Larson JL, Covey MK, Wirtz SE, Berry JK, Alex CG, Langbein WE, Edwards L: Cycle ergometer and inspiratory muscle training in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999, 160: 500-507.View ArticlePubMedGoogle Scholar
- Sbruzzi G, Schaan BD, Pimentel GL, Signori LU, Da Silva AN, Oshiro MS, Irigoyen MC, Plentz RD: Effects of low frequency functional electrical stimulation with 15 and 50 Hz on muscle strength in heart failure patients. Disabil Rehabil 2011, 33: 486-493. 10.3109/09638288.2010.498551View ArticlePubMedGoogle Scholar
- Quittan M, Wiesinger GF, Sturm B, Puig S, Mayr W, Sochor A, Paternostro T, Resch KL, Pacher R, Fialka-Moser V: Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure: a single-blind, randomized, controlled trial. Am J Phys Med Rehabil 2001, 80: 206-214. 10.1097/00002060-200103000-00011View ArticlePubMedGoogle Scholar
- Neder JA, Sword D, Ward SA, Mackay E, Cochrane LM, Clark CJ: Home based neuromuscular electrical stimulation as a new rehabilitative strategy for severely disabled patients with chronic obstructive pulmonary disease (COPD). Thorax 2002, 57: 333-37. 10.1136/thorax.57.4.333PubMed CentralView ArticlePubMedGoogle Scholar
- Sillen MJ, Speksnijder CM, Eterman RM, Janssen PP, Wagers SS, Wouters EF, Uszko-Lencer NH, Spruit MA: Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with chronic heart failure or COPD: a systematic review of the English-language literature. Chest 2009, 136: 44-61. 10.1378/chest.08-2481View ArticlePubMedGoogle Scholar
- Needham DM, Truong AD, Fan E: Technology to enhance physical rehabilitation of critically ill patients. Crit Care Med 2009,37(10 Suppl):S436-S441.View ArticlePubMedGoogle Scholar
- Ali NA: Have we found the prevention for intensive care unit-acquired paresis? Crit Care 2010, 14: 160. 10.1186/cc9005PubMed CentralView ArticlePubMedGoogle Scholar
- Gerovasili V, Stefanidis K, Vitzilaios K, Karatzanos E, Politis P, Koroneos A, Chatzimichail A, Routsi C, Roussos C, Nanas S: Electrical muscle stimulation preserves the muscle mass of critically ill patients: a randomized study. Crit Care 2009, 13: R161. 10.1186/cc8123PubMed CentralView ArticlePubMedGoogle Scholar
- Gerovasili V, Tripodaki E, Karatzanos E, Pitsolis T, Markaki V, Zervakis D, Routsi C, Roussos C, Nanas S: Short-term systemic effect of electrical muscle stimulation in critically ill patients. Chest 2009, 136: 1249-1256. 10.1378/chest.08-2888View ArticlePubMedGoogle Scholar
- Routsi C, Gerovasili V, Vasileiadis I, Karatzanos E, Pitsolis T, Tripodaki E, Markaki V, Zervakis D, Nanas S: Electrical muscle stimulation prevents critical illness polyneuromyopathy: a randomized parallel intervention trial. Crit Care 2010, 14: R74. 10.1186/cc8987PubMed CentralView ArticlePubMedGoogle Scholar
- Rodriguez PO, Setten M, Maskin LP, Bonelli I, Vidomlansky SR, Attie S, Frosiani SL, Kozima S, Valentini R: Muscle weakness in septic patients requiring mechanical ventilation: protective effect of transcutaneous neuromuscular electrical stimulation. J Crit Care 2012, 27: 319-e1-8.View ArticlePubMedGoogle Scholar
- Rodriguez PO, Setten M, Valentini R: Electrical muscle stimulation for prevention of critical illness polyneuropathy. Crit Care 2010, 14: 428. 10.1186/cc9081PubMed CentralView ArticlePubMedGoogle Scholar
- Gruther W, Kainberger F, Fialka-Moser V, Paternostro-Sluga T, Quittan M, Spiss C, Crevenna R: Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients: a pilot study. J Rehabil Med 2010, 42: 593-597. 10.2340/16501977-0564View ArticlePubMedGoogle Scholar
- Zanotti E, Felicetti G, Maini M, Fracchia C: Peripheral muscle strength training in bed-bound patients with COPD receiving mechanical ventilation. Chest 2003, 124: 292-296. 10.1378/chest.124.1.292View ArticlePubMedGoogle Scholar
- Chi-Fishman G, Hicks JE, Cintas HM, Sonies BC, Gerber LH: Ultrasound imaging distinguishes between normal and weak muscle. Arch Phys Med Rehabil 2004, 85: 980-986. 10.1016/j.apmr.2003.07.008View ArticlePubMedGoogle Scholar
- Seymour JM, Ward K, Sidhu PS, Puthucheary Z, Steier J, Jolley CJ, Rafferty G, Polkey MI, Moxham J: Ultrasound measurement of rectus femoris cross-sectional area and the relationship with quadriceps strength in COPD. Thorax 2009, 64: 418-423. 10.1136/thx.2008.103986View ArticlePubMedGoogle Scholar
- Kho ME, Damluji A, Zanni JM, Needham DM: Feasibility and observed safety of interactive video games for physical rehabilitation in the intensive care unit: a case series. J Crit Care 2012, 27: 219-e1-e6.View ArticlePubMedGoogle Scholar
- Hopkins RO, Spuhler VJ: Strategies for promoting early activity in critically ill mechanically ventilated patients. AACN Adv Crit Care 2009, 20: 277-289. 10.1097/NCI.0b013e3181acaef0View ArticlePubMedGoogle Scholar
- Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS: Reducing iatrogenic risks: ICU-acquired delirium and weakness - crossing the quality chasm. Chest 2010, 138: 1224-1233. 10.1378/chest.10-0466View ArticlePubMedGoogle Scholar
- Bigatello LM, Citerio G: The long-lasting damage of delirium: another burden to intensive care unit survivors. Crit Care Med 2012, 40: 319-320. 10.1097/CCM.0b013e318232d2ccView ArticlePubMedGoogle Scholar
- Morandi A, Jackson JC: Delirium in the intensive care unit: a review. Neurol Clin 2011, 29: 749-763. 10.1016/j.ncl.2011.08.004View ArticlePubMedGoogle Scholar
- Page V, Gough K: Management of delirium in the intensive care unit. Br J Hosp Med (Lond) 2010, 71: 372-376.View ArticleGoogle Scholar
- Genc A, Ozyurek S, Koca U, Gunerli A: Respiratory and hemodynamic responses to mobilization of critically ill obese patients. Cardiopulm Phys Ther J 2012, 23: 14-18.PubMed CentralPubMedGoogle Scholar
- Leditschke IA, Green M, Irvine J, Bissett B, Mitchell IA: What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J 2012, 23: 26-29.PubMed CentralPubMedGoogle Scholar