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Review ArticleReviews
EARLY MOBILIZATION AND REHABILITATION IN THE ICU: MOVING BACK TO THE FUTURE
Mohamed D Hashem, Archana Nelliot and Dale M Needham
Respiratory Care July 2016, 61 (7) 971-979; DOI:
https://doi.org/10.4187/respcare.04741
Mohamed D Hashem
Outcomes after Critical Illness and Surgery Group and the Division of Pulmonary
and Critical Care Medicine, School of Medicine, Johns Hopkins University,
Baltimore, Maryland.
MD
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Archana Nelliot
Outcomes after Critical Illness and Surgery Group and the Division of Pulmonary
and Critical Care Medicine, School of Medicine, Johns Hopkins University,
Baltimore, Maryland.
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Dale M Needham
Outcomes after Critical Illness and Surgery Group and the Division of Pulmonary
and Critical Care Medicine, School of Medicine, Johns Hopkins University,
Baltimore, Maryland.
Department of Physical Medicine and Rehabilitation, School of Medicine, Johns
Hopkins University, Baltimore, Maryland.
MD PhD
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* For correspondence: dale.needham@jhmi.edu
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ABSTRACT
Despite the historical precedent of mobilizing critically ill patients, bed rest
is common practice in ICUs worldwide, especially for mechanically ventilated
patients. ICU-acquired weakness is an increasingly recognized problem, with
sequelae that may last for months and years following ICU discharge. The
combination of critical illness and bed rest results in substantial muscle
wasting during an ICU stay. When initiated shortly after the start of mechanical
ventilation, mobilization and rehabilitation can play an important role in
decreasing the duration of mechanical ventilation and hospital stay and
improving patients' return to functional independence. This review summarizes
recent evidence supporting the safety, feasibility, and benefits of early
mobilization and rehabilitation of mechanically ventilated patients and presents
a brief summary of future directions for this field.
* ICU
* rehabilitation
* early mobilization
* bed rest
* physical therapy
* occupational therapy
* mechanical ventilation
INTRODUCTION
Early mobilization and rehabilitation of mechanically ventilated patients in the
ICU is a topic of growing interest. This review will summarize recent evidence
on safety, feasibility and potential benefits of early mobilization and
rehabilitation, in addition to highlighting some future directions for this
field.
HISTORICAL BACKGROUND
Reports of mobilizing hospitalized patients have been published since the late
19th century. For instance, in a publication from 1899,1 there was discussion of
a “radical change in the after-treatment of celiotomy cases.” This publication
recognized that the postoperative period of bed rest could be cut to hours,
instead of days or weeks, and result in reduced muscle weakness. Similar
findings were published in subsequent years for patients recovering from other
types of surgery and for women in the postpartum period.2–4
During World War II, these same concepts were employed to help injured soldiers
return to the battlefield more quickly.5,6 An early controlled clinical trial to
evaluate the effectiveness of early mobility after major surgery was published
in 1944.7 This trial described early mobility in 100 consecutive subjects
compared with another 100 subjects who had usual care. After similar surgeries,
the early mobility subjects sat in a chair and walked on the first day after
surgery, whereas the other group was confined to bed rest for 10–15 days as part
of usual care. The total number of complications, including local surgical,
pulmonary, cardiac, vascular, genitourinary and gastrointestinal complications,
was 17 versus 46 in the intervention versus control groups, and no major
complications (eg, pulmonary emboli or coronary thrombosis) occurred in the
early mobility group.7
In 1944, a conference on bed rest was held,6 and major journals were publishing
on related topics, such as the “evil sequelae of complete bed rest” and the
“abuse of rest in bed”8,9 around this time. After the subsequent creation of
ICUs, there were reports of the benefits of early mobilization in mechanically
ventilated patients.10,11 Thomas Petty, a leader in pulmonary and critical care
medicine, highlighted historical practices from the early days of critical care,
in contrast to later practice, by saying: “When we first started our unit in
1964, patients who required mechanical ventilation were awake and alert and
often sitting in a chair…. But what I see these days are paralyzed, sedated
patients, lying without motion, appearing to be dead, except for the monitors
that tell me otherwise.”12 Thus, there is a strong historical basis for early
mobilization and rehabilitation of hospitalized patients, including mechanically
ventilated patients in the ICU.
EFFECTS OF BED REST
Bed rest can lead to rapid deconditioning and muscle atrophy.13 Studies of young
healthy adults have shown that after 2 weeks of immobilization, there is a 5–9%
loss of quadriceps muscle mass and 20–27% decrease in quadriceps muscle
strength.14,15 These effects are often accelerated and more pronounced in older
adults, with a 3–6-fold greater rate of muscle loss.16,17
In mechanically ventilated patients, skeletal muscle cross-sectional area can
decrease by 12.5% over the first week in the ICU.18 In ventilated patients with
multiple-organ failure, muscle loss is much greater compared with those with
only single-organ failure (8.7% vs 1.8% after 3 d, and 15.7% vs 3.0% after 7 d
of ICU stay).18 Muscle biopsies from mechanically ventilated patients show signs
of inflammation, necrosis, and replacement of muscle fibers with adipose and
connective tissue.18,19
Bed rest in the ICU may be an important risk factor for long-term muscle
weakness. A prospective study longitudinally following 222 ARDS survivors at 3,
6, 12, and 24 months reported a 3–11% relative decrease in muscle strength for
every additional day of bed rest in the ICU, after adjusting for other potential
risk factors that may contribute to long-term weakness.20 Other physical outcome
measures, including 6-min walk distance and quality of life scores, remained
consistently lower than population norms through the 2-y follow-up period, with
worse results in those with versus without muscle weakness.20
Therefore, bed rest can be an important risk factor for weakness in ICU
patients. Early recognition of this issue is a key step in improving patient
outcomes.
ICU-ACQUIRED WEAKNESS
ICU-acquired weakness is defined as the presence of clinically detectable
weakness in ICU patients with no possible etiology other than critical
illness.21 Clinically detectable weakness is generally evaluated via a
standardized physical examination of strength, known as manual muscle testing,
using the ordinal 6-point Medical Research Council scale (ranging from 0 [no
palpable or visible muscle contraction] to 5 [normal strength]). Traditionally,
manual muscle testing is performed in 3 muscle groups in each extremity
bilaterally, with weakness diagnosed as a total score of <48 of 60.22,23 This
approach to evaluating strength has its limitations, including the need for
patients to be awake, cooperative, and capable of actively moving the
extremities.21,24 Although there is large variability in its reported
prevalence, more than one third of patients requiring mechanical ventilation for
at least 5 d may have ICU-acquired weakness.25
Such weakness of the extremities as occurs with ICU-acquired weakness is also
associated with respiratory muscle weakness and prolonged weaning from
mechanical ventilation.26–28 Consequently, recognition of ICU-acquired weakness
may be important due to patients' increased risk of ventilator-associated
pneumonia and recurrent respiratory failure.29
A prospective study compared 122 subjects with ICU-acquired weakness in a mixed
medical/surgical ICU with propensity-matched controls, finding that ICU-acquired
weakness was independently associated with a longer duration of mechanical
ventilation (11 d vs 8 d, P = .009) and hospital stay (36 d vs 23 d, P = .007),
greater total costs per patient ($23,277 vs $17,834, P = .040), and increased
1-y mortality (30.6% vs 17.2%, P = .02). Furthermore, subjects with persistent
and severe weakness (ie, Medical Research Council score <36 of 60 at the end of
ICU stay) had a higher risk of death over 1-y follow-up (hazard ratio 4.3, P <
.001).28
ICU survivors with ICU-acquired weakness also experience significant long-term
impairment in respiratory muscle strength, physical functioning, and quality of
life, lasting for months and years after hospital discharge.20,30–32 As outlined
below, early mobilization and rehabilitation of critically ill patients may play
an important role in preventing these sequelae.
SAFETY AND FEASIBILITY OF EARLY MOBILIZATION AND REHABILITATION
Given the growing literature on ICU-acquired weakness and the harms of bed rest,
early mobilization and rehabilitation of critically ill patients is regaining
attention. Despite the potential concerns about mobilizing mechanically
ventilated patients, many studies have repeatedly demonstrated its safety and
feasibility, with very low rates of potential safety events. In a German
national point prevalence study of 775 mechanically ventilated subjects, the
frequency of potential safety events was no higher with out-of-bed versus in-bed
activity.33 With mobilization of mechanically ventilated patients, the most
frequent potential events are physiological changes that are usually transient
and resolve after rest, without any intervention.34–36
Recently, a panel of experts agreed that endotracheal intubation should not be a
contraindication to active in-bed or out-of-bed mobilization or rehabilitation
in the ICU setting.37 This report provided relevant safety guidelines,
categorized by each body system (eg, respiratory, cardiovascular, and
neurological systems), for mobilizing critically ill patients. Figure 1
demonstrates an example of the panel's recommendations regarding respiratory
safety criteria.37
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Fig. 1.
Respiratory safety considerations. Green: Low risk of an adverse event. Proceed
as usual according to each ICU's protocols and procedures. Yellow: Potential
risk and consequences of an adverse event are higher than green but may be
outweighed by the potential benefits of mobilization. The precautions or
contraindications should be clarified before any mobilization episode. If
mobilized, consideration should be given to doing so gradually and cautiously.
Red: Significant potential risk or consequences of an adverse event. Active
mobilization should not occur unless specifically authorized by the treating
intensive care provider in consultation with senior physical therapy and nursing
staff. From Reference 37.
Feasibility of early mobility for mechanically ventilated patients is well
recognized. A study of 103 mechanically ventilated subjects admitted over a
6-month period assessed safety and feasibility of early progressive mobility,
including sitting on the edge of the bed, sitting in a chair, and ambulating. Of
1,449 mobility sessions, 41% involved intubated subjects, with 249 events in
which intubated subjects ambulated, and <1% occurrence of potential safety
events.36 Figure 2 is a photograph of a patient ambulating while receiving
mechanical ventilation via an endotracheal tube, with assistance from
respiratory and physical therapists.
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Fig. 2.
A patient ambulating while receiving mechanical ventilation via endotracheal
tube, with the assistance of a respiratory therapist (front) and a physical
therapist (behind). With patient and staff permission.
A bundle has been proposed that combines early mobility with awakening/breathing
coordination (ie, spontaneous awakening trials with cessation of any infusion of
sedative agents, combined with spontaneous breathing trials) and delirium
monitoring/management (the ABCDE bundle).38 Implementing the bundle in a
pre-post study of 296 subjects (187 mechanically ventilated) showed that
subjects in the post- versus pre-implementation period had more ventilator-free
days (median of 24 d vs 21 d, P = .04). After adjusting for age, severity of
illness, comorbidity, and mechanical ventilation status, subjects in the post-
versus pre- group were more likely to mobilize out of bed at least once during
an ICU stay (odds ratio 2.11, P = .003) and less likely to experience delirium
at any time in their ICU stay (odds ratio 0.55, P = .03).39 Hence, a coordinated
multidisciplinary approach can be effective in overcoming the barriers of deep
sedation and delirium, allowing patients to benefit from early mobilization.
EVIDENCE FOR EFFECT ON PATIENT OUTCOMES
Early rehabilitation of mechanically ventilated patients may have both short-
and long-term benefits. A non-randomized, controlled trial assigned 280
mechanically ventilated subjects to either receive usual care or a mobility
protocol that included 4 levels of activities, ranging from passive range of
motion to active transfer to a chair. The protocol was conducted by a dedicated
mobility team (critical care nurse, nursing assistant, and physical therapist) 7
d/week, starting within 48 h of mechanical ventilation. After adjusting for body
mass index, Acute Physiology and Chronic Health Evaluation II (APACHE II) score,
and vasopressors, subjects in the intervention group got out of bed much earlier
(5.0 vs 11.3 d, P < .001) and had a shorter stay in the ICU (5.5 d vs 6.9 d, P =
.02) and hospital (11.2 d vs 14.5 d, P = .006).40 A subsequent follow-up study
showed that lack of early mobility was independently associated with a higher
odds of death or readmission within 1 y of hospitalization (odds ratio = 1.77,
95% CI = 1.04–3.01, P = .036).41
In a randomized controlled trial conducted in 2 university hospital ICUs, 104
mechanically ventilated subjects were randomized to either receive usual care or
early physical therapy and occupational therapy interventions. Subjects
randomized to early physical therapy and occupational therapy interventions were
more likely to return to independent physical functioning at hospital discharge
(59% vs 35%, P = .02), have shorter duration of mechanical ventilation (3.4 d vs
6.1 d, P = .02), and have fewer days with delirium in the ICU (2 d vs 4 d, P =
.03). A key reason for these benefits was the early start to rehabilitation
interventions. Specifically, the intervention versus control group started
physical therapy and occupational therapy interventions at 1.5 d versus 7.4 d (P
< .001) after intubation and had a much greater daily median duration of
physical therapy/occupational therapy interventions while mechanically
ventilated (19 min/d vs 0 min/d, P < .001).42
On the other hand, a single-center randomized controlled trial randomized 150
subjects in the ICU for ≥5 d to usual care (ie, physical therapy available 7
d/week) versus an intensive exercise regimen in the ICU, ward, and out-patient
clinic. This trial demonstrated no significant difference in patient outcomes
over 12 months of follow-up.25 Another multi-center randomized controlled trial
randomized 120 mechanically ventilated subjects to up to 28 d of physical
therapy in the ICU and on the ward at 3 d/week (control group, with actual
average duration per session of 22 min) versus 7 d/week (intervention group,
with actual average duration per session of 39 min). The physical therapy
intervention started at a median (interquartile range) of 8 (6–11) d after
intubation. There was no significant difference in physical function at 1-, 3-,
and 6-month follow-up, with the primary outcome only measureable in one third of
patients at 1-month follow-up.43 In contrast to the trials with positive
results, described above, both of these negative trials started the
rehabilitation intervention relatively late after initiation of mechanical
ventilation and had control groups with physical therapy delivered at a much
higher intensity compared with control groups in the positive trials and
compared with usual practice.35,44 More research, with larger sample sizes,
should evaluate the optimal timing and dose of rehabilitation in the ICU.
However, based on current evidence, initiation of rehabilitation early after
intubation appears to improve patient outcomes compared with the usual practice
in most ICUs of little or no rehabilitation during mechanical ventilation.
STEPS TO CLOSE THE GAP BETWEEN RESEARCH AND PRACTICE
Despite the well-known detrimental effects of bed rest and research supporting
early initiation of rehabilitation, mobilizing ICU patients in routine clinical
practice remains uncommon, especially for mechanically ventilated patients. In a
recent point prevalence study of therapist-delivered mobility in 770 subjects
from 33 ICUs within the United States ARDS Network, sitting at the edge of bed
or greater activity occurred in only 16% of mechanically ventilated subjects.44
Likewise, 2 national single-day point prevalence studies in Germany and
Australia/New Zealand have been completed. The German study reported that, among
775 mechanically ventilated subjects, only 24% were at least sitting on the edge
of the bed,33 whereas the Australia/New Zealand study reported that none of the
222 mechanically ventilated subjects sat out of bed or walked.35
A common barrier to mobilizing critically ill patients is inadequate staffing of
physical and occupational therapists in ICUs. In the United States, physical
therapists are infrequently available in ICUs, with a median (interquartile
range) of 6.3 (4–10) physical therapists/100 ICU beds.45 Only 34% of ICUs report
having a dedicated physical therapy/occupational therapy team, and 30% have a
written protocol for early mobilization.46
However, even with adequate staffing, mechanically ventilated patients may still
be infrequently mobilized. For instance, in a prospective study of 192
mechanically ventilated subjects in Australia/New Zealand, where physical
therapists also deliver respiratory therapy and there is a median of 1 physical
therapist/9 ICU beds, 64% of subjects did not receive early mobilization, and
45% of all rehabilitation sessions were conducted with the subject in bed.47
Another Australian study of 106 ICU subjects reported that perceived barriers to
mobilization (eg, femoral lines, timing of procedures, and sedation) were
potentially avoidable in 47% of patient days where mobilization did not occur.48
Successfully closing this gap between research and clinical practice requires
the use of structured multistep quality improvement efforts. One such quality
improvement approach is the Translating Research into Practice model.49 Within
the Translating Research into Practice model, it is critical that a
multidisciplinary team be engaged to evaluate the research-to-practice gap
within the larger health-care setting. The model consists of 4 steps (Fig. 3):
(1) summarizing the evidence to understand the highest-yield intervention(s)
that will address the health-care problem (eg, early mobility/rehabilitation to
address physical impairments in critically ill patients); (2) identifying local
barriers to the implementation of these interventions; (3) creating metrics or
performance measures to evaluate progress with overcoming barriers and
implementing the intervention; and (4) ensuring that all patients receive the
intervention by using the “4 Es” framework, which involves an iterative process
of engaging stakeholders and then educating them before moving onward to
executing the intervention and continuously evaluating it using the progress
measures from Step 2.49,50 An example of executing this model took place in the
form of a quality improvement project at the Johns Hopkins Hospital, as
described in the next section.
* Download figure
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Fig. 3.
Summary of a quality improvement model for translating research evidence into
routine clinical practice to improve patient outcomes. From Reference 49, with
permission.
PRACTICAL EXPERIENCE FROM THE JOHNS HOPKINS HOSPITAL
In the Johns Hopkins Hospital medical ICU, a multidisciplinary quality
improvement project targeting early rehabilitation was planned over an 8-month
period and then executed over 4 months.51 The quality improvement project,
conducted using the Translating Research into Practice model, focused on all
medical ICU patients, with detailed data collection and evaluation completed for
patients requiring ≥4 d of mechanical ventilation, without any preexisting
cognitive or neuromuscular problems. Among the steps included in executing the
quality improvement project were modifying the default activity level in the
medical ICU admission order set from “bed rest” to “activity as tolerated,”
changing sedation practice from continuous infusions to “as needed” boluses,
providing guidelines for both physical therapy and occupational therapy
consultations, and implementing safety screening guidelines for rehabilitation
in ICU patients.
Compared with the 3-month period immediately preceding the quality improvement
project, there was a significant decrease in the use of sedative medications,
with a significant increase in the proportion of days in which patients were
alert (66% vs 29%, P <.001) and not delirious (53% vs 21%, P = .003). In
addition, there was a significant decrease in the proportion of ICU days in
which eligible patients failed to receive rehabilitation therapy (7% vs 41%, P =
.004). Among 294 physical therapy and occupational therapy treatments given,
there were only 4 (1.4%) potential safety events that were minor in nature.
Compared with the same 4-month period in the preceding year, the quality
improvement period had a 30% decrease in the average medical ICU stay (P = .02),
with a 20% increase in the number of medical ICU admissions.51
Following the success of this quality improvement project, Johns Hopkins
Hospital funded an early rehabilitation program that increased the full-time
rehabilitation staff dedicated to the medical ICU. In addition, a new sedation
protocol was created, and standardized delirium assessments by nurses became
routine practice.50,52 A prospective cohort study evaluating sustainability of
the quality improvement project compared data on consecutive ARDS subjects
admitted in the 3 y preceding the quality improvement project with ARDS subjects
admitted over a 3-y period starting 2 y after completion of the quality
improvement project. This comparison, extending out to 5 y after completion of
the quality improvement project, demonstrated that subjects in the post-quality
improvement period had a shorter time to initiation of physical therapy
(adjusted hazard ratio = 8.4, 95% CI 5.0–14.1, P < .001) that was significant
for each of the 5 y during the post-quality improvement period. In addition, in
the post-quality improvement versus pre-quality improvement period, there was a
significant increase in the proportion of subjects ever receiving physical
therapy (68% vs 16%, P < .001) and achieving a higher daily activity level
during physical therapy treatments (eg, sitting at the edge of the bed,
standing, or ambulating: 41% vs 4%, P < .001).53
Another follow-up study from the Johns Hopkins medical ICU evaluated the safety
of physical therapy interventions during 1,110 consecutive medical ICU
admissions (60% of which received mechanical ventilation) over a period of 53
months following completion of the quality improvement project. Of 5,267
physical therapy sessions, only 34 (0.6%) had any potential safety event (all
prospectively screened using standardized criteria). These events were mostly
transient physiologic changes (eg, changes in mean arterial pressure and oxygen
saturation) that resolved with rest. Less than 8 per 10,000 physical therapy
sessions had an event that required any additional therapy, with no event
requiring increased length of stay.34
A qualitative study conducted via independent semi-structured interviews with 20
medical ICU staff reported that the Johns Hopkins quality improvement project
resulted in an important shift in ICU culture, causing early mobility to be
perceived as “common sense.” In addition, 95% of staff reported improved job
satisfaction. Interviewees agreed that the components necessary for success of
the quality improvement project included a supportive culture, the presence of a
multidisciplinary team with good communication, a leader who could advocate for
rehabilitation, and adequate resources (personnel, equipment, and funding).54
This quality improvement project serves as an important example of the steps
needed to bridge the gap between research and practice, resulting in improved
patient outcomes.
FUTURE DIRECTIONS FOR THE FIELD
A number of technologies are being evaluated to assist with rehabilitation and
mobilization of critically ill patients. A few such technologies will be
mentioned here as part of future directions for the field.
Neuromuscular electrical stimulation is a rehabilitation modality that has been
used extensively in physical medicine and rehabilitation practice. It delivers
low-voltage electrical impulses through electrodes placed on the skin overlying
target muscles, causing passive contraction. It is used in both in-patient and
out-patient settings for the treatment of muscle weakness in patients with
chronic disease, such as advanced COPD and congestive heart failure,55,56 and
treatment of healthy athletes after sports-related injuries.57 In the critically
ill population, there has been increasing interest in neuromuscular electrical
stimulation for the prevention and treatment of ICU-acquired weakness, with
several systematic reviews summarizing the evolving evidence.58–61 This
promising therapy requires continued research before adoption into routine
clinical care in the ICU setting.
Cycle ergometry uses a bedside device on which a supine patient can perform
passive, active-assisted, or active in-bed cycling. Passive cycling may limit
muscle protein catabolism in unconscious patients.62 In addition, this
intervention does not appear to cause any clinically adverse hemodynamic or
respiratory changes, even when applied early (within 72 h of starting mechanical
ventilation).63 In a randomized controlled trial of 90 critically ill subjects
with respiratory failure, cycle ergometry significantly increased quadriceps
muscle strength, 6-min walking distance, and quality of life scores.64 A
prospective study has demonstrated the safety and feasibility of cycle
ergometry, as part of routine clinical practice, in the Johns Hopkins Hospital
medical ICU. Over an 18-month period, 181 subjects (80% mechanically ventilated)
received a total of 541 cycling sessions with trained physical therapists, with
only one safety event reported (0.2% rate).65
Functional electrical stimulation uses neuromuscular electrical stimulation to
stimulate multiple groups of muscles concurrently in a functional way that
mimics voluntary contraction. Functional electrical stimulation can be conducted
with cycle ergometry to achieve functional electrical stimulation-assisted
cycling. Results from a small pilot study indicate that functional electrical
stimulation-assisted cycling is safe and feasible, with potential benefit in
enhancing functional recovery and reducing incidence of delirium.66 An ongoing
multi-center randomized controlled trial (ClinicalTrials.gov identifier:
NCT02214823) is being conducted at 4 sites in Australia and the United States to
evaluate its effect on short- and long-term physical and cognitive outcomes in
mechanically ventilated subjects.67 Other innovative therapies used in
mechanically ventilated patients include hydrotherapy (mobilization in a
swimming pool to overcome gravitational forces)68 and interactive video games.69
CONCLUSIONS
In modern day critical care, bed rest is common practice, especially for
mechanically ventilated patients, with increasingly recognized short- and
long-term negative sequelae. Early mobilization and rehabilitation is safe and
feasible, with some evidence of improved patient outcomes, including decreased
mechanical ventilation duration and improved physical functioning. Structured
quality improvement projects are crucial for closing the large gap between these
research findings and routine clinical practice, in order to expedite the
post-ICU recovery of mechanically ventilated patients. Involving a
multidisciplinary team, with a recognized leader, can be effective in changing
ICU culture and practice to effectively deliver early mobilization and
rehabilitation.
FOOTNOTES
* Correspondence: Dale M Needham MD PhD, Pulmonary and Critical Care Medicine,
Johns Hopkins University, 1830 E Monument St, 5th Floor, Baltimore, MD 21205.
E-mail: dale.needham@jhmi.edu
* Dr Needham presented a version of this paper as the 3rd Annual Thomas L Petty
Memorial Lecture at the 61st AARC Congress, held November 7–10, 2015, in
Tampa, Florida.
* Copyright © 2016 by Daedalus Enterprises
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IN THIS ISSUE
Respiratory Care
Vol. 61, Issue 7
1 Jul 2016
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Early Mobilization and Rehabilitation in the ICU: Moving Back to the Future
Mohamed D Hashem, Archana Nelliot, Dale M Needham
Respiratory Care Jul 2016, 61 (7) 971-979; DOI: 10.4187/respcare.04741
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* Article
* Abstract
* Introduction
* Historical Background
* Effects of Bed Rest
* ICU-Acquired Weakness
* Safety and Feasibility of Early Mobilization and Rehabilitation
* Evidence for Effect on Patient Outcomes
* Steps to Close the Gap Between Research and Practice
* Practical Experience From the Johns Hopkins Hospital
* Future Directions for the Field
* Conclusions
* Footnotes
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* Figures & Data
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* rehabilitation
* early mobilization
* bed rest
* physical therapy
* occupational therapy
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Early Mobilization and Rehabilitation in the ICU: Moving Back to the Future
Mohamed D Hashem, Archana Nelliot, Dale M Needham
Respiratory Care Jul 2016, 61 (7) 971-979; DOI: 10.4187/respcare.04741
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