Early Mobilisation in Mechanically Ventilated Patients: A Systematic Integrative Review of Definitions and Activities

Clarissa et al.
Journal of Intensive Care (2019) 7:3

https://doi.org/10.1186/s40560-018-0355-z
RESEARCH Open Access
Early mobilisation in mechanically

ventilated patients: a systematic integrative
review of definitions and activities
Catherine Clarissa1* , Lisa Salisbury2, Sheila Rodgers1 and Susanne Kean1
Abstract
Background: Mechanically ventilated patients often develop muscle weakness post-intensive care admission.
Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their
outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear.
We aimed to systematically explore the definitions and activity types of EM-MV in the literature.
Methods: Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and
Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature
and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the
methodological quality of included studies. Data extraction and quality assessment of studies were performed
independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive
and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included
studies.
Results: Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition,
(2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that
EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The
remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the
negotiated decision-making process between patients and staff; and their interdependent relationship during
the implementation.
Conclusions: This review highlights the absence of an agreed definition and on what constitutes early mobilisation in
mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.
Keywords: Artificial respiration, Critical illness, Early ambulation, Early mobilisation, Humans, Integrative review,
Intensive care unit, Mechanical ventilators, Rehabilitation, Review
Background The reality of post-intensive care creates challenges

Advances in science, technology and patient care man- for patients and families including social recovery,
agement in the field of intensive care medicine have financial burden and adjustments to physical and psy-
led to a steady and continuing increase in patients chological impairments [7–13]. These long-term diffi-
surviving a critical illness episode [1–5]. However, as culties are now referred to as post-intensive care
Herridge [6] highlights surviving critical illness is not syndrome (PICS) [7, 8].
the happy ending that we imagined for our patients. Mechanically ventilated patients warrant closer attention
given the frequent use of mechanical ventilation in ICUs
worldwide [14, 15] and risk of patients developing Intensive
* Correspondence: clarissa@ed.ac.uk Care Unit Acquired Weakness (ICU-AW) which is a sig-
1
Department of Nursing Studies, School of Health in Social Science,
University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG,
nificant concern in PICS [16–18]. ICU-AW describes a
UK syndrome involving muscle wasting and is associated with
Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 2 of 19
higher mortality, poor patient outcomes and a delay of 2. What types of early mobilisation activities in mech-
weaning process [19–23]. anically ventilated patients are reported in the literature?
Early mobilisation while the patient is being mechanic-
ally ventilated has been proposed as a promising interven- Methods
tion to counteract ICU-AW, and research suggests it is a Design
safe and feasible intervention [24–26]. The term ‘early Whittemore and Knafl’s framework [29] guided this re-
mobilisation in mechanically ventilated patients’ (EM- view: problem identification, literature search, data evalu-
MV) is used interchangeably in the literature and is some- ation, data analysis and presentation. All quantitative and
times referred to as early rehabilitation, early mobility, qualitative designs were included in synthesising the
progressive mobility and early ambulation. While there is current evidence [29, 30]. The flow diagram of the identi-
some consensus regarding safety criteria to mobilise fied, included and excluded literature is presented using
mechanically ventilated patients [27] and physical rehabili- the Preferred Reporting Items for Systematic Reviews and
tation for ICU survivors [28], there is currently no unified Meta-Analyses [31] (see Fig. 1). The review protocol was
definition of EM-MV. This lack of definition impacts on registered with PROSPERO International Prospective
the generalisability of studies, their transferability when Register of Systematic Reviews: CRD42016039753 (http://
implementing EM-MV into practice and the conduct of www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=C
future research. In this current work, we provide a com- RD42016039753).
prehensive and systematic review of the literature to
understand how EM-MV is defined and described by dif- Search methods
ferent authors. The review questions are as follows: The search strategy was developed in consultation with
1. How is early mobilisation in mechanically ventilated the University of Edinburgh’s librarian to ensure that
patients defined across studies? we captured all relevant published (peer-reviewed) and
Fig. 1 PRISMA flow diagram (PRISMA 2009)

unpublished studies (including non-peer-reviewed and individual meetings with each review author. This
grey literature) of EM-MV. Three strategies were used strategy facilitated the process of comparison between
to identify literature: (1) searching six electronic the review authors and agreeing on the quality and
databases: CINAHL, MEDLINE, EMBASE, PsycINFO, extracted data of each study. Any disagreement in a
ASSIA and Cochrane Library; (2) identifying grey litera- sub-group was arbitrated by a third reviewer beyond
ture by searching: PubMed, Google Scholar, Centre for their pair. Five studies were excluded after the quality
Reviews and Dissemination (CRD), National Institute assessment as we agreed that the studies did not pass
for Health and Care Excellence (NICE) and Scottish the first section of CASP tools.
Intercollegiate Guidelines Network (SIGN); and finally
(3) hand-searching reference lists of included studies. Data analysis
Key terms, subject headings and the complete search Thematic analysis is one of the possible analytical ap-
strategy can be accessed at http://www.crd.york.ac.uk/ proaches for integrated systematic reviews to summarise
PROSPEROFILES/39753_STRATEGY_20160819.pdf. study findings [33]. We followed Braun and Clarke’s [34]
Two review authors (CC, LS) independently screened thematic analysis strategies with an inductive and data-
the title and abstracts for eligibility using our inclusion driven approach. The two overarching review questions
and exclusion criteria (Table 1). Full-text articles of po- guided the course of data analysis process: (1) ‘How is
tential studies were obtained for further assessment. EM-MV defined across studies?’ and (2) ‘What types of
Then, CC and LS had meetings to discuss and compare EM-MV activities are reported in the literature?’
the results. Disagreements were resolved by discussions Following the quality appraisal and data extraction,
with the other reviewers (SR and SK). all textual descriptions of EM-MV (definitions and
activities) stated in the published articles were consid-
Quality appraisal and data extraction ered as data and analysed and coded for themes using
We used the Critical Appraisal Skills Programme (CASP) NVivo11. Each study was read and examined to identify
tools [32] to appraise the quality of included studies texts and phrases used defining EM-MV or describing
according to their designs including case control, cohort, EM-MV activities. To explore EM-MV definitions, studies
randomised controlled trial, systematic review and qualita- were classified into one of two groups, studies with either
tive [32]. Two screening questions at the beginning of the full or partial definition of EM-MV. A full EM-MV defin-
CASP tools [32] were used to assess the quality of studies ition means that the study defines both ‘early’ and ‘mobil-
to determine their inclusion or exclusion. We used this isation’ (including their synonyms, for instance, mobility,
section as the cut-off points for indicating poor quality rehabilitation, ambulation). Studies defining either ‘early’
and excluded poor-quality studies at this point. or ‘mobilisation’ were considered as studies with a partial
The first author (CC) developed a data extraction form EM-MV definition. We collated the descriptions of the
in a Microsoft Office 2016 Excel spreadsheet with the fol- EM-MV activities from all included studies.
lowing variables: authors, country of origin, study designs, The first author (CC) analysed and coded all ob-
settings, aim(s), sample size, EM-MV definition and activ- tained verbatim extracts of EM-MV definitions and ac-
ities. Further, the first author (CC) performed the first tivities in included studies. Codes were then grouped
quality appraisal and data abstraction for all included for similarities and patterns into categories. Each cat-
studies. The studies were then divided into three groups egory was given a definition and codes were included
and assigned and reviewed independently by three differ- in more than one category if relevant. The categories
ent review authors (LS, SR, SK) before the first author had were developed by asking an analytical question: ‘What
Table 1 Inclusion and exclusion criteria used in this review

Inclusion criteria Exclusion criteria
1. Published in English and German. 1. Reported patients aged under 18 years.
2. Published between January 2000 and October 2018. 2. Reported on patients undergoing early mobilisation without
3. Reported on adult patients (aged 18 years and over) receiving early mechanical ventilation support.
mobilisation while being mechanically ventilated. 3. Evaluated the experiences, views and attitudes of other parties
4. Measured the outcomes of early mobilisation in mechanically ventilated other than ICU staff and/or patients involved in EM-MV.
patients or evaluated the experiences, views and attitudes of mechanically 4. Review articles without a formal search strategy and quality appraisal.
ventilated patients and/or ICU staff; and either: 5. Poster or conference proceedings.
5.1 Reported primary research using a quantitative approach (experimental
and/or observational study designs, including randomised controlled
trial, case control and cohort study) or any qualitative approach
(all study designs).
5.2 Reported secondary research including systematic reviews and
meta-analyses.
Abbreviations: EM-MV early mobilisation in mechanically ventilated patients, ICU intensive care unit
similarities/patterns do these codes imply?’ The devel- Themes

oping data analysis were discussed in regular team Following thematic analysis [34], four major themes
meetings. In meetings, we theorised codes and categor- were developed: (1) non-standardised definition, (2) con-
ies into themes and sub-themes by asking a question: textual factors, (3) negotiated process and (4) collabor-
‘What do these codes and categories mean?’ Import- ation between patients and staff. The definition of each
antly, the authors’ expertise in critical care nursing theme is given in Table 3. The first theme is informed by
(CC, SR, SK) and physiotherapy (LS) provided different the full and partial EM-MV definitions extracted from
professional insights and thus informed the develop- the 30 studies that provided a definition. Themes 2, 3
ment of themes and sub-themes from different theoret- and 4 are inferred from the descriptions of EM-MV ac-
ical backgrounds. Regular meetings were continued tivities from across all included studies.
until all review authors agreed on final themes and Each theme with the sub-themes and categories is dis-
sub-themes. cussed in the following section. Themes, sub-themes and
categories are summarised in Table 4 with examples of
Results verbatim extracts to illustrate our interpretations. The
Search outcome theme(s) identified in each study are presented in Table 5.
Figure 1 (PRISMA flow diagram) details the selection
process for inclusion/exclusion of studies in this review. Theme 1: Non-standardised definition
The initial search identified a total of 1160 articles. Re- The first theme, and the key insight of this review, re-
moval of duplicates and application of inclusion and ex- lates to the absence of a standardised EM-MV definition
clusion criteria when screening titles and abstracts across all included studies. A full definition of EM-MV
resulted in 136 studies for inclusion. Full texts of 136 was evident in 15 of 76 studies [24, 35–48]. A partial
studies were obtained and further assessed against inclu- definition of EM-MV was provided in 15 studies with
sion and exclusion criteria (Table 1). After comparing two studies defining ‘early’ [49, 50] and 13 studies defin-
the screening and quality appraisal results, 76 studies ing ‘mobilisation’ [51–63]. A total of 46 studies did not
(75 journal articles and one PhD thesis) were found eli- provide a definition. From the 30 studies with full and
gible for inclusion in this review. All reasons for exclu- partial definitions of EM-MV, we identified two recur-
sions were documented (see Fig. 1) ring sub-themes reflecting the different ways that
EM-MV was defined: (1) practice variation and (2) ex-
Overview of the included papers pectation of outcome.
Included studies were heterogeneous in study design,
setting and country of origin. All characteristics of in- Sub-theme 1.1: Practice variation
cluded studies are summarised in Table 2. Cohort stud- Practice variation is defined as diversity of delivery that
ies were the predominant study design (n = 33, 43%), existed among EM-MV definitions and includes the tim-
followed by RCTs (n = 18, 24%) and case control studies ing of commencement, the activities and the care team.
(n = 11, 15%). Almost half of the studies (n = 35, 46%) Most studies regarded any mobilisation activity as early
were conducted in general ICU settings and about one if it is commenced any time during the course of mech-
fifth in medical ICUs (n = 16, 21%). Most of the studies anical ventilation [36, 48] or between 48 and 72 h of
originate from the USA (n = 27, 36%) and Australia (n = 9, starting mechanical ventilation [43–45, 47]. Other au-
12%) perhaps indicating a current focus on and import- thors used ICU length of stay to refer to ‘early’ as either
ance of early mobilisation in these countries. Growing 24 h after admission [42], below 14 days length of stay
worldwide interest in EM-MV research is evidenced by [49] or throughout the ICU stay [24, 38]. EM-MV com-
more than a fourfold increase of published inter- mencement time was also reported in a non-time-bound
national studies in the last decade from 14 in 2000– manner including any period of time [51], during the re-
2010 to 62 in 2011–2018. Multidisciplinary research covery [39, 50] or acute stage of illness [40], patient’s
collaboration among healthcare professionals including ability to engage with the activities [36, 48] and the point
medical, nursing, physiotherapy and respiratory therapy at which the patients were deemed stable physiologically
staff was explicit, in that 32 studies (42%) were [24, 35, 36, 38, 50] and psychologically [50].
authored by professionals from two different profes- Twenty one of the 30 studies incorporated a descrip-
sional groups and 26 studies (34%) with at least three tion of activities in their definition by listing included
professional groups. EM-MV full definitions were ob- and excluded activities or providing general descriptions
tained from 15 studies (20%) and partial definitions of activities. Most of the studies reported an explicit list
were identified from 15 studies (20%). The rest of the of included activities such as cycle ergometry exercises
studies (n = 46, 61%) did not provide a definition. All [58, 59, 63], sitting on the edge of bed [24, 35, 38–40,
studies provided descriptions of EM-MV activities. 52, 59, 61], sitting out of bed (in a chair) [24, 35, 38–40,
Table 2 The characteristics of included studies Table 2 The characteristics of included studies (Continued)
Characteristic Number Percentage Characteristic Number Percentage
(n) (%)* (n) (%)*
Study designs All nursing staff 2 2.6
Case control 11 14.5 All physiotherapy staff 9 11.8
Case series 2 2.6 Combination
Cohort 33 43.4 Medical + nursing staff 4 5.3
Qualitative 8 10.5 Medical + occupational therapy staff 1 1.3
Randomised controlled trial 18 23.7 Medical + physiotherapy staff 23 30.3
Systematic review 4 5.3 Medical + respiratory therapy staff 1 1.3
Study settings Medical + profession unknown 1 1.3
General ICU 35 46.1 Nursing + physiotherapy staff 1 1.3
Medical ICU 15 19.7 Nursing + respiratory therapy staff 1 1.3
Medical-surgical ICU 4 5.3 Multidisciplinary (> 3 professions) 26 34.2
Neurological ICU 1 1.3 Definition of EM-MV
Post ICU 6 7.9 Full definition 15 19.7
Respiratory ICU 3 3.9 Partial definition
Surgical ICU 2 2.6 Definition of early 2 2.6
Not applicable (unclear or systematic 10 13.2 Definition of mobilisation 13 17.1
reviews)
No definition 46 60.5
Country of origin
*May not be exactly 100% due to rounding
Australia 9 11.8 Abbreviations: EM-MV early mobilisation in mechanically ventilated patients,
ICU intensive care unit
Australia and New Zealand 3 3.9
Australia and United Kingdom 1 1.3 51, 52, 55, 57, 59], standing using a tilt table [35, 39, 52],
Austria, Germany, United States 1 1.3 standing [35, 39, 40, 52, 55, 59], marching [61] and walk-
Belgium 1 1.3 ing [24, 35, 38–40, 52, 55, 57, 59, 61, 63]. The general
Brazil 5 6.6 descriptions of the activities were exercises involving
axial loading exercises [35, 52], movements against grav-
China 3 3.9
ity [35, 52, 61], active activities [37, 48, 55, 58, 59, 63]
Canada and United States 1 1.3
and activities requiring energy expenditure of patients
France 3 3.9 [62]. ‘Active’ was indicated in the EM-MV definitions as
Germany 1 1.3 patients having muscle strength and an ability to control
Italy 1 1.3 the activities [48], a conscious muscle activation (except
Japan 3 3.9 breathing) [63] and as certain types of activities such as
activities with physiological benefits [55], strengthening
Sweden 1 1.3
and mobility exercise [58] and assisted exercise [59].
Switzerland 1 1.3
Taiwan 5 6.6
Table 3 Definition of themes inferred in this review
Turkey 1 1.3
Theme Definition
United Kingdom 8 10.5 Non-standardised Absence of a standard EM-MV definition in
United States 27 35.5 definition the literature.
Multiple countries (> 3 countries) 1 1.3 Contextual factors Factors relating to patient’s mechanical
ventilation status and ICU settings that are
Publication year taken into account in EM-MV.
2000–2005 1 1.3 Negotiated process The process of negotiation taken by the key
2006–2010 13 17.1 stakeholders of EM-MV (mechanically ventilated
patients and staff) in order to actuate EM-MV.
2011–2016 42 55.3
Collaboration between The partnership between mechanically
2016–2018 20 26.3 patients and staff ventilated patients and staff to jointly carry
Professional groups of the authors out EM-MV.
Abbreviations: EM-MV early mobilisation in mechanically ventilated patients,
All medical staff 7 9.2
ICU intensive care unit
Table 4 Sub-themes, categories and example(s) of verbatim extracts of each theme in included studies
Themes Categories Example(s) of verbatim extracts and references
Sub-themes
Non-standardised definition
Practice variation Timing of commencement • Beginning within 24 h of ICU admission [42];
• Within 72 h of mechanical ventilation [45];
• Where the patients could assist with the activity using their own muscle strength and control [48].
Activities • Involved axial loading of the spine and/or long bones [35, 52];
• Any activity beyond range of motion [43].
Team diversity • A program of physiotherapist-directed [37];
• Performed by a care provider (nursing, physical or occupational therapy) [43].
Expectation of Preventative measures of • To prevent joint contractures [46];
outcome ICU complications
Maintaining patient’s • To maximize physical activity at the highest functional level the patient could achieve [37].
mobility
Improving impairment • To induce acute physiological responses (enhancing ventilation, central and peripheral circulation,
muscle metabolism, and alertness) [42]
Contextual factors
Mechanical Intubation types • MV was provided to 51% of patients, including 14% with tracheostomy [42];
ventilation utilisation • MV was defined as any ventilation via an endotracheal tube (ETT), tracheostomy tube, or
non-invasive positive pressure ventilation [77].
Mechanical ventilation • To initiate the early mobilization program within 72 hours of MV [87];
duration • Occurred while the patient was receiving invasive ventilation [48].
ICU context ICU stay • Continuing through the ICU stay [24].
Activity space • Mobilizing patients out of bed in the ICU can be seen as an earlier rehabilitation[64];
• Both leg and arm exercise with the patient in bed [75].
Protocol vs order • The early mobilization group (EMG) patients received a systematic early mobilization protocol,
twice a day, every day of the week[46];
• Activity orders for critically ill patients required a physician orders with all activity performed
by either the bedside nurse and/or a physical occupational therapist [43].
Negotiated process
Stakeholder decisions Clinical staff judgement • The decision to mobilise patients out of bed only after tracheostomy formation is based on
the decision that a tracheostomy presents as a stable airway [51].
Informed consent • The physical therapy intervention started when the informed consent was obtained [72];
• Acquire informed consent (e.g., waiting until evening family visits or allowing family members
time to think about the decision to enrol) [49].
Goal setting Progressive mobility • The types of functional activities performed during treatment sessions were recorded, including (1)
rolling, (2) sitting at the edge of the bed, (3) transferring from sitting to standing, (4) ambulation
[86].
Improving impairment • The 30-minute PT sessions, including abdominal breathing training, respiratory muscle weight train-
ing, passive and active joints exercises, upper and lower limb exercises[79].
Regaining independence • Sitting balance activities were followed by participation in activities of daily living (ADLs) and
exercises that encouraged increased independence with functional tasks [25].
Collaboration between patients and staff
Patient participation Active • Only in 24% of the sessions was more active functional mobilization performed (SOOB, standing,
and walking)[68].
Passive • A combination of passive exercise including positioning, joint range of movement, and hoist
transfer to chair [85].
Level of assistance Independence • Patients were first allowed to attempt each activity independently [26].
Staff assistance • With the assistance of a physical therapist, respiratory therapist and an ICU nurse [103].
Abbreviations: ADL activity of daily living, EMG early mobilisation group, ETT endotracheal tube, ICU intensive care unit, MP mobility protocol, MV mechanical
ventilation, PT physiotherapy, SOOB sit out of bed, SPT standard physical therapy
Several studies included the details of the care team in staff involved were physiotherapists (PTs) [24, 37, 43,
their EM-MV definitions. The team was diverse and 44], occupational therapists (OTs) [43, 44], respiratory
comprised of clinical and non-clinical staff. The clinical therapists (RTs) [24, 44] and nurses [24, 43, 44]. The
Table 5 A chronological summary of included studies

Author Study design* Setting Study aim(s) Total sample Theme**
(publication year) size (n)
1 2 3 4
Country
Martin et al. (2005) [74] Cohort Post ICU To evaluate the prevalence and magnitude of 49 ✓ ✓ ✓
USA weakness in patients receiving chronic mechanical
ventilation and the impact of providing aggressive
whole-body rehabilitation on conventional weaning
variables, muscle strength, and overall functional
status.
Chiang et al. (2006) [73] RCT Post ICU To examine the effects of 6 weeks of physical training 32 ✓ ✓
Taiwan on the strength of respiratory and limb muscles, on
ventilator-free time and on functional status in patients
requiring prolonged mechanical ventilation.
Bailey et al. (2007) [24] Cohort Respiratory ICU To determine whether early physical activity is 103 ✓ ✓ ✓ ✓
USA feasible and safe in respiratory failure patients.
Bahadur et al. (2008) [51] Cohort General ICU To define the number of occasions of sitting out of 30 ✓ ✓ ✓ ✓
United Kingdom bed in patients in the ICU following tracheostomy
formation.
Morris et al. (2008) [104] Cohort Medical ICU To assess the frequency of physical therapy, site of 330 ✓ ✓ ✓
USA initiation of physical therapy and patient outcomes
comparing respiratory failure patients who received
usual care compared with patients who received
physical therapy from a Mobility Team using the
mobility protocol.
Skinner et al. (2008) Cohort General ICUs To identify methods of exercise prescription by 111 ✓ ✓ ✓
[107] physiotherapists across Australian ICUs, including the
Australia most commonly used activities for both mechanically
ventilated and spontaneously breathing patients; and
to determine the outcome measures used for the
evaluation of exercise intervention.
Thomsen et al. (2008) [38] Cohort Respiratory ICU To determine whether transfer of respiratory failure 104 ✓ ✓ ✓ ✓
USA patients to the respiratory ICU improved ambulation,
independent of the underlying pathophysiology.
Malkoç et al. (2009) [105] Case control Medical ICU To evaluate the effect of physiotherapy on ventilator 510 ✓ ✓
Turkey dependency and lengths of ICU stay.
Schweickert et al. RCT Medical ICU To assess the efficacy of combining daily interruption 104 ✓ ✓ ✓
(2009) [25] of sedation with physical and occupational therapy
USA on functional outcomes in patients receiving
mechanical ventilation in intensive care.
Bourdin et al. (2010) [64] Cohort Medical ICU To describe the experience in early rehabilitation of 20 ✓ ✓ ✓
France ICU patients undergoing mechanical ventilation and
its effects on physiologic outcomes.
Needham et al. Case control Medical ICU To evaluate the effect of the quality improvement 57 ✓ ✓ ✓
(2010) [103] project on the number of physical and occupational
USA therapy consultations/treatments and length of stay,
in comparison with the prior year.
Pohlman et al. Cohort Medical ICU To describe a protocol of a daily sedative interruption 49 ✓ ✓ ✓
(2010) [26] and early physical and occupational therapy,
USA including neurocognitive state, potential barriers and
adverse events related to this intervention.
Yang et al. (2010) [79] Cohort Post ICU To understand the characteristics of ventilator 126 ✓ ✓ ✓
Taiwan dependence in patients and the potential effects of
physical therapy on ventilator weaning and patients’
functional status.
Zanni et al. (2010) [86] Cohort Medical ICU To describe the frequency, physiologic effects, safety 32 ✓ ✓
USA and patient outcomes associated with traditional
rehabilitation therapy.
Chen et al. (2011) [72] RCT Post ICU To study the outcomes of functional status, survival rate 34 ✓ ✓ ✓
Taiwan and ventilator-free status for prolonged mechanical
ventilation patients 1 year after physical therapy training
enrolment.
Table 5 A chronological summary of included studies (Continued)

1 2 3 4
Country
Clini et al. (2011) [75] Cohort Respiratory ICU To assess changes in functional status and whether the 77 ✓ ✓ ✓
Italy degree of functional recovery after a comprehensive
rehabilitation program influenced hospital outcomes in
a population of tracheostomised and chronically
ventilated patients admitted for weaning.
Nordon-Craft et al. Case series N/A To describe safety and feasibility of participation in 19 ✓ ✓ ✓
(2011) [97] physical therapy intervention for individuals with ICU-
USA acquired weakness who required MV for at least 7 days
and characterise the examination and intervention
procedures with sufficient detail that clinicians can
implement a similar strategy.
Chen et al. (2012) [96] RCT Post ICU To evaluate the effects of an exercise training program 27 ✓
Taiwan on pulmonary mechanics, physical functional status and
hospitalisation outcomes in terms of respiratory care
centre stay, mechanical ventilator weaning rate and
mortality rate in patients requiring prolonged mechanical
ventilation.
Dantas et al. (2012) [46] RCT General ICU To evaluate the effects of an early mobilisation 59 ✓ ✓ ✓ ✓
Brazil protocol on respiratory and peripheral muscles.
Ronnebaum et al. Case control General ICU To compare the effectiveness of two protocols: 28 ✓ ✓ ✓
(2012) [102] mobility protocol (MP) and Standard Physical Therapy
USA (SPT) for patients with respiratory failure.
Winkelman et al. Case control Medical-Surgical To compare standard care versus an early mobility 75 ✓ ✓ ✓ ✓
(2012) [49] ICUs protocol and to examine the effects of exercise on
USA vital signs and inflammatory biomarkers and the
effects of the nurse-initiated mobility protocol on
outcomes.
Berney et al. (2013) [57] Cohort General ICUs To document current physiotherapy mobilisation 498 ✓ ✓
Australia and New practices and focus specifically on mobilisation
Zealand practices in patients requiring prolonged mechanical
ventilation, defined as more than 48 h.
Camargo Pires-Neto et Case Series Medical ICU To evaluate the hemodynamic, respiratory and 19 ✓ ✓ ✓
al. (2013) [92] metabolic effects of a cycling exercise performed
Brazil during the first 72 h of mechanical ventilation.
Davis et al. (2013) [36] Cohort Medical-Surgical To determine the feasibility of employing a standard 15 ✓ ✓ ✓ ✓
USA ICU early mobilisation protocol, while systematically collecting
patient mobility data and short-term functional outcomes
from critically ill, mechanically ventilated, older adults.
Dinglas et al. (2013) [60] Cohort General ICUs To evaluate the association of patient, ICU and 514 ✓ ✓ ✓
USA hospital factors with the time to first occupational
therapy intervention in the ICU in a prospective
cohort of mechanically ventilated patients with acute
lung injury.
Harrold (2013) [35] Case control General ICU To implement a system change that supported safe 412 ✓ ✓ ✓ ✓
Australia increases in mobilisation rates of all intensive care
patients who were mechanically ventilated for three
or more calendar days.
Li et al. (2013) [59] Systematic N/A To investigate the effectiveness and safety of active 17 ✓ ✓ ✓ ✓
China review mobilisation on improving physical function and
hospital outcomes in patients undergoing mechanical
ventilation for more than 24 h.
Mendez-Tellez et al. Cohort General ICUs To evaluate the association of patient, ICU and 503 ✓ ✓ ✓
(2013) [106] hospital factors with the time to starting physical
USA therapy in a prospective cohort of mechanically
ventilated patients with acute lung injury.
Williams and Flynn, Qualitative N/A To explore the physiotherapists understanding and 6 ✓
(2013) [99] experience of implementing early rehabilitation in
United Kingdom critically ill patients.

1 2 3 4
Country
Dinglas et al. (2014) [58] Case control Medical ICU To evaluate the sustained effect of a quality 243 ✓ ✓ ✓ ✓
USA improvement project on the timing of initiation of
active physical therapy intervention in patients with
acute lung injury.
Dong et al. (2014) [67] RCT General ICU To investigate the feasibility of early rehabilitation 60 ✓ ✓ ✓
China therapy in patients with mechanical ventilation.
Jolley et al. (2014) [43] Cohort Medical ICU To assess clinician knowledge regarding early 120 ✓ ✓
USA mobilisation and identify barriers to its provision.
Nydahl et al. (2014) [65] Cohort General ICUs To undertake a 1-day point-prevalence study of 116 ✓ ✓
Germany mobilisation of mechanically ventilated patients in
ICUs across Germany, including evaluating associations
with perceived barriers to mobilisation and
complications during mobilisation.
Patel et al. (2014) [45] Cohort Medical ICU To determine if early mobilisation affects glycaemic 104 ✓ ✓
USA control and, in turn, exogenous insulin requirements
in critical illness.
Bakhru et al. (2015) [41] Cohort General ICUs To evaluate the current level of diffusion of early 500 ✓ ✓ ✓
USA mobilisation practice and examine environmental
factors that may influence its practice.
Barber et al. (2015) [88] Qualitative General ICU To determine the barriers and facilitators of early 25 ✓
Australia mobilisation in the ICU.
Berney et al. (2015) [76] Cohort General ICU To measure patterns of physical activity in a group of 41 ✓ ✓ ✓
Australia critically ill patients.
Collings and Cusack RCT General ICU To quantify and compare the acute physiological 10 ✓ ✓ ✓
(2015) [85] response of critically ill patients during a passive chair
United Kingdom transfer or a sitting on the edge of the bed.
Eakin et al. (2015) [116] Qualitative Medical ICU To describe a multidisciplinary team perspective 20 ✓
USA regarding how to implement and sustain a successful
early rehabilitation programme.
Harrold et al. (2015) [52] Cohort General ICUs To evaluate baseline practise and the perceived 830 ✓ ✓ ✓
Australia and United barriers to early mobilisation in ICU across multiple
Kingdom sites in two different countries with different systems
of health care delivery.
Holdsworth et al. Qualitative General ICU To elicit attitudinal, normative, and control beliefs 22 ✓ ✓ ✓ ✓
(2015) [61] towards mobilising ventilated patients in the ICU to
Australia generate items for a second-phase questionnaire and
inform the development of a tailored implementation
intervention.
Jolley et al. (2015) [100] Cohort General ICUs To determine what proportion of hospitals caring for 47 ✓ ✓ ✓
USA mechanically ventilated patients across Washington
State use physical activity in the ICU and to identify
process of care factors associated with reported
activity delivery.
Kayambu et al. RCT General ICU To determine whether early physical rehabilitation 50 ✓ ✓ ✓
(2015) [95] improves physical function and associated outcomes
Australia in patients with sepsis.
McWilliams et al. Case control General ICU To evaluate the impact of an early and enhanced 582 ✓ ✓ ✓
(2015) [66] rehabilitation programme for mechanically ventilated
United Kingdom patients in a large tertiary referral mixed-population
ICU.
Ota et al. (2015) [47] Case control General ICU To clarify the benefits of early mobilisation for 108 ✓ ✓ ✓ ✓
Japan mechanically ventilated patients for their survival to
discharge to home from the hospital.
Camargo Pires-Neto et Cohort Medical ICU To characterise the provision of early mobilisation 120 ✓ ✓ ✓
al. (2015) [68] therapy in critically ill patients in a Brazilian medical
Brazil ICU and to investigate the relationship between
physical activity level and clinical outcomes.

1 2 3 4
Country
Skinner et al. (2015) [69] Cohort General ICU To report the incidence of usual care physiotherapy, 100 ✓ ✓ ✓
Australia specifically treatment and modalities used, in a
sample of subjects admitted to a single tertiary
Australian ICU.
The TEAM Study Cohort General ICUs To investigate current mobilisation practice, strength 192 ✓ ✓ ✓ ✓
Investigators (2015) [48] at ICU discharge and functional recovery at 6 months
Australia and New among mechanically ventilated patients.
Zealand
Toccolini et al. Cohort General ICU To assess the effects of passive orthostatism on 23 ✓ ✓
(2015) [70] various clinicophysiologic parameters of adult ICU
Brazil patients, by daily placement on a tilt table.
Witcher et al. (2015) [71] Case control Neurological ICU To examine the effect of an early mobilisation 68 ✓ ✓ ✓
USA protocol on sedation practices of critically ill,
mechanically ventilated patients.
Bakhru et al. (2016) [56] Cohort General ICUs To evaluate organisational characteristics that enable 951 ✓ ✓ ✓
France, Germany, United early mobilisation practice.
Kingdom and USA
Dong et al. (2016) [93] RCT General ICU To evaluate the influence of early rehabilitation 106 ✓ ✓ ✓
China therapy on patients with more than 72 h of
prolonged mechanical ventilation after coronary
artery bypass surgery.
Hickmann et al. Cohort General ICU To demonstrate that early mobilisation performed 171 ✓ ✓ ✓ ✓
(2016) [42] within the first 24 h of ICU admission proves to be
Belgium feasible and well tolerated in the vast majority of
clinically ill patients.
Hodgson et al. (2016) RCT General ICUs To determine if the early goal-directed mobilisation 50 ✓ ✓ ✓ ✓
[37] intervention could be delivered to patients receiving
Australia and New mechanical ventilation with increased maximal levels
Zealand of activity compared with standard care.
Morris et al. (2016) [84] RCT Medical ICU To compare standardised rehabilitation therapy to 300 ✓ ✓ ✓
USA usual ICU care in acute respiratory failure
Schaller et al. (2016) RCT Surgical ICUs To test if early, goal-directed mobilisation, using a 200 ✓ ✓ ✓
[101] strict mobilisation algorithm combined with facilitated
Austria, Germany and inter-professional communication leads to improved
USA mobility during admission, decreased length of stay,
and increased functional independence at hospital
discharge.
Curtis and Irwin (2017) Qualitative N/A To increase understanding of nurses’ perspectives on 8 ✓ ✓ ✓
[50] ambulating mechanically ventilated patients, and to
United Kingdom determine why this is not a routine part of ICU
patient care.
Dunn et al. (2017) [62] Systematic N/A To evaluate the strength of existing publications to 8 ✓
USA review determine if active mobilisation interventions in
prolonged mechanical ventilation patients improves
physical function, ventilator weaning rates, pulmonary
mechanics, and clinical hospital outcomes such as
length of stay and mortality.
Jolley et al. (2017) [77] Cohort General ICU To determine the prevalence and character of 42 ✓ ✓ ✓
USA mobility for ICU patients with acute respiratory failure.
Lai et al. (2017) [87] Case control Medical ICU To evaluate the effects of a quality improvement 153 ✓ ✓ ✓
Taiwan programme to introduce early mobilisation on the
outcomes of patients with mechanical ventilation in
the ICU.
McWilliams et al. Case control General ICUs To investigate whether the Sara Combilizer® could 63 ✓ ✓ ✓ ✓
(2017) [39] facilitate safe and early mobilisation of critically ill
United Kingdom patients at high risk of ICU-acquired weakness who
would otherwise be unable to get out of bed, thereby
reducing time to first mobilisation.

1 2 3 4
Country
Parry et al. (2017) [98] Qualitative General ICU To identify the barriers and enablers that influence 26 ✓ ✓ ✓
Australia clinicians’ implementation of early rehabilitation in
critical care.
Sibilla et al. (2017) [78] Cohort General ICUs To characterise the highest level of mobilisation 161 ✓ ✓ ✓
Switzerland achieved in mechanically ventilated patients as
defined by the valid and reliable ICU Mobility Scale
and to characterise the potential safety events related
to mobilisation and perceived barriers to mobilisation.
Weeks et al. (2017) [44] Cohort Medical-Surgical To investigate the feasibility of early mobilisation and 42 ✓ ✓ ✓ ✓
USA ICU describe the rehabilitation interventions and functional
discharge outcomes in critically ill patients with cancer.
de Queiroz et al. Systematic N/A To evaluate of the description of the active mobilisation 17 ✓ ✓ ✓
(2018) [63] review protocols in patients on invasive mechanical ventilation
Brazil at ICUs.
Goddard et al. Qualitative N/A To explore barriers and facilitators to early rehabilitation 40 ✓
(2018) [81] for critically ill patients receiving invasive mechanical
Canada and USA ventilation.
Liu et al. (2018) [83] Cohort General ICU To investigate the safety of early mobilisation according 72 ✓ ✓ ✓
Japan to the Maebashi Early Mobilisation protocol conducted
by ICU physicians.
McWilliams et al. RCT N/A To explore the feasibility of earlier and enhanced 102 ✓ ✓ ✓ ✓
(2018) [40] rehabilitation for patients mechanically ventilated for
United Kingdom ≥5 days and to assess the impact on possible long-term
outcome measures for use in a definitive trial.
Medrinal et al. RCT N/A To compare the physiological effects of four common 19 ✓ ✓ ✓
(2018) [90] types of bed exercise in intubated, sedated patients
France confined to bed in the ICU, in order to determine
which was the most intensive.
Phelan et al. (2018) [55] Systematic N/A To identify the key factors that underpin successful 13 ✓ ✓ ✓
Australia review implementation and sustainability of early
mobilisation in adult intensive care units.
Ringdal et al. (2018) [91] Qualitative General ICUs To explore patient recollections and experiences of 11 ✓ ✓ ✓
Sweden early mobilisation, including in-bed cycling.
Sarfati et al. (2018) [80] RCT Surgical ICU To investigate whether cardiothoracic surgery patients 125 ✓ ✓ ✓
France expected to require prolonged ICU management
benefited from the addition of daily tilting to an early
mobilisation program.
Taito et al. (2018) [54] Cohort General ICUs To clarify intensive care unit-level factors facilitating 168 ✓ ✓ ✓
Japan out-of-bed mobilisation in mechanically ventilated
patients with orotracheal tubes.
Verceles et al. (2018) [53] RCT Post ICU To compare the effects of adding a progressive 32 ✓ ✓ ✓ ✓
USA multimodal rehabilitation program to usual care.
Winkelman et al. RCT General ICUs To examine whether the delivered intervention 54 ✓ ✓ ✓
(2018) [94] influenced inflammatory serum markers and to
USA explore whether the dose of the delivered
intervention influenced patient outcomes.
Wright et al. (2018) [82] RCT Medical-surgical To evaluate the effects of two different intensities of 308 ✓ ✓ ✓
United Kingdom ICU early rehabilitation therapy - intensive versus standard -
on the recovery of physical health-related quality of life
at 6 months.
*Based on CASP tools
**1 non-standardised definition, 2 contextual factors, 3 negotiated process, 4 collaboration between patients and staff
Abbreviations: CASP Critical Appraisal Skills Programme, ICU intensive care unit, MP mobility protocol, N/A not applicable (unclear or systematic reviews), SPT
standard physical therapy, RCT randomised controlled trial
non-clinical staff were technicians [24]. PTs and OTs 72 h [57, 80, 82, 90, 93–95]. Long-term duration was be-
were reported as key professional groups in evaluating a yond 7–21 days [39, 40, 47, 53, 72, 73, 75, 96, 97].
patient’s readiness for EM-MV [37, 44].
Sub-theme 2.2: ICU context
Sub-theme 1.2: Expectation of outcome ICU context refers literally to the ICU setting and in-
Expectation of outcome reflects the descriptions of the de- cludes the use of protocol or order to initiate EM activ-
sired effects of EM-MV including preventing ICU compli- ities. EM-MV activities were initiated during ICU stay in
cations, maintaining patient’s mobility and improving different timeframes: as soon as possible after admission
impairment. Two studies referred to specific preventions [74, 98, 99], between 24 and 48 h after admission [42,
such as joint contractures [46] and delirium [44], and one 75], before 14 days of admission [49] and throughout ad-
study referred to general prevention which was to counter- mission [24, 25, 36, 38, 46, 51, 56, 98–100]. ‘In-bed’ or
act immobilisation [62]. Patient’s mobility was targeted at ‘out-of-bed’ captures different locations in which EM-
achieving the highest functional level or regaining the func- MV happened (Table 6).
tional status before ICU admission [37, 41, 44, 53, 56]. The Several studies reported that EM-MV was initiated
expected responses of EM-MV in improving impairment using a protocol or an order. EM-MV was automatic-
were stated in the definitions by describing affected body ally triggered by a protocol to initiate activities follow-
systems including muscular, respiratory, circulatory and ing patients’ admissions to ICU in 31 studies [24–26,
nervous systems [42, 46, 53]. 35–40, 42, 46, 49, 58, 60, 66, 67, 72, 74–76, 80, 83, 84,
In summary, EM-MV is either not fully defined in stud- 87, 93, 94, 101–105]. Across the studies reporting the
ies or when a definition is provided this is not standar- requirement of a formal order to initiate EM-MV, staff
dised across studies. In the 15 of 76 studies which prescribing the order varied from physicians [43, 47,
provided a full definition of EM-MV, there was no stan- 64, 79, 86], PTs [48, 51, 68, 85], PTs and OTs [44, 71]
dardised EM-MV definition. The sub-themes practice to the care team [45].
variation and expectation of outcomes identify how the To summarise, the overall categories and sub-themes
definitions differed between authors and reflect the main encompassed within theme contextual factors suggest
features of EM-MV definitions found in included studies. that EM-MV activities are contextual depending on pa-
tient’s mechanical ventilation status, the setting of ICU
where EM-MV takes place and the use of a protocol or
Theme 2: Contextual factors an order for initiating EM-MV. The findings highlight
The theme contextual factors encompass the aspects of diverse contexts and inconsistency in EM-MV provision
mechanical ventilation use and the context of ICU set- across included studies.
tings in the course of EM-MV. This theme was evident
in almost all studies (see Table 5) and consists of two Theme 3: Negotiated process
sub-themes: (1) mechanical ventilation utilisation and Negotiated process is concerned with the negotiation oc-
(2) ICU context. curring between mechanically ventilated patients and
Sub-theme 2.1: Mechanical ventilation utilisation Table 6 Reported in-bed and out-of-bed activities in
Mechanical ventilation utilisation is associated with the included studies
type of intubation patients received and the duration of In-bed activity Out-of-bed activity
ventilation support while undertaking EM-MV. Forty one Range of motion [39, 49, 77, 90, Bed-transfer training [102, 107]
of 76 included studies provided the information on intub- 101]
ation type in patients undertaking EM-MV activities. Bridging [37] Sitting at the edge of bed [54, 57, 77]
Patients using tracheostomy undertaking EM-MV were re-
Turning [36, 44, 73] Sitting in a chair [49, 51, 65, 77],
ported in 33 studies [24, 36–40, 42, 48, 51, 52, 57, 61, 63–
Transferring [25] Standing [49, 65, 77]
83]. The use of endotracheal tube (ETT) during EM-MV
activities was reported in 32 studies [24, 35–40, 47, 48, 52, Limb exercise [44, 75] Marching [53, 65, 77]
54, 57, 61, 63, 65–71, 77, 78, 80–88]. Patients undertaking Self-care activities [44] Ambulating [24, 26, 35, 37, 38, 41, 42,
EM-MV activities with non-invasive ventilation (NIV) was 44, 46, 48, 56, 58, 61, 64–69, 71, 72,
Breathing exercise [90] 76–79, 85, 93, 100–103, 107]
only evident in six studies [65, 77, 78, 80, 82, 89]. Electrical stimulation [90]
EM-MV activities were reported taking place during
Sitting in bed [25, 39, 46, 71, 76,
mechanical ventilation with two apparent categories of 78, 83]
duration, namely short term and long term. The short- Sitting at the edge of bed [53, 71]
term duration was described as within 48 h [25, 43, 52,
Cycling [42, 53, 83, 90, 91]
58, 84, 90, 91], within 72 h [44, 45, 87, 92] or after 48–
Table 7 Reported treatment goals and activities in included Table 7 Reported treatment goals and activities in included
studies studies (Continued)
Goal Type of activities References Goal Type of activities References
Progressive mobility Positioning [36, 46, 47, 50, 65–69, Activity of daily [25, 26, 36, 44, 60, 86]
73, 85, 104, 105] livings
Bed head elevation [41, 47, 65, 67, 93] Rolling [26, 36, 44, 48, 65, 86, 97]
Sitting* Bridging [36, 48]
Sitting in bed [25, 37, 41, 46, 54, 58, Staircase exercises [74]
65, 74, 76, 78, 87, 93,
103, 104] Sitting see* (progressive
mobility)
Sitting at the edge [24–26, 35–39, 41, 44,
of bed 46, 51, 52, 55, 57–59,
61, 65–68, 71, 74, 76–
78, 82, 83, 85–87, 93, staff as stakeholders to bring about EM-MV. This theme
94, 97, 100, 101, 103, has two sub-themes: (1) stakeholder decisions and (2)
104, 107] goal setting.
Sitting out of bed [24, 26, 35–39, 42, 44,
46, 49–52, 54, 58, 59, Sub-theme 3.1: Stakeholder decisions
64–68, 72, 75–78, 85,
87, 93, 95, 100, 103, 104] Stakeholder decisions refers to factors relating to staff
Standing [26, 35, 36, 42–47, 50,
and patients affecting the decision-making process to
54, 55, 63, 65–69, 71– initiate EM-MV including clinical staff judgement and
80, 82, 83, 85, 88, 93, informed consent given by the patients or their prox-
94, 97, 101–104]
ies. The staff judgement was related to the assessment
Ambulating [24–26, 35, 37–39, 41, of patient safety in undertaking EM-MV and based on
42, 44, 46, 48–50, 54,
56, 58, 61, 64–69, 71, patient’s physiological status [24, 35, 36, 38, 49, 87,
72, 74–80, 82, 83, 85, 103], level of consciousness [26, 71, 98, 103], patient
86, 89, 93–95, 100–103, compliance [98] and an established tracheostomy as a
107]
sign of a stable airway [51]. Level of consciousness
Improving impairment Respiratory system ranged from alert and cooperative patients [98] to
Breathing [36, 44, 47, 54, 69, 72, those that were delirious based on the Confusion Assess-
exercises 79, 97, 105, 106]
ment Method for the Intensive Care Unit (CAM-ICU)
Muscles and joints [26]. The tools for measuring the level of consciousness
Range of motions [26, 36, 41, 49, 54, 60, were Richmond Agitation-Sedation Scale (RASS) [103]
71, 73, 76, 77, 79, 85, and Glasgow Coma Scale (GCS) [71]. Patients with RASS
97, 101, 102, 104, 106]
≥ − 3 [103] or GCS ≤ 8 [71] were considered as comatose
Limb exercises [36, 44, 47, 48, 60, 68,
75, 76, 79, 87]
and excluded from the EM-MV activities. Most studies re-
ported that informed consent was sought before commen-
Strengthening [53, 58, 72, 73, 82, 86,
96, 98] cing EM-MV from the patients or their proxies. In some
cases, it was argued that informed consent was not re-
Stretching [36, 46, 68, 86, 96]
quired because EM-MV was part of routine care [24, 35,
Counter-resistance [36, 42, 46, 59, 68, 72–
75, 79, 89, 104]
38, 42, 44, 51, 52, 60, 64, 66, 74, 76, 80, 86, 102–104].
Weight bearing [26, 35, 41]
Sub-theme 3.2: Goal setting
Cycling [41, 42, 46, 53, 54, 58, Goal setting is the sub-theme associated with the treat-
59, 74, 75, 83, 90–92,
96] ment aims of EM-MV activities delivered to mechanic-
Regaining independence Transfer training [25, 26, 39, 44, 46, 53,
ally ventilated patients and evident across the literature.
55, 61, 69, 73–78, 83, The goals include (1) progressive mobility, (2) improving
89, 93–95, 97, 100, 107] impairment and (3) regaining independence. The activ-
Marching [25, 26, 36, 53, 61, 65, ities related to each goal are detailed in Table 7.
69, 74, 76–78, 83, 89, The progressive mobility reflects the progression of mo-
94, 97, 101, 107]
bility achieved by the patients in EM-MV over time. Mo-
Balance training [25, 26, 36, 37, 46, 53, bility progression was phased starting with positioning (n
86, 89, 104]
= 13) followed by elevating the head of the bed (n = 5) and
sitting which was further divided into with three stages:
(1) sitting in bed (n = 14), (2) sitting without back support
or at the edge of the bed (n = 40) and (3) sitting out of bed 104, 106]. Other commonly reported passive activities
(n = 34). Progression following on from sitting was stand- across studies were in-bed positioning [59, 66, 85] and
ing (n = 39) with ambulation (n = 46) being the highest transfer to a chair with assistance [42, 77, 78, 85]. Assist-
level of mobility and which was explicitly stated as the pri- ance was required in non-specific active activities [25,
mary goal of EM-MV in some studies [24, 38, 86]. 37, 42, 46, 48, 107] or specific active activities such as
The second goal relates to improving impairment ROM [26, 41]. A further important aspect of EM-MV
which is concerned with patients’ homeostasis, particu- was patient’s ability to interact with staff [87, 98]. Conse-
larly the functionality of the respiratory system and quently, passivity was described as being associated with
muscle and joint strength because of EM-MV activities. the unconscious, sedated and paralysed patients [66, 87].
Breathing exercises were the most commonly reported
respiratory-related activity (n = 10). EM-MV activities Sub-theme 4.2: Level of assistance
aiming at muscles and joints consisted of a variety of Level of assistance refers to the level of support mechan-
exercises such as ROM (n = 17), limbs exercises (n = 10), ically ventilated patients require when undertaking
strengthening (n = 8), stretching (n = 5), counter-resistance EM-MV activities. Patients may undertake activities in-
(n = 12), weight bearing (n = 3), and cycling (n = 13). dependently or while being supported by staff or in com-
The goal of regaining independence is related to EM- bination with equipment. The most commonly used
MV activities aiming at preparing the patients for their equipment were a tilt table [35, 39, 42, 52, 64, 66, 69, 70,
life after hospital discharge and consisted of functional 80, 82] and walking aids [24, 36, 38, 75, 103]. Several au-
exercises. Commonly identified exercises were transfer thors reported that assisting a mechanically ventilated
training (n = 23), marching (n = 17), balance training patient to mobilise required support between one to four
(n = 9), activity of daily livings (ADLs) (n = 6), rolling people [24, 48, 93, 103]. Staff members included nurses,
(n = 7), bridging (n = 2), staircase exercises (n = 1) and OTs, physicians, PTs and RTs [24, 48, 87, 93, 100, 103]
sitting (sitting in bed, n = 14; sitting at the edge of while non-clinicians included visiting family members
bed, n = 40; sitting out of bed, n = 34). [87] and technicians [24]. Thirteen studies mentioned
In summary, the theme negotiated process suggests that that patients could perform EM-MV activities independ-
the implementation of EM-MV is a result of negotiations ently without the support of staff including sitting and
between mechanically ventilated patients and staff. walking [24–26, 35–39, 48, 55, 59, 93, 102].
Decision-making of staff around whether or not the pa- Overall, the sub-themes patient participation and level
tient is safe to undertake EM-MV and what type of activ- of assistance reflect the collaboration between mechanic-
ities are appropriate with a view of setting a goal was ally ventilated patients and staff to actuate EM-MV ac-
prevalent in the literature. In most studies, EM-MV was tivities. What constitutes active or passive about patient
usually initiated by a clinical order or by protocol. The participation remains inconclusive as there were some
requirement of informed consent from the patient or their overlaps of interpretations across included studies. The
proxy to commence EM-MV was varied, and consent was descriptions provided by included studies about the level
not sought if EM-MV was part of routine care. of assistance required by the patients either the physical
support from staff or the use of equipment were scarce
Theme 4: Collaboration between patients and staff and inadequate to conclude the meaning of independent
The theme collaboration between patients and staff re- in EM-MV.
fers to the interdependent relationship between mechan-
ically ventilated patients and staff as the stakeholders Discussion
suggesting that EM-MV requires involvement of both to It is evident from this systematic review that a definition
succeed. The theme is based on two sub-themes: (1) pa- for EM-MV remains far from being agreed and that EM-
tient participation and (2) level of assistance. MV activities are poorly understood. Our analysis of
EM-MV definitions in the literature suggests that EM-
Sub-theme 4.1: Patient participation MV is both broadly and narrowly defined and thus is
Patient participation describes the degree of active or problematic for advancing research and practice. The
passive involvement in EM-MV activities. The same broader definitions are heterogeneous with a vast scope
activities were not consistently classified as active or pas- of EM-MV. In contrast, while narrow definitions are de-
sive across all studies. For example, head up position sirable in improving validity and reliability in scientific
was considered as a passive activity in one study [41], research, we suggest that the variability in, for example,
but was viewed as active in another study [67]. Similarly, timing and various EM activities, challenges the transfer-
ROM could be an active [25, 26, 36, 41, 49, 63, 71, 75, ability of study results.
79, 80, 87, 95, 97] or passive activity [26, 36, 41, 46, 47, The inconsistency in both broad and narrow defini-
49, 54, 59, 60, 71, 74, 77, 79, 80, 85, 87, 90, 95, 97, 101, tions raises an issue of comparability between studies
and weakens the evidence base for clinicians at the Our findings show that EM-MV was commonly deliv-
bedside. Questions such as ‘When should we start mobi- ered by a team consisting of clinical and non-clinical
lising our patients?’ and ‘Which activities should we staff. The multidisciplinary of EM-MV is reflected by the
choose?’ are therefore difficult to answer. Researchers authors of included studies ranging from medical staff,
should provide a detailed report of timing of EM-MV nursing, PT, OT to RT either as individual or as multi-
initiation and details of activities in their research since disciplinary author(s). This is an important point since
transparency on these details will promote the uptake of different disciplinary background will impact on how
research evidence into practice [108–110]. EM-MV is defined and implemented. Future research
Regardless of the existence or non-existence of a needs to pay attention to this aspect to maximise in-
EM-MV definition in a given study, most included stud- sights from different professional backgrounds.
ies have reported the initiation time of EM-MV in rela-
tion to mechanical ventilation duration or the length of
Review strengths and limitations
ICU stay which varied considerably. This variation is an
A major strength of this review is that the analysis was
issue of interest and has been previously highlighted by
conducted inductively with transparent documentation
researchers [35, 40, 56]. Bakhru et al. [56], for example,
at each stage. Thus, the sub-themes and themes inherent
deliberately stated that they did not define ‘early’ due to
in the definitions and activities of EM-MV are based on
there being no consensus. Harrold [35] conducted a sys-
the existing literature without imposing preconceptions
tematic review to explore timing and activities of
and assumptions of the authors. Furthermore, this
EM-MV and predetermined the classifications of timing
review included both primary and secondary studies
into three criteria: (1) in ICU with mechanical ventila-
with a range of objectives. Therefore, it offers broad
tion, (2) in ICU without mechanical ventilation and (3)
coverage of literature in this area. The different profes-
not in ICU with no information on mechanical ventila-
sional perspectives (nursing and physiotherapy) is an-
tion. Given the rapid onset of muscle wasting within
other strength of this review since our professional
hours of mechanical ventilation [111–114], we believe
definitions of what exactly constitutes mobilisation var-
that Harrold’s [35] classification still appears to be too
ied, and this was reflected both in the research reviewed
broad. We suggest that research should be focused on
and in current multidisciplinary ICU care. Finally, the
the optimal EM-MV initiation timing after a patient is
review provides insights into the aspects of EM-MV def-
mechanically ventilated.
inition and activities lacking consensus, as demonstrated
The interchangeable use of EM-MV terminology
by conflicting perspectives of authors.
requires some reflection and agreement for consistency.
Two potential limitations are apparent in this study.
Despite no formal count of verb frequency in our work,
The diverse terminology used around EM-MV in the lit-
we noticed that ‘early mobilisation’ was the most fre-
erature may be a hindrance in capturing all relevant arti-
quently used term. Other terms were ‘early activity’, ‘early
cles. Additionally, this review only included studies in
exercise’, ‘early mobility’, ‘early occupational/physical ther-
English and German as these are the primary languages
apy’ and ‘early rehabilitation’. We found that studies ori-
of the authors. This restriction may have missed studies
ginating in the USA commonly use the term ‘mobilisation’,
published in other languages. However, attempts have
whereas in the UK and Europe authors often use the term
been made to minimise this limitation by including mul-
‘rehabilitation’. This inconsistency was also evident in
tiple databases in the search strategy combined with
individual studies which frequently used terminology
hand searching of the grey literature and the reference
interchangeably in their published work. It is not unrea-
lists of included studies.
sonable to assume that readers may think that different
terminologies are referring to different concepts. For
example, the studies referring to EM-MV as ‘early re- Implications for future research
habilitation’ seem to focus on functional activities such as The findings of this review substantiate the need for an
bridging and ADLs. Studies focusing on ‘early mobility’ agreed definition and terminology of EM-MV. If we
or ‘early mobilisation’ tend towards stepwise mobility want to promote evidence-based practice, researchers
activities including sitting, standing and ambulation. need to speak the same language about what EM-MV is.
Understanding and defining what ‘mobilisation’ and ‘re- The absence of a consensus may impede the implemen-
habilitation’ imply across the international community tation of evidence-based practice on this topic [115].
might be one step in clarifying the conundrum of var- The inconsistency of EM-MV terminology may become
ied EM-MV terminologies. These differences of termin- a complicating matter in EM-MV definitions. We believe
ologies may reflect differing views of researchers and that the agreement of terminology used to refer EM-MV
emphasise the absence of a standardised definition of is a stepping-stone to moving forward into a clear and
EM-MV. consistent definition. We strongly recommend that ICU
experts reach consensus on a formal and consistent def- Acknowledgements

inition of EM-MV. The authors thank the University of Edinburgh Librarian Rowena Stewart for
her assistance in developing the search strategy.
Furthermore, the sub-themes and themes that were
identified in this review provide a strong base to under- Funding
stand current underlying conceptualisation of EM-MV This work is part of the first author’s PhD studies supported by Lembaga Pengelola
Dana Pendidikan (LPDP) (Indonesia Endowment Fund for Education), grant number
which could inform the construction of a standardised 20160222045521. No other source of funding contributes to this review.
definition and the type of activities that are considered as
EM-MV. Recognising the importance of detailed reporting Availability of data and materials
All data analysed during this research are included in this published article.
of research for the purpose of allowing study replication
and promoting research evidence uptake into practice Authors’ contributions
[108–110], our results can also be used as a guideline for CC, LS, SR and SK conceived and planned the review. CC carried out the literature
search. CC and LS screened the records. CC, LS, SR and SK contributed to the data
the details to include in reporting research related to EM- extraction and analysis and the interpretation of the results. CC took the lead in
MV. writing the manuscript with critical input from LS, SR and SK. All authors read and
Most included studies adopted quantitative approaches approved the final manuscript.
in investigating EM-MV (see Table 2). Considering that Ethics approval and consent to participate
qualitative research could contribute to the insights into Not applicable
effective EM-MV delivery, this review highlights the ur-
Consent for publication
gency of the need for more qualitative studies. Some Not applicable
studies have attempted to explore the clinician’s percep-
tions of EM-MV [50, 61, 81, 88, 98, 99, 116], yet re- Competing interests
The authors declare that they have no competing interests.
search into patients’ views of EM-MV is lacking as
evidenced by only one study found in this review [91].
Publisher’s Note
Exploring patient views is essential as they are the pri- Springer Nature remains neutral with regard to jurisdictional claims in published
mary participants in EM-MV. Rigorous qualitative re- maps and institutional affiliations.
search should be developed to facilitate the design of
Author details
EM-MV as a complex intervention that is aligned with 1
Department of Nursing Studies, School of Health in Social Science,
patient and staff expectations [117, 118]. EM-MV prac- University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG,
tice could then be optimised and promote improved out- UK. 2Division of Dietetics, Nutrition and Biological Sciences, Physiotherapy,
Podiatry and Radiography, Queen Margaret University, Queen Margaret
comes for patients. University Drive, Musselburgh EH21 6UU, UK.
Received: 23 October 2018 Accepted: 11 December 2018
Conclusion
This review highlights the varied definitions of EM-MV References
1. Vincent J-L, Creteur J. Paradigm shifts in critical care medicine: the progress
and the necessity for an agreed EM-MV terminology
we have made. Crit Care. 2015;19:S10.
and definition based on consensus and a deeper under- 2. Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the
standing of what activities constitute EM-MV. This lack global burden of critical illness in adults. Lancet. 2010;376:1339–46.
3. Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Peñuelas O, Abraira V,
of consistency complicates the benchmarking or com-
et al. Evolution of mortality over time in patients receiving mechanical
parison of results across studies which further hinders ventilation. Am J Respir Crit Care Med. 2013;188:220–30.
the translation of evidence into practice as well as study 4. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for
United States intensive care unit admissions from 1988 to 2012. Crit Care.
replication in other settings. A mutual understanding of
2013;17:R81.
EM-MV including the terminology, the definition and 5. Scottish Intensive Care Society Audit Group. Audit of critical care in
the constituting activities is required to advance research Scotland 2017 reporting on 2016. 2017. http://www.sicsag.scot.nhs.uk/docs/
2017/2017-08-08-SICSAG-Report.pdf?24. Accessed 25 Aug 2017.
and to trigger a further discussion on this topic.
6. Herridge MS. Introduction: life after the ICU. In: Stevens RD, Hart N, Herridge
MS, editors. Textbook of post-ICU medicine: the legacy of critical care.
Oxford: Oxford University Press; 2014. p. 3–4.
Abbreviations 7. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H,
ADL: Activity of daily living; CAM-ICU: Confusion Assessment Method for the et al. Improving long-term outcomes after discharge from intensive
Intensive Care Unit; CASP: Critical Appraisal Skills Programme; CRD: Centre for care unit. Crit Care Med. 2012;40:502–9. https://doi.org/10.1097/CCM.
Reviews and Disseminations; EM-MV: Early mobilisation in mechanically 0b013e318232da75.
ventilated patients; GCS: Glasgow Coma Scale; ICU: Intensive care unit; 8. Harvey MA, Davidson JE. Postintensive care syndrome: right care, right
ICU-AW: Intensive Care Unit-Acquired Weakness; NICE: National Institute now…and later. Crit Care Med. 2016;44:381–5. https://doi.org/10.1097/
for Health and Care Excellence; NIV: Non-invasive ventilation; OT: Occupational CCM.0000000000001531.
Therapist; PICS: Post-intensive care syndrome; PRISMA: Preferred Reporting 9. Kean S, Salisbury LG, Rattray J, Walsh TS, Huby G, Ramsay P. ‘Intensive care
Items for Systematic Reviews and Meta-Analyses; PROSPERO: International unit survivorship’ – a constructivist grounded theory of surviving critical
prospective register of systematic reviews; PT: Physiotherapist; RASS: Richmond illness. J Clin Nurs. 2017;26:3111–24.
Agitation-Sedation Scale; ROM: Range of motion; RT: Respiratory therapist; 10. Ågård AS, Lomborg K, Tønnesen E, Egerod I. Rehabilitation activities, out-
SIGN: Scottish Intercollegiate Guidelines Network patient visits and employment in patients and partners the first year after
ICU: a descriptive study. Intensive Crit Care Nurs. 2014;30:101–10. https://doi. 32. Critical Appraisal Skills Programme (CASP). CASP CHECKLISTS. 2016. http://
org/10.1016/j.iccn.2013.11.001. www.casp-uk.net/. Accessed 13 Jun 2016.
11. Griffiths J, Hatch RA, Bishop J, Morgan K, Jenkinson C, Cuthbertson BH, et al. 33. Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising
An exploration of social and economic outcome and associated health- qualitative and quantitative evidence: a review of possible methods. J Heal
related quality of life after critical illness in general intensive care unit Serv Res Policy. 2005;10:45–53. https://doi.org/10.1258/1355819052801804.
survivors: a 12-month follow-up study. Crit Care. 2013;17:R100. https://doi. 34. Braun V, Clarke V. Using thematic analysis in psychology using thematic
org/10.1186/cc12745. analysis in psychology. Qual Res Psychol. 2006;3:77–101. https://doi.org/10.
12. Kamdar BB, Sepulveda KA, Chong A, Lord RK, Dinglas VD, Mendez-Tellez PA, 1191/1478088706qp063oa.
et al. Return to work and lost earnings after acute respiratory distress 35. Harrold ME. Early mobilisation of mechanically ventilated adults in intensive
syndrome: a 5-year prospective, longitudinal study of long-term survivors. care: implementation of practice change and benchmarking of practice.
Thorax. 2018;73:125–33. https://doi.org/10.1136/thoraxjnl-2017-210217. Perth: Curtin University; 2013.
13. Khandelwal N, Hough CL, Downey L, Engelberg RA, Carson SS, White 36. Davis J, Crawford K, Wierman H, Osgood W, Cavanaugh J, Smith KA, et al.
DB, et al. Prevalence, risk factors, and outcomes of financial stress in Mobilization of ventilated older adults. J Geriatr Phys Ther. 2013;36:162–8.
survivors of critical illness. Crit Care Med. 2018;46:e530–9. https://doi. https://doi.org/10.1519/JPT.0b013e31828836e7.
org/10.1097/CCM.0000000000003076. 37. Hodgson CL, Bailey M, Bellomo R, Berney S, Buhr H, Denehy L, et al. A
14. Lone NI, Walsh TS. Prolonged mechanical ventilation in critically ill patients: binational multicenter pilot feasibility randomized controlled trial of early
epidemiology, outcomes and modelling the potential cost consequences of goal-directed mobilization in the ICU. Crit Care Med. 2016;44:1145–52.
establishing a regional weaning unit. Crit Care. 2011;15:R102. https://doi.org/10.1097/CCM.0000000000001643.
15. Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU 38. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory
occupancy and mechanical ventilator use in the United States. Crit Care failure increase ambulation after transfer to an intensive care unit where
Med. 2013;41:2712–9. early activity is a priority. Crit Care Med. 2008;36:1119–24.
16. Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, 39. McWilliams D, Atkins G, Hodson J, Snelson C. The Sara Combilizer® as
et al. Functional disability 5 years after acute respiratory distress syndrome. an early mobilisation aid for critically ill patients: a prospective before
N Engl J Med. 2011;364:1293–304. and after study. Aust Crit Care. 2017;30:189–95. https://doi.org/10.1016/j.
17. Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, aucc.2016.09.001.
Needham DM. Neuromuscular dysfunction acquired in critical illness: a 40. McWilliams D, Jones C, Atkins G, Hodson J, Whitehouse T, Veenith T, et al.
systematic review. Intensive Care Med. 2007;33:1876–91. https://doi.org/10. Earlier and enhanced rehabilitation of mechanically ventilated patients in
1007/s00134-007-0772-2. critical care: a feasibility randomised controlled trial. J Crit Care. 2018;44:407–
18. Griffiths RD, Hall JB. Exploring intensive care unit-acquired weakness. Crit 12. https://doi.org/10.1016/j.jcrc.2018.01.001.
Care Med. 2009;37(10 Suppl):S295. 41. Bakhru RN, Wiebe DJ, McWilliams DJ, Spuhler VJ, Schweickert WD. An
19. Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med. environmental scan for early mobilization practices in U.S. ICUs. Crit Care
2010;38:779–87. Med. 2015;43:2360–9. https://doi.org/10.1097/CCM.0000000000001262.
20. Lipshutz AKM, Gropper MA. Acquired neuromuscular weakness and 42. Hickmann CE, Castanares-Zapatero D, Bialais E, Dugernier J, Tordeur A,
early mobilization in the intensive care unit. Anesthesiology. 2013;118: Colmant L, et al. Teamwork enables high level of early mobilization in
202–15. critically ill patients. Ann Intensive Care. 2016;6:80. https://doi.org/10.1186/
21. Hermans G, Van Mechelen H, Clerckx B, Vanhullebusch T, Mesotten D, s13613-016-0184-y.
Wilmer A, et al. Acute outcomes and 1-year mortality of intensive care unit- 43. Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical intensive care unit
acquired weakness. A cohort study and propensity-matched analysis. Am J clinician attitudes and perceived barriers towards early mobilization of
Respir Crit Care Med. 2014;190:410–20. critically ill patients: a cross-sectional survey study. BMC Anesthesiol. 2014;
22. Latronico N, Piva S, McCredie V. Long-term implications of ICU-acquired 14:84. https://doi.org/10.1186/1471-2253-14-84.
muscle weakness. In: Stevens RD, Hart N, Herridge MS, editors. Textbook of 44. Weeks A, Campbell C, Rajendram P, Shi W, Voigt LP. A descriptive report of
post-ICU medicine: the legacy of critical care. Oxford: Oxford University early mobilization for critically ill ventilated patients with cancer. Rehabil
Press; 2014. p. 259–68. Oncol. 2017;35:144–50. https://doi.org/10.1097/01.REO.0000000000000070.
23. Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, et al. 45. Patel BK, Pohlman AS, Hall JB, Kress JP. Impact of early mobilization on
Diaphragmatic dysfunction in patients with ICU-acquired weakness and its glycemic control and ICU-acquired weakness in critically ill patients who are
impact on extubation failure. Intensive Care Med. 2016;42:853–61. mechanically ventilated. Chest. 2014;146:583–9. https://doi.org/10.1378/
24. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early chest.13-2046.
activity is feasible and safe in respiratory failure patients. Crit Care Med. 46. Dantas CM, Silva PF, Siqueira FH, RMF P, Matias S, Maciel C, et al. Influence
2007;35:139–45. https://doi.org/10.1097/01.CCM.0000251130.69568.87. of early mobilization on respiratory and peripheral muscle strength in
25. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, critically ill patients. Rev Bras Ter Intensiva. 2012;24:173–8. https://doi.org/10.
et al. Early physical and occupational therapy in mechanically ventilated, 1590/S0103-507X2012000200013.
critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–82. 47. Ota H, Kawai H, Sato M, Ito K, Fujishima S, Suzuki H. Effect of early
https://doi.org/10.1016/S0140-6736(09)60658-9. mobilization on discharge disposition of mechanically ventilated patients. J
26. Pohlman MC, Schweickert WD, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Phys Ther Sci. 2015;27:859–64. https://doi.org/10.1589/jpts.27.859.
et al. Feasibility of physical and occupational therapy beginning from 48. The TEAM Study Investigators. Early mobilization and recovery in
initiation of mechanical ventilation. Crit Care Med. 2010;38:2089–94. https:// mechanically ventilated patients in the ICU: a bi-national, multi-centre,
doi.org/10.1097/CCM.0b013e3181f270c3. prospective cohort study. Crit Care. 2015;19:81. https://doi.org/10.1186/
27. Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, et s13054-015-0765-4.
al. Expert consensus and recommendations on safety criteria for active 49. Winkelman C, Johnson KD, Hejal R, Gordon NH, Rowbottom J, Daly J, et al.
mobilization of mechanically ventilated critically ill adults. Crit Care. 2014;18: Examining the positive effects of exercise in intubated adults in ICU: a
658. https://doi.org/10.1186/s13054-014-0658-y. prospective repeated measures clinical study. Intensive Crit Care Nurs. 2012;
28. Major ME, Kwakman R, Kho ME, Connolly B, McWilliams D, Denehy L, et al. 28:307–18. https://doi.org/10.1016/j.iccn.2012.02.007.
Surviving critical illness: what is next? An expert consensus statement on 50. Curtis L, Irwin J. Ambulation of patients who are mechanically ventilated:
physical rehabilitation after hospital discharge Crit Care. 2016;20:354. https:// nurses’ views. Nurs Manag. 2017;24:34–9.
doi.org/10.1186/s13054-016-1508-x. 51. Bahadur K, Jones G, Ntoumenopoulos G. An observational study of sitting
29. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv out of bed in tracheostomised patients in the intensive care unit.
Nurs. 2005;52:546–53. Physiotherapy. 2008;94:300–5. https://doi.org/10.1016/j.physio.2008.08.003.
30. Torraco RJ. Writing integrative literature reviews: guidelines and examples. 52. Harrold ME, Salisbury LG, Webb SA, Allison GT. Early mobilisation in
Hum Resour Dev Rev. 2005;4:356–67. intensive care units in Australia and Scotland: a prospective, observational
31. PRISMA. PRISMA 2009 Flow Diagram. 2009. http://www.prisma-statement. cohort study examining mobilisation practises and barriers. Crit Care. 2015;
org/documents/PRISMA 2009 flow diagram.pdf. Accessed 10 Nov 2016. 19:336. https://doi.org/10.1186/s13054-015-1033-3.
53. Verceles AC, Wells CL, Sorkin JD, Terrin ML, Beans J, Jenkins T, et al. A 72. Chen S, Su C-L, Wu Y-T, Wang L-Y, Wu C-P, Wu H-D, et al. Physical training
multimodal rehabilitation program for patients with ICU acquired weakness is beneficial to functional status and survival in patients with prolonged
improves ventilator weaning and discharge home. J Crit Care. 2018;47:204– mechanical ventilation. J Formos Med Assoc. 2011;110:572–9.
10. https://doi.org/10.1016/j.jcrc.2018.07.006. 73. Chiang L-L, Wang L-Y, Wu C-P, Wu H-D, Wu Y-T. Effects of physical training
54. Taito S, Shime N, Yasuda H, Ota K, Sarada K, Lefor AK, et al. Out-of-bed on functional status in patients with prolonged mechanical ventilation. Phys
mobilization of patients undergoing mechanical ventilation with orotracheal Ther. 2006;86:1271–81.
tubes: a survey study. J Crit Care. 2018;47:173–7. https://doi.org/10.1016/j. 74. Martin UJ, Hincapie L, Nimchuk M, Gaughan J, Criner GJ. Impact of
jcrc.2018.06.022. whole-body rehabilitation in patients receiving chronic mechanical
55. Phelan S, Lin F, Mitchell M, Chaboyer W. Implementing early mobilisation in ventilation. Crit Care Med. 2005;33:2259–65. https://doi.org/10.1097/01.
the intensive care unit: an integrative review. Int J Nurs Stud. 2017;2018(77): CCM.0000181730.02238.9B.
91–105. https://doi.org/10.1016/j.ijnurstu.2017.09.019. 75. Clini EM, Crisafulli E, Antoni FD, Beneventi C, Trianni L, Costi S, et al.
56. Bakhru RN, McWilliams DJ, Wiebe DJ, Spuhler VJ, Schweickert WD. Intensive Functional recovery following physical training in tracheotomized and
care unit structure variation and implications for early mobilization practices. chronically ventilated patients. Respir Care. 2011;56:306–13. https://doi.org/
An international survey. Ann Am Thorac Soc. 2016;13:1527–37. https://doi. 10.4187/respcare.00956.
org/10.1513/AnnalsATS.201601-078OC. 76. Berney SC, Rose JW, Bernhardt J, Denehy L. Prospective observation of
57. Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, et al. physical activity in critically ill patients who were intubated for more
Intensive care unit mobility practices in Australia and New Zealand: a point than 48 hours. J Crit Care. 2015;30:658–63. https://doi.org/10.1016/j.jcrc.
prevalence study. Crit Care Resusc. 2013;15:260–5. 2015.03.006.
58. Dinglas VD, Parker AM, Reddy DRS, Colantuoni E, Zanni JM, Turnbull AE, 77. Jolley SE, Moss M, Needham DM, Caldwell E, Morris PE, Miller RR, et al. Point
et al. A quality improvement project sustainably decreased time to prevalence study of mobilization practices for acute respiratory failure
onset of active physical therapy intervention in patients with acute patients in the United States. Crit Care Med. 2017;45:205–15. https://doi.org/
lung injury. Ann Am Thorac Soc. 2014;11:1230–8. https://doi.org/10. 10.1097/CCM.0000000000002058.
1513/AnnalsATS.201406-231OC. 78. Sibilla A, Nydahl P, Greco N, Mungo G, Ott N, Unger I, et al. Mobilization of
59. Li Z, Peng X, Zhu B, Zhang Y, Xi X. Active mobilization for mechanically mechanically ventilated patients in Switzerland. J Intensive Care Med. 2017:
ventilated patients: a systematic review. Arch Phys Med Rehabil. 2013;94: 088506661772848. https://doi.org/10.1177/0885066617728486.
551–61. https://doi.org/10.1016/j.apmr.2012.10.023. 79. Yang P-H, Wang C-S, Wang Y-C, Yang C-J, Hung J-Y, Hwang J-J, et al.
60. Dinglas VD, Colantuoni E, Ciesla N, Mendez-Tellez PA, Shanholtz C, Outcome of physical therapy intervention on ventilator weaning and
Needham DM. Occupational therapy for patients with acute lung injury: functional status. Kaohsiung J Med Sci. 2010;26:366–72. https://doi.org/10.
factors associated with time to first intervention in the intensive care unit. 1016/S1607-551X(10)70060-7.
Am J Occup Ther. 2013;67:355–62. https://doi.org/10.5014/ajot.2013.007807. 80. Sarfati C, Moore A, Pilorge C, Amaru P, Mendialdua P, Rodet E, et al.
61. Holdsworth C, Haines KJ, Francis JJ, Marshall A, O’Connor D, Skinner EH. Efficacy of early passive tilting in minimizing ICU-acquired weakness: a
Mobilization of ventilated patients in the intensive care unit: an elicitation randomized controlled trial. J Crit Care. 2018;46:37–43. https://doi.org/
study using the theory of planned behavior. J Crit Care. 2015;30:1243–50. 10.1016/j.jcrc.2018.03.031.
https://doi.org/10.1016/j.jcrc.2015.08.010. 81. Goddard SL, Lorencatto F, Koo E, Rose L, Fan E, Kho ME, et al. Barriers and
62. Dunn H, Quinn L, Corbridge SJ, Eldeirawi K, Kapella M, Collins EG. facilitators to early rehabilitation in mechanically ventilated patients—a
Mobilization of prolonged mechanical ventilation patients: an integrative theory-driven interview study. J Intensive Care. 2018;6:4. https://doi.org/10.
review. Hear Lung J Acute Crit Care. 2017;46:221–33. https://doi.org/10. 1186/s40560-018-0273-0.
1016/j.hrtlng.2017.04.033. 82. Wright SE, Thomas K, Watson G, Baker C, Bryant A, Chadwick TJ, et al.
63. de Queiroz RS, Saquetto MB, Martinez BP, Andrade EA, da Silva PAMP, Intensive versus standard physical rehabilitation therapy in the critically
Gomes-Neto M. Evaluation of the description of active mobilisation ill (EPICC): a multicentre, parallel-group, randomised controlled trial.
protocols for mechanically ventilated patients in the intensive care unit: a Thorax. 2017;73(3):213–21, thoraxjnl-2016-209858. https://doi.org/10.1136/
systematic review of randomized controlled trials. Hear Lung. 2018;47:253– thoraxjnl-2016-209858.
60. https://doi.org/10.1016/j.hrtlng.2018.03.003. 83. Liu K, Ogura T, Takahashi K, Nakamura M, Ohtake H, Fujiduka K, et al. The
64. Bourdin G, Barbier J, Burle J-F, Durante G, Passant S, Vincent B, et al. The safety of a novel early mobilization protocol conducted by ICU physicians: a
feasibility of early physical activity in intensive care unit patients: a prospective observational study. J Intensive Care. 2018;6:10. https://doi.org/
prospective observational one-center study. Respir Care. 2010;55:400–7. 10.1186/s40560-018-0281-0.
65. Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr H-J, et al. 84. Morris PE, Berry MJ, Files DC, Thompson JC, Hauser J, Flores L, et al.
Early mobilization of mechanically ventilated patients: a 1-day point- Standardized rehabilitation and hospital length of stay among patients with
prevalence study in Germany. Crit Care Med. 2014;42:1178–86. https:// acute respiratory failure. JAMA. 2016;315:2694. https://doi.org/10.1001/jama.
doi.org/10.1097/CCM.0000000000000149. 2016.7201.
66. McWilliams D, Weblin J, Atkins G, Bion J, Williams J, Elliott C, et al. 85. Collings N, Cusack R. A repeated measures, randomised cross-over trial,
Enhancing rehabilitation of mechanically ventilated patients in the intensive comparing the acute exercise response between passive and active sitting
care unit: a quality improvement project. J Crit Care. 2015;30:13–8. https:// in critically ill patients. BMC Anesthesiol. 2015;15:1. https://doi.org/10.1186/
doi.org/10.1016/j.jcrc.2014.09.018. 1471-2253-15-1.
67. Dong Z, Yu B, Sun Y, Fang W, Li L. Effects of early rehabilitation therapy on 86. Zanni JM, Korupolu R, Fan E, Pradhan P, Janjua K, Palmer JB, et al.
patients with mechanical ventilation. World J Emerg Med. 2014;5:48. https:// Rehabilitation therapy and outcomes in acute respiratory failure: an
doi.org/10.5847/wjem.j.issn.1920-8642.2014.01.008. observational pilot project. J Crit Care. 2010;25:254–62.
68. Camargo Pires-Neto R, Lima NP, Cardim GM, Park M, Denehy L. Early 87. Lai C-C, Chou W, Chan K-S, Cheng K-C, Yuan K-S, Chao C-M, et al. Early
mobilization practice in a single Brazilian intensive care unit. J Crit Care. mobilization reduces duration of mechanical ventilation and intensive
2015;30:896–900. https://doi.org/10.1016/j.jcrc.2015.05.004. care unit stay in patients with acute respiratory failure. Arch Phys Med
69. Skinner EH, Haines KJ, Berney S, Warrillow S, Harrold M, Denehy L. Usual Rehabil. 2017;98:931–9. https://doi.org/10.1016/j.apmr.2016.11.007.
care physiotherapy during acute hospitalization in subjects admitted to the 88. Barber EA, Everard T, Holland AE, Tipping C, Bradley SJ, Hodgson CL.
ICU: an observational cohort study. Respir Care. 2015;60:1476–85. Barriers and facilitators to early mobilisation in intensive care: a
70. Toccolini BF, Osaku EF, de Macedo Costa CRL, Teixeira SN, Costa NL, Cândia qualitative study. Aust Crit Care. 2015;28:177–82. https://doi.org/10.1016/
MF, et al. Passive orthostatism (tilt table) in critical patients: j.aucc.2014.11.001.
Clinicophysiologic evaluation. J Crit Care. 2015;30:655.e1. 89. Morris PE, Berry MJ, Files DC, Thompson JC, Hauser J, Flores L, et al.
71. Witcher R, Stoerger L, Dzierba AL, Silverstein A, Rosengart A, Brodie D, Standardized rehabilitation and hospital length of stay among patients with
et al. Effect of early mobilization on sedation practices in the acute respiratory failure: a randomized clinical trial. JAMA. 2016;315:2694–
neurosciences intensive care unit: a preimplementation and 702. https://doi.org/10.1001/jama.2016.7201.
postimplementation evaluation. J Crit Care. 2015;30:344–7. https://doi. 90. Medrinal C, Combret Y, Prieur G, Robledo Quesada A, Bonnevie T, Gravier
org/10.1016/j.jcrc.2014.12.003. FE, et al. Comparison of exercise intensity during four early rehabilitation
techniques in sedated and ventilated patients in ICU: a randomised cross- 111. Levine S, Nguyen T, Taylor N, Friscia M, Budak M, Rothenberg P, et al. Rapid
over trial. Crit Care. 2018;22:1–8. diuse atrophy of diaphragm fibers in mechanically ventilated humans. N
91. Ringdal M, Warren Stomberg M, Egnell K, Wennberg E, Zätterman R, Engl J Med. 2008;358:1327–35.
Rylander C. In-bed cycling in the ICU; patient safety and recollections with 112. Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C, et al. Rapidly
motivational effects. Acta Anaesthesiol Scand. 2018;62:658–65. https://doi. progressive diaphragmatic weakness and injury during mechanical
org/10.1111/aas.13070. ventilation in humans. Am J Respir Crit Care Med. 2011;183:364–71.
92. Camargo Pires-Neto R, Fogaça Kawaguchi YM, Sayuri Hirota A, Fu C, Tanaka C, 113. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, et al.
Caruso P, et al. Very early passive cycling exercise in mechanically ventilated Acute skeletal muscle wasting in critical illness. JAMA. 2013;310:1591.
critically ill patients: physiological and safety aspects - a case series. PLoS One. https://doi.org/10.1001/jama.2013.278481.
2013;8:e74182. https://doi.org/10.1371/journal.pone.0074182. 114. Parry SM, El-Ansary D, Cartwright MS, Sarwal A, Berney S, Koopman R, et al.
93. Dong Z, Yu B, Zhang Q, Pei H, Xing J, Fang W, et al. Early rehabilitation Ultrasonography in the intensive care setting can be used to detect
therapy is beneficial for patients with prolonged mechanical ventilation changes in the quality and quantity of muscle and is related to muscle
after coronary artery bypass surgery. Int Heart J. 2016;57:241–6. https://doi. strength and function. J Crit Care. 2015;30:1151.e9–1151.e14.
org/10.1536/ihj.15-316. 115. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence
94. Winkelman C, Sattar A, Momotaz H, Johnson KD, Morris P, Rowbottom JR, et based practice: a conceptual framework. Qual Saf Heal Care. 1998;7:149–58.
al. Dose of early therapeutic mobility: does frequency or intensity matter. https://doi.org/10.1136/qshc.7.3.149.
Biol Res Nurs. 2018;20:522–30. https://doi.org/10.1177/1099800418780492. 116. Eakin MN, Ugbah L, Arnautovic T, Parker AM, Needham DM. Implementing
95. Kayambu G, Boots R, Paratz J. Early physical rehabilitation in intensive care and sustaining an early rehabilitation program in a medical intensive care
patients with sepsis syndromes: a pilot randomised controlled trial. Intensive unit: a qualitative analysis. J Crit Care. 2015;30:698–704. https://doi.org/10.
Care Med. 2015;41:865–74. https://doi.org/10.1007/s00134-015-3763-8. 1016/j.jcrc.2015.03.019.
96. Chen Y-H, Lin H-L, Hsiao H-F, Chou L-T, Kao K-C, Huang C-C, et al. Effects of 117. Medical Research Council. Developing and evaluating complex
exercise training on pulmonary mechanics and functional status in patients interventions: new guidance, vol. 2008; 2008. https://www.mrc.ac.uk/
with prolonged mechanical ventilation. Respir Care. 2012;57:727–34. https:// documents/pdf/complex-interventions-guidance/. Accessed 6 Mar 2018
doi.org/10.4187/respcare.01341. 118. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process
97. Nordon-Craft A, Schenkman M, Ridgeway K, Benson A, Moss M. Physical evaluation of complex interventions: Medical Research Council guidance.
therapy management and patient outcomes following ICU-acquired BMJ. 2015;350(mar19 6):h1258. https://doi.org/10.1136/bmj.h1258.
weakness: a case series. J Neurol Phys Ther. 2011;35:133–40.
98. Parry SM, Remedios L, Denehy L, Knight LD, Beach L, Rollinson TC, et al.
What factors affect implementation of early rehabilitation into intensive care
unit practice? A qualitative study with clinicians. J Crit Care. 2017;38:137–43.
https://doi.org/10.1016/j.jcrc.2016.11.005.
99. Williams N, Flynn M. An exploratory study of physiotherapists’ views of early
rehabilitation in critically ill patients. Physiother Pract Res. 2013;34:93–102.
100. Jolley SE, Dale CR, Hough CL. Hospital-level factors associated with report of
physical activity in patients on mechanical ventilation across Washington
State. Ann Am Thorac Soc. 2015;12:209–15.
101. Schaller SJ, Anstey M, Blobner M, Edrich T, Grabitz SD, Gradwohl-Matis I, et
al. Early, goal-directed mobilisation in the surgical intensive care unit: a
randomised controlled trial. Lancet. 2016;388:1377–88. https://doi.org/10.
1016/S0140-6736(16)31637-3.
102. Ronnebaum JA, Weir JP, Hilsabeck TA. Earlier mobilization decreases the
length of stay in the intensive care unit. J Acute Care Phys Ther. 2013;3:204–
10. https://doi.org/10.1097/01592394-201303020-00005.
103. Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, et
al. Early physical medicine and rehabilitation for patients with acute
respiratory failure: a quality improvement project. Arch Phys Med Rehabil.
2010;91:536–42. https://doi.org/10.1016/j.apmr.2010.01.002.
104. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early
intensive care unit mobility therapy in the treatment of acute respiratory
failure. Crit Care Med. 2008;36:2238–43. https://doi.org/10.1097/CCM.
0b013e318180b90e.
105. Malkoç M, Karadibak D, Yldrm Y. The effect of physiotherapy on ventilatory
dependency and the length of stay in an intensive care unit. Int J Rehabil
Res. 2009;32:85–8. https://doi.org/10.1097/MRR.0b013e3282fc0fce.
106. Mendez-Tellez PA, Dinglas VD, Colantuoni E, Ciesla N, Sevransky JE,
Shanholtz C, et al. Factors associated with timing of initiation of physical
therapy in patients with acute lung injury. J Crit Care. 2013;28:980–4. https://
doi.org/10.1016/j.jcrc.2013.06.001.
107. Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise
prescription in Australian intensive care units. Physiotherapy. 2008;94:220–9.
108. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.
Developing and evaluating complex interventions: the new Medical
Research Council guidance. Int J Nurs Stud. 2013;50:587–92. https://doi.org/
10.1016/j.ijnurstu.2012.09.010.
109. Glasziou P, Meats E, Heneghan C, Shepperd S. What is missing from
descriptions of treatment in trials and reviews. BMJ. 2008;336:1472–4.
https://doi.org/10.1136/bmj.39590.732037.47.
110. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock
SJ, et al. Strengthening the reporting of observational studies in
epidemiology (STROBE): explanation and elaboration. Int J Surg. 2014;12:
1500–24. https://doi.org/10.1016/j.ijsu.2014.07.014.

Early Mobilisation in Mechanically Ventilated Patients: A Systematic Integrative Review of Definitions and Activities

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Early Mobilisation in Mechanically Ventilated Patients: A Systematic Integrative Review of Definitions and Activities

Uploaded by

Copyright:

Available Formats

Clarissa et al.

Journal of Intensive Care (2019) 7:3

RESEARCH Open Access

Early mobilisation in mechanically

Background The reality of post-intensive care creates challenges

Fig. 1 PRISMA flow diagram (PRISMA 2009)

Table 1 Inclusion and exclusion criteria used in this review

similarities/patterns do these codes imply?’ The devel- Themes

Table 5 A chronological summary of included studies

Table 5 A chronological summary of included studies (Continued)

Table 5 A chronological summary of included studies (Continued)

Table 5 A chronological summary of included studies (Continued)

Table 5 A chronological summary of included studies (Continued)

experts reach consensus on a formal and consistent def- Acknowledgements

Received: 23 October 2018 Accepted: 11 December 2018

You might also like