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Early Mobilisation in Mechanically Ventilated Patients: A Systematic Integrative Review of Definitions and Activities
Early Mobilisation in Mechanically Ventilated Patients: A Systematic Integrative Review of Definitions and Activities
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
© 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
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(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
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 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
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 6 of 19
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
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 7 of 19
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–
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 13 of 19
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
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 14 of 19
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
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 15 of 19
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
Clarissa et al. Journal of Intensive Care (2019) 7:3 Page 16 of 19
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.
Conclusion
This review highlights the varied definitions of EM-MV References
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