Elsevier

Critical Care Clinics

Volume 23, Issue 1, January 2007, Pages 1-20
Critical Care Clinics

Moving Our Critically Ill Patients: Mobility Barriers and Benefits

https://doi.org/10.1016/j.ccc.2006.11.003Get rights and content

Diagnosis and resuscitation for critically ill patients have improved in the last 25 years, and survival has also increased. With improvements in mortality, the field of critical care has seen increased opportunities to improve posthospital quality of life for survivors of critical illness. This article focuses particularly on how mobilization may improve quality of life for patients.

Section snippets

Mobility as a therapy

Some may view mobility in the context of the resources required to turn an ICU patient in bed for a bath, or pulling the patient back up to the head of the bed, or mobilizing a patient from the bed to a stretcher for transport. Some hospitals have gone as far as instituting a lift team to help bedside caregivers deal with these tasks. It is the intent of the articles in this issue of Critical Care Clinics that the term ICU mobility be equated with exercise and with therapy. In the ICU context,

Impact of inactivity for critically ill patients

The deconditioning effects of acute illness are extrapolated from studies on acute inactivity, with a great deal of the information stemming from studies of young healthy persons put on bed rest in space programs and low-gravity research [9]. Recorded alterations include changes in mood, coordination, muscle strength, balance, and work tolerance [10]. Immobilization of laboratory animals long has been a model of deconditioning investigation. Both of these types of investigations have provided

Mechanisms of muscle pathology in ICU patients

Critically ill patients may lose significant muscle mass by the time of hospital discharge. Herridge and colleagues [7] reported an 18% reduction in body weight by the time of discharge for patients who had acute respiratory distress syndrome (ARDS). Wagenmakers [28] comments that more than 1.5 kg of skeletal muscle mass per day and up to 50% of the total muscle mass in 2 weeks time may be experienced by ICU patients.

Wagenmakers has theorized that a functional denervation may be associated with

Role of ICU-associated neuropathies

Patients with prolonged critical illness are at risk for developing compression neuropathies [37]. Two of the more common compression neuropathies for ICU patients involve the ulnar nerve at the elbow's retrocondylar groove and the peroneal nerve as it passes superficially over the fibular neck. Sensory deficits may be detected when there is involvement of the ulnar nerve, with deficits on the volar and dorsal surfaces of the fourth and fifth digits and weakness of the palmaris brevis, abductor

Effect of ICU inactivity on bone and cardiovascular function

Muscle tissue unfortunately is not alone in demonstrating alterations in ICU patients as a result of immobility. Like muscle, bone and cardiovascular systems respond to acute decreases in physical activity [14], [16], [38], [39], [40], [41]. A concern for ICU-oriented mobility programs will be cardiovascular assessment and optimization of cardiovascular function. Certainly the data from outpatient study show that improvement of physical fitness decreases cardiovascular mortality risk by upwards

Are there data regarding either the positive or negative effects of bed rest?

In a piece published in the early 1940's, Dock [47] noted that in the 19th century, bed rest was offered primarily as treatment of many disorders. For hospitals, there remains an association between beds and patients. Even today, hospitals are identified using the parameter of number of beds.

For many areas of health care, the therapeutic value of bed rest has been questioned [48]. In the postpartum period and for those patients with an uncomplicated MI, safe reductions in hospital stays have

Safety concerns

There are potential reasons why mobility therapy might be withheld by a caregiver early in a patient's ICU stay. ICU caregivers might be concerned that early mobility might risk an immediate adverse event. These events could include a dislodgement of a vascular access device or an endotracheal tube. Applying too aggressive of an ICU mobility program to patients on mechanical ventilation with altered mental status could be viewed by some as a potential for an orthopedic, plastic surgery, or even

Are there benefits to mobility?

In general, studies on inpatient medical rehabilitation are based on patients who survived until the post-ICU setting to qualify for the rehabilitation unit. There is some degree of a selection bias within inpatient rehabilitation studies, because most subjects are those whose performance allowed survival to a floor bed setting. Traditional rehabilitation programs, whether they are conducted in hospital, in a rehabilitation in-patient facility, or as an outpatient facility, do not typically

What is passive range of motion?

When searching through various textbooks, the reader will find fairly consistent, although frequently superficial, definitions of passive ROM. Few definitions offer mechanistic explanations for the proposed goals of passive ROM, that being preservation of the range of the joint. Most definitions reflect that performing passive ROM exercises consists of repeated movement of a joint within the available limits (range) of the joint. There are no studies that set out to specifically determine the

Summary

Mobility has been recognized as a component of primary, secondary, and tertiary prevention of overall disease morbidity and mortality [10]. ICU data are limited as to the role mobility exercise might play in treating the effects of acute illness and acute deconditioning. An increased attention to data generation regarding ICU mobility programs would be necessary to support the notion that ICU deconditioning may be potentially reversible or preventable.

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