THERAPY Magazin
Use of the bed bike as part of early mobilisation in the intensive care unit
Discover how the bed bike can aid early mobilisation in intensive care units—boosting recovery, reducing hospital stays and easing staff workload. A promising tool backed by evidence and practical experience.
Tobias Giebler
Intensive care medicine and neurosurgery expert, Tübingen University Hospital
A recent meta-analysis highlights the benefit
“Life is like riding a bicycle. To keep your balance, you must keep moving.” This quote by Albert Einstein from 1930 also seems to apply to the functional principle of the critically ill human body. The cycling movement could potentially help severely ill patients regain balance.
Early mobilisation, defined as the initiation of movement within the first 72 hours, is critical [10], as it is associated with a low risk [6] and offers particularly long-term benefits [12]. The aim of early mobilisation in intensive care units is to minimise impairments following a critical illness and to restore mobility and autonomy as early as possible for an active and self-determined participation in life. It can also reduce the length of hospital stays and positively influence weaning from ventilatory support and other organ replacement procedures [11, 14].
Early mobilisation, defined as the initiation of movement within the first 72 hours, is critical [10], as it is associated with a low risk [6] and offers particularly long-term benefits [12]. The aim of early mobilisation in intensive care units is to minimise impairments following a critical illness and to restore mobility and autonomy as early as possible for an active and self-determined participation in life. It can also reduce the length of hospital stays and positively influence weaning from ventilatory support and other organ replacement procedures [11, 14].
The bed bike enables safe early mobilisation even during ventilation and when bedridden.
The positive effects of early mobilisation of patients in intensive care are clearly outlined in the systematic review and meta-analysis by Wang et al [14]. Included were 39 studies with a total of 3,837 patients.
The overall results of the review show:
2.1 fewer ventilation days,
2.7 fewer days in the intensive care unit, Hospital stay reduced by 3.7 days,
12% more muscle power,
13% more patients regain independence in terms of care.
The overall results of the review show:
2.1 fewer ventilation days,
2.7 fewer days in the intensive care unit, Hospital stay reduced by 3.7 days,
12% more muscle power,
13% more patients regain independence in terms of care.
Current scientific findings on early mobilisation
The expansion of knowledge has increased significantly in recent years driven by the publication of numerous scientific papers. Not least, the S3 guideline on Lagerungstherapie und Mobilisation von kritisch Erkrankten auf Intensivstationen (Positioning therapy and mobilisation of critically ill patients in intensive care units), published in July 2023 by the Deutsche Gesellschaft für Anasthesiologie und Intensivmedizin e.V. (DGAI) (German Society for Anaesthesiology and Intensive Care Medicine) [10], emphasises the effects and the importance of early mobilisation in intensive care units at a high level.
The expansion of knowledge has increased significantly in recent years driven by the publication of numerous scientific papers. Not least, the S3 guideline on Lagerungstherapie und Mobilisation von kritisch Erkrankten auf Intensivstationen (Positioning therapy and mobilisation of critically ill patients in intensive care units), published in July 2023 by the Deutsche Gesellschaft für Anasthesiologie und Intensivmedizin e.V. (DGAI) (German Society for Anaesthesiology and Intensive Care Medicine) [10], emphasises the effects and the importance of early mobilisation in intensive care units at a high level.
Challenges posed by the skills shortage
At a time of skills shortages, which have been shown to hinder early mobilisation [1], the potential of technical aids is gaining increasing attention.
The current evidence for the use of the bed bike in early mobilisation is examined in more detail below. The focus is on clinical studies and empirical findings that investigate the benefit of this method. In particular, the effects on functional outcomes, muscle preservation, cardiovascular stability and the reduction of complications, such as deconditioning or delirium, are analysed. Furthermore, possible areas of application as well as limitations and challenges in practical implementation are discussed.
At a time of skills shortages, which have been shown to hinder early mobilisation [1], the potential of technical aids is gaining increasing attention.
The current evidence for the use of the bed bike in early mobilisation is examined in more detail below. The focus is on clinical studies and empirical findings that investigate the benefit of this method. In particular, the effects on functional outcomes, muscle preservation, cardiovascular stability and the reduction of complications, such as deconditioning or delirium, are analysed. Furthermore, possible areas of application as well as limitations and challenges in practical implementation are discussed.
Guideline recommendation over time
Whereas the most recent S2e guideline on “Positioning therapy and early mobilisation in prophylaxis or therapy of pulmonary disorders“ by the DGAI [9] recommended the bed bike across a wide range of applications – from passive to resistive use – for nearly all patients, the current S3 guideline [10] takes a more cautious approach in its recommendations.
The guideline authors justify this with hete-rogeneous study protocols, particularly with regard to the control groups and treatment outcomes, making it currently impossible to give a clear recommendation.
As such, the new S3 guideline states: “We are currently unable to make a recommendation for the use of a bed bike as an adjunct to mobilisation.” In a further passage, however, it is noted: “We suggest considering the use of a bed bike as part of early mobilisation only if functional training is not sufficiently possible.” Moreover, the fundamental prioritisation remains the same: “An earlier start of therapy should be preferred over a later start, active training is preferable to passive movement therapy.”
This makes it clear that the S3 guideline does not directly adopt the earlier, broader recommendation of the S2e guideline, but instead calls for a more differentiated assessment, in which the indication for the use of the bed bike should be determined more specifically.
Whereas the most recent S2e guideline on “Positioning therapy and early mobilisation in prophylaxis or therapy of pulmonary disorders“ by the DGAI [9] recommended the bed bike across a wide range of applications – from passive to resistive use – for nearly all patients, the current S3 guideline [10] takes a more cautious approach in its recommendations.
The guideline authors justify this with hete-rogeneous study protocols, particularly with regard to the control groups and treatment outcomes, making it currently impossible to give a clear recommendation.
As such, the new S3 guideline states: “We are currently unable to make a recommendation for the use of a bed bike as an adjunct to mobilisation.” In a further passage, however, it is noted: “We suggest considering the use of a bed bike as part of early mobilisation only if functional training is not sufficiently possible.” Moreover, the fundamental prioritisation remains the same: “An earlier start of therapy should be preferred over a later start, active training is preferable to passive movement therapy.”
This makes it clear that the S3 guideline does not directly adopt the earlier, broader recommendation of the S2e guideline, but instead calls for a more differentiated assessment, in which the indication for the use of the bed bike should be determined more specifically.
Safety and areas of application
Safe feasibility is confirmed. However, close monitoring is recommended for neurologically affected patients with a risk of increased intracranial pressure [13].
Evidence of positive effects of the bed bike in the context of early mobilisation is found particularly in patients following planned cardiac surgical interventions [8]. Furthermore, studies suggest that the use of the bed bike in acute lung failure can be associated with a shorter duration of ventilation, a reduced stay in the intensive care unit and an improved functional recovery [15].
Safe feasibility is confirmed. However, close monitoring is recommended for neurologically affected patients with a risk of increased intracranial pressure [13].
Evidence of positive effects of the bed bike in the context of early mobilisation is found particularly in patients following planned cardiac surgical interventions [8]. Furthermore, studies suggest that the use of the bed bike in acute lung failure can be associated with a shorter duration of ventilation, a reduced stay in the intensive care unit and an improved functional recovery [15].
New scientific findings
In October 2024, the European Society of Intensive Care Medicine published an article on the use of the bed bike in intensive care units. The underlying systematic review and meta-analysis appeared in the prestigious New England Journal of Medicine, one of the journals with the second-highest impact factor in general and internal medicine [7].
In October 2024, the European Society of Intensive Care Medicine published an article on the use of the bed bike in intensive care units. The underlying systematic review and meta-analysis appeared in the prestigious New England Journal of Medicine, one of the journals with the second-highest impact factor in general and internal medicine [7].
Patients with mobility restrictions particularly benefit from the bed bike.
The study entitled Leg Cycle Ergometry in Critically Ill Patients – An Updated Systematic Review and Meta-Analysis considered 33 randomised controlled trials (RCTs) from 13 countries. In total, data was analysed from 3,272 adult patients who were at least 18 years old and received care in an intensive care unit (ICU) for more than 24 hours.
Subject of investigation of the studies
Cycling as part of a multi-component intervention (n=15, 45%)
Cycling & conventional physiotherapy (n=11, 33%)
Cycling alone (n=4, 12%)
Cycling plus electrical stimulation & conventional physiotherapy (n=3, 9%)
Cycling as part of a multi-component intervention (n=15, 45%)
Cycling & conventional physiotherapy (n=11, 33%)
Cycling alone (n=4, 12%)
Cycling plus electrical stimulation & conventional physiotherapy (n=3, 9%)
Application methods of the bed bike
The bed bike was most commonly scheduled for use 5 times per week (n=9).
The bed bike was mostly used up to 1x daily (n=17, corresponding to 52%), closely followed by 2x daily (n=14, corresponding to 42%).
The application duration varied between 3 and 60 minutes (information available in 91% of all studies)
The bed bike was most commonly scheduled for use 5 times per week (n=9).
The bed bike was mostly used up to 1x daily (n=17, corresponding to 52%), closely followed by 2x daily (n=14, corresponding to 42%).
The application duration varied between 3 and 60 minutes (information available in 91% of all studies)
Positive effects of the bed bike in early mobilisation
The current meta-analysis shows that the use of the bed bike in intensive care units can potentially have positive effects on functional recovery and length of hospital stay.
Physical function at discharge from the intensive care unit: The use of the bed bike probably improves physical function upon discharge from the ICU (12 RCTs, 1,291 patients; SMD 0.33; 95% CI 0.05 to 0.62; low evidence). The assessment was conducted using established measurement tools such as the Physical Function in ICU Test (PFIT), the ICU Mobility Scale (IMS) and the Functional Status Score for the Intensive Care Unit (FSS-ICU).
Physical function upon discharge from hospital: There is evidence to suggest that the bed bike probably also improves physical function at hospital discharge (8 RCTs, 865 patients; SMD 0.23; 95% CI 0.04 to 0.42; low evidence). Here, in addition to the PFIT, the 6-minute or 2-minute walk test as well as the 36-Item Short-Form Health Survey (SF-36) were also used.
Reduction in length of stay in the intensive care unit: The use of the bed bike may potentially reduce the length of stay in the ICU by an average of 1.06 days (29 RCTs, 2,575 patients; 95% CI 0.33 to 1.80 fewer days; low evidence).
Reduction in hospital length of stay: Similarly, the analysis suggests that the total hospital length of stay can likely be reduced by 1.48 days (22 RCTs, 2,060 patients; 95% CI 0.47 to 2.49 fewer days; moderate evidence).
Muscle power at hospital discharge: The use of the bed bike could increase muscle power at discharge (5 RCTs, 500 patients; SMD 0.40; 95% CI -0.06 to 0.86; low evidence), although the results still show uncertainties here.
The current meta-analysis shows that the use of the bed bike in intensive care units can potentially have positive effects on functional recovery and length of hospital stay.
Physical function at discharge from the intensive care unit: The use of the bed bike probably improves physical function upon discharge from the ICU (12 RCTs, 1,291 patients; SMD 0.33; 95% CI 0.05 to 0.62; low evidence). The assessment was conducted using established measurement tools such as the Physical Function in ICU Test (PFIT), the ICU Mobility Scale (IMS) and the Functional Status Score for the Intensive Care Unit (FSS-ICU).
Physical function upon discharge from hospital: There is evidence to suggest that the bed bike probably also improves physical function at hospital discharge (8 RCTs, 865 patients; SMD 0.23; 95% CI 0.04 to 0.42; low evidence). Here, in addition to the PFIT, the 6-minute or 2-minute walk test as well as the 36-Item Short-Form Health Survey (SF-36) were also used.
Reduction in length of stay in the intensive care unit: The use of the bed bike may potentially reduce the length of stay in the ICU by an average of 1.06 days (29 RCTs, 2,575 patients; 95% CI 0.33 to 1.80 fewer days; low evidence).
Reduction in hospital length of stay: Similarly, the analysis suggests that the total hospital length of stay can likely be reduced by 1.48 days (22 RCTs, 2,060 patients; 95% CI 0.47 to 2.49 fewer days; moderate evidence).
Muscle power at hospital discharge: The use of the bed bike could increase muscle power at discharge (5 RCTs, 500 patients; SMD 0.40; 95% CI -0.06 to 0.86; low evidence), although the results still show uncertainties here.
Despite positive studies, implementation in hospitals is often slow.
Safety and adverse events: The pooled rate of adverse events in the intervention group was only 1% (11 RCTs, 4,623 sessions; 95% CI 0 to 2%; low evidence), suggesting that the bed bike could be a safe tool in the context of early mobilisation.
The minimal time required for an exercise session with the bed bike is highlighted, as well as the possibility of beginning training while bedridden, under sedation and during ventilation.
These results highlight the potential of the bed bike as a supportive measure to promote functional recovery in the intensive care unit, while the body of evidence for some endpoints remains limited.
The minimal time required for an exercise session with the bed bike is highlighted, as well as the possibility of beginning training while bedridden, under sedation and during ventilation.
These results highlight the potential of the bed bike as a supportive measure to promote functional recovery in the intensive care unit, while the body of evidence for some endpoints remains limited.
Its use can reduce the length of stay in the intensive care unit and in hospital.
An effect on the occurrence of intensive care unit-acquired weakness (ICUAW) as well as on mortality in the intensive care unit or in hospital could not be demonstrated. The authors point out that the quality of the underlying evidence and the methodological heterogeneity of the evaluated studies limit the validity of the results.
Discussion about the practical significance and possible applications
The use of a bed bike holds potential for early mobilisation in the intensive care unit, particularly for patients with limited autonomous activity or reduced ability to engage in contact, which makes active participation in therapy more difficult. In these cases, the possibilities for early mobilisation are often limited, and the bed bike can be a suitable measure in the therapy concept.
According to current knowledge, the presence of an endotracheal ventilation tube mentioned in the meta-analysis does not present a barrier to early mobilisation from the bed. The feasibility and safety of this measure have been established for some time [2,4,6]. Nevertheless, implementation in clinical practice lags behind scientific findings, and mechanical ventilation continues to be viewed as a barrier to early mobilisation [3,4,5].
In addition to the scientific findings, there are positive experiences from clinical practice. Patients with painful changes in the lower extremities, for example in connection with severe oedema or intensive care unit-acquired weakness (ICUAW), report that movement with the bed bike is perceived as a pleasant experience and can also contribute to pain relief.
The use of a bed bike holds potential for early mobilisation in the intensive care unit, particularly for patients with limited autonomous activity or reduced ability to engage in contact, which makes active participation in therapy more difficult. In these cases, the possibilities for early mobilisation are often limited, and the bed bike can be a suitable measure in the therapy concept.
According to current knowledge, the presence of an endotracheal ventilation tube mentioned in the meta-analysis does not present a barrier to early mobilisation from the bed. The feasibility and safety of this measure have been established for some time [2,4,6]. Nevertheless, implementation in clinical practice lags behind scientific findings, and mechanical ventilation continues to be viewed as a barrier to early mobilisation [3,4,5].
In addition to the scientific findings, there are positive experiences from clinical practice. Patients with painful changes in the lower extremities, for example in connection with severe oedema or intensive care unit-acquired weakness (ICUAW), report that movement with the bed bike is perceived as a pleasant experience and can also contribute to pain relief.
Observations from daily clinical practice indicate that the use of the bed bike promotes the recovery of stable circulatory regulation and can support the weaning process from cardiovascular-acting medications.
Obese patients in particular benefit significantly from the bed bike. In addition to the positive effects on the cardiovascular system and thrombosis prophylaxis, the bed bike enables effective contracture prophylaxis and the preservation of joint structures, since passive manual movement in this patient group is often only possible to a limited extent or not at all.
Another advantage lies in the minimal time required in relation to the potential benefit. The total time required for a training session – including setup, removal and cleaning – is 15 to 20 minutes. During the training session itself, only supervision and, if necessary, motivation are required, enabling the healthcare professional to prepare additional mobilisation measures or complete documentation tasks. The use of the bed bike can therefore help alleviate staff shortages or free up additional training sessions throughout the day.
Obese patients in particular benefit significantly from the bed bike. In addition to the positive effects on the cardiovascular system and thrombosis prophylaxis, the bed bike enables effective contracture prophylaxis and the preservation of joint structures, since passive manual movement in this patient group is often only possible to a limited extent or not at all.
Another advantage lies in the minimal time required in relation to the potential benefit. The total time required for a training session – including setup, removal and cleaning – is 15 to 20 minutes. During the training session itself, only supervision and, if necessary, motivation are required, enabling the healthcare professional to prepare additional mobilisation measures or complete documentation tasks. The use of the bed bike can therefore help alleviate staff shortages or free up additional training sessions throughout the day.
Conclusion
Although the current S3 guideline on positioning therapy and mobilisation [10] does not provide a comprehensive recommendation for the use of the bed bike as part of early mobilisation, the results of the current meta-analysis [7] as well as practical experience provide arguments for its integration as a component of early mobilisation. Its use is of particular interest in situations where assistive or active participation in therapy is not possible and other early mobilisation measures cannot yet be implemented. The comparatively minimal time required for a therapy session, the very low safety risk, as well as initial indications of positive effects regarding functional improvements and a potential reduction in the length of stay, make the use of the bed bike attractive for both patients and hospitals. Moreover, an implementation could bring economic benefits for the healthcare system.
In order to enable well-founded recommendations for the clinical use of the bed bike as a component of early mobilisation, further stu-
dies with standardised protocols are required.
Although the current S3 guideline on positioning therapy and mobilisation [10] does not provide a comprehensive recommendation for the use of the bed bike as part of early mobilisation, the results of the current meta-analysis [7] as well as practical experience provide arguments for its integration as a component of early mobilisation. Its use is of particular interest in situations where assistive or active participation in therapy is not possible and other early mobilisation measures cannot yet be implemented. The comparatively minimal time required for a therapy session, the very low safety risk, as well as initial indications of positive effects regarding functional improvements and a potential reduction in the length of stay, make the use of the bed bike attractive for both patients and hospitals. Moreover, an implementation could bring economic benefits for the healthcare system.
In order to enable well-founded recommendations for the clinical use of the bed bike as a component of early mobilisation, further stu-
dies with standardised protocols are required.
The minimal time required makes it an effective adjunct to mobilisation.
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THERAPY Magazine
Tobias Giebler
Intensive care medicine and neurosurgery expert, Tübingen University Hospital
Tobias Giebler graduated as a physiotherapist at the University Hospital of Freiburg
in 2013. Due to his several years of working as a paramedic in the emergency services,
he already brought knowledge in dealing with patients in the intensive care unit into
his physiotherapeutic training. He has been working intensively on the topic of early
mobilisation for 9 years. He works at the Tübingen University Hospital in the Therapy
Centre and has been the deputy area expert for intensive care medicine and neurosurgery
since 2023.
References:
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- S2e-Leitlinie der AWMF: (2015). Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.v. (DGAI)
- S3-Leitlinie der AWMF (2023) Lagerungstherapie und Mobilisation von kritisch Erkrankten auf Intensivstationen, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- S3-Leitlinie der AWMF (2020): Einsatz der extrakorporalen Zirkulation (ECLS / ECMO) bei Herz- und Kreislaufversagen, Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG)
- Schweickert WD, Pohlman MC, Pohlman AS et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009
- Waldauf P, Hruskova N, Blahutova B, et al. Functional electrical stimulation-assisted cycle ergometry-based progressive mobility programme for mechanically ventilated patients: randomised controlled trial with 6 months follow-up. Thorax. 2021
- Wang J, Ren D, Liu Y et al. Effects of early mobilization on the prognosis of critically ill patients: A systematic review and meta-analysis, 2020
- Yu L, Jiang JX, Zhang Y, et al. Use of in-bed cycling combined with passive joint activity in acute respiratory failure patients receiving mechanical ventilation. Ann Palliat Med., 2020