
Cover story
Early rehabilitation
Training critically ill patients in intensive care units begins early
For faster regeneration in intensive care units, it is essential that critically ill patients are mobilised as soon as possible. The current guideline on “Positioning therapy and early mobilisation for the prophylaxis or therapy of pulmonary dysfunctions” of the German Society of Anaesthesiology and Intensive Care Medicine [1] recommends that patient mobilisation should begin within the first three days after admission to the intensive care unit and should be carried out twice a day for at least 20 minutes using an algorithm.
Text: Tobias Giebler
Why is it essential for therapy to start quickly?
Immobility, the result of a lack of early mobilisation, has plenty of negative effects on the body. For the cardiovascular system, it means that the resting heart rate increases, the vascular system loses the ability to react adequately to changes in position (orthostatic hypotension) and the risk of developing thrombosis also increases. The musculoskeletal system quickly starts to atrophy. In addition to muscle atrophy, the bones also lose stability, the joint cartilage is under-supplied and the capsular ligaments shrink. The consequences are long-term restricted movement and painful changes in the joints. In terms of the lungs, immobility means reduced ventilation, usually in the lowest areas. The consequences can be a blockage of the secretory duct, the formation of atelectasis and dystelectasis, and ultimately the development of pneumonia. The central nervous system also atrophies if it is not required. Psychological stress also occurs; the incidence of depression, fear, anxiety disorders and delirium increases. PTSD (post-traumatic stress disorder) is often a late complication. Immobility also has negative effects on other organ systems such as the metabolism, the endocrine system, the kidneys and the gastrointestinal tract. Evidence-based effects are reductions in:Delirium, a neuro-psychiatric syndrome with states of confusion affecting 80% of intubated patients. In addition, one-year mortality per day of delirium increases by 10% [6]
- ICUAW (Intensive care unit acquired weakness), a neuromuscular organ failure with muscle weakness extending to plegia and a mortality of up to 60% [6]
- Ventilation time [6]
- ICU length of stay [5]
- Mortality [5]

Early mobilisation guideline
The risk from early mobilisation can therefore be considered negligible, but in any case the opportunities outweigh the risks. So how can it be implemented?The ABCDEF bundle [4] is an evidence-based guide for clinicians with the aim of specifying organisational changes conducive to improved recovery and outcomes for intensive care patients. It explicitly refers to mobilisation. The letters stand for the following: A = Assess, prevent, and manage painB = Both spontaneous awakening & breathing trials
C = Choice of medication management
D = Delirium
E = Early mobilisation & exercise
F = Family engagement and empowerment The main focus here is early mobilisation. It quickly becomes clear, however, that all other points cannot be excluded. For example, an optimal pain and ventilation situation is essential for mobilisation and often has to be adjusted during the process. Within this broader approach, it also becomes clear that early mobilisation is an interdisciplinary task.

- Passive mobilisation
- Active-assisted mobilisation
- Active mobilisation
Focal points of passive mobilisation
- Passive movement in functional patterns
- Promotion of sensory perception with various stimuli and senses (thermal, mechanical, acoustic, vestibular)
- Respiratory therapy in various positions; secretolysis if present, thoracic mobilisation, improvement of ventilation in poorly ventilated areas
- Bed bicycle passive
Focal points of active-assisted mobilisation
- Promoting the beginning of independent activity and using therapeutically
- Assistive movement – if possible, with meaningful actions, e.g. bringing small sticks with water to the mouth
- Developing movement transitions, using the patient’s potential
- Mobilisation in the assisted seat
- Developing core stability, a prerequisite for all higher starting positions.
- Verticalisation, initiation of standing
- Promotion of sensory perception and cognitive training
- Respiratory therapy
Focal points of active mobilisation
- Resistive exercises – according to personal preferences (fun as motivation)
- Practising active movement transitions --> Independence
- Bed bicycle active
- Standing and gait training
- Any form of handling can be used --> Training aspect
Bed Cycling
The patient in focus
In summary, early mobilisation is a challenging team task that requires a high level of motivation of all involved and aims to enable the patient to return to an independent life. Only when all the disciplines involved evaluate and plan together and have a common goal can this task be optimally solved. This requires a systematic approach, good planning and consistent, attentive implementation. Here, the focus must be on the patient, they must always feel safe, well looked after and involved. The surrounding atmosphere plays a decisive role, especially for patients who are not yet fully oriented. The patient needs clear, short instructions. Since processing is usually slowed down, the time for reaction must be created.
At a glance - Summarised
- Critically ill patients should be mobilised promptly – if possible within the first three days. Bed bicycles can be useful aids and make work easier for therapists.
- Early mobilisation, even in intensive care units, has many positive effects – among others, it reduces ventilation time, length of stay in intensive care units and mortality rates. The probability of returning to an independent life increases.
- A lack of exercise leads to a higher resting pulse and an increased risk of thrombosis and has negative effects on bone stability and metabolism. Overall, immobility can lead to movement restrictions in the long term.

Literature
[1] Bein T, Bischoff M, Brückner U et al. (2015). S2e-Leitlinie: „Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).…
[2] Burtin C, Clerckx B, Robbeets C et al. (2009). Early exercise in critically ill patients enhances short-term functional recovery.
[3] Hodgson C, Needham D, Bailey M et al. (2014). ICU Mobility Scale.
[4] Marra A, Ely EW, Pandharipande PP, Patel MB (2018). The ABCDEF Bundle in Critical Care.
[5] Morris PE, Goad A, Thompson C et al. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure.
[6] Nessizius S, Rottensteiner C, Nydahl P (2017). Frührehabilitation in der Intensivmedizin – Interprofessionelles Management, S. 90-174.
[7] Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM (2017). Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis.
[8] Schefer M (2008). Wie anstrengend ist das für Sie?
[9] Schweickert WD, Pohlman MC, Pohlman AS et al. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.
Author

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 ICU patients into his physiotherapeutic training.
He has been working on the topic of early mobilisation in intensive care units at the University Hospital of Tübingen for 6 years.