BENEFITS, BARRIERS, CHALLENGES
Background and Origin
Progressive mobility refers to a series of planned and sequential movements aimed at bringing the patient back to his or her baseline (Vollman, 2010). It consists of positioning and mobility techniques. A meta-analysis of 39 randomized trials was conducted to examine the effect of bed rest on 15 different medical conditions and procedures. Four short-term medical conditions were identified for critically ill patients. But the major and long-term complication was the reduced quality of life after discharge on account of lost physical functions during their stay at the ICU. Another study conducted among survivors of acute respiratory conditions found that they lost 18% of their body weight and suffered much functional limitations from muscle wasting and fatigue. The more than 5 million who get confined at the ICU must come to terms with both the short- and long-term complications of immobility or prolonged bed rest. These significantly affect morbidity, mortality, health cost, and the overall quality of life (Vollman).
Traditional Bed Rest and Progressive Mobility
The traditional belief was for ICU patients to remain in bed to conserve energy for recovery (Kleinpell, 2011). But soon, its adverse effects became known. Muscle strength decreases by 1-1.5% per day or up to 20-30% in a week to 9 days of bed rest. At 5 weeks, muscle strength can deplete by 50% yet a single contraction a day at 50% of maximal strength can prevent this decrease. The decrease is greatest in the quadriceps and extensors. The consequential lack of gravitational force and pull of the muscles on the bones leads to osteopenia, in turn, causing hypercalcemia. Calcium is expelled by the body 2-3 days after immobilization. High calcium levels remain for 3 weeks up to 5-6 weeks. The excretion of calcium in addition to phosphorus leads to atrophy and reduces the bone's threshold for fracture. Immobility or bed rest also decreases gastrointestinal motility, which often leads to constipation and loss of appetite. Because of the loss of muscle strength, diaphragm movement and chest expansion also decrease, impairing secretion clearance. Immobility also reduces efficient cardiovascular function and stroke volume. The heart rate also increases. Skin likewise atrophies and pressure or bed sores develop (Strax et al.). In response to these observations, early mobility of critically ill ICU patients has been established as the new standard of care (Kleinpell).
Progressive mobility advances the patient's level of mobility according to a planned order of succession (Kleinpell, 2011). It begins with exercises for turning and active or passive range of motions; dangling; chair position; and ambulation. More and more studies have found that early and progressive mobilization of critically ill ICU patients is workable, safe and advantageous in improving or restoring their physical functioning promptly. It is also meant to gain secondary benefits, such as reducing heavy sedation, which reduces or prevents activity (Kleinpell).
Feasibility and Safety of Early Mobilization
A review of 15 scientific studies in electronic databases from 2000-2011, including PubMed, CINAHL, Medline and The Cochrane Library, showed only a limited number of such studies, which evaluated the topic (Adler & Malone, 2012). But the few that did reported on the safety and effectiveness of early mobilization as an intervention that can produce significant positive outcomes on functioning. These cover randomized controlled trials, which include only a limited sampling of 171 patients. Findings of these studies found early physical therapy and ICU mobilization as feasible and safe interventions. The level of improvements on quality of life and muscle strength could not be determined at this time because of limited research (Adler & Malone).
Moderate Exercise Beneficial
More studies were conducted on patient outcomes from exercise for ICU patients. Some of these showed that moderate exercise was useful in controlling inflammation caused by immobility and in increasing muscle strength and overall physical function (Truong et al., 2009). Recent ones confirmed the safety and feasibility of early mobility in the ICU and its potential in reducing even short-term physical impairments. Immobility encourages the inflammation mechanisms and atrophy of skeletal muscle from non-use. Early mobility has been shown to be both feasible and effective in improving clinical outcomes. The continuous pre-clinical and clinical research efforts on ICU-acquired weakness promises to improve the physical function and quality of life of patients who survive (Truong et al.).
Benefits to Mechanically Ventilated ICU Patients
ICU-acquired weakness from critical illness often leads to severe functional impairment (Kress, 2009). It also often requires routine mechanical ventilation and for prolonged duration. The patient needs frequent sedative medications for the procedures. Recent research has suggested the feasibility and potential advantage of mobilizing these patients right at the ICU. The intervention requires an entire multidisciplinary team to perform it. The team must consist of a nurse, a physical therapist, an occupational therapist and a respiratory therapist. Recent investigation reported on the safety and positive outcomes of the intervention, especially among the very ill. Among these outcomes are the large number of patients who are able to move around the ICU and the hospital and shortened hospital stay. Preliminary studies support the feasibility and efficiency of the intervention (Kress).
Benefits and Barriers
In recent years, improvements in mortality for ICU patients have been quite marked (Vollman, 2010). As a consequence, critical care has correspondingly raised the opportunities, which would enhance a successful outcome for critically ill ICU patients. In the past, surviving at 28 days or alive and off the ventilator was already an accomplishment. Recently, the focus of efforts was the speed with which a critically ill at the ICU could retrieve pre-illness function. Mobility is not limited to turning the ICU patient for a bath, pulling him or her back to bed, or mobilizing him or her from bed to a stretcher for transporting. It is viewed as a therapy similar to exercise prescriptions for medical conditions, such as COPD and myocardial infarction. It also involves quantity and duration of dose and frequency. Mobility with exercise contributes a lot to recapturing pre-illness functional status (Vollman).
Rehab data show that the use of early intervention mobility therapy to critically ill ICU patients has demonstrated a number of benefits (Morris, 2007). These include shorter total length of ICU and hospital stays, faster accomplishment of functional endpoints, reduced depressive symptoms in cardiac patients, and reduced muscle wasting through stretching. On the other hand, potential barriers to the use of this therapy at the ICU include safety concerns, multiplicity of vascular access, sedation, costs, obesity, and time constraints. A vascular access device or tube may be dislodged. An aggressive mobility program on patients with altered mental states may be unadvisable. It may also cause further decrease in oxygenation. Some patients may have or require more than one vascular intervention. Sedation interferes with the goal of putting and placing the patient in a calm and pain-free condition. An early mobilization program may entail workforce and device costs for the patient. Obesity creates an independent risk of death for ICU patients. Maintaining a hospital staff to tackle ICU mobility concerns of morbidly obese patients will exact more cost than on those with normal mass index. And hospital care professionals face time constraint in applying the program. The nurse alone requires additional time to perform the needed documentation. They need to consider priorities in overall hospital performance. Surveyed nurses reported a 6% decline in patient care and the deficit was because of time constraint (Morris).
The Role of Physical Rehab
Exercise programs have demonstrated their significant effect on the physical and psychological well-being of ICU patients (Bakers & Malone, 2008). While there is still insufficient evidence on their overall value, there exists much evidence to support their value to cardiac and pulmonary patients. A randomized clinical trial evaluated the impact of a six-week rehab program on the physical and psychological recovery of ICU patients. The respondents received a self-help rehab manual, complemented with weekly telephone contact. The experiment produced significantly better physical function in the patients. It concluded by considering physical rehab following intensive care (Bakers & Malone).
Early Mobility Predicts Improvements
Hospitals aim at reducing both hospital stays and readmissions (Morris et al., 2011). Readmission specifically of acute respiratory failure patients within 12 months after discharge has been a concern as a cohort study associated their condition with readmission or death within that duration. The 280 respondents to the study were survivors who required subsequent hospitalization and who participated in an early ICU mobility program. The study found that 132 or 47% of the respondents were re-admitted or died within a year from discharge. These respondents were female, underwent tracheostomy, had a higher Charlson Comorbidity Index and did not participate in the early ICU mobility program. The study concluded that survivors of respiratory failure needed mechanical ventilation are likely to be readmitted and have a high mortality rate within the following year. Of the four factors associated with readmission or death, only ICU mobility therapy may be modified to suit an in-patient's conditions or preferences (Morris, et al.).
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