Despite the awareness of the damaging effects immobility has and the extensive benefits of EM, as already commented upon, it is not a practice that has been integrated into daily care. Only 14% of the 86 ICUs interviewed in Spain had implemented EM protocols or algorithms.27 This may be conditioned by the existence of different barriers which include lack of knowledge by the staff and the variability of care, fear of falls, pain during mobilization, physiological instability of the patient, over-sedation, lack of human and technical resources and lack of time, insufficient collaboration between the interprofessional team and an absence of specific protocols.23,28–32

In our environment there is also very little presence of physiotherapists in the ICUs27,33 and on a geographical level, training and competences of physiotherapists are highly variable.33–37

The European Respiratory Society and the European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients recommend developing clinical physiotherapy guidelines, identifying patient characteristics of those susceptible to this treatment and increasing awareness among professionals of the damaging effects of immobility and the benefits of EM.14

In keeping with the above, the general objective of this study was to create an EM guideline to be implemented in daily ICU practice, for the purpose of increasing patients’ physical activity: sitting up and getting out of bed.

Specific objectives were to:

• 1

  Propose validated tools to measure the degree of mobilisation achieved by the patient and to assess their functional capacity.

• 2

  Identify the patients at greatest risk of ICU-AW.

• 3

  Design an EM algorithm for the critical patient in general.

• 4

  List several recommendations for EM in specific sub-populations of the critical patient most at risk regarding mobilization: neurocritical, traumatic, subjected to continuous renal replacement therapies (CRRT) and with ventricular assist devices (VAD) or extracorporeal oxygenation membranes (ECMO).

Professionals who care for critical patients: nurses, physicians (intensive care, anaesthetists, rehabilitators) physiotherapists and occupational therapists.

Patients in multi-purpose ICUs, doctors, heart and/or coronary surgeons, surgical, trauma, postsurgical resuscitation and semicritical care units.

Patients undergoing rehabilitation who were hospitalised in long-stay units or in hospital wards were not considered in this guide, even though they had been in the ICU.

A bibliographic review was undertaken which was completed on 1st December 2019. The following criteria were considered:

• ‐

  inclusion: critically ill patient, admitted into the acute ICU, studies which provided an algorithm/guide/protocol/EM interventions.

• ‐

  exclusion: studies focusing only on rehabilitation therapies such as the use of electrostimulation or mobilisation interventions in end-of-life patients.

The databases consulted were Medline (vía PubMed), CINAHL, PEDro and the Cochrane Library. The selection process of articles is contained in the Flow diagram (Fig. 1).

Figure 1.

Diagram of the study selection process.

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The limits used were articles published in the last 10 years (2009–2019), language (English and Spanish), selected for adults aged = 19 or above.

The following MeSH terms were used for the search of related scientific literature in the databases of Medline (PubMed), CINAHL and the Cochrane Library: “rehabilitation, “exercise therapy”, “early ambulation”, “intensive care units”, “critical care”. In the PEDro databases the terms were as follows: “rehabilitation”, “exercise therapy”, “early ambulation”, “early mobilizationͭ”, “intensive care units”, “critical care”. In both cases these were combined with the Booleans AND and OR.

In addition, an inverse search was made from the bibliographic references of selected studies, together with other unidentified sources from the review. These comprise the articles cited as secondary review in Fig. 1.

The results obtained were analysed independently by 5 of the authors of this review (MRT, ERM, BPP, JDM y GZE), bearing in mind the study objectives and the inclusion and exclusion criteria.

A quantitative review of the algorithm/protocols/EM interventions or early EM was also undertaken with the following criteria:

• ‐

  Variables recommended for guiding the mobilisation level: consciousness and physical function.

• ‐

  Use of mobilization support apparatus.

• ‐

  Times recommended for each physiotherapy activity.

Of the 30 studies included, as shown in Appendix A Table 1 of the Supplementary material, 10 held evidence levels 1A and 1B (randomised clinical trials), 17 evidence levels 2B, 2C and 2D (cohort studies, of cases and controls or pre-post studies), 2 level 3D (case reports) and one level 4D (expert opinion).

The heterogeneity of the results found in the current literature impeded study comparison. Fig. 2 shows this variability, grouped into 7 different topics.

Figure 2.

Classification of the main topics around which results in the literature are grouped. MV: mechanical ventilation; SOFA: Sequential organ failure assessment; VAP: ventilator-associated pneumonia.

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Also, despite the previously described advantages of EM, according to available evidence, it does not involve changes to quality of life, mortality in the hospital or changes in physical health. It cannot be assessed whether there are effects in cognitive function, mental health or the capacity to return to work, due to insufficiency of data.26 The latest Cochrane review provides similar results: lack of evidence to determine whether EM improves daily life activities, muscle strength or quality of life.38

The tools are classified into those that measure muscle mass (anthropometry, bioimpedance, ultrasonography), muscle weakness (manual testing with Medical Research Council-Sum score [MRC-SS] or dynamometer) and physical function with this dimension being the one with the most developed tools, but few which are suitably validated. They best ones are those with psychometric qualities which are the Chelsea critical care physiotherapy (CPAx), Physical Function in Intensive Care Test (PFIT) and the ICU Mobility Scale (IMS).39

On the one hand, to assess muscle weakness, both the manual test of the muscle and the dynamometry require the patient’s cooperation. The most used scale for manual testing is the MRC-SS. This assesses muscle strength from 0 (no muscle contraction) to 5 (maximum contraction). Three muscle groups are examined in each of the upper and lower limbs, and the total score is over 60. Accessible evaluation protocol can be consulted in https://seeiuc.org/estudio-movipre/, adapted from Hermans et al.40

On the other, with regard to physical function, the IMS was created to replace the 6-min walk test,41,42 not applicable in the critical patient and it is the only mobility scale designed to standardize the language of nurses and physiotherapists when they describe patient mobilization during ICU stay.43,44

One limitation of many studies which have assessed the effectiveness of early mobilisation in the ICU is that of not having used a validated mobility scale to define the different degrees of activity the patients achieve. The IMS was therefore validated into the Spanish cultural context, with recommendations from experts for the tool to have an equivalent semantic, and conceptual level of technical content and criteria in the different languages45 (see Table 1).

As commented upon in the introduction, since 2014 different ICU-AW-associated risk factors have been identified: These include age,19,46 greater degree of dependence in daily life activities,1,19 hyperglycaemia3,46 and administration of corticoids,3,46 but none of the studies were conducted in Spain, and it is therefore unknown whether specific ICU characteristics exist that may impact the incidence of these factors, or add several new ones, bearing in mind the Spanish organizational and cultural environment.

The authors of this paper conducted a national multicentre study (MoviPre, Movilización Precoz)47 in 80 ICUs in Spain during the months of March to July 2017. These included 642 patients (62.1% medical patients, 32.4% surgical patients and 5.5% trauma patients). Using logistic regression analysis (for the period between days 3 and 5 of hospitalization, when the EM should be implemented) they identified the following risk factors of developing ICU-AW: older age (OR 1.1 95% CI [1.00–1.03]) and more days with continuous renal replacement therapy (CRRT) (OR 1.01 95% CI [1.00–1.02]). In contrast, the following protect against the development of ICU-AW : being male (OR .58 95% CI [.38–.89]), a higher score on the Barthel scale (OR .97 95% CI [.95–.99]), more days collaborating for the evaluation of the MRC (OR .98 95% CI [.97–.99]) or developing hyperactive delirium (OR .98 95% CI [.97–.99]) and more days with active mobilization (IMS ≥ 4) (OR .98 95% CI [.97–.99]).

• ‐

  Having a portable ventilator and monitor, aspiration device, oxygen, manual resuscitator (if IMS ≥ 7).

• ‐

  Anticipate: think which safety risk may appear during the mobilisation of this patient and what strategies should be taken in to account.

• ‐

  Consider the asepsis regulation, particularly disconnection of invasive airways.

• ‐

  It is recommended to have an intensive care doctor nearby.

• ‐

  Change the length of the infusion tubes and systems, in keeping with the level of mobilisation pursued.

• ‐

  Consider tube and infusion system attachments.

• ‐

  Assess whether pressure in the airways is not too high for leaving a margin in case it may increase during mobilisation.

• ‐

  Have a chair available nearby for the patient to sit on if they need to (wheelchair).

• ‐

  Consider the employment safety risks for professionals and the appropriate strategies to mitigate them.

Fig. 3 (decision making) and Fig. 4 (IMS objective in keeping with safety checklist).

Figure 3.

Algorithm of decision-making.

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Figure 4.

IMS objective in keeping with safety checklist.

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• ‐

  Change in systolic blood pressure (SBP) > 20%, compared with baseline at rest.

• ‐

  Heart rate (HR)  > 200-(age in years).

• ‐

  Drop in oxygen saturation 5%, compared with baseline at rest.

• ‐

  Breathing effort according to the Borg scale ≥ 7 (0 = very easy, 10 = maximal exertion). First, try to increase the breathing pressure in the ventilator by 4 mbar and reassess. If there is no improvement, stop mobilisation.

• ‐

  Physical training exertion according to the Borg scale ≥ 7 (0 = very easy, 10 = maximal exertion). First try a short rest (e.g., sit down on a chair for one minute) and reassess: if there is no improvement stop mobilisation.