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Effects of early mobilisation in the functional rehabilitation of critically ill patients: a systematic review

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Série IV - n.° 5 - apr./may/jun. 2015
pp.129-138
Revista de Enfermagem Referência
Journal of Nursing Referência
Abstract
Resumo Resumen
REVIEW PAPER
Effects of early mobilisation in the functional
rehabilitation of critically ill patients: a systematic review
Efeitos da mobilização precoce na reabilitação funcional em doentes críticos: uma revisão
sistemática
Efectos de la movilización temprana en la rehabilitación funcional de los pacientes en
estado crítico: una revisión sistemática
Paulo Manuel Dias da Silva Azevedo*; Bárbara Pereira Gomes**
Background: Early mobilisation has been considered as an intervention capable of modifying risk factors for morbidity, with an
impact on the functional rehabilitation of critically ill patients.
Objective: To determine the effects of early mobilisation in the functional rehabilitation of patients admitted to intensive care units.
Review method: Using the PICO strategy, a systematic review was conducted of full-text scientic articles on adults admitted to
intensive care units who underwent early mobilisation and published between 2003 and 2003. The search was performed in the
following databases: PubMed, CINAHL, Cochrane Controlled Trial Database, Elsevier, LILACS, British Nursing Index and SciELO,
and in scientic journals of reference and citations of the selected articles. Tools for methodological quality assessment were used
in the nal analysis of the studies.
Interpretation of results: The six studies identied show that early mobilisation may facilitate the functional rehabilitation of
these patients, promoting muscle strength gains and increased participation in the activities of daily living.
Conclusion: Further studies using the same assessment tools and demonstrating the interest of this intervention for the Nursing
discipline are needed.
Keywords: rehabilitation; intensive care; early ambulation.
Received for publication: 08.05.14
Accepted for publication: 13.01.15
Marco contextual: La movilización temprana ha sido considerada
una intervención capaz de modicar los factores de riesgo de
morbilidad con un impacto en la rehabilitación funcional de los
pacientes críticos.
Objetivo: Determinar los efectos de la movilización temprana
en la rehabilitación funcional de los pacientes internados en
cuidados intensivos.
Método de revisión: Utilizando la estrategia PICO, llevamos a
cabo una revisión sistemática de la literatura entre 2003 y 2013,
teniendo en cuenta artículos cientícos con texto completo,
estudios realizados con adultos ingresados en cuidados intensivos
sometidos a la movilización temprana. Para esto, se consultaron
las bases de datos PubMed, CINAHL, Cochrane Controlled Trial
Database, Elselvier, LILACS, British Nursing Index y SciELO;
revistas cientícas de referencia y las citas de los artículos
seleccionados. Para el análisis nal de los estudios se utilizaron
herramientas de evaluación de la calidad metodológica.
Interpretación de los resultados: Los resultados de los seis
estudios indican que la movilización temprana puede facilitar la
rehabilitación funcional de estos pacientes, haciendo que ganen
fuerza muscular y una mayor participación en las actividades
diarias.
Conclusión: Se necesitan estudios que utilicen las mismas
herramientas de evaluación y que demuestren el interés de la
intervención para la disciplina de enfermería.
Palabras clave: rehabilitación; cuidados intensivos;
ambulación precoz.
Contexto: A mobilização precoce vem sendo considerada uma
intervenção capaz de modicar factores de risco de morbilidade, com
impacto na reabilitação funcional em doentes críticos.
Objetivo: Determinar os efeitos da mobilização precoce na
reabilitação funcional de doentes internados em cuidados intensivos.
Método de revisão: Utilizando a estratégia PICO, realizou-se uma
revisão sistemática da literatura entre 2003 e 2013, considerando-se
artigos cientícos em texto integral de estudos realizados com adultos
internados em cuidados intensivos e submetidos à mobilização
precoce. Pesquisaram-se as bases de dados PubMed, CINAHL,
Cochrane Controlled Trial Database, Elsevier, LILACS, British
Nursing Index e SciELO, revistas cientícas de referência e as citações
dos artigos selecionados. Na análise nal dos estudos utilizaram-se
ferramentas para avaliação da qualidade metodológica.
Interpretação dos resultados: Dos seis trabalhos identicados
resulta que a mobilização precoce pode facilitar a reabilitação
funcional destes doentes, promovendo ganhos de força muscular e
maior participação nas atividades de vida diária.
Conclusão: São necessários estudos que usem as mesmas ferramentas
de avaliação e que demonstrem o interesse da intervenção para a
disciplina de Enfermagem.
Palavras-chave: reabilitação; cuidados intensivos; mobilização
precoce.
* MSN, Nursing Science. Specialist in Rehabilitation Nursing. Coordinating Nurse.
Hospital of Arrábida Gaia, Ph.D. student in Nursing Science, Institute of Biomedical
Sciences Abel Salazar, 4520-155, Santa Maria da Feira, Portugal [paulo.m.azevedo@gmail.
com]. Contribution to the article: Bibliographic search, data collection, data analysis and
discussion, article writing. Address for correspondence: Rua das Corgas, nº 22, Santa Maria
da Feira, 4050-313, Porto, Portugal.
** Ph.D., Nursing Science. Coordinating Professor, Porto Nursing College, 4200-072, Porto,
Portugal [bgomes@esenf.pt]. Contribution to the article: Bibliographic search, data
collection, data analysis and discussion.
ISSNe: 2182.2883 | ISSNp: 0874.0283
Available: http://dx.doi.org/10.12707/RIV14035
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
Effects of early mobilisation in the functional rehabilitation of critically ill patients:
a systematic review
130
Introduction
Over the last few decades, there has been an increase
in the number of patients admitted to intensive
care units (ICUs). Simultaneously, the growing
capacity of supporting vital functions, together with
the effectiveness of new treatments, has increased
the survival rates of critically ill patients. In this
context, a critically ill patient is a person whose life is
threatened due to failure or imminent failure of one
or more vital functions, and whose survival depends
on advanced means of surveillance, monitoring and
therapy (Regulamento nº 124, de 18 de Fevereiro.
Diário da República nº 35/11 - II Série. Ordem dos
Enfermeiros. Lisboa, Portugal). According to the
Intensive Care National Audit & Research Centre
(ICNARC) (Intensive Care National Audit & Research
Centre, 2013), more than 100,000 people every year
are admitted to ICUs in England and Wales, and 76%
of them are discharged from the hospital. In Australia
and New Zealand, there are more than 120,000 ICU
admissions every year, and 70% of these patients
are discharged home (Australian and New Zealand
Intensive Care Society, 2013). According to the most
recent data published by the Health Financing and
Computer Management Agency (IGIF) (Instituto
de Gestão Informática e Financeira da Saúde,
2005), 11,583 people were discharged from ICUs in
Portugal. Considering these gures and the growing
number of people with multiple comorbidities and
of medical indications for ICU admission, together
with an increase in the average life expectancy in
developed countries, it can be concluded that the
number of people who survive a severe disease
episode will tend to increase. This justies a more
thorough analysis of the transition processes of the
survivors of ICU admission. It is a deeply disturbing
sight to look beyond the short-term results, such
as the survival rate after discharge. The legacy of an
ICU admission is extremely heavy and difcult. It is
characterised by a profound and persistent disability
(Unroe et al., 2010) and has negative long-term
repercussions on the patients’ quality of life and at
a physical and neuropsychiatric level (Desai, Law, &
Needham, 2011). These consequences force patients
to struggle to regain independence, in particular in
terms of physical strength and functional capacities
(Ågård, Egerod, Tønnesen, & Lomborg, 2012). At the
same time, the multiple care transitions lead to higher
healthcare costs. It is thus important to understand
the trajectory of recovery of critically ill patients, as
it may reveal the modiable risk factors, as well as
assess the interventions that might contribute to
reduce the number of comorbidities associated with
ICU admission.
The beginning of the rehabilitation of critically ill
patients at the ICU has been a topic for research
and considered an important part of a care plan.
In functional rehabilitation, the early mobilisation
of critically ill patients has been suggested as an
important therapy to modify the risk of developing
sequelae affecting their physical and functional
morbidity, as they are related to the loss of muscle
strength that leads to ICU-acquired weakness. In
a recent study of critically ill patients with acute
respiratory failure, the lack of early mobility was
identied as predictor of readmission or death within
the rst year of hospital discharge (Morris et al.,
2011). On the other hand, several factors may also
contribute to the loss of muscle strength, such as the
direct effects of the illness or the use of certain drugs
(e.g., muscle relaxants and corticosteroids). Another
important risk factor is the prolonged periods of bed
rest, which may be modiable if rehabilitation starts
in the early treatment stage. Therefore, the aim is to
promote the recovery of muscle strength in order
to improve performance and the transition to an
independent performance of basic activities of daily
living. According to Grap and McFetridge (2012),
early mobilisation (also termed progressive mobility)
describes a pattern of increasing activity beginning
with passive mobilisation until ambulation, which
begins immediately after the haemodynamic and
respiratory stabilisation, generally within 24–48 hours
after ICU admission. However, the early mobilisation
of critically ill patients has several specicities
inherent to the context of action, and uses various
activities depending on the patients’ individual needs.
In this way, and in order to assess the quality of care
in rehabilitation Nursing, it is important to assess the
rehabilitation process based on the interventions and
the patient outcomes (Gomes, Martins, Gonçalves,
& Fernandes, 2012). There is a lack of knowledge
of the expected outcomes, which is needed to plan
the most appropriate interventions for each patient
based on the objectives initially set out. Thus, the
search for scientic evidence based on the principles
of the evidence-based practice is essential for the
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
PAULO MANUEL DIAS DA SILVA AZEVEDO, et al.
131
Systematic Review Method
The systematic review began with the formulation
of the guiding question based on the PICO strategy
(Population, Intervention, Comparison, and
Outcome). Inclusion/exclusion criteria were dened
(Table 1) to guide the search and select the literature
according to the expected results and the research
question.
decision-making process within the scope of the
critically ill patient’s rehabilitation process. In the
search for the best evidence available to improve
the quality of care, a systematic literature review was
performed to identify the effects of early mobilisation
in the functional rehabilitation of patients admitted
to ICUs. The review question What are the effects of
early mobilisation in the functional rehabilitation of
critically ill patients? guided the search for relevant
information for decision-making concerning the
rehabilitation plan of this group of patients.
Table 1
Inclusion criteria
Selection criteria Inclusion criteria
Study design Cohort studies
Controlled studies
Randomised studies
Publication date Between 2003 and 2013
Language Portuguese, English and Spanish
Intervention Patients undergoing early mobilisation and admitted to an ICU
Other criteria Full-text articles
Studies conducted in clinical settings with adults admitted to an ICU
Strategy for search and identication of
studies
The review targeted studies published between 2003
and 2013. The following databases were searched:
PubMed, CINAHL, Cochrane Controlled Trial
Database, Elsevier, LILACS, British Nursing Index,
and SciELO. Some scientic journals of reference
were also consulted in paper format (Critical Care
Medicine and Intensive Care Medicine). To ensure
a more comprehensive literature review, the lists of
references of the selected articles were also searched
to identify potentially relevant articles for the topic
under study.
The search strategy used a logical structure combining
search terms, Boolean operators, and the components
of the PICO strategy. The following topics were used
as search descriptors: mobilization, mobilisation,
mobility, physical activity, exercise, intensive care
unit, and critical illness. The Boolean expression was
built as follows: critical illness AND intensive care
unit AND mobilization OR mobilisation OR mobility
OR physical activity OR exercise.
Two reviewers, who independently analysed the titles
and abstracts of the articles according to the same
criteria, selected the studies.
Assessment of the methodological quality
of the studies
Both reviewers used proforma tools to assess the
quality of the studies. The tool proposed by the
Critical Appraisal Skills Programme (CASP) (Public
Health Resource Unit, 2006) was used for randomised
clinical trials, while the criteria proposed by Suzumura,
Oliveira, Buehler, Carballo, and Berwanger (2008)
were used for the critical appraisal of cohort studies.
Data extraction and synthesis
The articles were independently analysed by the
reviewers, and a consensus was reached on which to be
included in the methodological analysis. The articles
were then generally described based on their country
of origin, study design, objectives and participants,
the onset and duration of the intervention, results
and conclusions. Then, the items were compiled into
an extraction table so the reviewers could proceed
with the narrative data synthesis.
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
Effects of early mobilisation in the functional rehabilitation of critically ill patients:
a systematic review
132
Presentation of results
Considering the procedures described above, the
search results were rened throughout the process
based on the previously established criteria until all
articles to be included in this review were selected
(Figure 1):
Figure 1. Study selection process.
Six studies (two cohort studies and four
randomised controlled studies) were selected for final analysis, which are summarised in the
following table (Table 2):
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PAULO MANUEL DIAS DA SILVA AZEVEDO, et al.
133
Table 2
Identication of studies for nal analysis
Study identication number Authors Year Type of study
S1 Thomsen, Snow, Rodriguez, and Hopkins 2008 Cohort
S2 Morris et al. 2008 Cohort
S3 Schweickert et al. 2009 Randomised controlled
S4 Burtin et al. 2009 Randomised controlled
S5 Dantas et al. 2012 Randomised controlled
S6 Denehy et al. 2013 Randomised controlled
After the methodological assessment of the quality
of cohort studies, it can be concluded that they
have some limitations. The results of S1 can only be
considered with respect to patients with respiratory
conditions. In this study, without a control group,
there is a potential for bias in patient selection since
only those patients who were more likely to ambulate
were selected. In addition, the statistical power of
the study is not indicated. No mention was made to
possible factors inuencing the results, such as the
administration of corticosteroids and neuromuscular
agents. As for S2, the possible confounding factors
arising from drug administration were controlled
for and the study has an adequate statistical analysis.
However, although the level of signicance was
reported, the power of the study regarding the
calculation of the sample size was not referred. A
possible bias of this study is the discrepancy between
groups concerning rehabilitation, which was lower in
the control group.
As for the randomised controlled trials, although the
results of S3 are accurately presented, it is limited to
the fact that patients under mechanical ventilation
did not receive rehabilitation care and the patients in
the control group only received it when prescribed.
S3 reports the control of the sedation and analgesia
variables, but not the use of corticosteroids. No
mention is made in S4 to whether it was a blinded
study. It also has other limitations such as the
lack of statistical power of the sample, the lack of
reference to the control for confounding factors
(e.g., administration of certain drugs), the presence
or lack of muscle weakness in both groups, and the
assessment of some parameters at hospital discharge
without control of the rehabilitation undergone after
ICU discharge (considering that the patients were
discharged to different services). S5 also presents
some limitations, such as the lack of statistical power
of the sample, the lack of clarity of the randomisation
method used, and whether it was a blinded study or
not. No reference is made to whether the confounding
factors, such as the administration of drugs, were
controlled for. In this study, the differences in muscle
strength between both groups were clear from the
start, with the control group showing more muscle
weakness. Despite being a well-designed longitudinal
study, S6 has certain limitations related to the fact that
it did not reach the number of participants necessary
for it to have the statistical power to determine
differences in the six-minute walk test performed
twelve months after ICU discharge, and which was
the main result being assessed. No reference is also
made to whether the confounding factors, such as
the administration of drugs with an impact on muscle
strength, were controlled for.
Following the critical appraisal of the studies, the
most relevant results to the topic under analysis are
presented in the following table:
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
Effects of early mobilisation in the functional rehabilitation of critically ill patients:
a systematic review
134
Table 3
Synthesis of data extracted after the critical appraisal of the studies
Study Country Study
design Objectives and
participants Onset and duration
of mobilisation Results Conclusions
S1 USA Cohort Objective: To increase
the ambulation of
patients with acute
respiratory failure
due to medical illness
or surgical or trauma
events, transferred
from another ICU
where activity is a key
care component.
n = 104.
First 24 hours if
conscious and
meeting early activ-
ity criteria. Until
ICU discharge.
The mean distance ambu-
lated by the survivors was
72.5 m.
The percentage of patients
sitting on the edge of the
bed or sitting in a chair who
ambulated more than 30 m
increased within the rst 24
hours after ICU transfer.
The no. of patients
who ambulated
increased. Controlled
studies are needed
to determine if early
ICU activity improves
the outcomes.
S2 USA Cohort Objective: To com-
pare outcomes of
medical intensive
care patients with
acute respiratory fail-
ure, between patients
who received usual
care and patients
who participated in a
mobility protocol.
n = 330. Control
group n = 165 vs.
intervention group
n = 165.
Within 48 hours
in patients of
the intervention
group. Until ICU
discharge.
Patients in the interven-
tion group were out of bed
earlier. More than half of the
patients in the intervention
group reached the last level
of the protocol that includ-
ed resistance exercises,
sitting and active transfers
to chair. Shorter ICU and
hospital length of stay in the
intervention group. No sig-
nicant difference between
both groups concerning
ventilation time.
Mobilisation was
feasible, safe, and did
not increase costs.
Better outcomes in
the patients of the
intervention group.
S3 USA Ran-
domised
con-
trolled
Objective: To de-
termine the no. of
patients receiving
mechanical ventila-
tion who were func-
tionally independent
at hospital discharge,
by comparing pa-
tients subjected to
an early mobilisation
to patients receiving
usual care.
n = 104. Control
group n = 55 vs.
intervention group
n = 49.
An average of 1.5
days after intuba-
tion. Until hospital
discharge or previ-
ous functional
status.
Patients in the intervention
group:
Higher Barthel Index score.
More patients achieved an
independent functional
status at hospital discharge.
Fewer patients with muscle
weakness.
More patients were able to
perform activities such as
transferring to chair, using
the toilet, bathing, getting
dressed, grooming and
walking.
Shorter ventilation time.
No signicant differences in
length of ICU and hospital
stay.
The overall rehabilita-
tion strategy was safe
and well tolerated,
and resulted in better
functional outcomes
at hospital discharge.
S4 Belgium Ran-
domised
con-
trolled
Objective: To deter-
mine whether a daily
session using a cycle
ergometer is effective
in preventing the
decrease in functional
status in medical and
surgical patients.
n = 90. Control
group n = 45 vs.
intervention group
n = 45.
Eligibility veried
on day 5; no refer-
ence is made to the
starting date.
Moderate correlation be-
tween the quadriceps force,
the 6MWT, and the SF36,
with higher scores in the
intervention group.
More patients in the inter-
vention group were able
to walk independently. No
signicant differences were
found regarding length of
ICU and hospital stay and
ventilation times.
Early exercise en-
hanced recovery of
functional capacity
and muscle force at
hospital discharge.
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
PAULO MANUEL DIAS DA SILVA AZEVEDO, et al.
135
mobilisation. The implementation of this intervention
is believed to have reduced the time until the rst
time patients get out of bed (S2) and increased the
number of patients with muscle strength gains (S3,
S4 and S5), patients who were able to ambulate (S1
and S4), and patients who enhanced their capacity to
perform various activities of daily living (S2, S3 and
S6). However, some limitations found in the selected
studies should be considered when interpreting the
results.
The main difculties are clearly related to the
characteristics of the population under study. This
population is heterogeneous and their disease usually
evolves suddenly, making it difcult to compare the
health status achieved after ICU hospitalisation and
the health status prior to development of a highly
severe condition. On the other hand, the contextual
realities of the countries where the selected studies
were conducted are quite different from each other.
Only one study was conducted in Europe (E4).
Given the well-known traditional differences in the
organisation and planning of care between European
and North American ICUs, it is important to clarify
S5 Brazil Ran-
domised
con-
trolled
Objective: To assess
the effects of an early
mobilisation protocol
in peripheral and
respiratory muscles
in mechanically venti-
lated patients.
n = 28. n = 14 in
the control group vs
n = 14 in the inter-
vention group.
No reference
is made to the
starting date of
rehabilitation in
both groups. For
the control group,
rehabilitation went
until ICU discharge.
Signicant increase of
maximal inspiratory pres-
sure and muscle strength
in the intervention group.
No signicant differences
regarding mechanical ven-
tilation time between both
groups.
No signicant differences
regarding ventilation time
and ICU and hospital length
of stay.
Gains in inspira-
tory and peripheral
muscle strength in
patients subjected to
early mobilisation.
S6 Australia Ran-
domised
con-
trolled
Objective: To investi-
gate the effectiveness
of a rehabilitation
programme start-
ing at the ICU and
continuing into the
ward and community
in critically ill patients
with different condi-
tions. Assessment
at ICU and hospital
discharge, and 3, 6
and 12 months after
ICU discharge.
n = 150. Control
group n = 76 vs.
intervention group
n = 74.
Started at the 5th
day of hospital stay.
The intervention
group underwent
rehabilitation in the
ICU, the ward and
as outpatients
No signicant differences
were found between the
groups regarding physical
function as measures by the
6MWT at 12 months after
ICU discharge, although
the intervention group
presented a higher recovery
score in the 6MWT in the
rst assessment at three
months.
No signicant differences
were found between the
groups regarding the length
of ICU hospital stay.
Further research is
needed on the trajec-
tory of recovery in
this population of
patients.
Interpretation of results
Nowadays, the sequelae resulting from ICU
hospitalisation are a matter of concern when assessing
health outcomes. Physical morbidity, with its strong
impact on the decrease of functional capacities,
has been a subject of research in an attempt to nd
effective interventions in preventing and reducing
this problem. Regarding the rehabilitation of critically
ill patients, early mobilisation has been suggested as a
way of mitigating its adverse functional effects. Hence,
it is important to identify the results achieved in the
studies conducted so far.
From the analysis of the selected studies, it can be
concluded that early mobilisation in critically ill
patients is possible, safe and can start immediately after
their physiological stabilisation (S2 and S3). There is
evidence that it contributes to improve functional
rehabilitation outcomes. In total, the articles selected
involved 806 patients who enhanced their functional
recovery. These improvements may have been the
result of a modication of the usual rehabilitation
care standards through the introduction of early
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
Effects of early mobilisation in the functional rehabilitation of critically ill patients:
a systematic review
136
and describe the basic rehabilitation care to better
understand and compare the achieved outcomes.
Another aspect to consider is the duration of the
rehabilitation programmes, which range from ICU
admission, ICU discharge, and hospital discharge to
a 12-month follow-up. For this reason, it is not yet
possible to conclude whether these effects are long-
term or not.
The tests used to assess the obtained results are also
different (S3 – Barthel Index, S4 – SF36 and 6MWT,
S6 – 6MWT), as well as the moments chosen to
assess them. Two studies have used the same test
(the 6MWT), but in very different moments. S4 used
it only at hospital discharge, while S6 used it after
ICU discharge, hospital discharge, and at 3-, 6-, and
12-month follow-up after ICU discharge. Thus, it is
difcult to compare results between studies. Given
that different assessment tools were used, the results
will also be different. Other assessment tools that can
be consistently reproduced are needed to produce
comparable outcome indicators. On the other hand,
as the rehabilitation process has a multiprofessional
and multidisciplinary nature, it is also necessary to
establish results of interest to the Nursing discipline
that may serve as a guide for practice and research,
and this was not observed in any of the studies
analysed.
Moreover, only two studies reported the control of
factors such as the administration of drugs (S2 and
S3), which seem to inuence the development of
muscle weakness, namely corticosteroids (except for
S3) and neuromuscular agents (Schweickert & Hall,
2007; Grifths & Hall, 2010). Thus, no clear conclusion
can be drawn on their inuence on the results
obtained in the other studies. However, the results
of S3 showed muscle strength gains in the patients
of the intervention group, and that more than half of
them were able to achieve functional independence
at hospital discharge. This study was also the rst
one to report a decrease in the incidence of delirium,
which, associated with a better physical capacity,
led to shorter periods of mechanical ventilation.
Patients with improved physical capacities and state
of consciousness are able to participate more in their
rehabilitation process, which also enhances recovery
of the ability to perform self-care activities.
After a critical appraisal of the studies, it can be
concluded that the quality of the evidence is moderate,
and that further studies with statistical power and
control for confounding factors are needed to conrm
the effectiveness of this intervention. This review
conrmed that early mobilisation is feasible and safe
for critically ill patients, and that it may be initiated
immediately after their physiological stabilisation. In
addition, considering the balance between desirable
and undesirable effects, it can be concluded that early
mobilisation has more positive than adverse effects.
Therefore, it is recommended that early mobilisation
should be introduced in the care plan for critically ill
patients as early as possible during ICU stay.
In order for it to be considered as a priority,
early mobilisation, as a strategy to improve the
rehabilitation outcomes of critically ill patients, also
entails a cultural change in the healthcare team
towards a patient-centred care approach. To this
end, the practices in use should be reviewed, the
obstacles and constraints in the multidisciplinary
team identied, and the advantages arising from the
adoption of a strategy requiring more interaction with
the patients and more participation of the patients in
their rehabilitation process should be understood. In
this respect, the nurse specialist in rehabilitation plays
a key role in identifying and modifying the risk factors
and implementing interventions that may enhance
the onset of early rehabilitation and extend to the
follow-up of these patients. This way it will be clearly
possible to identify the impact on the physical and
non-physical recovery, as well as on the quality of life
of patients and families.
Conclusion
Given the increasing number of ICU admissions and
the need for optimisation of human and nancial
resources, healthcare professionals should take on
the responsibility of advocating and developing
sustainable and efcient ways to improve the
rehabilitation outcomes of patients with severe
conditions, which, according to the evidence, have
profound negative effects in their quality of life.
Thus, the benets resulting from a more proactive
rehabilitation strategy throughout the process
of recovery of critically ill patients should be
continuously assessed as they are discharged from the
ICU to the ward and community.
Studies on this topic and more specically on the
effects of early mobilisation are still scarce. Based on
Revista de Enfermagem Referência
Journal of Nursing Referência - IV - n.° 5 - 2015
PAULO MANUEL DIAS DA SILVA AZEVEDO, et al.
137
the moderate methodological quality of the existing
studies, it can be concluded that this intervention
is feasible, safe, and that it facilitates functional
recovery, particularly in terms of muscle strength
gains and performance of some activities. There
is no consensus regarding the intensity, frequency
and duration of the interventions; however,
evidence suggests that structured and individualised
programmes may facilitate the recovery of critically ill
patients. The limitations found in these studies derive
from the complex responses of critically ill patients to
their diseases, as well as from the lack of consistent
outcome assessment tools. Moreover, the effects of
administrating drugs that affect muscle strength and
their association with the evolution of recovery are
still under-investigated.
From the point of view of rehabilitation Nursing, the
presence of muscle strength gains is not enough. It
is necessary to assess the extent to which these gains
may contribute to empower patients to self-care,
perform Basic Activities of Daily Living and reacquire
the maximum possible independence, as well as
verify the sustainability of the results over time, which
cannot be conrmed based on the selected studies.
This review intends to provide useful data for decision-
making and justication of interventions in the area of
the rehabilitation of critically ill patients. Given that
this area has been gaining increasing importance,
controlled studies should be conducted focused
on a longitudinal approach in order to identify the
subpopulations of patients who may benet the most
from the introduction of early mobilisation.
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... A aspiração de secreções, a supervisão, o ajuste e desmane ventilatório são também partes integrantes de um programa de reabilitação e intervenção precoce. McFetridge (10) assinala que a MP deve iniciar-se logo após a estabilização hemodinâmica e respiratória, geralmente entre as 24 e 48 horas após admissão nas UCI. ...
... cada vez mais um maior número de internamento na UCI (21) . De ressalvar que o prognóstico e a incidência de comorbilidades desenvolvidas no internamento são influenciadas por um conjunto de características intrínsecas prévias de carácter agudo ou crónico (10) . ...
... Considerando que na primeira sessão do plano de intervenção, todos os participantes se encontravam sob sedação, os efeitos da terapêutica medicamentosa, podem ter influenciado o surgimento de fraqueza muscular, como é o caso de corticosteroides ou agentes de BNM (10) . Na situação de sedação, o grau de participação e consciência dos doentes, conduziram os participantes para a fase 1 do protocolo de MP. ...
... Nas últimas décadas verificou-se um aumento significativo no número de pessoas admitidas nas unidades de cuidados intensivos em Portugal (1) . A grande maioria destas pessoas vivencia uma situação crítica de maior ou menor criticidade, com frequente e severa instabilidade, que necessita de vigilância, monitorização e de tratamento intensivo, evidenciando-se a ventilação mecânica invasiva como uma das modalidades de tratamento mais frequentemente utilizadas. ...
... A grande maioria destas pessoas vivencia uma situação crítica de maior ou menor criticidade, com frequente e severa instabilidade, que necessita de vigilância, monitorização e de tratamento intensivo, evidenciando-se a ventilação mecânica invasiva como uma das modalidades de tratamento mais frequentemente utilizadas. Graças aos mais recentes avanços tecnológicos e científicos na área da medicina intensiva, sobretudo na melhoria da capacidade de suporte das funções vitais e no aumento da eficácia de novos tratamentos, verifica-se um aumento da sobrevida nesta população (1,2) , inclusivamente em pessoas em situação crítica com situações patológicas de elevada complexidade (3) . Não obstante, após a experiência de ventilação mecânica invasiva, sobretudo quando acompanhada de períodos prolongados de repouso no leito e de imobilidade, circunstanciais ou induzidos, reconhecese um aumento da morbilidade física e psicológica nesta população (4)(5)(6) . ...
... À semelhança do que advogam outros autores, pela quase inexistência de eventos adversos, os resultados obtidos neste estudo confirmam que a implementação dos exercícios terapêuticos de mobilização articular, por parte do enfermeiro especialista em enfermagem de reabilitação, à pessoa submetida a ventilação mecânica invasiva, é uma intervenção fazível e segura (1,5,6,13,(20)(21)(22)(23)(24) . ...
Article
Objetivo: avaliar a efetividade de um programa de mobilização articular precoce, que inclui a implementação de exercícios terapêuticos de mobilização articular, para a manutenção ou melhoria da amplitude articular da pessoa submetida a ventilação mecânica invasiva sujeita a longos períodos de imobilidade e de repouso no leito. Método: estudo de caso piloto, quantitativo, descritivo e transversal, aplicado a pessoas submetidas a ventilação mecânica invasiva, a uma amostra acidental de três pessoas. Utilizou-se o método de goniometria manual para avaliação da amplitude articular. Recorreu-se à estatística descritiva para análise dos resultados obtidos. Resultados: confirmou-se a manutenção ou melhoria da amplitude articular de todas as articulações selecionadas para o programa de mobilização articular precoce de todas as pessoas incluídas na amostra. Conclusão: comprova-se a efetividade do programa de mobilização articular precoce para a pessoa submetida a ventilação mecânica invasiva. Conclui-se que os exercícios terapêuticos de mobilização articular contribuem para prevenção de contraturas articulares associadas à imobilidade e ao repouso prolongado no leito da pessoa submetida a ventilação mecânica invasiva. No entanto, em virtude da reduzida dimensão da amostra, sugere-se a realização de mais estudos para confirmar a efetividade destas intervenções nesta população.
... Similar to what was found, Azevedo, Paulo; Gomes and Barbara [15] included six studies in their systematic review, showing that early mobilization can facilitate the functional rehabilitation of these patients, promoting gains in muscle strength and greater participation in activities of daily living [15]. ...
... Similar to what was found, Azevedo, Paulo; Gomes and Barbara [15] included six studies in their systematic review, showing that early mobilization can facilitate the functional rehabilitation of these patients, promoting gains in muscle strength and greater participation in activities of daily living [15]. ...
... Nine systematic reviews [26][27][28][29][30][31][32][33][34] and three qualitative studies of mixed quality focussed on early mobilisation in ICU. Sixteen trials were reported in more than one review. ...
... Functional ability, in particular walking, was consistently found to improve following early mobilisation [26,[28][29][30]34]. One study of 7 RCTs and 774 participants [29] reported improved walking independently (RR 1.42, 95% CI 1.17 to 1.72). ...
Article
Objectives To establish the evidence for rehabilitation interventions tested in populations of patients admitted to ICU and critical care with severe respiratory illness, and consider whether the evidence is generalizable to patients with COVID-19. Methods The authors undertook a rapid systematic review. Medline (via OvidSP), CINAHL Complete (via EBSCOhost), Cochrane Library, Cochrane Database of Systematic Reviews and CENTRAL (via Wiley), Epistemonikos (via Epistemonikos.org), PEDro (via pedro.org.au) and OTseeker (via otseeker.com) searched to 7 May 2020. The authors included systematic reviews, RCTs and qualitative studies involving adults with respiratory illness requiring intensive care who received rehabilitation to enhance or restore resulting physical impairments or function. Data were extracted by one author and checked by a second. TIDier was used to guide intervention descriptions. Study quality was assessed using Critical Skills Appraisal Programme (CASP) tools. Results Six thousand nine hundred and three titles and abstracts were screened; 24 systematic reviews, 11 RCTs and eight qualitative studies were included. Progressive exercise programmes, early mobilisation and multicomponent interventions delivered in ICU can improve functional independence. Nutritional supplementation in addition to rehabilitation in post-ICU hospital settings may improve performance of activities of daily living. The evidence for rehabilitation after discharge from hospital following an ICU admission is inconclusive. Those receiving rehabilitation valued it, engendering hope and confidence. Conclusions Exercise, early mobilisation and multicomponent programmes may improve recovery following ICU admission for severe respiratory illness that could be generalizable to those with COVID-19. Rehabilitation interventions can bring hope and confidence to individuals but there is a need for an individualised approach and the use of behaviour change strategies. Further research is needed in post-ICU settings and with those who have COVID-19. Registration: Open Science Framework https://osf.io/prc2y
... Relativamente à Intervenção do ER no processo de desmame ventilatório, os participantes realçaram a importância da reabilitação motora; reabilitação respiratória e avaliação da pessoa no sucesso do mesmo, também vários autores (7,9) referem que os programas de reeducação funcional motora e respiratória nas UCI devem fazer parte dos cuidados prestados pelos ER com o objetivo de aumentar a força muscular e melhorar o estado funcional da pessoa, pois estão associados ao sucesso no desmame ventilatório. Importa salientar que embora não exista consenso quanto à intensidade, frequência e duração das intervenções, os programas estruturados e individualizados demonstram evidência na recuperação do doente crítico (11) e salientaram a importância das técnicas de reeducação funcional respiratória na pessoa em desmame ventilatório, com o objetivo de melhorar a força dos músculos respiratórios, promover a eliminação de secreções e controlar a ansiedade (7,12) . ...
Article
Full-text available
Introdução: O sucesso desmame ventilatório é fundamental, traduzindo-se na redução do tempo de internamento nas Unidades de Cuidados Intensivos (UCI), na minimização das sequelas da ventilação mecânica e na maximização da qualidade de vida, onde o Enfermeiro de Reabilitação (ER) assume um papel fundamental. Metodologia: Estudo qualitativo, descritivo, exploratório. Participaram todos os ER (4)a exercer funções numa UCI da ARS Norte. Recorreu-se à entrevista semiestruturada e à observação não participada sistemática, após a qual se efetuou análise de conteúdo e cruzamento dos dados colhidos nas entrevistas e na observação. O objetivo é conhecer a perceção dos ER no desmame ventilatório. Resultados: A reabilitação motora, respiratória e a avaliação da pessoa são intervenções identificadas pelos ER no cuidado à pessoa em desmame ventilatório, as quais devem ser iniciadas precocemente. As dificuldades identificadas prendem-se com a falta de material, ausência de um protocolo de desmame ventilatório, défice de interação entre a equipa e défice na continuidade de cuidados Discussão: A intervenção do ER na pessoa em desmame ventilatório traduz-se em ganhos positivos tais como a minimização das sequelas da imobilidade, o aumento da força muscular, a capacitação para a autonomia e o célere desmame ventilatório. A elaboração de um instrumento de avaliação estruturado e sistematizado são elementos fulcrais neste processo Conclusão: O desmame ventilatório é um processo muito específico onde a intervenção do ER requer a aquisição e desenvolvimento de competências muito próprias. Destaca-se a inclusão destes conteúdos na formação especializada, formação contínua e no reconhecimento de experiências em realidades semelhantes.
... Tal como o artigo deAzevedo & Gomes, (2015) nos demonstra, o plano de intervenção deve ser aplicado o mais precocemente possível, de modo a evitar o aparecimento de complicações (perda de massa muscular, perda de capacidade de equilíbrio e de marcha, dificuldade respiratória, edemas, alterações gastrointestinais e alterações genito-urinárias). Cerol, Martins, Sousa, Oliveira & Silveira (2019) realçam os resultados do estudo em análise, já que constataram que os principais benefícios da mobilização precoce são a melhoria da capacidade funcional, a diminuição das complicações, a redução do número de dias sob ventilação mecânica invasiva e consequentemente a diminuição de permanência na unidade de cuidados intensivos e de internamento hospitalar. ...
Article
Full-text available
Introdução: A mobilização precoce é uma técnica, que pode facilitar a realização dos autocuidados, promovendo ganhos em força muscular e um aumento do grau de independência, reduzindo consequentemente, o tempo de internamento assim como, os custos inerentes a ele. Objetivos: Identificar através de um estudo de revisão sistemática da literatura os benefícios da mobilização precoce em doentes de cuidados intensivos. Metodologia: Realizou-se uma revisão sistemática da literatura baseada na metodologia proposta pelo Joanna Briggs Institute. A pesquisa foi realizada nas bases de dados MedLine®, CINAHL®, PubMed ® considerando como critérios de inclusão estudos publicados nos últimos 10 anos. Foram utilizados os instrumentos da JBI para avaliação metodológica dos estudos. Resultados: Foram incluídos 5 estudos, de um total de 160 artigos identificados A inatividade prolongada leva a inúmeras complicações, nomeadamente cognitivas, funcionais e emocionais, que através da mobilização precoce podem ser minimizadas e/ou evitadas. Conclusão: Através da análise dos artigos verificamos que a mobilização precoce reduz o tempo de internamento e evita complicações e permite ganhos em saúde. Contudo, foram identificadas algumas barreiras tais como a carga de trabalho dos enfermeiros, a pouca clareza quanto à responsabilidade da mobilização, os riscos de lesões da equipa, a motivação do doente e a participação da família que fragilizam a mobilização precoce.
... This disorder is characterized by an acute neuromuscular impairment associated with generalized muscle weakness, usually related with prolonged use of mechanical ventilation, increase hospital stay, and with an important negative impact regard to functional status of survivors (Jolley et al., 2016). Early ID:p0125 mobilization is as a safe and effective intervention that can improve functional outcomes (Azevedo & Gomes, 2015). These benefits are most evident if mobilization is part of a broader approach, including awakening and breathing coordination and delirium monitoring/management (Balas et al., 2014;Marra et al., 2017). ...
Article
Background and purpose: Mobilization of critical patients should be precocious and the inclusion of nursing in this task can be decisive in paradigm shift. The purpose of this study was to validate the Portuguese version of the intensive care unit Mobility Scale for nursing use. Methods: Prospective multicenter observational study. Patients' mobility was evaluated by rehabilitation nurses in order to determine interobserver agreement. The validation criteria was tested by determining the correlation between the evaluation results of mobility, strength, and functionality levels at discharge. Results: Good interobserver agreement (R = 0.98; K = 0.76). Positive correlation with muscle strength (R = 0.77) and functionality (R = 0.85) levels at discharge. Conclusions: Based on the correlations observed the scale is a valid instrument for nurses and could be a useful tool for routine use. More research is recommended to make the results more robust. Keywords: ICU Mobility Scale; critical care; nursing; rehabilitation; validation studies.
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Introdução: Atualmente, reconhece-se que tão importante quanto sobreviver à doença crítica, é viver com qualidade, dignidade e pleno exercício da cidadania, após a alta dos cuidados intensivos. Este reconhecimento, coloca um foco importante no papel do Enfermeiro Especialista em Enfermagem de Reabilitação nas Unidades de Cuidados Intensivos. Objetivos: Refletir sobre o contributo da Enfermagem de Reabilitação nas Unidades de Cuidados Intensivos. Principais tópicos em análise: as complicações decorrentes do internamento em cuidados intensivos; o Enfermeiro Especialista em Enfermagem de Reabilitação nas Unidades de Cuidados Intensivos; critérios de segurança para a reabilitação precoce; e as barreiras e fatores facilitadores na reabilitação precoce nas Unidades de Cuidados Intensivos. Conclusão: a presença dos Enfermeiros Especialistas em Enfermagem de Reabilitação nas Unidades de Cuidados Intensivos, de modo consistente e sustentado, é imperativa. As suas intervenções, baseadas na melhor evidência disponível e atentas à segurança da pessoa em situação crítica, podem contribuir para a melhoria da qualidade dos cuidados prestados, o que acarreta benefícios quer para a pessoa doente/família quer para as instituições hospitalares.
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Introdução: A mobilização precoce da pessoa em situação crítica tem sido considerada uma intervenção capaz de modificar fatores de risco de morbilidade, com impacto positivo na capacidade funcional. Objetivos: Avaliar a segurança de um programa de reabilitação instituído numa Unidade de Cuidados Intensivos portuguesa; avaliar se a implementação do programa de reabilitação é precoce; avaliar se o levante é precoce e identificar os ganhos em força muscular periférica. Método: Realização de um estudo descritivo e quantitativo. O tratamento e análise de dados foi efetuado com o recurso ao programa informático Microsoft Excel e o software Tableau 10.1. Resultados: Trata-se de uma amostra de 146 indivíduos de ambos os sexos, que estiveram internados numa UCI e que foram submetidos a um programa de reabilitação motora com um total de 800 sessões. Foram monitorizados vários parâmetros cujos resultados foram: Média de idade de 63,9 anos e uma média de dias de internamento de 20,6; taxa de 7,25% de eventos adversos e de 8,5% em complicações decorrentes da imobilidade; implementação do programa de reabilitação até as primeiras 72 horas (56,62%); efetuados 25% de levantes do total dos programas de reabilitação, com uma maior representatividade no levante do leito com pés pendentes; verificou-se um aumento de força muscular periférica com médias entre 0,364 a 2,6 graus de força nos diferentes grupos. Conclusão: A implementação do programa de reabilitação foi precoce, segura e com ganhos em saúde para a pessoa. O estudo não foi conclusivo relativamente ao levante poder ser considerado precoce.
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Generalized muscle weakness when related to the critical patient is an important and common complication in patients admitted to the intensive care unit (ICU). It is known that inactivity can lead to secondary dysfunctions and the main system is the osteomyelitis that may undergo muscle strength decrease by up to 30% in 7 days, and 20% in each additional week. The objective of the study was to correlate the functional status at admission with functional mobility at ICU discharge. It is an exploratory, longitudinal study developed in a school hospital. Patients underwent evaluation through functional independence measure (FIM) at admission. Afterwards, an early evolutionary mobilization protocol was applied, divided into three phases. At the time of discharge, the patients were reassessed by the functional mobility scale in the ICU (FMS). There was a significant (p=0.0001) correlation (r=0.5) between the admission FIM and the FMS at the time of ICU discharge from the critical patients included. There was a significant correlation (p<0.0001) positive (r=0.5) in the female patients and positive and weak (r=0.4) in the male patients. There was a correlation between the functional status at admission and the level of mobility at discharge in patients admitted to the ICU, i.e. , the higher the functionality before admission, the greater the functional mobility at discharge. Keywords: Mobility Limitation. Intensive Care Units. Physical Therapy Specialty Resumo A fraqueza muscular generalizada quando relacionada ao doente crítico é uma complicação importante e comum em pacientes internados em unidade de terapia intensiva (UTI). Sabe-se que a inatividade pode acarretar disfunções secundarias e o principal sistema acometido é o osteomioarticular que pode sofrer diminuição da força muscular em até 30% em 7 dias, e 20% a cada semana adicional. O objetivo do estudo foi correlacionar o status funcional na admissão com a mobilidade funcional na alta de pacientes na UTI. Trata-se de um estudo do tipo exploratório, longitudinal, desenvolvido em um hospital-escola. Os pacientes foram submetidos a avaliação por meio da medida de independência funcional (MIF) na admissão. Após, foi aplicado um protocolo de mobilização precoce evolutivo dividido em três fases. No momento da alta, os pacientes foram submetidos a uma nova avaliação pela escala de mobilidade funcional em UTI (EMF). Verificou-se correlação significativa (p<0,0001) positiva (r=0,5) entre a MIF de admissão e a EMF no momento da alta da UTI dos pacientes críticos incluídos. Houve correlação significativa (p<0,0001) positiva (r=0,5) nas pacientes do sexo feminino e positiva e fraca (r=0,4) nos pacientes do sexo masculino. Houve correlação entre o statusfuncional na admissão com o nível de mobilidade na alta de pacientes internados em UTI, isto é quanto maior a funcionalidade antes da internação, maior a mobilidade funcional na alta. Palavras-chave: Limitação de Mobilidade. Unidades de Terapia Intensiva. Fisioterapia
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This article is an attempt to present a route to identify factors that contribute to the quality of nursing care for inpatient rehabilitation units and to identify instruments used to design and evaluate a way to create an assessment instrument for care in rehabilitation nursing. This is a qualitative study conducted in the medical services of a hospital in the north of Portugal, whose participants were twelve nurse specialists in rehabilitation, and the data collection method was semi-structured interview. The results that emerge from the participants’ narratives translate into a set of attributes that illustrate the model proposed by Donabedian, based on three components of health care: structure, process and outcome, and the cycle of continuous improvement proposed by Deming. We analised the specific requirements for good practice in rehabilitation care.
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Introduction The purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during intensive care (ICU) admission and continuing into the outpatient setting compared with usual care on physical function and health related quality of life in survivors of ICU. Methods This was a single center assessor blinded randomized trial. One hundred and fifty participants were stratified and randomized to receive usual care or intervention if they were in ICU ≥ 5 days and had no permanent neurological insult. The intervention group received intensive exercises in the ICU, ward and outpatients. Participants were assessed at recruitment, ICU, hospital discharge and 3, 6 and 12 months. Physical function was evaluated using the 6 minute walk test (6MWT) (Primary outcome); timed up and go test and the physical function in intensive care test. Patient-reported outcomes were measured with Short form 36 version 2 (SF36v2) and Assessment of Quality of Life (AQoL) instrument. Data were analysed using mixed models. Results The apriori enrolment was not reached. There were no between group differences in demographic and hospital data, including acuity and length of acute hospital stay (LOS) [APACHE II: 21v19; Hospital LOS: 20v24 days]. No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12months post ICU discharge. However, exploratory analyses showed the rate of change over time and mean between group differences in 6MWT from first assessment were greater in the intervention group. Conclusions Further research examining the trajectory of improvement with rehabilitation is warranted in this population. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606. Keywords Critical illness, Rehabilitation, Exercise, Physiotherapy, Physical function, Health related quality of life
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