Background
Methods
Eligibility criteria
Population
Intervention
Comparators
Outcomes
Study types
Information sources and search strategy
Data extraction
Risk of bias assessment
Data synthesis
Confidence in evidence
Results
Study selection
Study characteristics
Study | Country, timeframe | Population | Group | No. of participants | Female n (%) | Age in years mean (SD)/median (IQR) | APACHE II score mean (SD)/median (IQR) | Patient admission diagnoses |
---|---|---|---|---|---|---|---|---|
(i) Systematic early vs. late mobilization | ||||||||
Schweickert et al. [23] | USA 2005–2007 | Adult ICU patients, mechanically ventilated < 72 h, independent at baseline | Comparator | 55 | 23 (41.8) | 54.4 (46.5–66.4) | 19.0 (13.3–23.0) | Lung injury (56%), COPD exacerbation (10%), acute exacerbation of asthma (9%), sepsis (15%), hemorrhage (3%), malignancy (3%), other (5%) |
Intervention | 49 | 29 (59.2) | 57.7 (36.3–69.1) | 20.0 (15.8–24.0) | ||||
Morris et al. [32] | USA 2009–2014 | Adult ICU patients, acute respiratory failure requiring mechanical ventilation | Comparator | 150 | 82 (54.7) | 58 (14) | 75.0 (27.0)b | Acute respiratory failure (98%), coma (2%) |
Intervention | 150 | 84 (56.0) | 55 (17) | 76.0 (26.0)b | ||||
(ii) Systematic early vs. standard early mobilization | ||||||||
Dantas et al. [24] | Brazil 2009–2011 | Adult ICU patients on mechanical ventilation, adequate cardiovascular and respiratory reserve | Comparator | 14 | 10 (71.4) | 50.4 (20.5) | 21.1 (7.2) | Acute respiratory failure (46%), pneumonia (14%), cardiomyopathy (0%), collagenosis (4%), postoperative after thoraco-abdominal surgery (11%), acute myocardial infarction (7%), leptospirosis (4%), acute renal insufficiency (4%), pulmonary tuberculosis (7%), neoplasms (4%) |
Intervention | 14 | 7 (50.0) | 59.1 (15.2) | 23.7 (8.5) | ||||
Denehy et al. [25] | Australia 2007–2009 | Adult ICU patients, ICU length of stay ≥ 5 days | Comparator | 76 | 31 (40.8) | 60.1 (15.8) | 20.7 (7.7) | Pneumonia (23%), cardiac (15%), cardiac arrest (7%), cardiac surgery (30%), other surgery (21%), liver disease/transplant (14%), sepsis (11%), renal (5%), other (7%) |
Intervention | 74 | 24 (32.4) | 61.4 (15.9) | 19.0 (6.0) | ||||
Brummel et al. [26]a | USA 2011–2012 | Adult ICU patients, respiratory failure and/or septic, cardiogenic or hemorrhagic shock, critically ill for < 72 h | Comparator | 22 | 14 (63.6) | 60 (51–69) | 27.0 (17.5–31.0) | Sepsis/ARDS/pneumonia (60%), abdominal surgery (15%), other surgery (3%), airway protection (9%), cirrhosis/GI bleeding (5%), CHF/arrhythmia/cardiogenic shock (2%), other (6%) |
Intervention (1) | 22 | 9 (40.9) | 62 (48–67) | 21.5 (20.0–28.8) | ||||
Intervention (2) | 43 | 15 (34.9) | 62 (54–69) | 25.0 (19.5–29.5) | ||||
Dong et al. [27] | China 2010–2012 | Adult ICU patients, mechanically ventilated between 48–72 h with expected ventilation of ≥ 1 week, clear consciousness, cardiovascular and respiratory stability | Comparator | 30 | 10 (33.3) | 55.5 (16.2) | 16.0 (4.1) | Abdominal infections (18%), ARDS (32%), sepsis (7%), severe acute pancreatitis (15%), pneumonia (23%), COPD exacerbation (5%) |
Intervention | 30 | 9 (30.0) | 55.3 (16.1) | 15.0 (4.2) | ||||
Kayambu et al. [28] | Australia 2010–2012 | Adult ICU patients, mechanically ventilated ≥ 48 h, diagnosis of sepsis or septic shock | Comparator | 24 | 10 (41.7) | 65.5 (37–85) | 27.0 (6.8) | Sepsis (100%) |
Intervention | 26 | 8 (30.8) | 62.5 (30–83) | 28.0 (7.6) | ||||
Dong et al. [29] | China 2012–2015 | Adult patients, prolonged mechanical ventilation > 72 h, eligible for coronary artery bypass surgery | Comparator | 53 | 31 (58.5) | 60.2 (15.1) | 17.2 (4.3) | Coronary artery bypass surgery (100%) |
Intervention | 53 | 33 (62.3) | 62.6 (12.8) | 16.3 (4.2) | ||||
Hodgson et al. [31] | Australia/New Zealand 2013–2014 | Adult ICU patients, mechanically ventilated within 72 h of ICU admission | Comparator | 21 | 12 (57.1) | 53 (15) | 15.9 (6.9) | N/A |
Intervention | 29 | 8 (25.9) | 64 (12) | 19.8 (9.8) | ||||
Schaller et al. [33] | USA/Germany 2011–2015 | Adult surgical ICU patients, mechanically ventilated for less than 48 h and for at least further 24 h, functionally independent at baseline | Comparator | 96 | 35 (36.5) | 64 (45–76) | 17 (11–22) | Visceral surgery (27%), vascular surgery (17%), ENT and ophthalmological surgery (10%), transplant surgery (4%), neurosurgery (3%), orthopedic surgery (3%), thoracic surgery (3%), gynecological surgery (2%), urological surgery (1%), plastic surgery (1%), medical or neurological diagnosis (6%), trauma (26%) |
Intervention | 104 | 39 (37.5) | 66 (48–73) | 16 (12–22) | ||||
Eggmann et al. [34] | Switzerland 2012–2016 | Adult ICU patients, expected to stay on mechanical ventilation for at least 72 h, independent before critical illness | Comparator | 57 | 16 (28.1) | 63 (15) | 23.0 (7.0) | Cardiac surgery (18%), neurology/neurosurgery (8%), other surgery (12%), gastroenterology (12%), trauma (4%), respiratory insufficiency (22%), hemodynamic insufficiency (23%), other (2%) |
Intervention | 58 | 22 (37.9) | 65 (15) | 22.0 (8.0) | ||||
(iii) Systematic early vs. no mobilization | ||||||||
Fischer et al. [30] | Austria 2011–2012 | Patients with cardiothoracic surgery, anticipated ICU stay of ≥ 48 h | Comparator | 27 | 7 (25.9) | 69.7 (13.1) | N/A | Cardiothoracic surgery (100%) |
Intervention | 27 | 9 (33.3) | 63.3 (15.5) | N/A |
Study | Group | Intervention description | Time to first intervention | Intervention frequency | Intervention duration | Intervention continuation |
---|---|---|---|---|---|---|
(i) Systematic early vs. late mobilization | ||||||
Schweickert et al. [23] | Comparator | Standard care: therapy as ordered by the primary care team | Median 7.4 days (IQR 6.0–10.9) after intubation | N/A | Median 0.0 h (IQR 0.0–0.0) per day during ventilation; 0.2 h (IQR 0.0–0.4) per day without ventilation | Not specified |
Intervention | Passive range of motion, active range of motion, including bed mobility exercises, activities of daily living and other exercises increasing independency, transfer training (sit to stand, bed to chair, bed to commode), pre-gait exercises, walking | Median 1.5 days (IQR 1.0–2.1) after intubation | Once daily | Median 0.3 h (IQR 0.2–0.5) per day during ventilation; 0.2 h (IQR 0.1–0.3) per day without ventilation | Until hospital discharge | |
Morris et al. [32] | Comparator | Usual care: weekday physical therapy when ordered by the team | Median 7 days (IQR 4–10) after ICU admission | N/A | N/A | Not specified |
Intervention | Passive range of motions, physical therapy and progressive resistance exercises | Median 1 days (IQR 0–2) after ICU admission | 3 times daily, 7 days a week | N/A | Until hospital discharge | |
(ii) Systematic early vs. standard early mobilization | ||||||
Dantas et al. [24] | Comparator | Conventional physical therapy: passive mobilization of the four limbs five times a week and active-assisted exercises according patients’ improvements | N/A (all participants completed first session within 48 h after admissionb) | 5 times per week | N/A | Until ICU discharge |
Intervention | Passive stretching and mobilization of the four limbs, positioning of the joints, active assisted exercises of the four limbs, transfer from lying to sitting position, active resistive exercises (against gravity or with weight) of upper limbs, cycle ergometry for lower limbs, transfer from sitting to chair, orthostatic posture, counter-resistance exercise on upper limbs, balance exercises, walking | N/A (all participants completed first session within 48 h after admissionb) | Twice daily | N/A | Until ICU discharge | |
Denehy et al. [25] | Comparator | Usual care: active bed exercises, sitting out of bed, marching or walking | N/A (enrollment earliest at day 5b) | N/A | N/A | Until hospital discharge |
Intervention | ICU: arm and leg active and active resistance movements, moving from sitting to standing, marching in place; ward: cardiovascular, progressive resistance strength training and functional exercise; Outpatient: cardiovascular, progressive resistance strength training and functional exercise | N/A (enrollment earliest at day 5) | Once daily while ventilated; twice daily after weaning | 15 min per day in mechanically ventilated; 2 times 15 min per day in weaned; 2 times 30 min per day on ward; 2 times 60 min per week as outpatients for 8 weeks | Beyond hospital stay | |
Brummel et al. [26]a | Comparator | Usual care: existing ICU mobility protocol | Median 3 days (IQR 2–6) after enrollment | 1–2 times per week | N/A | Not specified |
Intervention (1) | Physical therapy: passive range of motion, sit at the edge of bed, stand, walk, activities of daily living | Median 1 days (IQR 1–1) after enrollment | Once daily | Median 15 min (IQR 10–20) for physicians & nurses; median 23 min (IQR 16–26) for physiotherapy | Until hospital discharge | |
Intervention (2) | Cognitive plus physical therapy: same as in physical therapy only + orientation, digit span forward, matric puzzle, real world, digit span reverse, noun list recall, letter-number sequences, pattern recognition | Median 1 days (IQR 1–1) after enrollment, 3 days (IQR 2–4) after ICU admission | Cognitive therapy twice daily; Physical therapy once daily | Cognitive therapy median 20 min; Physical therapy median 15 min for physicians & nurses, median 23 min for physiotherapy | Beyond hospital stay | |
Dong et al. [27] | Comparator | Control (not further described) | N/A | N/A | N/A | Not specified |
Intervention | Heading up actively, transferring from supine to sitting position, to sitting at the edge of bed, to sitting in a chair, from sitting to standing, walking bedside | N/A | Twice daily | Tailored depending on the condition of patients | Until hospital discharge | |
Kayambu et al. [28] | Comparator | Standard care: same as in intervention group but less | N/A (4% completed first session within 48 hoursb) | N/A | N/A | Until ICU discharge |
Intervention | NMES, passive range of motion, active range of motion, active resistance exercises, sitting up in bed, sitting out of bed, sit to stand, marching on the spot, sitting and standing balance exercises, arm or leg ergometry, tilt table therapy, ambulation | N/A (46% completed first session within 48 hoursb) | 1–2 times daily | 30 min | Until ICU discharge | |
Dong et al. [29] | Comparator | Therapy only after ICU | N/A | N/A | N/A | Not specified |
Intervention | Head up, transferring from supine to sitting position, sitting at the edge of bed, sitting in a chair, transferring from sitting to standing, walking along the bed | N/A (100% completed first step in first session) | Twice daily | N/A | Not specified | |
Hodgson et al. [31] | Comparator | Passive movements, same equipment would have been available | Median 4 days (IQR 3–5)b | Once daily | 5–10 min per day | Until ICU discharge |
Intervention | Functional activities, active bed exercises, comprising walking as long as possible, standing as long as possible, balance exercises, sitting in or out of bed, sitting balance, sit to stand, rolling | Median 3 days (IQR 2–4) | Once daily | 30–60 min depending on the condition of patients | Until ICU discharge | |
Schaller et al. [33] | Comparator | In line with the individual centers’ practice guidelines for mobilization and physical therapy | N/A | N/A | N/A | Not specified |
Intervention | Mobilization according to mobility algorithm: passive range of motion, sitting, standing, ambulation. Interprofessional mobility goal setting and identification of barriers | N/A | Once daily | Tailored depending on the condition of patients | Not specified | |
Eggmann et al. [34] | Comparator | Usual care as per the European standard physiotherapy and individually tailored but subject to medical prescription | Median 2.2 days (IQR 1.5–2.9) after ICU admission | Once daily, 5 days per week | Median 18 min (IQR 14–21) | Until hospital discharge |
Intervention | Motor-assisted bed-cycle, resistant training for upper and lower limbs, sitting on bedside, sitting in a chair, standing, walking | Median 2.0 days (IQR 1.4–2.8) after ICU admission | Up to 3 times daily, 7 days per week | Median 25 min (IQR 19.5–27) | Not specified | |
(iii) Systematic early vs. no mobilization | ||||||
Fischer et al. [30] | Comparator | Sham NMES | First postoperative day | Twice daily, 7 days per week | 30 min per session (60 min daily) | Until ICU discharge |
Intervention | NMES | First postoperative day | Twice daily, 7 days per week | 30 min per session (60 min daily) | Until ICU discharge |
Risk of bias and certainty of evidence
Outcomes | Anticipated absolute effects (95% CI) | Relative effect (95% CI) | No. of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
---|---|---|---|---|---|---|
Late mobilization or standard early mobilization | Systematic early mobilization | |||||
MRC Sum Score (MRC-SS), measured at ICU discharge | (i) Systematic early vs. late mobilization | – | 104 (1 RCT) | ⨁⨁◯◯ LOWa,b | ||
The median MRC-SS in the comparator group was 48 (0 to 58) | The median MRC-SS in the intervention group was 52 (25 to 58) | |||||
(ii) Systematic early vs. standard early mobilization | – | 203 (4 RCTs) | ⨁◯◯◯ VERY LOWa,c,d | In a sensitivity analysis, omitting the study by Dantas et al. due to a high baseline imbalance in MRC-SS resulted in an MRC-SS in the intervention group, which was 2.2 higher (2.5 lower to 6.9 higher). For that result, the certainty of evidence is judged low (no serious inconsistency) | ||
The mean MRC-SS in the comparator group in studies ranged from 40.3 to 47.3 | The mean MRC-SS in the intervention group was 5.8 higher (1.4 lower to 13.0 higher) | |||||
Patients developing ICUAW, measured at hospital discharge | (i) Systematic early vs. late mobilization | RR 0.62 (0.38–1.03) | 104 (1 RCT) | ⨁⨁◯◯ LOWa,b | ||
49 per 100 | 31 per 100 | |||||
(ii) Systematic early vs. standard early mobilization | RR 0.90 (0.63–1.27) | 395 (3 RCTs) | ⨁◯◯◯ VERY LOWc,e | |||
39 per 100 | 36 per 100 | |||||
6-min Walk Test (6MWT), measured at various time points | (ii) Systematic early vs. standard early mobilization* | – | 232 (2 RCTs) | ⨁⨁◯◯ LOWa,f,g | ||
The mean 6MWT distance in the comparator group was 246 m in Eggmann et al. and 267 m in Denehy et al. at hospital discharge | The mean 6MWT distance in the intervention group was 223 in Eggmann et al. and 244.2 in Denehy et al. at hospital discharge | |||||
The mean change in 6MWT from baseline in the comparator group was 184.3 m at 3 months and 219.5 m at 6 months after hospital discharge in Denehy et al | The mean change in 6MWT from baseline in the intervention group was 63.7 m higher (14.2 to 113.2) at 3 months and 72.6 m higher (9.3 to 135.8) at 6 months in Denehy et al | |||||
Time to walking, measured during hospital stay | (i) Systematic early vs. late mobilization | – | 104 (1 RCT) | ⨁⨁◯◯ LOWa,b | ||
The median time to walking in the comparator group was 7.3 days (4.9 to 9.6) | The median time to walking in the intervention group was 3.8 days (1.9 to 5.8) | |||||
(ii) Systematic early vs. standard early mobilization | – | 53 (2 RCTs) | ⨁◯◯◯ VERY LOWa,c,h | |||
The median time to walking in the comparator group was 6 days in Hodgson et al. and 23 days in Eggmann et al | The median time to walking in the intervention group was 6 days in Hodgson et al. and 8 days in Eggmann et al | |||||
Patients returning to independence from assistance, measured at hospital discharge | (i) Systematic early vs. late mobilization* | RR 1.71 (1.11–2.64) | 104 (1 RCT) | ⨁⨁◯◯ LOWa,b | ||
35 per 100 | 59 per 100 | |||||
SF-36 Physical Function Domain Score (PFS), measured 6 months after hospital discharge | (i) Systematic early vs. late mobilization | – | 161 (1 RCT) | ⨁◯◯◯ VERY LOWa,b,c | ||
The mean SF-36 PFS in the comparator group was 43.6 | The mean SF-36 PFS in the intervention group was 12.3 higher (3.9 to 20.8) | |||||
(ii) Systematic early vs. standard early mobilization | – | 126 (2 RCTs) | ⨁◯◯◯ VERY LOWa,c,d,e | |||
The mean SF-36 PFS in the comparator group in studies ranged from 42.4 to 75.0 | The mean SF-36 PFS in the intervention group was 8.1 higher (15.3 lower to 31.4 higher) | |||||
SF-36 Physical Health Component Summary Score (PCS), measured 6 months after hospital discharge | (i) Systematic early vs. late mobilization | – | 161 (1 RCT) | ⨁◯◯◯ VERY LOWa,b,c | ||
The mean SF-36 PCS in the comparator group was 33.5 | The mean SF-36 PCS in the intervention group was 3.4 higher (0.01 higher to 6.8 higher) | |||||
(ii) Systematic early vs. standard early mobilization | – | 152 (2 RCTs) | ⨁◯◯◯ VERY LOWc,e | |||
The mean SF-36 PCS in the comparator group in studies ranged from 42.7 to 44.4 | The mean SF-36 PCS in the intervention group was 2.4 lower (6.1 lower to 1.3 higher) |